Remarks to the Rural Voices Leadership and Policy Workshop

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by HRSA Administrator Mary K. Wakefield

April 4, 2011
Washington, D.C.

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Welcome, and thank you for being able to join us today.  

The staff at our Office of Rural Health Policy is among the best I have at HRSA.  In particular, I want to thank Nisha Patel, Shelia Tibbs and Nadia Ibrahim.   They have put a lot of effort into pulling this together, and I know you’re going to get a lot out of it.

It wasn’t too long ago that I was sitting where you are.  

From my experience growing up and working in North Dakota, it always struck me that rural areas present people who want to lead with a great deal of opportunity to do so.

Rural areas are natural laboratories where a person can apply his or her expertise and create innovative solutions to challenges.  If necessity is the mother of invention, rural areas often are headwaters of ideas, not the isolated backwaters as stereotypes often suggest.  

Through my work in rural health care and rural health policy, I’ve seen first-hand many of the challenges that you confront, and I commend your dedicated hard work and commitment to rural health issues.  I hope you come away from these meetings energized with new ideas and even more motivation to expand the vital work you’re doing in rural communities across America.

As you know, before becoming Secretary of HHS, Kathleen Sebelius was governor of a rural state, Kansas.  She, too, is intimately familiar with the issues and challenges rural areas are facing in providing adequate access to health care, and she’s personally committed to helping rural areas.  

For example, she was the first HHS Secretary in 13 years to attend the Rural Health Advisory Committee Meeting in person.  In senior staff meetings, she very frequently raises rural issues.  She’ll ask the CDC, ‘How are you defining rural with this initiative?’  Or she’ll ask CMS, ‘What’s the impact of this policy on critical access hospitals?’

The Secretary and I want to strengthen rural health care, and the key to that is rural health leadership.  Our health care is as good as the people who lead it.  I think we have some of the best and we want more of the best.  Please tell us how we can improve: be the canary in the mine.  You’re our boots on the ground and we’re your boots in the federal government.  We share a common agenda in different locations.

Before I go any further, let me say a word about the focus of our work at HRSA.  We manage an $8 billion budget and 80 different grant programs:

• You know that we house the Department’s Office of Rural Health Policy, which bolsters rural hospitals and coordinates coalitions of rural providers. Nearly 7 out of 10 health professions shortage areas nationwide are in rural communities, and HRSA is the lead federal agency in helping them come up with solutions to health care scarcity.
• In addition, HRSA promotes and supports the expanded use of telehealth to connect underserved people to distant providers through remote monitoring devices and teleconferencing. This is especially crucial in rural and remote parts of the country.
• In our Community Health Center system, we have more than 1,100 grantees that provide primary and preventive care at more than 8,100 clinical sites across the nation.  This network, which will expand dramatically over the next several years, served nearly 19 million patients in 2009. 
• HRSA also manages the National Health Service Corps, which places primary care professionals in medically underserved areas in exchange for student loan repayments and scholarships. 
• Similarly, HRSA strengthens the nation’s primary care workforce by supporting institutions that train physicians, nurse practitioners and physician assistants – and by supporting innovation in curricula, faculty development, and scholarship and loan repayment programs for health professions students.
• Our Maternal and Child Health block grants to states pay for health care services, screening and counseling that reach 6 of every 10 women in the U.S. who give birth and their infants.  Within this effort, our Healthy Start program is in more than 100 communities with high infant mortality rates.
• HRSA also administers the Ryan White HIV/AIDS Program, whose 900 grantees provide top-quality care and life-sustaining medication to more than half a million low-income and uninsured people living with HIV/AIDS. That’s half of all Americans who’ve been diagnosed.
• Finally, HRSA oversees the nation’s Poison Control Centers; our federal organ procurement and allocation efforts; and the National Vaccine Injury Compensation Program, among others.

Our strategic plan has four goals.  Each of these is clearly relevant from a rural perspective – think about them and what action steps could be deployed.

1. The first is to improve access to quality health care and services.
2. Our second goal is to strengthen the health workforce.
3. Goal number three is to build healthy communities.
4. Our fourth goal is to improve health equity and eliminate disparities in access to health care.

These goals align exactly with those of the Affordable Care Act.

President Obama signed the Affordable Care Act one year ago in March.  As residents of states with large rural populations, both Secretary Sebelius and I cheered this new health care law.  We knew that it would give Americans more freedom in their health care choices, lower costs and improve the quality of care, especially for those in rural communities.

The ACA expands the benefits of health insurance to 32 million people, many of whom live in rural areas.  Many rural health leaders helped lead the way in getting this historic bill passed, and it's a real tribute to their efforts.   

I’d just like to give you a brief update of our activities in rural areas and the impact of the ACA on your work.

HRSA is responsible for implementing 50 provisions of the ACA, and is a key partner with other agencies for implementing 16 other provisions.

The Affordable Care Act invests $11 billion over the next five years to expand health center sites and services, and will allow health centers to nearly double their current patient base of 19 million.  The impact of this growth will be notable in rural areas since more than 40 percent of all health centers serve a mostly rural patient base.

Even before passage of the ACA, we received a sizable boost through the Recovery Act, which directed $2 billion in new funds to HRSA to expand the number of health center sites, the range of services they provide, and their hours of operation.  

These investments are designed to improve access to primary care and preventive services, and encourage health care professionals to serve where they are needed most.

As you know, rural areas have long faced challenges in attracting and retaining the health care providers they need. Almost two thirds of the primary care health professional shortage areas are in rural America.

It is against this backdrop that the ACA invested heavily in the National Health Service Corps, more than half of whose 7,500 members serve in rural areas. Thanks to the ACA and the Recovery Act, we’ll basically triple the number of the NHSC since 2008 – from 2,800 clinicians then to nearly 10,700 by the end of next year – thousands more health care providers serving in hard to reach communities.

And the NHSC is working with the ORHP to increase our investment in the National Rural Recruitment and Retention Network.  This matching service links providers who want to work in rural areas with communities who need them. In 2009, the Network helped to place more than 1,256 clinicians in remote counties and parishes across 49 states.
HRSA also applied funding from the ACA’s Public Health and Prevention Fund to make an immediate investment in supporting the workforce.  Funding includes:

• Primary Care Residencies and Physician Assistant training ($197 million)
• Primary Care Nurse Practitioner training ($31 million)
• State Health Workforce Development Grants for Primary Care ($5.6 million)

These funds build on Recovery Act investments of half a billion dollars for the health care workforce and solid appropriations in 2009 and 2010 after many years of anemic funding for health care workforce programs.  I want to be absolutely clear that the President and everyone at HRSA understand the importance of addressing the challenges that rural communities are facing.

By the end of January, HRSA had awarded more than $270 million in ACA grants for health care workforce training.  

Last month was match day for medical students selecting residencies, and we saw another year of up-tick in primary care choices. Additionally, 177 new primary care residency slots were funded by the ACA through the Public Health and Prevention Fund I just mentioned and through Teaching Health Centers.  Both efforts focus on community-based training, and we know people are more likely to serve underserved populations if they have experience working there.

Finally, the Affordable Care Act expanded the reach of the 340B drug pricing program in ways that particularly benefit rural areas.  The 340B program, as you probably know, provides significant discounts on pharmaceutical drug purchases to eligible safety-net entities.  The ACA added five entities to the eligible list:

• Critical Access Hospitals
• Rural Referral Centers
• Children’s Hospitals
• Free Standing Cancer Hospitals
• Sole Community Hospitals

Three of these five – critical access hospitals, rural referral centers and sole community hospitals – represent the rural community.  Since last August, we’ve already enrolled more than 850 hospitals and outpatient sites as new participants in the 340B program.  

HRSA is committed to expanding access to cost-effective pharmacy services in rural areas.   We expect to enroll over 5,000 new hospital and health center sites and increase the number of enrollees by a third, from 15,000 to 20,000.

As is the case for many of you, my rural background has greatly influenced the course of my career.  I was involved with the Office of Rural Health Policy from the very beginning, contributing to the creation of these programs when I worked in the Senate.  I remember how hard we fought to make these programs flexible enough to address the broad range of needs in rural communities.  

I think we’re meeting those challenges.  Today we see the tremendous impact these programs are making in rural communities.  It is because of your work that many of the major rural health issues are being addressed.  You understand the needs in your communities and the importance of collaboration, and your efforts are essential to sustaining and improving the health and wellness of rural Americans.   

I know this because I’ve had the pleasure of hearing about the innovative projects and important issues you’re focusing on. For example:

• The Coochiching County Community Services in Minnesota has teamed up with a consortium of partners to create the Arrowhead Health Alliance, which will provide home visits and child health services to some of the most at-risk families and women in the northeast part of the state.
• In Ashland, Wisconsin, the Northwest Concentrated Employment Program, another grantee, has joined efforts with local tribes, training institutions, agencies, and providers to train personal care health workers to meet severe shortages of in-home direct care services to the elderly.
• And through the President’s Rural Health Initiative, ORHP has funded a grant program that supports getting more health professions students into rural training sites.  In September, we issued 20 new Rural Workforce Training Network awards.  One grantee, which identified workforce recruitment and retention as a key focus area in Camden, Tennessee, is exposing medical residents throughout the state to rotations in rural areas.

The Rural Health Initiative also is helping us identify the challenges that family medicine Rural Training Track residency programs (the so-called “1+2 programs”) face in program development, financing, recruiting, and training of resident physicians.  

Another important area for rural communities is Health IT and telehealth.  A lot of the early innovation in the use of electronic records and telehealth networks was done in rural communities, but vast swaths of rural practice remain beyond the reach of commercial broadband networks.  

As many as 3 out of 10 rural health clinics, and more than 1 out of 4 critical access hospitals, don’t have access to broadband networks.  We are working very hard with the Department to help bridge this gap.  ORHP has developed a pilot program focused on rural HIT that will award up to 40 grantees $300,000 a year over three years. The funds will allow networks to purchase equipment, train staff and hire personnel as needed.

I am co-leading, with the Office of the National Coordinator, an HHS rural Health IT taskforce established by the Secretary to address the challenges rural communities face in adopting HIT and to provide resources at the federal level.

Recent accomplishments include an inventory of Department-wide activities on HIT in rural areas; the preliminary stages of development of a rural HIT ToolKit; and the development of very collegial and productive relationships with the Federal Communications Commission and the US Department of Agriculture.  

Our Telehealth Network Grant Program funds projects that demonstrate the use of telehealth networks to improve healthcare services for medically underserved populations. And 9 of our current 26 grantees are focusing on the cost-effectiveness of tele-homecare.

I know that several of you here today are from tribal organizations or serve areas that are predominantly Native American.   At HRSA, we are taking an agency-wide approach to identify potential changes that we can make to our policies and programs to support existing and potential American Indian/Alaska Native grantees and stakeholders.  

• HRSA has re-established a Tribal workgroup with representatives from each Bureau and Office to inform senior leadership of the activities, challenges and opportunities for AI/AN entities.
• HRSA and the Indian Health Service are working together to increase the number of AI/AN representatives on HRSA’s Advisory Committees and to make tribal health centers eligible for the National Health Service Corps.    
• We also working to increase the number of AI/AN representatives in our grant review process.  We now have 188 AI/AN reviewers in our database, and 49 AI/AN reviewers served on 36 different program competitions in FY 2010.  Please help us bring a rural perspective to our grants process.
• Additionally, we are working to improve technical assistance. Over the past year, we have held 19 technical assistance activities directly geared toward AI/AN organizations.
• And we have just created a centralized electronic mailbox specifically for any ideas, suggestions or feedback involving American Indian and Alaskan Native people.  It is AIANhealth@hrsa.gov.

In closing, I want to stress how glad I am that you are here today. We need folks who can “connect the dots” and get results – and because you are here today, I imagine that you are among those people in your respective communities.  

That’s why I’m thrilled you’re part of this program, because we want to do all we can to enhance and build on your skills.  Over the course of the next day, you’re going to learn a lot about policy and regulatory issues.  You’re going to have a great day of leadership training.  And you’re going to hear from a number of folks just like you: exceptional community leaders who happen to live in rural America.

Keep a very close eye on opportunities in HRSA’s health center and health professions programs.  You may find opportunities there that supplement or complement what you do as rural health grantees.

Our ORHP staff will monitor your questions over the next few days.  They’ll address what they can at the close of this meeting and compile everything else so that we follow up on your concerns and ideas.

So please share your thoughts, since they will inform us and benefit many others, and thank you again for all that you do on behalf of rural communities.