Remarks to the First Annual Cervical Cancer-Free America Forum

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by HRSA Administrator Mary K. Wakefield

May 5, 2011
Washington, D.C.

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Thank you for inviting me today for this inaugural session of the Cervical Cancer-Free America forum.

I appreciate the opportunity to talk about the strides HRSA is making in addressing women’s health, generally, and cervical cancer, specifically.  But first I want to just take a moment to say how important I think it is that you have joined together in this cause.

Efforts at early detection have improved dramatically in the last 30 years – thanks in part to an array of federal efforts – including The National Breast and Cervical Cancer Early Detection Program run by the Centers for Disease Control and Prevention in partnership with HRSA and 7 other federal agencies.

However, while we have seen sharp declines in mortality, certain segments of the population continue to bear a disproportionate burden of cervical cancer, particularly women in rural areas, the elderly, those with less formal education, and women of color.

The mortality rate for African-American and Vietnamese women, for example, continues to be twice as high as for white women – and about 50 percent higher for Latinas.  Meanwhile, in rural communities, uninsured white women have some of the poorest access to routine screening of any patient population.

As was mentioned, this is a preventable disease that strikes hardest at the uninsured and those living in underserved communities in which health care services are scarce. Like so many other conditions – HIV and diabetes both come to mind – the CDC has documented that cervical cancer is disproportionately a disease of poverty.

For lack of timely prevention, the Nation spends $1.4 billion per year on cervical cancer treatment.

It is disparities like this that engage you and that the Affordable Care Act will explicitly help to address.

As most of you likely know by now, the Affordable Care Act is already directly addressing Women’s Health and health care:

• For example, insurers can no longer discriminate against women for pre-existing conditions like cancers or pregnancy; and starting in 2014, they will no longer be allowed to charge women higher premiums than men;
• Women can’t be charged co-pays for many preventive screenings like mammograms and diabetes tests if they’ve joined a new insurance plan since March, 2010; PAP tests are explicitly included; and HPV vaccinations given prior to exposure to lower the rate of HPV infection for both women and men are now on the Recommended Adult Immunization Schedule;
• Also under the ACA, all women have the right to choose their own primary care clinician, including OB-GYN specialists.

As a resource for on-going changes – and for a complete list of improvements in women’s health services under the ACA – I highly recommend that you visit www.Healthcare.gov, then click on the word “individuals,” then “women.” 

Beyond these broader policy changes, HRSA also has been charged under the ACA with advancing women’s health in very practical and immediate ways. So I want to just take a moment to quickly outline what HRSA does and where we fit in the battle line protecting the health of women and in the fight against cervical cancer.

HRSA is part of HHS, and has a set of programs largely dedicated to improving access to high quality health care for vulnerable populations. 

Its total budget authority has risen steadily from about $6.9 billion in FY 2008 to over $9 billion today, and we got a huge boost from the Recovery Act in 2009.

With this budget, HRSA funds 80 different grant programs in partnership with state, local and community organizations across the country – several of which contain a cervical cancer prevention component.

I’ll just mention some of them now, and say a bit more in a moment:

• Our Community Health Center system supports the delivery of primary and preventive care at more than 8,100 clinical sites across the nation.  Health centers currently serve about 19 million patients.  Anyone who walks in the door is served; fees are charged on a sliding scale, depending on income.  And about 40 percent of patients served annually have no health insurance.

In recognition of National Women’s Health Week – May 8-14 – I have asked HRSA Grant Program Directors to encourage women to use health centers for their preventive screenings, including Pap tests. The clinics are open, and the services are available, so I would likewise urge everyone here today to encourage women to use them, regardless of the financial status.

• HRSA also oversees the National Health Service Corps, which places primary care professionals – including nurse-practitioners and nurse-midwives – in medically underserved areas in exchange for student loan repayments and scholarships.
• 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. Additionally, HRSA funds 102 Healthy Start sites in communities at highest risk for infant mortality in 38 states, the District of Columbia and Puerto Rico.  Cervical cancer screens are a built-in component of these nationwide programs.

• 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.  Part of the standard screening protocol is STD testing and cervical cancer screens for our 295,000 women clients.
• In addition, HRSA has major responsibilities in rural health policy; federal organ procurement and allocation efforts; Poison Control, and the National Vaccine Injury Compensation Program, which includes the HPV vaccine.

When I arrived at HRSA in early 2009, Congress had just passed the Recovery Act, which invested $2 billion in the national health center network, and another $500 million in strengthening HRSA programs to expand the health care workforce.   That pushed us all into overdrive.

A year later came the Affordable Care Act, which pushed my agency into hyper-overdrive.  Congress assigned 50 provisions of the Affordable Care Act to HRSA to implement.

One of those 50 items is a directive to expand the number of health centers sites and the range of services they offer.

This investment has the potential to significantly improve access to high-quality, primary and preventive health care in every corner of the nation – particularly for women.

By 2015, HRSA’s health center grantees are expected to serve many more patients – over and above the 19 million in calendar year 2009. To give you some idea of what the impact of this expansion may be on women’s health, let me share a few benchmarks:

• More than 11 million patients served in health centers are women and girls. That’s 6 out of every 10 patients.  Of that population, 68 percent are women over 20 – comprising the largest single patient-category in the system;
• Health Centers not only offer the HPV vaccine, they administer PAP tests to about 1.8 million women per year – resulting in  some 117,000  Abnormal Cervical Findings; so we can clearly see that expansion of the health center system would result in early detection for many more women, especially those in greatest need and at greatest risk;
• 320,000 women also receive mammograms in health centers; and 480,000 are ushered into prenatal care – 67 percent of them in the first trimester. And about 265,000 give birth – including 178,000 that are attended by a health center clinician;
• Of the 9,125 attending physicians in health centers, almost one in 10 is an OB-GYN specialist, accounting for more than 3 million patient visits– or 9 percent of the 34 million visits to health centers annually.

Clearly, if these trends hold, expansion of the health center system will extend these benefits and others to many more women. So the time has never been better to re-double our efforts to bring more women into the system, particularly those in geographically isolated or economically fragile circumstances.

And while we’re on the subject, I’d like to mention that HRSA makes it easy to access these services. Simply go to www.HRSA.Gov and click “Find-A-Health Center,” or download the free “Find-A-Health-Center” app for your I-Phone through the HRSA web site.

As we work to expand access to health center sites and services, we are working just as hard to improve the quality of care that health centers deliver.

For example, the expansion of services stimulated by the Recovery Act and ACA investments is increasing health centers’ ability to “treat the whole patient” in one place, at one time, magnifying their impact on patient’s lives.

While not directly related to today’s topic, you might be interested to know that two-thirds of our health centers now provide mental and behavioral health services that reach more than 750,000 people every year.  And a third provide substance abuse treatment and counseling that reaches more than 115,000 patients.

Health centers also have ramped up their oral health component – a 131 percent increase over the past decade.

We’re also improving the way we measure performance at health centers.  Earlier this year HRSA added four more clinical performance measures to the six we collect annually from our health center grantees.  The new measures cover weight screening, asthma treatment rates and tobacco cessation interventions.

As many of you likely know, tobacco use has been implicated in HPV’s progression into cervical cancer.

We continue to collect data on performance measures specific to women, including the number who receive prenatal care, cervical cancer screenings and mammograms.  We also collect data on other measures impacting women, including diabetes, hypertension and STD testing.

To staff this expanding primary care infrastructure – and strengthen primary care in other settings that serve the underserved – the ACA provides for doubling the ranks of the National Health Service Corps.

The NHSC is comprised of advanced practice nurses, physicians, dentists, psychologists and others who agree to provide primary care in medically underserved areas for at least two years in exchange for academic debt relief.

In 2009, the NHSC had only 3,600 providers in the field. Today – thanks to investments from the Recovery Act and the Affordable Care Act – the field strength of the Corps has grown by 57 percent to 7,530 clinicians. That’s the largest expansion in the Corps’ 39-year history.

Under President Obama’s leadership, we are planning for the Corps’ ranks to grow even further by the end of 2011.  And we expect that about half of those clinicians will work in the Health Centers I was talking about a moment ago.

The Corps is all about increasing access to primary health care.  And here’s what the recent expansion has meant for women’s health and women clinicians:

• A 91 percent increase in NHSC Nurse-Midwives in two years – from 124 to 237;
• A 157 percent increase in Nurse-Practitioners from 598 to 1,536; and
• An enviable record of gender parity: Of the almost 28,000 clinicians who have served in the National Health Service Corps in the past 6 years – including primary care physicians, dentists and others -- slightly more than half have been women health professionals.

Here again, I’m sure we are all familiar with the importance of female practitioners in matters of reproductive health, particularly within certain populations.

The Affordable Care Act also authorizes $1.5 billion over five years for the Maternal, Infant, and Early Childhood Home Visitation Program.

Under this program, nurses, social workers and others will visit expectant mothers and their families in high-risk communities.  There, they will provide counseling and intervention services designed to improve health outcomes for mothers, infants and families; school readiness for children; parenting skills and economic self-sufficiency.

The evidence behind the program clearly indicates that providing these interventions sooner decreases the need for more costly clinical care and social services later. 

For too long, we have watched unprepared young mothers and their newborns leave the health care system after delivery with few if any resources or skills to meet their new role as parents – only to watch them return days, weeks or months later through the emergency room door.

Home visitation not only focuses on addressing a host of deficits to improve maternal and infant health outcomes – including routine screenings – but also improves every mother’s long-term prospects through evidence-based programs designed to help them stop smoking, adopt healthier lifestyles, and combat post-partum depression.  The program also puts in place community resources to decrease domestic violence and crime, and improve educational opportunities.

All 50 States, the District of Columbia, Puerto Rico and five other U.S. Territories received grants last summer to fund statewide assessments to identify existing home visiting programs and areas of high need within their borders.

This year, the program will get underway nationwide, supported by a first installment of $227 million in funding.

As a new vehicle for expanding care into populations at highest risk for HPV and cervical cancer, Home Visitation has obvious groundbreaking potential – as many more expectant mothers and their infants will be guided into routine screening and primary care.

It’s our opinion at HRSA that the time is right to really advance in a meaningful way Women’s Health. In addition to what I’ve already described, we now have authorization under the ACA to establish:

• The Office on Women’s Health within the Department of Health and Human Services – and offices in six of its agencies, including HRSA.  (Others are CDC, FDA, NIH, AHRQ and SAMHSA);
• A Coordinating Committee on Women’s Health within the Department; and
• A National Women’s Health Information Center.

The time is also right because, with our resources are limited, HHS leadership is committed to applying our health resources as effectively and robustly as possible in ways that produce better care outcomes for all women.

As part of this effort, HHS is currently involved in developing guidelines for women’s preventive services under a contract with the Institute of Medicine, and I certainly want to recognize your efforts – and the efforts of so many other women’s advocates – to have HPV and cervical cancer screening included.

The IOM has conducted a series of hearings to get input from relevant organizations and the public, and is expected to issue guidelines by mid-July.  The Department will then release the final guidelines sometime in August.

I’m glad to be here today to contribute to the conversation, and I offer HRSA as a partner in your very important work.

Thank you.