Remarks to Grantmakers in Health

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by HRSA Administrator Mary K. Wakefield

June 16, 2011
Washington, D.C.

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Thank you for joining us here today. I’m very happy to be here with our partners in the Federal-State Implementation Project and with all of you who share a common mission and sense of purpose: to improve access to health care for those who can’t afford it.  

A lot has happened since the last time we met at your annual meeting in March of last year. Just two weeks after that meeting, President Obama signed the Affordable Care Act into law.  The Act created a sea change in the health care of our nation and – most notably for those we serve – in the health care safety net.  And it brought about some very important changes to HRSA, whose programs are viewed by many as synonymous with “safety net” care.

Today I want to tell you about some of the ways the Affordable Care Act has affected our work at HRSA and the people we serve. And I hope to encourage thinking about where our agendas align and how we can create and sustain partnerships to be more effective and efficient in deploying our respective resources.

With a budget of more than $9 billion and 80 different grant programs, we have a two-pronged focus: to help educate the workforce and to support the delivery of primary care services. We support primary and preventive care for 19 million patients nationwide through our health center grantees and their 8,100 clinical sites.  

• Through partnerships with state and local governments to improve maternal and child health, we touch the lives of six out of every 10 women who give birth in the U.S.
• Through the National Health Service Corps, we currently support about 7,500 health care professionals who work in medically underserved communities.
• Through the Ryan White HIV/AIDS Program, we support 900 grantees that provide top-quality care and life-sustaining medication to more than 500,000 people, about half the entire estimated population of Americans living with HIV/AIDS.
• Through our Bureau of Health Professions, we strengthen our nation’s primary care workforce by giving financial support to colleges and universities.
• Through the Department’s Office of Rural Health Policy, we are the lead federal agency that bolsters rural hospitals and coordinates coalitions of rural health providers.

We also oversee all organ, tissue and blood cell donations.  And we are the federal agency primarily responsible for poison control.

So as you can see, there is no shortage of areas where we could intensify partnerships for our common goals. To accomplish all these tasks, we function similarly to many of you. HRSA works through 3,000 grantee organizations.  These partners include state and local government agencies, non-profits and community-based organizations, foundations, clinical providers, universities, research centers and others.

The number of activities we are undertaking – and the sheer number of programs and grantees we support – have not always been this high, or this intense. Our 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, which invested $2 billion in the national health center network and another $500 million to help us expand the health care workforce.

Of course, we’re also seeing pressure to manage the federal debt, with implications for our programs like everyone else.

In the past couple of years, HRSA has found itself at the center of health care reform. And over the past year, HRSA and our partners have been taking the steps required to put the Affordable Care Act into practice.  

HRSA’s responsibilities as they pertain to the Affordable Care Act are many. We are the lead agency in implementing 50 provisions of the law and are co-lead on 16 others, all with a focus on three key goals:

• Improving access to quality primary health care and services;
• Strengthening the health care workforce; and
• Improving health equity and eliminating disparities in access to health care.

Once again, you can see how our agendas overlap in many ways and provide opportunities for collaboration to reach our common goals.

The Affordable Care Act recalibrates the focus of health care to strengthen primary care – and increasing access to primary care is the biggest responsibility HRSA was given under the Act.

To do this, the Act provides $11 billion over five years to HRSA-funded community health centers, creating the largest expansion of the health center system in the program’s history.  We have used these funds to build new centers and to expand and renovate existing ones.   

These investments in infrastructure will allow us to sustain health centers as they continue to expand the range of services they offer – in spite of the tough budget times ahead.  Two-thirds of our health centers now provide mental and behavioral health services, they recently expanded vision services, and they have greatly ramped up their oral health components.

By 2015, HRSA’s health center grantees are expected to serve millions more patients than the 19 million they served in calendar year 2009.

In addition, the ACA funded community-based Nurse-Managed Health Centers that are managed by advanced practice nurses. These clinics reach into public housing to expand access to primary care for vulnerable populations and provide critical clinical training opportunities for nurses and other health professions students.

Another component of the Affordable Care Act that has been relatively little-noticed by the public is its emphasis on disease prevention and health promotion activities.  

For example, the Act authorizes $1.5 billion over five years for a Maternal, Infant, and Early Childhood Home Visitation Program. Under this model, nurses, social workers and others will visit expectant mothers and their families in high-risk communities.  There, they will provide evidence-based counseling and intervention services known to have improved health outcomes for mothers, infants and families.

Applications are being accepted now from states for 2011 funding.

Further, the Act authorizes $200 million over the next four years for the construction, renovation and expansion of school-based health centers. That way, even the most disadvantaged kids can get care conveniently – and get it before major health problems take root.  School nurses, of course, have been the backbone of school-based care – first responders to students – for years.

Sustaining such a tremendous expansion of the health center system – and ensuring that rural and urban underserved populations have access to primary care and clinical and preventive health services – requires special attention to workforce.

The Affordable Care Act invests nearly $2 billion in training new primary care health professionals and providing incentives for providers to serve in primary care settings.  We want to make sure that we have enough health care professionals on hand to meet the growing demand for health care services and place them where they’re needed most.

The Act provides $1.5 billion to the National Health Service Corps through 2015. That’s enough to fund thousands of new loan-repayment contracts and scholarships for primary care clinicians. These clinicians include nurse-practitioners, nurse-midwives, physicians and physicians assistants, dentists and hygienists, and mental and behavioral health professionals.

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 to more than 7,500 clinicians. That’s the largest expansion in the Corps’ 39-year history.

And for the first time in the 38-year history of the Corps, we’re also now accepting applications for part-time clinicians – those who might want to split time between a health center position and family commitments or assume a teaching job while also working in a school clinic.

In addition to supporting the NHSC, the ACA also funded the Public Health and Prevention Fund, which made an immediate investment in supporting the workforce.  Funding last year included:

• Primary Care Residencies and Physician Assistant training ($197 million)
• Primary Care Nurse Practitioner training ($31 million)
• State Health Workforce Development Grants for Primary Care ($5.7 million)

There is also the Teaching Health Center Graduate Medical Education program, a five-year, $230 million effort to support greater numbers of primary care and dental residents training in community-based settings across the country. With these funds, Teaching Health Centers can seek additional primary care residents through the National Resident Matching program and will begin training approximately 50 resident-trainees beginning next month. Interest in this program has exceeded available resources.

These investments provide an important platform for expanding the primary care workforce and create more opportunities to prepare physicians to practice in community-based settings, while ensuring that primary care services are available to more of our nation’s most underserved communities.

The ACA 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.

In this context, the importance of interprofessional training becomes evident. We need to educate and advance interprofessional health care teams that provide patient-centered care in new delivery system models which improve care coordination, quality and safety of care. And there are provisions in the Act that support this focus.

Also, as you may know, two reports were released last month on core competencies and action strategies for interprofessional education.  This important effort was the result of a partnership with the Interprofessional Education Collaborative, the Macy Foundation, the Robert Wood Johnson Foundation, the American Board of Internal Medicine Foundation, and others.

The Collaborative is just one example of what we can achieve together when we merge forces and complement our strengths to achieve improved and measurable outcomes.

Moving forward, if we are to strengthen interprofessional collaboration we will need to partner with other foundations, like the ones you represent. We will need to partner  to support demonstration projects that develop the skills necessary for interprofessional collaboration for students, faculty, and current practitioners. We still have much to learn about what and how to make collaboration effective. The need to test these competencies and measure their impact for improving patient-centered care and health outcomes must be part of this effort.

As I mentioned earlier, HRSA has had tremendous funding boosts in the past two years. But we are entering a period of what are likely to be protracted budget cuts.  At the same time, demand for services will continue growing, and with it the need for more primary care providers, more health centers, and more training opportunities, especially in rural and other underserved areas.

We must find ways to do more with less. One way we can do this is by harnessing another tool provided by the Affordable Care Act: support for evidence-based models of care and innovative tools for care delivery.

For example, states will use most of the funds from the Early Childhood Home Visitation Program to support the use of one or more of seven evidence-based home visiting models. But the  Act also encourages innovation by allowing for up to 25 percent of funds to support promising approaches that do not yet qualify as evidence-based models.

The common sense behind this evidence-based approach is obvious. What good is it for health care systems to spend millions of dollars to provide care to babies in an ICU and then send them home with unprepared teenage mothers or other at-risk parents?  International research tells us that countries with nurse home visiting programs have lower infant mortality rates than the United States.

We also have evidence now that older adults who live in areas with high concentrations of primary care doctors are less likely than those in areas with fewer such doctors to be hospitalized for illnesses that can be managed outside a hospital. Research published in JAMA last month showed that seniors with greater access to primary care doctors also have lower death rates.

These findings underscore the importance of improving access to primary care in underserved communities. They also impress upon us the value and consequence of collaborating with partners like you to achieve this challenging goal.  

At HRSA, we’re taking advantage of new and creative partnerships with private foundations and other government agencies. We have a number of joint efforts with other federal agencies. For example:

• We’re working with CMS and the Office of the National Coordinator for Health IT to help primary care providers become meaningful users of electronic health records.
• With the Centers for Disease Control and Prevention, we are co-funding a 21-month study that addresses this central question: “How do we improve population health and reduce
  
  health disparities by effectively integrating and coordinating public health and primary care?”
• We are also working with the Institute of Medicine to identify ways to improve access to oral health care.
• We’re working with the Substance Abuse and Mental Health Services Administration to support the integration of behavioral health and primary care; strengthen Screening, Brief Intervention and Referral to Treatment; and expand the capacity of health centers to care for patients with mental illnesses and addictions.
• In addition, we’re working closely with the Indian Health Service to identify activities that HRSA can do to provide greater assistance to existing and potential American Indian/Alaska Native grantees and stakeholders.  

Beyond our joint efforts with federal partners, we have ongoing collaborations with many of you. For example, our Maternal and Child Health Bureau and our Office of Policy, Analysis and Evaluation both have ongoing cooperative agreements to provide technical assistance – the first with the Epilepsy Foundation for state demonstration projects; the second with the Nemours Foundation for the Healthy Weight Collaborative.

We have a lot of informal collaboration efforts that we need to strengthen and expand, we have a lot of discussions and plans that we need to implement and follow through. Some examples in the pipeline include expanding the use of some health care workers – like promotoras – and workforce curriculum development.

I’ve been very appreciative of our working together and of the interest and leadership that Grantmakers in Health has shown to the populations we serve. With our partners, we can exploit our common strengths, resources and opportunities to make strides in the many areas that need our attention.  

And although I am extremely pleased with what we have achieved together in the past year, I believe we can do much more – by identifying clear and measurable goals; sharing our work, lessons learned, successes and shortcoming; combining our expertise; and maximizing limited resources.

There are many areas where we could intensify partnerships for our common goals, and workforce is perhaps the most urgent.

• Workforce shortages: While projections for future workforce shortages vary greatly, what we do know for sure is that the nations’ population is going to keep getting older, and demand for care will continue to grow.
• Workforce diversity: At a time when African-Americans and Latinos represent more than a quarter of the U.S. population, they are substantially underrepresented in health professions. Workforce diversity cannot be just an afterthought, it must become an integral part of a workforce development strategy if we are to eliminate disparities.
• Interprofessional training: I know some may be thinking, “We’ve gone down this interprofessional road before and it didn’t quite pan out,” but these are new and different times.We must develop training for accountable care organizations and patient-centered medical homes. So we must try different roads and approaches if we are to increase efficiencies and effectiveness, and improve patient outcomes.

Finally, I cannot stress enough that I am not here to tell you what to do. Collaboration is not a one-way street, and I want to hear your ideas, suggestions, and criticisms.

If you see ways in which we can do something better, we want to know about it. If you’re not happy with past experiences, don’t give up on us: tell us what went wrong, share your experiences with us, and let’s try again.

We need your best practices to improve our performance, and I am committed to open communications and honest feedback with all our stakeholders.

Together we can continue to make important strides in expanding access to efficient and high-quality health care.

Our ability to prove the value of your programs, and ours – and to enhance their performance  – will improve the health of the populations we collectively care deeply about, and will influence the course of health care. Let me conclude today by telling you how pleased I am to be a partner in your efforts.

Thank you.