Remarks to the U.S. Conference on AIDS

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by HRSA Administrator Mary K. Wakefield

November 13, 2011
Chicago, IL

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I’m happy to be here with you, and as a nurse I want to say how very proud I am to be part of an Administration that is working hard to protect the interests of people living with HIV/AIDS – while delivering care to those in need, and advancing improved prevention and treatment.

While I’m coming from the perspective of HRSA, I want to amplify a bit on the comments of Secretary Sebelius in her opening address to you all and the remarks of Jeff Crowley from the Office of National AIDS Policy, not to mention the HHS staffers who have been here this weekend serving on panels and attending meetings.

At HRSA, our agency’s mission interfaces with the decades-long struggle against the HIV virus. The collective focus of HRSA’s programs is on the underserved and medically vulnerable populations, and on “improving health and achieving health equity through access to quality services, through a skilled health workforce and through innovative programs.”

And that’s a focus we share with you, and one that is highly relevant across the care, treatment and prevention of HIV/AIDS.

That said, we know that for all the progress we’ve made, the struggle certainly isn’t over for people living with HIV/AIDS.

At HRSA, we know that there still places where people have to travel great distances to reach a skilled and knowledgeable Ryan White provider.  We know there are still practices that prefer not to accept HIV-positive patients.  And we know that many states in these hard economic times have cut back their public health services to an array of populations, including those living with HIV/AIDS – including drug assistance.

We know these circumstances exist because HRSA oversees the $2.3 billion Ryan White program – a program that operates in partnership with providers, communities and states – and at HRSA many of our programs touched those living with HIV and AIDS before the program was first authorized in 1990.

Ours is a long-standing commitment, and we have not come this far to stop now.  I want to say at the outset that serving people who are living with HIV/AIDS matters deeply to us at HRSA. Supporting this community is one of our statutory missions, yes.  But inside the agency it’s a mission so important that I’ve worked with my colleagues across most of HRSA’s seven bureaus to leverage nearly every programmatic arrow in our quiver to target facets of these issues.  And we’ve also worked in close consultation on HIV/AIDS with our peers at CMS, the CDC, the VA and SAMHSA – to name just a few.

As you heard the Secretary say in her remarks the other day, our aim is nothing less than “an AIDS-free generation.”

Under provisions of the Affordable Care Act, HRSA now has an even broader role, and an even bigger mandate.  So our work is strengthened, not only under the National HIV/AIDS Strategy, the first initiative of its kind, but also under the historic Affordable Care Act.

HRSA is responsible for 50 individual provisions in the new law that generally fall into three major categories:

• Expanding the primary care safety net for all Americans – especially those who are geographically isolated, economically disadvantaged or medically vulnerable – for example, through expansion of the Community Health Center program;
• Also, HRSA is responsible for helping to train the next generation of primary care professionals, while improving the diversity of the workforce and re-orienting it toward interdisciplinary, patient-centered care.  We do this through targeted support to students and clinicians and grants to colleges, universities and other training institutions;
• Finally, HRSA, working with its partner agencies, is expected to greatly expand prevention and public health efforts to catch patients’ problems early – before they require major intervention; to improve health outcomes and quality of life; and to help contain health care costs in the years ahead.

If these goals sound familiar, they should: these have been the aims of the Ryan White program since it was first conceived as a means of covering the enormous gaps in HIV/AIDS services in a badly broken health care system.  Now, thanks to the Affordable Care Act, we have a rare opportunity to achieve these goals on a larger scale.

As we move towards reauthorization of Ryan White in 2013, and full implementation of the ACA one year later, I want everyone to know that HRSA remains as committed as ever to identifying gaps in services and protecting vulnerable populations. And, as you have heard, this Administration fully supports reauthorization.

Mapping out how the Ryan White program aligns with the Affordable Care Act is one of our highest priorities.

I’ll return to this point in a moment and give you a sense of how HRSA is preparing for reauthorization.  But first, I think it’s important to note the progress we’ve already made under the insurance provisions of the new health care law:

As you heard the Secretary say, the new law already is proving that a better health care system is possible:

• Perhaps most significantly, the Affordable Care Act’s “Patients’ Bill of Rights” has ended many of the worst abuses of the insurance industry.  Lifetime caps on benefits are now banned; these caps often meant that people lost health coverage just when they needed it most – a practice that once had cruel consequences for people who were HIV-positive;
• Further, we’ve recently learned that more than 19 million Medicare beneficiaries have gotten at least one free preventive screening, thanks to the law; no-cost or low-cost health screenings will soon be a reality for everyone under the law.  This is an important provision because, as Dr. Cal Cohen noted, individuals with HIV/AIDS are aging out with what increasingly has become a chronic condition.
• What’s more, under the ACA kids can no longer be denied coverage because of pre-existing conditions.  By 2014, discrimination in coverage based on pre-existing conditions ends for all Americans – yet another harsh practice that punished people needing coverage the most, including those living with HIV; 

There’s more that could be said on these fronts. But suffice it to say that we’ve made a lot of progress in a year and a half – with especially important gains for groups of people who previously were discriminated against.

I’m sure I don’t need to tell anyone here that 88 percent of Ryan White clients have been either priced-out or locked-out of the conventional insurance market.  But that is about to change as a result of the ACA.

Of course, such large-scale improvement in access will require a larger, better-trained health care workforce.

Long underfunded, HRSA’s workforce training programs have received strong support from the Obama Administration, including millions of dollars in additional grant authorization to address disparities that have spanned decades.

For example, under the Recovery Act of 2009, HRSA received $500 million for health professions education programs to do the federal government’s part to energize the Nation’s struggling primary care workforce.

These funds already have supported more than 14,000 students, with an emphasis on retaining and expanding primary care faculty and boosting the participation of disadvantaged and minority candidates.

This is important because almost 3 out 4 people served by the Ryan White program are racial minorities, and we know from recent studies that patient outcomes generally improve when people are served by clinicians sensitive to their cultural and social backgrounds.

Recovery Act funds also went to expanding HRSA’s National Health Service Corps – which pays down the academic debt of students in certain health professions in exchange for their promise to practice in rural and underserved communities and populations.

The Recovery Act investment in the NHSC was bolstered by an additional $1.5 billion over 5 years from the Affordable Care Act.  When President Obama took office, the NHSC had only 3,600 providers in the field.  Now, thanks to those investments, the Corps has grown to more than 10,000 primary care clinicians.

While this is an improvement from your perspective and ours, what’s also important is that for those of you with tribal affiliations we have for the first time made tribal sites automatically eligible for NHSC clinicians.

And HRSA has stepped up the development of important training components for these new providers that cover such topics as Primary Care for HIV-Positive Patients and HIV Screening protocols.

From this Administration’s perspective, it’s not just about increasing the supply of primary care clinicians, but also the supply of clinicians with the necessary knowledge and skill set.

In addition to investing in the workforce, another significant HRSA-specific investment that Congress and President Obama made under the Affordable Care Act is its targeting of $11 billion over five years for the operation, expansion, and construction of the nation’s community health centers.

Since the beginning of 2009 alone, health centers have increased the number of patients served annually by 2.4 million people – while adding more than 18,600 new full-time positions to increase their workforce to almost 132,000 staffers nationwide. This support will enable our grantees to add many more patients by 2015.

At HRSA, we are well aware of the concern about how these expansions will affect people living with HIV/AIDS, generally, and those who depend on the Ryan White program in particular.

We share that concern, and it’s our charge as stewards of the program to ensure that the expansion of services envisioned by the ACA, the National HIV/AIDS Strategy and the Ryan White program are a set of efforts deployed as seamlessly as possible over the next few years.

Efforts are already underway across HRSA’s bureaus and offices, as they are throughout HHS and our companion federal agencies – including the VA, the CDC and the Department of Housing and Urban Development.

In concrete terms, here are a few examples of what we’re doing:

• The HIV/AIDS Bureau has three concurrent studies underway, looking at the HIV clinician workforce and staffing requirements, the critical problem of retention in treatment, and where gaps in services might still occur in an expanded primary care environment;
• Staying on this theme, HRSA’s Bureau of Health Professions is working in partnership with 11 major universities on developing teaching components for future clinicians on a host of issues, ranging from “HIV in elderly patients” and chronic disease management in vulnerable populations to on-site training for medical students in outreach centers for homeless people living with HIV;
• HRSA’s Bureau of Health Professions also is funding six major universities to develop curricula for schools of public health on such subjects as housing and retention-in-treatment, HIV surveillance, and state-level HIV prevention;
• Meanwhile, HRSA’s Bureau of Primary Health Care, which oversees the Nation’s 1,100 health center grantees, reports a 30 percent increase in the number of patients screened annually for HIV since 2008.  More than 780,000 patients were tested last year – 40 percent of them in the 12 jurisdictions hardest hit by the virus.  Health centers know that we expect them to increase delivery of routine HIV testing, as well as care and treatment.
• Of these 1,100 health centers, 160 are participating in the Part C program for Early Intervention Services in high-impact communities and 24 more are taking part in capacity-building programs through the new National Center For HIV Care in Minority Communities.  These health centers already are serving almost 1,800 HIV-positive patients without the benefit of Ryan White funding;
• Many community health centers, it should be noted, are members of the National Coalition for LGBT Health – and some actually began as LGBT clinics.  Of these members, I want to recognize The AIDS Foundation of Chicago and Philadelphia’s Mazzoni Center for joining a group of 129 organizations nationwide that received $10 million in planning grants this year to help them become health centers.
• HRSA has also awarded $248,000 to Boston’s Fenway Health to create a national LGBT technical assistance and training center for health centers and state primary care associations. That’s the first installment of a three-year grant that could total close to $850,000. This is the first time that HRSA has entered into a national cooperative agreement focusing on LGBT health, and it’s the largest HRSA grant ever awarded to target the health care needs of LGBT people.
• As a final example of investments driving change, we are also proposing to re-compete the entire Ryan White Part D Program to provide more effective, comprehensive health care services for women, children and youth living in areas of greatest need. This will not result in a reduction of the program.  The value of Part D is well recognized, as it has been instrumental in one of our greatest successes against this epidemic – which is the almost-unbelievable reduction in perinatal HIV transmission.

With that by way of background, I think we all would agree that – with 56,000 new diagnoses per year and almost 600,000 AIDS deaths to date in the U.S. – we should be promoting screening and retention at every opportunity, especially when we consider that one in five HIV-infected people are unaware of their status.

Heavily implicated in the problem of non-retention, of course, are behavioral health issues. Today, 75 percent of Part C grantees, 54 percent in Part D, and two-thirds of all health centers provide mental health counseling services.

Creating a high-quality system of care in which behavioral health professionals are on every primary care team and behavioral health needs are addressed in every treatment plan is another goal shared by both Ryan White and Health Center grantees.

This is another effort that cuts across HRSA’s various bureaus – and in conjunction with our partners at the federal, state and local level – that is furthered by the Affordable Care Act.

SAMHSA – the Substance Abuse and Mental Health Services Administration – and HRSA have entered into a cooperative agreement with the National Council for Community Behavioral HealthCare that is expected to run through 2014, focusing on further integrating behavioral health into primary care settings – including community-based, HIV/AIDS care providers.

Finally, I’m very happy to report that HRSA has had an increase in funding for the AIDS Drug Assistance Program. As the name indicates, ADAP funds provide access to life-saving medications for Ryan White patients.  Its funding level in FY 2011 is $885 million – that is, in fact, 38 percent of the entire Ryan White budget.  This is significant because in CY 2010, ADAP served 229,000 clients.

The increase of $50 million for FY 2011 allowed us to further improve access to ADAP drugs and help reduce the waiting list.  These funds continue efforts we began in August 2010, when we distributed $25 million in supplemental ADAP funds to states.

The new supplemental ADAP funds have been made available to all states. Of these funds, $10 million was distributed based on the number of people living with HIV/AIDS in a state.  The remaining $40 million was targeted to states with ADAP waiting lists, and to states with cost containment measures in place. 

As of Nov. 4, there are 6,476 people on the ADAP Waiting List. That’s 30 percent fewer than just 2 months ago. We know, however, that there is continued pressure on the ADAP program.

So in addition to the new funds, HRSA’s Ryan White program experts are working closely with states that have ADAP waiting lists to find the best way to ensure that people have access to the life-saving medications they need.

Looking forward, it is critically important that we deploy our resources to achieve improvements in adherence and retention if we are to meet the challenge of an “HIV-Free Generation.”

HRSA is in this fight with you, and we are in it to win it.

Thank you for inviting me to be here today – and for all that you do.