Remarks to the Nursing in 3D Summit

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by HRSA Administrator Mary K. Wakefield, PhD, RN

August 16, 2012
Bethesda, MD

Good morning and welcome to our Nursing Workforce Diversity program grantees – and to all others joining us, either here or virtually.

The focus of this meeting is an extremely important one for us at HRSA – not just for nursing, and not just for the Bureau of Health Professions. Frankly, it’s a critically important issue for HHS because the composition of the health care workforce is tied in important ways to the health and health care outcomes of communities across the country.

Most of you know that HRSA has long been a leading federal agency in the delivery of care to underserved populations. So this focus on reducing health disparities isn’t exactly a new one – but the way we’re approaching it in the Obama Administration is. We have a renewed commitment through an HHS-wide plan that focuses explicitly on health disparities because this is a high priority for Secretary Sebelius – and that focus comes at her direction.

Additionally, we have new tools and new opportunities as a direct result of the passage of the Affordable Care Act. The ACA has changed the trajectory of the country in terms of attacking health disparities and in building a health care workforce that reflects the America it serves. And that new trajectory has turbo-charged HRSA’s historic commitment to the underserved.

On its broadest scale, the ACA tackled a primary social determinant of poor health – lack of access to health care – by expanding eligibility for Medicaid, by expanding HRSA’s Community Health Centers, by investing in the National Health Service Corps, and by making it easier for tens of millions of individuals and small businesses to obtain and afford care.

And, of course, the ACA followed the President’s reauthorization of the Children’s Health Insurance Program, which extended access to care to millions of additional low-income children. If you recall, signing that legislation was one of the first actions President Obama took upon taking office in 2009.

In addition, First Lady Michelle Obama has taken up social determinants of health in her anti-obesity efforts by pushing for greater access to healthy food in distressed and minority communities.

While full implementation of the ACA won’t occur until 2014, we’re already seeing historic gains in access to care:

• More than 3 million young adults have gained health insurance coverage through the ACA provision that allows them to stay on their parents’ health plans until age 26.
• More than 100 million Americans no longer face lifetime dollar limits on health benefits. That change guarantees continuing access to care, often during health crises when people need it most.
• And the parents of more than 17 million children with pre-existing conditions like asthma or a heart defect no longer have to live in fear that their kids will be denied health insurance. The ACA has already banned insurance companies from denying coverage to those children, and in 2014 discrimination against all patients with pre-existing conditions, young or old, will be prohibited.
• For seniors, the law means greater access to pharmaceuticals. More than 5.2 million seniors and people with disabilities who’ve hit the prescription drug coverage gap known as the “donut hole” have saved almost $4 billion on prescription drugs since the law was enacted. And the law completely closes the donut hole coverage gap by 2020.
• For small businesses, the law offers sizable tax credits to help them buy coverage for their employees. In 2014, similar tax breaks will be made available to low-income individuals who don’t have employer-based insurance through state-based Affordable Insurance Exchanges.
• And, as of Aug. 1, 47 million women are getting greater control over their health care and access to eight new prevention-related health care services without paying more out of their own pocket. These new services include well-woman visits, domestic and interpersonal violence screening and counseling, and FDA-approved contraceptive methods.
  So, as you can see, eliminating barriers to accessing health care has been a core focus of the Administration’s work to date. To reflect this new trajectory, HRSA had to update its organizational mission, the one we post on our website. That new mission – to improve health and achieve health equity through access to quality services, a skilled health workforce and innovation – has four goals:
  • Improve access to quality health care and services;
  • Strengthen the health workforce;
  • Build healthy communities; and
  • Improve health equity.

Clearly, to achieve all four of these goals, one very high priority for us has to be to build a health workforce that is culturally and linguistically diverse and more representative of America. Greater diversity among health professionals is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better patient-clinician communication. For us, diversity is not an end in itself; it’s an evidence-based strategy to reduce health disparities. That’s how we see it.

And when we talk diversity, we mean it in the fullest, most inclusive way possible. Our definition goes beyond racial, ethnic and gender diversity to include geographic diversity, LGBT individuals, members of the disabled community, and more.

To give you an idea of the resources we bring to bear on these issues, let me give you a brief overview of what we do. HRSA has an $8.2 billion portfolio of 80 different grant programs, all of which have direct and indirect impacts on health disparities. Among the programs and activities we support are these:

• Our Maternal and Child Health block grants to states help 6 out of every 10 women who give birth and their infants. And our Healthy Start program fights high rates of infant mortality in more than 100 low-income, predominantly minority communities across the country, largely by working to overcome social determinants that negatively affect young mothers: poverty, lack of access to prenatal care, poor education, and poor nutrition. I was visiting one such site yesterday in Pittsburgh and learned first-hand about both these challenges and the new, innovative strategies that address them.
• Our Office of Rural Health Policy is actually the full Department of Health and Human Services’ main repository of expertise on rural health issues. The office works to bolster rural hospitals and coordinate health care among rural coalitions.
• HRSA also funds Poison Control Centers, the National Vaccine Injury Compensation Program, and federal organ procurement and donation systems.

These programs are part of our broad portfolio. However, I want to spend my remaining minutes talking about HRSA’s efforts to reduce disparities in health outcomes, increase minority participation in the health professions, and address social determinants of health, and these efforts have their largest scope in our Community Health Centers program, the Ryan White HIV/AIDS program, and our health professions workforce programs.

Let me start with health centers. Our health centers deliver primary and preventive care to more than 20 million patients annually at more than 8,500 service delivery sites around the country – that’s up by 3 million patients since President Obama took office.

The gains, of course, are the result of passage of the Affordable Care Act, which invests $11 billion in health centers over five years. That followed a $2 billion investment through the 2009 Recovery Act. Of those 20 million patients served last year, more than a quarter (25.2%) was African American and over a third (34.5%) was Hispanic. Another 3.4 percent was Asian and
1.5 percent was American Indian/Alaska Native.

With this large minority patient base, health centers are leaders in providing culturally competent care. Many grantees have multiple translators to deliver care in the native language of the patient. Language skills are pretty critical: one in four health center patients is best served in a language other than English. In 2011, nearly 40 percent of health center patients had no health insurance. It doesn’t get much more medically underserved than that.

From a nursing workforce perspective, right now there are about 16,000 nurses – including 4,300 advanced practice nurses – working at health centers across the U.S. Since the expansion began, health centers have added about 3,000 nursing positions, including 800 in advanced practice.

Health centers also are great places to educate students in the nursing, medical and behavioral health fields to provide community-based care to medically underserved populations. We know that health care professionals trained in health centers are more likely to work in a health center or in an underserved area than those not trained at health centers.

The second program I want to mention – another program that was expanded through the ACA – is the National Health Service Corps. This program is important for many reasons – not the least of which is that we’re making progress in expanding minority participation in the Corps.

To meet anticipated demand for primary care, the ACA dedicated $1.5 billion to build the ranks of the NHSC through 2015. And that followed a $300 million investment under the Recovery Act.

As a result of that investment, the Corps now has about 8,700 primary care professionals practicing in health centers and other medically underserved sites. That’s more than double the number in the field when President Obama took office. These clinicians represent a range of disciplines – advanced practice nurses, physicians and dentists, among a larger group. In exchange for their service, clinicians receive federal loan repayments along with a competitive salary.

Nationally, African Americans and Hispanics together represent 26 percent of the population but only about 10 percent of the nurse practitioner workforce.

In the NHSC, however, African Americans and Hispanics total more than 20 percent of the Corps’ 1,400 nurse practitioners: obviously, that’s double their percentage of the national nurse practitioner workforce! Of that 20 percent, 14 percent are African American, which is a tad above their percentage of the overall U.S. population. Just 6 percent are Hispanic, so we have room for improvement there.

And financially, the NHSC is a great deal. NHSC clinicians who work in the very neediest areas can qualify for up to $60,000 in annual loan repayments, and even those who practice in less needy areas get up to $40,000 in loan repayments. You can find out more about the benefits of joining the NHSC from the HRSA website at www.hrsa.gov.

And beyond health centers and the NHSC, the ACA affirms nurses’ vital role in delivering primary health care by investing in several nurse training and education programs that HRSA administers. In fact, HRSA has committed nearly $1.1 billion over the past almost four years to educate new nurses, improve the education of today’s nurses, and place nurses in areas of the country where they are needed most.

HRSA’s Nursing Education Loan Repayment Program, for example, has seen its budget more than double since 2009 to almost $94 million today. Under this program, RNs who work for two years in a facility with a critical nursing shortage can get 60 percent of their school debt paid off. We currently have ¬more than 2,300 nurse scholars and loan repayors working under this program nationwide.

And in response to Secretary Sebelius’ interest in strengthening our primary care workforce, HRSA has taken steps to ensure that more nurse practitioners take advantage of this loan repayment program. In December of last year we released guidance that reserved half of available 2012 funds to repay the loans of nurse practitioners. We want nurse practitioners in the workforce as quickly as possible, and this will help them go to school full-time.

And at the Center for Medicare and Medicaid Services, our sister agency at HHS, ACA dollars are being used to put more Advanced Practice Registered Nurses at the forefront of primary care. Under Graduate Nurse Education Demonstration grants announced just a couple of weeks ago, CMS will reimburse hospitals that train APRNs, using $200 million in ACA funds over four years. The demonstration is operated by CMS’ Innovation Center, which the ACA set up to test innovative payment and service delivery models that are structured to cut costs while enhancing care quality. Their work is definitely worth keeping a close eye on.

To keep up with all the many developments regarding the Affordable Care Act, I suggest you bookmark the site: www.healthcare.gov. It’s updated regularly and has the facts about the law.

Let me now move on to HRSA’s Ryan White HIV/AIDS program, whose grantees provide top-quality primary medical care, essential pharmaceuticals, and vital support services to more than 500,000 people living with HIV/AIDS – that’s about half the estimated total population in the U.S. living with the disease. In an effort to address some of the social inequities these patients face, Ryan White programs also provide wrap-around services, transportation, and child care while adult patients are being treated.

People living with HIV are, on average, poorer than the general population, and Ryan White HIV/AIDS Program clients are poorer still. For them, Ryan White is the payor of last resort because they have inadequate insurance, or none at all, and because no other source of payment for services, public or private, is available.

About 7 in 10 of the people treated every year through Ryan White-supported programs are minorities. About half of all patients are African American, with another 20 percent Hispanic.

HRSA has oriented our HIV/AIDS work to the goals of President Obama’s National HIV/AIDS Strategy, which he announced two years ago next month. The Strategy has three primary goals:

• Reducing the incidence of HIV;
• Increasing access to care and optimizing health outcomes; and – and here you hear the focus explicitly on disparities again – the third goal:
  • Reducing HIV-related health disparities.

On this last goal, HRSA is working with CDC on a five-year project to retain HIV-positive patients in medical care by testing interventions at a set of HIV clinics serving predominantly minority populations. Early findings have been positive, with overall improvements in continuity of care by patients.

At the full Department level, HHS is moving to implement the President’s National Strategy through its “12 Cities Project,” an effort to support comprehensive HIV/AIDS planning and cross-agency response in 12 big cities hit hard by HIV/AIDS. These 12 metro areas – from Atlanta to Washington, D.C. – have heavy minority populations and account for about 44 percent of the total estimated persons living with AIDS in the United States.

The 12 Cities demonstration concentrates HHS resources from CMS, HRSA and CDC on these areas, coordinates federal resources and actions across categorical program lines, and scales up effective HIV prevention and treatment strategies.

Now let me move on to HRSA’s other very specific efforts to expand the diversity of the health professions workforce, which is a topic in which all of our bureaus and offices are deeply engaged.

You all know that compared to whites, minority populations have less access to health care, receive lower-quality health care, and experience higher rates of chronic disease and mortality and poorer health outcomes. At HRSA, as I mentioned earlier, one key strategy we employ to reverse these trends is to increase the number of minority health professionals.

These are issues that some of HRSA’s health professions programs have addressed for many years. For example, our Nursing Workforce Diversity and Scholarships for Disadvantaged Students Programs are specifically designed to increase diversity among health professionals.

And as I mentioned at the beginning of my remarks, last year HHS Secretary Kathleen Sebelius launched a National Partnership for Action to End Health Disparities to improve nationwide coordination of strategies to eliminate health disparities and achieve health equity.

To give you just one example of what we’re doing differently to further the Secretary’s agenda to end disparities, we instituted a new policy: as of last year, applicants for almost all of our health professions grants must include in their proposals innovative strategies to develop and retain a diverse and culturally competent workforce. Applicants must describe plans to recruit, retain, and graduate students from underrepresented minority groups and students from educationally and economically disadvantaged backgrounds. And they must show that these plans are effective in reaching proposed goals.

Another important element in building a diverse and culturally competent workforce is the collection of reliable workforce data that illuminate the challenges and problems and track progress. After all, to identify and then disseminate the best methods to reduce health disparities, we need evidence on “what works.” So the ACA created the National Center for Health Workforce Analysis and housed it in HRSA.

Later this year or early in 2013, the National Center will release three studies that will help orient our work to increase minority participation in the health care workforce and reduce disparities in health outcomes.

• The first, tentatively titled “Diversity in the Health Professions 2012,” will include data on more than 30 health professions by race, ethnicity and gender for practitioners and new graduates.
• The second report is a state-by-state health workforce data base, including data on workforce diversity, something we’ve been working on for some time.
• Finally, the National Center will produce a series of reports that project workforce needs by occupation. First up is a report on physicians, nurse practitioners and physician assistants by clinical area. That will be followed by biennial projections for a wide range of professions beginning in late 2013.

Well, before I close, I’d like to discuss the growing recognition – codified in the ACA – that team-based health care represents an essential strategy for improving quality care, delivering patient-centered care, and keeping costs in check.

This recognition – while not always easy to execute – is, I think, an essential underpinning to move health and health care from where we are to where we need to go.

To show you how this orientation is resonating at high levels, it’s where HHS Secretary Sebelius sees us going, too. Last year she told the Senate Finance Committee, quote:

“Too often, health care takes place in a series of fragments or episodes. We need to make it possible for entirely new levels of seamlessness, coordination, and cooperation to emerge among the people and the entities that provide health care … over time and in different places.” [end quote]

To achieve the shift that the Secretary and many other public and private sector representatives talk about requires both health professional educators and clinical leaders working together across disciplines to create appropriate training and care models. And we need health care systems to embrace the changes needed to incorporate this orientation.

Earlier this year I spoke to a meeting on delivering quality care that invited health professionals from a broad array of disciplines. People at the meeting recognized that change really begins “upstream,” with new ways to educate the health workforce to deliver care that has quality and safety – and their requisite attributes of care coordination and team engagement – at its core. We need more of these cross-sector conversations. We need to make the boundaries between professions and between sectors more porous.

In an effort to do our part to reorient care delivery, HRSA has become deeply involved in efforts across the health care spectrum to push forward the concept of interprofessional education and team practice.

For example, late last month the application period closed on an $800,000 grant to create a new Coordinating Center for Interprofessional Education and Collaborative Practice. Once established, the new Center is designed to help advance the evolution of the health care delivery system to one that encourages collaborative, team-based practice informed by interprofessional education.

And, illustrative of our work and with other partners on this agency, HRSA and representatives of the Interprofessional Education Consortium in May of last year announced the creation of a set of interprofessional competencies that have been disseminated for use in health professions education and practice. We’ll soon be announcing more activity to drive this agenda forward.

That’s a relatively quick summary of just some of what we have underway at HRSA. Now, to get this agenda right, we need the best thinking from everyone and, to that end, I’m asking each of you for your active participation throughout this meeting.

You are about to hear from a number of accomplished speakers on the topics for which we have gathered. But they’re not the only experts we want to hear from. We want you to make this a participatory, interactive meeting.

So we’re asking you to provide real-time feedback on the content, the topics being discussed, and your own experiences with them. We encourage you to do that through Twitter at #nursing3d.

Division of Nursing staff will be monitoring the tweets and will pass them along to the moderators and presenters in real time to help guide and enhance the presentations and panels as they progress. For those of us who aren’t “tweeters,” we’re providing index cards at each table, and staff will collect them regularly.

One other thing: please tell your friends and colleagues back home that today’s and tomorrow’s sessions are available via online through our website at www.hrsa.gov for the first 500 people who sign up. And after the summit ends, the webinar will remain available there online.

Thank you for the invitation to be with you today, and thanks in advance for your full participation in this important dialogue.