Remarks to the Mongan Commonwealth Fund/Harvard University Fellowship in Minority Health Policy Leadership Forum

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by HRSA Administrator Mary K. Wakefield, PhD, RN

September 19, 2012
Boston, MA

It’s a pleasure to be here with all of you – to quote the Harvard Medical School Mission Statement: “the best people committed to leadership” in alleviating human suffering caused by disease. It’s a special honor to be here at the invitation of the founder of the fellowship, Dr. Joan Reede, who is so highly respected in government circles.

The Mongan Commonwealth Fund Fellowship in Minority Health Policy at Harvard is a program that lives up to its name and mission.

I know this because we have hired five of your alums of the Fellowship in recent years, and they have served with distinction during one of the most exciting times in the history of my agency – the Health Resources and Services Administration, also known as HRSA – as we lead or partner in the implementation of 63 provisions of the Affordable Care Act.

If you’re intrigued by what you hear, perhaps more of you will consider joining us in federal service.

For those of you not too familiar with HRSA, let me provide you with a brief overview. The mission of this operating division of HHS is to improve health and achieve health equity through access to quality services, a skilled health workforce and innovative programs.

Against that backdrop, as Dr. Reede indicated, HRSA provides access to high-quality, primary health care for people living in poverty; for geographically isolate communities where health care is scarce; and for those who are medically vulnerable due to serious health problems, such HIV/AIDS or the need for organ transplants.

Our mission statement has four goals:

• Improve access to quality health care and services;
• Strengthen the health workforce;
• Build healthy communities; and
• Improve health equity.

When we talk about that last goal – improving health equity -- we use the fullest, most inclusive definition. At HRSA, it goes beyond racial, ethnic and gender diversity to include geographic diversity, LGBT individuals, members of the disabled community, and more.

It’s worth pointing out that under President Obama, these issues, of course, have gotten more attention than they did in the past. In fact, last year HHS Secretary Kathleen Sebelius launched a National Partnership for Action to End Health Disparities and improve nationwide coordination of strategies to eliminate health disparities and achieve health equity.

So at HRSA, we administer a budget of $8.2 billion; those funds allow us to operate 80 different programs. These programs provide grants to 3,000 partners in state and local agencies, non-profit organizations, hospitals, clinics, colleges and universities, and more.

We are perhaps most widely known for our support and oversight of the Community Health Center Network; the National Health Service Corps; Maternal and Child Health; the Ryan White HIV/AIDS program; and our health professions programs. I’ll talk more about these programs in the context of the Affordable Care Act and health equities strategies in a few minutes. And we also do far more, especially in rural health and organ donation.

Our Office of Rural Health Policy plays a unique role. It serves as the Department’s chief voice on rural health issues and is charged with advising the Secretary on rural health policy. The Office also runs a number of State and community-based grant and technical assistance programs to help HHS better meet the health care needs of rural communities.

We also fund Poison Control Centers, the National Vaccine Injury Compensation Program, and federal organ procurement and donation systems. There are more than 100,000 people on waiting lists for organs, and 18 die waiting each day. U.S. minority groups have a disproportionately higher need for organ donation – with higher rates of kidney disease, for example – and HRSA has for many years funded education and outreach campaigns to increase donation in minority communities. Those efforts continue, in diverse communities and in many languages. But we have a lot of work in this area yet to do.

As I said a moment ago, HRSA is very involved in implementing the Affordable Care Act and the law’s impact on health disparities and equitable health outcomes. Frankly, these challenges around equity have been with us for a long time – a lot of them since the birth of this nation.

Fast forward to 1985, when the HHS Secretary’s Task Force on Black and Minority Health issued a seminal report on health disparities, known as the Heckler Report. It highlighted “the stark reality of the continuing, significant differences between the health of racial and ethnic minorities in the United States and the general population,” calling them “an affront both to our ideals and to the ongoing genius of American medicine.”

In that single statement, you hear a plea to the Harvard Medical Schools of the world to step up and help address this signal challenge.

A few years later, in 1991, the Institute of Medicine issued an equally alarming report on the quality of care delivered by our country’s health care system. Among the core areas in need of major improvement was equity – a call for health care that “does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”

And yet, more than a decade later we have yet to make significant headway in closing the “equity gap.” The challenge that these disparities pose persists.

As you know, racial and ethnic minorities are less likely to get the preventive services they need to stay healthy; less likely to have access to the care that they need when they are sick; and when they do get sick, too often they are more likely to receive poorer quality of care.

They are also more likely to suffer from chronic disease. And minorities represent more than half of the uninsured, even though they make up only one-third of the population in the U.S. Health disparities represent an American issue – and one with deep social consequences.

As Secretary Kathleen Sebelius has summed it up: “When one community suffers disproportionately, we all pay a price. And we all need to act.”

When we reflect on expert reports and opinions like the brief samples I’ve just cited – and when we listen to input from stakeholders across the country, and the experiences of communities most impacted – we get a bit of an understanding of the complex mix of factors that contribute to health disparities. But even with all the accompanying complexities, the ACA affords us new tools to tackle some of them head-on.

• For example, accessing preventive services, such as cancer screenings or vaccinations, has notably been a challenge due to the cost associated with those services, such as co-pays and deductibles. As a result of the new health care law, those recommended preventive services are provided at no cost. And now an additional 54 million Americans with private insurance, including more than 14 million racial and ethnic minorities, now have access to preventive services that come unaccompanied by out-of-pocket costs.
• The law also protects minorities and other Americans who were previously denied coverage because of pre-existing conditions, such as asthma or diabetes. It’s now illegal for insurance companies to deny coverage to children because of a pre-existing condition. And in 2014, discriminating against anyone with a pre-existing condition is banned. Low-income families from racial and ethnic minorities are often most adversely impacted by insurance practices like these.
• Just the lack of health insurance can be a significant driver of disparities. Clearly, the Insurance Exchanges that will be implemented in 2014 will increase access to health coverage.
• Young adults are also an important target population of the ACA as they often have high rates of un-insurance. Because of the health care law, 2.5 million more young adults – including 1.3 million minorities – now have access to health insurance because the new law allows many young adults to stay on their parents’ insurance until the age of 26. Proportionately, the biggest increase in access to insurance among young adults has occurred among minorities.
• In addition, the law improves the infrastructure of our health care system to better address health disparities. It created six new offices of minority health in other agencies of HHS (AHRQ, CDC, CMS, FDA, HRSA, SAMHSA), and elevated the National Center on Minority Health and Health Disparities to a full-fledged institute.

With that by way of background, let me turn specifically to HRSA’s role in bringing these and other ACA mandates into being, and transforming policy in practice.

One of HRSA’s key responsibilities is its oversight of the Community Health Center system. How many of you have heard of CHCs? They’re a key part of the safety net infrastructure, providing significant amounts of care to minority populations.

Our health centers annually deliver primary and preventive care to more than 20 million patients regardless of their ability to pay. That’s an increase of 3 million people since President Obama took office.

Health center services are now delivered at more than 8,500 clinical sites around the country, regardless of patients’ ability to pay. By law, they must provide care to anyone seeking it – and, in exchange, they benefit from special reimbursement formulas and grant funds.

The health care law provides $11 billion to strengthen and expand HRSA-supported community health centers over the next five years. These funds follow on the heels of a $2 billion investment through the 2009 Recovery Act. Such a large funding increase is unprecedented in the history of the program.

Not only have new community health centers already been built, but services provided at existing community health centers – such as behavioral health, oral health, and pharmacy services – have been improved and extended. As we continue to move toward the kind of interdisciplinary, patient-centered care envisioned and enabled by the new law, health centers already are broadly adopting the patient-centered medical home model of care.

These investments in community health centers are vital to reducing disparities because, in fact, more than half of their patients are minorities. This is a very substantial expansion of frontline resources. Of those 20 million health center patients:

• More than a quarter (25.2%) are African American and over a third (34.5%) are Hispanic;
• Another 4.6 percent are Asian, Native Hawaiian or Pacific Islander; and 1.5% are American Indian/Alaska Native.

Not everyone is aware of this, but rolled into the ACA and specific to American Indian and Alaska Native populations, the Affordable Care Act permanently reauthorizes the Indian Health Care Improvement Act, which authorizes Congress to fund services through the Indian Health Service.

The ACA also authorizes new IHS programs to improve the health of all American Indians and Alaska Natives; clears the way for HRSA to work with IHS clinics and facilities to qualify for National Health Service Corps practitioners; and includes tribes and territories in the new $1.5 billion Home Visiting program for pregnant women, their children and families living in at-risk communities. There is a severe need for these services across many tribes.

So the Indian Health Service is here to stay. And as a result of the ACA, tribal members will have more choices – including all the benefits of the new insurance protections, State Exchanges, Medicaid, and a stronger Medicare. The Act has the potential to benefit all American Indians and Alaska Natives for a lot of reasons, not the least of which is that better health insurance coverage means improved and more consistent reimbursements to Indian health facilities.

As for community health centers more generally, with their large minority patient bases, they are often leaders in providing culturally competent care. Many grantees have multiple translators to deliver care in the native language of the patient. These language skills are often critical because one in four health center patients are best served in a language other than English.

Health centers are also ideal venues for training medical and nursing school students, and students in behavioral and mental health disciplines. Again, the Affordable Care Act greatly expands these community-based learning components.

We strongly believe that community-based learning opportunities provide important exposure to the patient circumstances and medical conditions – often chronic – that many nurses, physicians, public health providers and others will face in their daily practice after they complete their training.

Moreover, not lost on us are research findings which show that medical residents, for example, who received training in community health centers – places which often provide health care for our nation’s vulnerable, underserved populations – are more likely to practice in these important care delivery settings after their training ends.

Where are these CHCs? Well, within two miles of where we are right now are 31 HRSA-supported health center locations. Of these sites, at least three serve predominately Hispanic neighborhoods; nine focus on women, children and families in crisis; two serve the homeless; and one – the Fenway Institute – acts as HRSA’s National Training and Technical Assistance Center on health care for Lesbian, Gay, Bisexual and Transgender people.

I mention this simply to note that expanding capacity to provide care and incorporate training opportunities is happening everywhere now in the Community Health Center system, spurred on by the Affordable Care Act provisions that help us to directly address key contributors to health disparities.

Not only does the ACA push out the boundaries of the patient-care infrastructure, it also provides new resources to boost the number of doctors, nurses, and other health care providers in underserved communities and enhance the diversity of the workforce through investments in programs such as the National Health Service Corps.

Research findings suggest that minority health professionals are more inclined to practice in areas with a high proportion of uninsured and underrepresented racial and ethnic groups – and greater diversity among health professionals is also associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better patient-clinician communication.

Strengthening the participation of minorities in health professions careers has been a focus for some of HRSA’s health professions programs for many years. For example, our Nursing Workforce Diversity, Scholarships for Disadvantaged Students, and Centers of Excellence programs are specifically designed to increase diversity among health professionals.

To further the Secretary’s plan to promote diversity in the professions, HRSA last year adjusted to a new grant policy: applicants for almost all of our health professions grants must include in their proposals new, innovative strategies to develop and/or retain a diverse and culturally competent workforce.

Potential applicants now need to 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.

In the National Health Service Corps in particular, our determined efforts to encourage diversity are trending favorably. We’re making some nice progress in expanding minority participation. Let me give you an example.

Right now, the Corps has about 9,000 primary care professionals practicing in medically underserved areas, in exchange for academic loan-repayments from HRSA. That’s more than double the number in the field when President Obama took office.

That increase results from the Affordable Care Act’s investment of $1.5 billion to build up the Corps through 2015. And that followed a $300 million outlay for the Corps in the Recovery Act.

NHSC clinicians represent a range of disciplines – advanced practice nurses, physicians and dentists, among a larger group. And they reflect America.

For example, across the nation, African Americans and Hispanics are only about 11 percent of the physician workforce, even while they’re 26 percent of the U.S. population.

In the NHSC, however, African Americans and Hispanics total more than 27 percent of the Corps’ 2,150 physicians. So for physicians in the NHSC, African American and Hispanic representation is about equal to their percentage of the U.S. population – and more than double their percentage of the national physician workforce.

As the diversity of the Corps increases, so does their training to provide care to diverse populations.

And within the NHSC, we’re using ACA resources for our clinicians, focusing on developing cultural competency, knowledge and skills in various settings that clinicians can access any time.

Additionally, the NHSC has partnered with the National LGBT Cancer Network and the Network for LGBT Health Equity to improve access to healthcare for LGBT individuals, and to help reduce health disparities related to sexual orientation and gender identification.

Financially, the NHSC is a great deal. In exchange for their service, clinicians receive loan repayments that can reach as high as $60,000 a year for those working in the neediest areas.

Switching to another front, it’s a serious concern that the United States still suffers from a notable infant mortality rate, particularly in terms of disparities and across populations. For example, an African American woman is nearly three times as likely to die from childbirth as a non-Hispanic White woman, and an African American baby is still more than twice as likely to die within the first year of life as a non-Hispanic White baby.

Broadly, HRSA’s Maternal and Child Health block grants to states touch 6 out of every 10 women who give birth and their infants each year.

With respect to closing the maternal mortality gap, they know – and I know – that we need to do a number of things, including improving women's health before pregnancy for all women, and improving the quality and safety of maternal healthcare for all women.

So here, too, for us the game-changer for maternal health, especially for minority communities, is the Affordable Care Act.

Beginning in August with implementation of clinical preventive services for women, millions of women are gaining access to health care without co-pays even when they are not pregnant, including preconception and interconception care. That provides an extraordinary opportunity to improve women’s health not only during pregnancy, but before, between, and beyond pregnancy and across their life course.

We've also begun the process of transforming the Healthy Start program, which concentrates resources and outreach on about 100 low-income neighborhoods with high levels of infant mortality. We’re taking a place-based, systems approach to addressing both clinical factors and social determinants that underlie much of the persistent and wholly unacceptable gap in infant mortality across races and ethnicities in our nation.

For many years, HRSA and the CDC have led a movement to improve preconception health and health care, and the Office of Minority Health has led a campaign to promote women’s preconception health through peer education in predominantly communities of color. But our Maternal and Child Health Bureau is planning, in partnership with other public and private partners, to launch a major initiative around maternal quality and safety next year.

Let me now move on to the Ryan White HIV/AIDS program, another HRSA program with a major impact on minority populations.

Ryan White 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.

People living with HIV are, on average, poorer than the general population; and Ryan White HIV/AIDS Program clients are poorer still. For them, the Ryan White program is the payor of last resort because they are uninsured or have inadequate insurance and cannot cover the costs of care on their own -- and because no other source of payment for services, public or private, is available.

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

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

• Reducing the incidence of HIV;
• Increasing access to care and optimizing health outcomes; and
• 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 six HIV clinics serving predominantly minority patients. Early findings have been positive, with overall improvements in clinic attendance by patients.

Keeping people in treatment is absolutely essential – particularly in terms of new or re-engaging patients, and younger patients – and those with higher viral loads had larger relative improvements.

Without the Ryan White program and its value as the payor of last resort, the disparities in HIV/AIDS would be far worse, since African Americans make up nearly half of all new infections. And in July, Secretary Sebelius announced an infusion of $80 million in additional Ryan White program funds to increase access to care by low-income people living with HIV/AIDS. The funds will eliminate state-based lists of people waiting to receive life-saving HIV/AIDS health care and medications.

Now, if we dive deeper for just a moment, the ACA also is sparking a transformation in patient care by changing incentives to reward providers for improving quality and outcomes.

For example, a total of 154 health organizations serving 2.4 million Americans have already signed up under the law to form Accountable Care Organizations, in which providers share in the savings when their patients stay healthy – a huge first step.

And the ACA-supported Partnership for Patients shows that it is possible to unite a nationwide alliance behind a common set of goals. In this case, reducing preventable injuries in hospitals by 40 percent, and cutting hospital readmissions by 20 percent.

More than 3,700 hospitals have signed up, which I think tells us something about the pent-up demand for change. When you suddenly have everyone on the same team, they can stop looking for slow, incremental adjustments to existing practices and start building a culture of rapid innovation and continuous improvement.

And here’s where HRSA’s workforce programs come in. All along the career ladder continuum – from support for recruiting and training frontline workers, such as home health aides, who provide care to patients and families in the community; to support for nursing students, physician faculty, and physician residents; to support for continuing education to ensure that our workforce maintains its skills in a changing health care environment.

Just this month, Secretary Sebelius announced the Obama administration’s latest commitment to training the next generation of America’s health care teams: a continuing HRSA grant to the University of Minnesota Academic Health Center to be the site of a new Coordinating Center for Interprofessional Education and Collaborative Practice.

As all of you know, interprofessional education means simply learning together with the aim of delivering high-quality care together. Rather than training the next generation workforce in their own health profession silos, we can provide a more meaningful and practical education for students – no matter what health profession they’re studying – by giving them the opportunity to study and work together.

Now, as you might expect, the partnership between HRSA and Harvard extends back several decades. Harvard is one of the oldest, continuously-funded grantees for HRSA in the history of our agency.

We’re proud to count Harvard as a partner in our goal of building a high-performance health care system that fights longstanding health disparities and promotes health equity.

Let me conclude by saying that it has been a wonderful opportunity to be here. It is incredibly important work you are doing now, and there is so much that all of us can do together in the days to come.

Thank you for inviting me here today.