Remarks to the National Rural Health Association

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by HRSA Administrator Mary K. Wakefield

February 4, 2013
Washington, D.C.

Good morning.  Thank you for the invitation to be here this morning.  I am delighted to have the opportunity to talk with you about rural health issues and the related directions that we’re pursuing.  In addition to talking about the issues, I also want to mention some of the people engaging on rural health issues – the point being that, from my vantage point, we’ll continue to place significant attention on rural issues.

At HHS, we begin the second term under President Obama with the same great leadership team, people who know and understand rural health issues first-hand because they’ve worked in rural states.  Secretary Sebelius, of course, was Governor of Kansas before coming to Washington, and Deputy Secretary Bill Corr began his career working in community health centers in rural eastern Tennessee.

Additionally, over the past year or so, we have more people who have become directly involved in rural health issues and, of course, we have our great ORHP team – a number of whom are here today.  Please introduce yourselves to them and tell them what’s on your mind.

So, as I look forward to the next four years, I think that we have created the right partnerships with HHS leadership on rural issues, and we can continue to focus on improving access to high-quality health care in rural communities. 

Going forward, the key to much of this focus is of course the ACA.  Since 2010, we’ve all been working hard to implement the Affordable Care Act, perhaps most notably by increasing access to affordable prescription drugs for seniors; by providing coverage to millions of previously uninsured young Americans; and by eliminating life-time coverage limits that affected almost 16 million rural Americans. 

As we continue to implement key phases of the ACA through 2014, more changes will benefit rural communities through provisions that address payments to health care providers and by expanding coverage that will improve access to health care services in rural areas. 

And across HHS we look forward to working with you and others to help get the word out back home about the new opportunities afforded through the creation of the state-based Health Insurance Marketplaces later this year.  Ensuring that people living in rural communities are aware of coverage options is absolutely critical because, as we know, rural residents are more likely to be uninsured than their urban counterparts.

The source of information that you can use for your own family and others is a specific website, and it’s very best place to learn about the Marketplace and other coming benefits is the website www.healthcare.gov. 

There, rural Americans will be able to get comprehensive information about insurance benefits and quality, side by side with facts about price, in order to help them make the best coverage decision.

They’ll also be able to learn, with a single application, whether they qualify for a free or low-cost health insurance plan, or a new kind of tax credit that lowers their monthly premiums.  And because the law outlaws discrimination against pre-existing conditions, nobody will be turned away because of their health status.

I encourage you to go there often to learn more about upcoming changes.  And please link it, email it, put it in newsletters, recommend it as an information source to your patients, friends, and family members. 

When I was back home in North Dakota a few months ago, a friend was really concerned about the affordability of her health insurance policy.  I popped in her zip code and found a number of options with a range of prices and coverage, incredibly easy to compare.

So to help people in your rural communities, we really do need you to help spread the word.  It could be in a letter to the editor of the local newspaper, an announcement in a church bulletin, on the radio or in a Rotary club meeting.  We all have a role to play in ensuring that all Americans get the coverage and care they need.

Let me shift your attention to other aspects of the ACA.  Clearly, health insurance will be more affordable for many families, thanks to new rules that make it easier to get help managing costs for people who need assistance.  Different financial assistance programs will be directly linked in the Marketplace, including Medicaid and the Children’s Health Insurance Program, as well as tax credits that can help pay private health plan premiums in advance.

All of this is particularly relevant for rural communities, where nearly a third of employment is generated by small businesses, and where finding affordable health insurance for employees can be a challenge.  In fact, rural areas have historically suffered from high rates of un-insurance and some of the highest per-family premium costs in the nation.  

The ACA provides special relief for small businesses, offering tax credits to help small business owners afford coverage for their employees.  It’s been estimated that nearly half of all workers living in remote communities are employed by small firms that qualify for these tax credits.

And for the hospital and clinic administrators and primary care providers here today, this helps to level the playing field for you, too.  As someone who grew up in a rural community, I know that you don’t turn folks away when they need health care, regardless of whether they have insurance.  That orientation, of course, goes with being a good neighbor and serving as the safety net in your community.  But that generosity has meant that traditionally, you’ve taken a financial hit by doing so. 

But now – whether you’re a hospital or a clinic – you’re going to see more insured patients come through the door, and Critical Access Hospitals that were not eligible for Disproportionate Share Hospital payments will be able to reduce their levels of uncompensated care.

Also going forward, we know it’s going to be important for all key rural health safety net providers – Rural Health Clinics, Critical Access Hospitals, Sole Community Hospitals, Medicare Dependent Hospitals and others – to establish contracts with the Qualified Health Plans that will be offered through the Marketplace.  It will be important to talk to the plans and state insurance officials to help educate them about the important role that you play.

Well, in addition to focusing on coverage issues, the ACA is also assisting us in addressing workforce issues.  In fact, I don’t think you can really talk about increasing access to services without also looking at our health professions workforce. 

At HRSA we’re working to grow the health care workforce both by leveraging our current programs and by focusing on where emerging workforce needs are. Over the past year and-a-half, we’ve ramped up our analytical capacity through the work of the National Center for Healthcare Workforce Analysis, which was authorized by the ACA and is housed within HRSA.  

The Center has been given the task of improving our ability to identify current and future priority health workforce needs.  In addition to improving data collection and analysis, the Center is responsible for projecting national health workforce supply and demand and disseminating data and information to help inform decision-making at all levels of government. 

Working with ORHP, the Center is incorporating analysis of rural issues within many of its projects, particularly on topics that have important implications for health workforce planning.  The Center will release several reports in the coming year that should be relevant to you and your work.

We’re also working on a large data project that will provide a comprehensive resource on the supply, distribution, education, and practice characteristics for over 30 health professions. Of special interest to all of you will be an accompanying database that will include state-level data on these occupations.

Another important initiative of the National Center that some of you already know about is the building of a Minimum Data Set on the health care workforce that is driving toward comparability across states in terms of the workforce data they collect.

We don’t currently have an MDS; instead, what we do have is significant variability across states and professions regarding data collection.  So it’s really hard to roll up information across states, conduct comparisons, and so on.  An MDS is something we badly need, since accurate, comparable data is critical to inform state and federal policymakers.  

So the Center is working with existing efforts, especially those of state licensure boards, to build the MDS to give us information over a wide range of professions about what practitioners do  – such as patient care, research or specialty – how many hours a  week they work, where they practice, and in what type of setting.

Another major component of our health workforce efforts that is ACA-related and of special importance to rural areas is the National Health Service Corps, which has long been a lifeline for some rural communities.  As a result of ACA and Recovery Act investments, the number of NHSC clinicians is at an all-time high – rising from 3,600 in 2008 to almost 10,000 in 2012.

Nearly half of our NHSC clinicians are serving at rural sites.  That includes some 900 physicians, 700 nurse practitioners, 600 physician assistants, 500 dental professionals, and 1,200 mental and behavioral health professionals.

Among rural NHSC providers, studies have repeatedly found that half or more continue to live and work in non-metropolitan counties several years after they leave the Corps.  In fact, a study funded by HRSA and released this past summer found that NHSC clinicians tended to serve for an average of more than 8 years in the same clinical facilities.  I’ll say a bit more about rural workforce in a minute.

Right now, I want to shift your focus to the part of HRSA you know very well.  Obviously I couldn’t talk about rural health care without looking at the contribution of HRSA’s Office of Rural Health Policy – which by the way celebrated its 25^th anniversary last November. 

Under Tom Morris’ leadership, ORHP has been unbelievably engaged in looking for new ways to leverage existing programs to meet ongoing and emerging needs, even while incorporating policy and programmatic changes enacted through legislation. 

This orientation is embodied in the ongoing work of the Improving Rural Health Care Initiative, which has been in each of the President’s budget requests over the past four years.  Through this effort, the Administration charged ORHP with focusing on four key areas:

1. Moving toward a more evidence-based approach in rural programs;
2. Improving recruitment and retention of workforce in rural communities;
3. Linking HRSA’s telehealth programs to ongoing work with rural communities; and
4. Collaborating with other partners in HRSA, HHS and across the federal government

I’ll say a word about some of what we are undertaking in each of these four areas.

First, building an evidence base for rural health care quality.  Acting on this charge, ORHP, through the work of Nisha Patel and her team, have transformed our community-based programs in terms of building an evidence base for improved quality.  You can see it in the Rural Health Outreach, Network and Quality programs, with a new emphasis on metrics and outcomes while building on successful models. 

You can also see it in the work the Office does with rural hospitals, led by Kristi Martinsen and the Hospital-State Division of ORHP.  Through the combined emphasis on the Flex program and the Medicare Beneficiary Quality Improvement program, 1,074 of the 1,329 critical access hospitals have voluntarily committed to report quality data and engage in the kind of benchmarking that improves patient outcomes.

To help drive this quality-focused work forward with ORHP, Paul Moore is spending part of each week at the Department with the Partnership for Patients initiative, and with a new rural workgroup in the Innovation Center at CMS.  We reached out to CMS early on, just as the Partnership was being launched, and Paul has worked hard to keep rural front and center with our colleagues on this important national initiative. 

Second, in terms of recruitment and retention:  I’m also really pleased with ORHP’s work with the NRHA and other partners to increase recruitment and retention of the primary care workforce in rural areas.  One clear success story is the rural training tracks, or RTTs. 

As some of you know, we started a pilot program three years ago to support the existing 23 rural training tracks, while at the same time encouraging communities to start new RTTs and increase student interest in medical residencies in rural settings. 

So far, the results have been encouraging.  We have 10 new programs in the pipeline thanks to the work of ORHP’s Dan Mareck and the folks at NRHA, including Amy Elizondo, Randy Longenecker and Dave Schmidt.  We’ve also seen an uptick in the number of students matching to these residency slots.  

And new RTTs can qualify for Medicare GME support through an exception to the residency cap.  This is very important because we know that this model works.  Roughly 70 percent of RTT graduates choose to practice in rural communities.  We’ve seen enough promise with that activity that we’re planning to fund a second cycle of grants with this focus.

There also continues to be great interest in other scholarship and loan programs.  Many of you know about the two loan repayment and scholarship programs for nurses who work in health centers, rural health clinics, hospitals and other facilities experiencing a critical shortage of nurses. 

These were the Nursing Education Loan Repayment Program and the Nurse Scholarship Program.  They’ve now been bundled together into the NURSE Corps program, through which we offer loan repayment and scholarships to more than 2,900 nurses providing high-quality care to underserved communities at facilities nationwide, including CAHs and rural health clinics.

Later today, you’ll hear from USDA Secretary – and Chair of the White House Rural Council – Tom Vilsack about some of the changes we’ve made to the NHSC program, specifically for CAHs.

We’re also pleased that HRSA’s Teaching Health Center program – stood up and funded through the ACA – includes a number of rural sites; in fact, 15 of the 22 new Centers are serving rural communities. 

This ACA-funded program is at the cutting edge of physician resident training, shifting the focus out of hospitals and into community settings, where we’re able to make investments in the next generation of safety-net physicians who will focus on community-oriented primary care.  Currently, the program supports 137 new primary care medical residents.

The third focus of the President’s Improving Rural Health Care Initiative is telehealth.  We’ve also responded to the Administration’s charge to enhance our telehealth efforts. 

Under the leadership of Sherilyn Pruitt, we’ve strengthened a national network of telehealth resource centers to help rural communities that want to get started in leveraging telehealth technology or to help existing programs enhance what they’re doing. 

Related to this, we funded a planning meeting with the Institute of Medicine this past summer that looked at the role of telehealth in an evolving health care system.  It’s been more than 10 years since the IOM focused on telehealth, so the time was right to revisit its role in health care delivery.    

The summary report from that meeting, which is on the IOM website, reinforces what we know: that the next challenge will be to show how telehealth can drive improved health outcomes, as it becomes just one of a number of tools practitioners have in diagnosing and treating their patients.

And finally, the fourth component of the Administration’s charge to the Improving Rural Health Care Initiative is collaboration.  As you know by now, collaboration is threaded through the way business is typically done in rural America, and similarly has always been an essential element of the Office of Rural Health Policy.

In addition to the folks I have already mentioned, Sahi Rafiullah has led our efforts to collaborate with ONC and USDA on HIT issues.  Heather Dimeris leads our border health efforts across HRSA and with the U.S.-Mexico Border Health Commission.

We’ve also had a great partnership with CMS on regulatory issues, where we’re led by Michelle Goodman and the rest of the Office’s policy staff.  They do the hard and unbelievably important work of reading through all those regulations with an eye toward how they might affect rural communities.

Perhaps the best example of our ongoing collaboration is through the White House Rural Council.  The Council has created a forum for HRSA and HHS to engage all of their federal partners and develop some new relationships.  Tom Morris and the Secretary’s Deputy Chief of Staff, Dawn O’Connell, who I mentioned at the beginning of my remarks, are the HHS representatives on the Council. 

They, with the help of your next speaker, Doug McKalip, have championed the important role of health care in rural America.  Doug has been a lead for the White House’s Domestic Policy Council, which, along with USDA and the National Economic Council, are the driving forces behind the White House Rural Council, assisting the chair, Secretary Vilsack.

Doug has made sure health care has been a key part of the Council’s work and has been extremely supportive of the policy proposals that HHS has put forth.  He quickly saw the role health care could play to expand jobs and economic development, recognizing the interdependency between the health of rural communities and the health of rural economies.  He’s really encouraged and promoted the health-related policy ideas we have put forward.

This afternoon at 3:30, you’ll be able to listen in on a National Stakeholder Call hosted by Secretary Sebelius and Secretary Vilsack discussing a number of new regulatory changes developed by HHS to ease the burden on rural health care providers. 

So I would just like to close by thanking Doug for his support and take this opportunity to really salute the White House for its work in support of rural America.  Part of the good news is, we don’t have to go looking for individuals in the Federal government with commitment to health care for rural Americans.  They’re here.  And thanks to all of you for being our partners in this very important work.