U.S. Department of Health & Human Services
Health Resources and Services Administration
HRSA Press Office: (301) 443-3376
by HRSA Administrator Mary K. Wakefield
May 10, 2013
Good morning. Thank you for the invitation to be with you. As a nurse, it’s especially nice to be able to talk with fellow health care providers and leaders in health care. And from an agency perspective, I think it’s important for us to be able to engage with health care stakeholders like you, especially at a moment as important as this one is to health care in America.
The Affordable Care Act is bringing new and much needed approaches to help strengthen primary care and public health and to leverage health through attention to both areas.
As you know, we’re really at an historic time in health care. The stakes are high, because there are – for the first time – sweeping opportunities to make substantive and positive contributions to improve health care and health outcomes.
In fact, across my 25 years of health policy work and over 35 years of being a nurse, I don’t know of any public policy that has the potential to have such a profound – and frankly long-overdue – impact on the nation’s health. In terms of executing new strategies to strengthen health care, a new set of opportunities opened up in March 2010 when President Obama signed the ACA.
Before I get into specifics about the Affordable Care Act from HRSA’s perspective, let me say just a word about two landmark reports by the Institute of Medicine. These reports are relevant to nursing practice and to primary health and are important to consider in the context of the ACA. And I understand you have received some background information on them.
The first is the 2010 IOM-Robert Wood Johnson Foundation report on The Future of Nursing, which put down an important marker that envisions nurses as key leaders in building better health care in America. Its focus on markedly strengthening health care is of course also a focus of the ACA, and this aim is critically important because – as we all know – while we have many strengths across health care in this country, we also have a challenges that we’re working to address.
So it is not surprising that the IOM report recommends that nurses bring their knowledge and skills fully into the clinical arena, from delivery care, to leading health systems changes, to advancing the public’s health.
In fact, the thrust of the IOM report – having nurse leaders at all levels and all sectors of health and health care, from academia to community health to public policy and elsewhere, is very important, in no small part because we need to leverage the assets of all parts of health care and all health care disciplines. And as part of all that, nurses have been and need to be even more robust and full partners with others in redesigning health care in the United States.
In its report, the IOM also noted that health care delivery is shifting from a model dominated by acute care to one focused on primary care, prevention, and care coordination. This work requires not just adequate numbers of nurses, but also a nursing workforce that has the competencies and skills to function within new approaches to health and health care.
And when we consider nursing workforce, as the IOM has done, from our vantage point at HRSA, we also need to recognize that the health of the nation is best served not only with a competent and adequate supply of nurses, but also through efforts to effectively deploy the nursing workforce to settings and geographic areas that need them most.
As an aside, the ACA is supporting efforts in all three of those areas, and I’ll say more about that in a minute. The bottom line, as the IOM states and the ACA supports, is that clearly, nursing is an important discipline to leverage, particularly given that the nation’s 2.8 million nurses make up the largest workforce segment of our health care system.
The second IOM report targets the integration of Primary Care and Public Health. As you will recall, the CDC co-funded the study with HRSA, and for this report, we asked the IOM to provide specific recommendations about actions we could take together to integrate primary care and public health in order to improve population health. HRSA recognizes that nurses often serve as a bridge between primary care and public health and play a key role in team-based care and community prevention.
For its part, the IOM identified five principles for successful integration of primary care and public health. I’ll mention a couple of them:
- A shared goal between primary care and public health focused on improved population health; and
- Aligned leadership between primary care and public health that bridges disciplines and programs and that has the capacity to manage change.
As the IOM report suggests, primary care and public health aligned and leveraged hold great promise for managing and ultimately reducing chronic and non-communicable conditions. And yet they are often implemented in isolation of each other. By making the traditional barriers that separate primary health care, academic medicine and public health professionals more porous, integration can also improve care quality.
One of the major focuses of my term as HRSA administrator has been to integrate public health into the delivery of all the primary care services that our grants support. I do want to point out that even before the IOM published its recommendations on primary-care public-health integration, HRSA was working on integration on several fronts, including integrating oral and mental health services into primary care and other services.
Under the leadership of HRSA’s Chief Public Health Officer, HRSA and our CDC colleagues are not letting any dust settle on the IOM report and are working hard to take ideas and recommendations and turn them into actions. Together with CDC, we are focusing efforts in four broad areas:
- Promote understanding of integration of primary care and public health;
- Identify and disseminate best practices and supporting demonstrations;
- Leverage workforce programs, including those with a nursing focus; and
- Align funding with policy and data.
So this is important, significant work for us – albeit not easy work – and at the end of my remarks I’ll come back to the important topic of public health and primary care integration. With the IOM reports as a backdrop to our efforts in health reform, let me turn your attention to the ACA.
In terms of the ACA at HRSA, our team has been working day and night to implement the 63 ACA provisions for which we are responsible. So I have a fair amount of knowledge about what this law is and what it’s not.
We are moving into the next phase of the law, but we’ve already achieved very important accomplishments. Broadly, as a result of the ACA, tens of millions of Americans are already benefitting from stronger insurance coverage:
71 million Americans with private insurance can now receive preventive services like cancer screenings and flu shots without out of pocket expenses. And 115 million Americans no longer have to fear their benefits will disappear because of lifetime caps on the amounts insurance companies will pay.
The law has also begun to slow rising costs across the system: Anti-fraud efforts from the ACA have returned a record $4.2 billion to taxpayers in 2012. Hospital readmissions in Medicare have fallen for the first time on record. And more than 250 new Accountable Care Organizations are getting paid according to the quality of care they deliver, not the quantity.
These reforms have contributed to the slowest sustained national health spending growth in 50 years: More specifically, U.S. health care spending grew at historic lows for a third consecutive year in 2011. Medicare per capita spending rose just 0.4 percent last year, while Medicaid spending actually dropped by 1.9 percent. And, in the past three years, the share of double-digit premium increases requested by insurance companies has plummeted from 75 percent to 14 percent.
These are just a few examples of the achievements that have already occurred from a law that is barely 3 years on the books. Looking forward, beginning less than 8 months from now, next January, the law will finally end discrimination against nearly 130 million Americans with pre-existing conditions, including discrimination against women based on their gender. This is on top of the law already helping more than 3 million young people gain coverage under their parents’ plans.
And starting in October, the next phase of the ACA begins with Americans being able to enroll in the state-based Health Insurance Marketplace. The Marketplace is designed to help people find health insurance that fits their budget – and their needs. In preparing for this expansion in coverage, the federal government has put together a website at healthcare.gov that provides an easy to use source of information on health insurance and how to get it.
If you haven’t been to the website, I strongly encourage you to go there – and please encourage colleagues, family members, and others to do the same. On this website, consumers will soon be able to find comprehensive information about different insurance plans, benefits, and quality – with side-by-side price comparisons to help them make the best coverage decision.
When it comes to this part of the ACA, our job in health care – whether in federal government or local health departments or in health care delivery systems – part of our collective work is to make sure that those who have been standing outside of the health system get in.
We need health care providers who are well educated about the law so that they in turn can assist colleagues, patients, and communities about the health care law. This is especially important because there are a lot of benefits that people simply don’t know about.
There are parents putting off check-ups and vaccinations because they’re worried about a co-pay that no longer exists. There are families who are afraid to call up their insurance company because they don’t know their child who was born with a heart defect can no longer be turned away.
You have colleagues who may not know that their patient who is graduating from college can still keep coverage through her parent’s plan. So we need you to be educators about this law so that patients take full advantage of its benefits.
And we also need your help to make sure people actually sign up for coverage. We’ve learned from our efforts to get children enrolled in CHIP and Medicaid that simply making coverage available is not enough. Some people may not realize that they qualify. Others are dealing with a language barrier. Some simply assume that affordable health coverage will never be within reach.
Our ability to get more people covered and create healthier families is going to be determined by our ability to educate people and sign them up. And we’re going to need your help. Right now, you can go to HealthCare.gov and sign up for e-mails and text messages that will help prepare them for enrollment this fall. You can encourage your patients to sign up too.
So, here too, nurses and other health care providers and leaders can use their skills and the trust the American public has in them to help take this critically important step toward health by ensuring access to health insurance coverage. And we at HRSA and across HHS are here to partner with you and others in this important effort.
The uninsured may not see us in the federal government, but they see all of you. They live in towns and cities across Georgia where many of you live, and they are impacted by you. That puts you and your colleagues in a critically important position to help them get health care coverage.
Right now, this is some of the most important work we can do to help improve health of millions of people. With that task in mind, let me talk more specifically about the role of the ACA and nurses specifically.
I am often asked how the ACA will affect nurses. And while there are a number of you in the audience who are not nurses, I know that from your perspectives in academia, administration, and public health, you can appreciate the importance of health care providers’ roles, including nurses, in health care reform.
The ACA expands investments in primary and preventive care programs in which nurses play a vital role. Its emphasis expands our focus in exactly the direction most of us know it needs to go, which is to explicitly target efforts to keep people healthy, prevent illness, and manage chronic conditions – all of which call on the expertise of nurses and others.
In two key HRSA programs – Community Health Centers and the National Health Service Corps – the ACA made enormous new investments to expand access to primary and preventive health care in communities that need it most. And there’s a lot of need out there—across Georgia and the rest of the nation.
HRSA’s health center network delivers primary and preventive care to more than 20 million patients at some 9,000 sites. Health centers are projected to serve well over 21 million patients at the end of 2012 – once all the year-end data comes in – and that’s 4 million more people than the 17 million patients they served in 2009. There are 29 health center program grantees in Georgia, operating 170 clinic sites.
Of course, as millions more Americans obtain health insurance through the ACA, demand for primary care services will increase, and that’s why at HRSA we’ve been working to strengthen the local primary health care infrastructure – right in the towns where many of you live.
Most of these Centers provide a full spectrum of services that include medical, dental, and mental health care, nutrition and social service resources, and more. Our health centers are an essential part of the national safety net because they serve anyone who walks in.
Nurses are an essential component of the health center workforce. Right now about 16,000 nurses – including 4,300 advanced practice nurses – work at health centers across the U.S. Since the expansion began in 2009, health centers have added about 3,000 nursing positions, including 800 advanced practice nurses.
And, in addition to helping ensure access to health care, these nurses and other providers are directly involved in quality improvement. In health centers, and elsewhere, the ACA promotes patient-centered medical homes.
Currently, more than 20 percent of HRSA-funded Community Health Centers have been recognized as Patient-Centered Medical Homes.
Even though we are in the early stages of studying the PCMH model, studies conducted so far have shown that patient-centered medical homes can improve health outcomes, enhance the experiences of patients and providers, and reduce unnecessary ER use. Patient-centered medical homes also can improve care processes.
Another HRSA program that strengthens access to care and in the process offers great opportunities for nurses is our National Health Service Corps program. The Corps places primary care providers in underserved urban and rural areas for at least two years in exchange for paying down their student loans. Eligible nursing specialties include primary care nurse practitioners, certified nurse midwives, and psychiatric nurse practitioners.
The ACA invests in this program too by allocating $1.5 billion over five years to grow the NHSC. About half of all NHSC clinicians work in health centers, so growth in the Corps was an important element of the health center expansion. As a result of these investments, the ranks of the NHSC have grown from about 3,600 clinicians in 2008 to nearly 10,000 last year. In Georgia, there were more than 220 NHSC providers at the end of FY2012, and more than 170 of them were funded through the ACA. Without the ACA, you’d have fewer than 50 in underserved areas.
The number of nurse practitioners in the NHSC has nearly doubled to 1,600 since President Obama took office. During the same period, the number of certified nurse midwives rose to more than 200. Bottom line: That’s a lot of new access to primary care services in neighborhoods and towns with previous shortages.
HRSA has a similar program for nurses that provides scholarships and pays student loans in return for service in health care facilities in underserved communities. Recently retitled, we call it NURSE Corps –– and we have close to 3,000 nurses taking advantage of the benefits from this program.
But beyond these opportunities, support for nursing from the Affordable Care Act is certainly clear when you look at the additional investments made in funding for nurse education programs that HRSA administers. HRSA has committed more than $1 billion over the last four years (FY2010-13) to educate new nurses and prepare them to deliver care in redesigned health care delivery settings and systems.
For example, the ACA specifically directed $15 million to Nurse-Managed Health Clinics, which are run by advanced practice nurses and affiliated with schools of nursing. These clinics train new nurses while delivering primary care to vulnerable populations like public housing residents.
The Act also directed $31 million to prepare primary care APRNs and $200 million for a graduate nurse education program that funds preparation of APRNs for primary care and care coordination roles.
Another way HRSA is meeting the challenges posed by increased demand for services is by focusing on a well-supplied pool of faculty. The IOM report that I mentioned earlier noted this need for more nursing faculty and recommended doubling the number of nurses with doctorates. The ACA helps to address this recommendation by lifting the cap on funds for doctoral education, as well as through increases in funding for the nurse faculty loan programs.
Well, even as we’re sharply focused on preparing new nurses, we’re also equally focused on the competencies nurses and other providers need to have to ensure that consumers receive high-quality, coordinated care, as opposed to what too frequently has been fragmented, and even at times unsafe care.
The ACA’s emphasis on team-based care recognizes that there are gaps in health care between settings and among health care providers. And these gaps can put the health of patients at risk while driving inefficiency and increasing costs.
We can help resolve these problems by changing the way we educate and deploy our health care workforce. So at HRSA, we are working to catalyze the delivery of health care by provider teams – people working across disciplines and across settings to ensure that health care services are seamless, coordinated and collaborative – no gaps, no inefficiencies.
In support of these aims, HRSA is funding and partnering in a new National Center for Interprofessional Practice and Education, which brings together multidisciplinary health care leaders promoting innovation in education and practice. The National Center, located at the University of Minnesota, is working to identify new models of team-based care, including teams that are comprised of a number of traditional primary care professionals – as well as allied health professionals, direct care workers, and community health workers.
Looking forward, new models of care delivery will continue to emerge. And a key challenge will be to make sure that the education of health professionals explicitly educates new providers in these new models of care and bridges the gap between public health and primary care.
In terms of important public health investments that merge with primary care, the ACA created a new five-year, $1.5 billion program that is, at its heart, emblematic of the integration of primary care and public health: the Maternal, Infant, and Early Childhood Home Visitation Program.
Under this program, nurses, social workers and others visit pregnant women and young children in high-risk communities. There they provide counseling and intervention services that – based on evidence – are known to improve health outcomes.
HRSA administers the Home Visiting program, but it’s run at the state level and implemented in local communities with support from the ACA. In Georgia, the Governor’s Office for Children and Families is implementing Great Start Georgia, a Home Visiting program in the state’s seven most at-risk communities to offer comprehensive screening and to link families to services and support for improved outcomes.
Across the nation, as of October 1 of last year, the Home Visiting program, funded through the ACA, had supported more than 160,000 home visits to about 20,000 high-risk families in more than 500 communities in almost all states across the nation. Through the Home Visiting program, the ACA promotes evidence-based practices as a basis of improvements in care quality.
Another element in this integration of public health and primary care is the ACA’s setting aside of $200 million to expand school-based health centers, which allow kids – and particularly importantly, disadvantaged kids – to get care before major health problems take root.
Another example of public health and primary care integration since the release of the IOM report on public health and primary care integration is the work being done by the CDC’s Epidemic Intelligence Service and HRSA’s National Health Service Corps, who are meeting regularly to explore whether, where, and how public health and primary care professionals can train and work together. HRSA and the CDC together are looking at FOAs from both agencies to see where integration can be implemented, and we have a joint data working group to see where alignment can be achieved.
We believe there are many ways in which the concept of integration between public health and primary care can be transitioned from the theoretical to the practical. For example, a primary care practitioner who treats a significant number of people with asthma could engage with public health partners to identify risk factors, such as environmental pollutants or the quality of housing, and address these risk factors through further engagement with community stakeholders, policy-makers, employers, businesses, and the like. The ultimate goal, of course, is to improve outcomes for individuals and communities.
And the Georgia public health and primary care communities have been quite active in pursuing integration. After the IOM study was launched in September 2010, but even before the report was released in 2012, HRSA, CDC, and the Georgia Association for Primary Care convened colleagues from six HRSA-supported community health centers and six public health departments in October 2011 to discuss integration within the safety net community. This forum identified examples, barriers, and recommendations.
The barriers, as I’m sure you’re aware, involve differences in organizational structure or cultures, funding streams, reimbursement mechanisms, and legal requirements – among many others. But these barriers did not inhibit forum attendees from identifying actions that could be taken immediately to achieve better integration in the areas of education, governance, reimbursement and planning.
In Emmanuel County, for example, public health nurses trained community health center nurses on how to administer immunizations. And a neighborhood health center that is part of a hospital-owned primary care network in Hall County is physically located within the health department. In Floyd County, collaboration between primary care and public health partners has resulted in the establishment of a rural dental clinic.
So in closing, I would like to thank you for the work you have been doing and the creative ways you have been breaking down barriers to the integration of public health and primary care.
I hope my remarks have helped you appreciate the importance of the Affordable Care Act, its leveraging of the assets of the nursing profession, and through that and more, the importance of the ACA to the health and wellbeing of American people.
While I realize this symposium is highlighting and celebrating National Nurses Week, I think our other colleagues in the audience would agree with me that there is an abundance of opportunities, not only for nurses but for all of us, to improve population health through integration of primary care and public health and through implementation of the many provisions of the Affordable Care Act.
In recognition of National Nurses Week, I’ll end by saying that I’m very proud to be a member of the profession that I have the privilege of sharing with many of you. I thank you for listening and for all that you do.
I would be happy to take questions now.
