Remarks to the 40th Annual Arizona Rural Health Conference

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By HRSA Administrator Mary K. Wakefield

August 21, 2013
Prescott, Arizona

Thank you, Dr. (Dan) Derksen, and all of you for the opportunity to join you today for this 40th annual conference.  It’s wonderful to be part of this 40th anniversary gathering.  

I also want to acknowledge another HRSA employee that some of you know, Dr. John Moroney, who leads our regional office that includes Arizona.  John is a great contact, incredibly knowledgeable and as a team that works with him.  He’s easy to spot in a crowd because he’s so tall.

Well, this first-of-its-kind conference was founded by Andy Nichols, even before there was a State Office of Rural Health here in Arizona.  Having known Andy personally, I am well-acquainted with his health policy work.  The field of rural health in this state owes much to him and many of us across the country do as well.  What I observed about Andy was his forward thinking and his fearlessness, willing to take on any challenge.  For example, he was the first person to champion promotores, recognizing and helping the rest of us understand the profound impact they could have in their communities.  He supported their training and their recognition as legitimate and important members of the health care team.  For a host of reasons, it’s a particular honor to deliver the lecture that bears his name.

I also want to acknowledge the University of Arizona’s Center for Rural Health for the leadership you’ve demonstrated over your 30-plus years of existence.  And congratulations to the Center staff, who were recently honored for their work by the National Rural Health Association.  As a result of your collaborations -- with state, federal, clinical practice and research partners – residents of Arizona’s rural areas and border region have access to care they might very well otherwise be without.

We can take a moment to think about how much has changed in rural health care in the wake of that first gathering 40 years ago and since the Arizona Center for Rural Health came into being a few years later. The convening of the conference then and the establishment of the Center are moments in time that align with some of the first major policy actions taken to address shortages in rural health services. Consider some of the key developments from that era, 30 to 40 years ago, that have had a very significant impact since then on the health of rural communities, including:

• The considerable growth and reach of Medicare and Medicaid;
• The creation of the Community Health Center Program and the National Health Service Corps; and
• The passage of the Rural Health Clinic Act in 1977.

Over this same period of time, Arizona was ahead of the game in seeing rural health as a critical public policy issue, and you became a significant model for much of the rest of the country.
In the succeeding years, we’ve seen other important programs and initiatives with relevance to rural health, including the focus on policy through:

• At the Federal level, the creation of a Federal Office of Rural Health Policy and State Offices of Rural Health program in each of the 50 States, an infrastructure that we almost take for granted today, but that is new enough that I remember when very little of that infrastructure existed, and where it did it was quite limited.
• We’ve seen over the past couple of decades a focus on workforce around an increased emphasis on Federal training programs for primary care providers in medicine and nursing.
• And a focus on stabilizing health care infrastructure through the creation of the Critical Access Hospital program.

These and other accomplishments have provided a strong, substantive foundation for our current work.  They are building blocks that remain essential to improving access to health care across rural communities.

And now, we find ourselves standing at a very historic time in the evolution of health care delivery in this country as we complete the implementation of the Affordable Care Act.  When the Health Insurance Marketplace opens for business October 1, we’ll begin the next phase of important work -- expanding insurance coverage to millions of uninsured Americans.  

I think Andy Nichols would have loved to see this happen.  I remember hearing that when he served in the Arizona legislature he would introduce a universal coverage bill at the beginning of every session, so clearly he recognized the importance access to of health insurance coverage.  

In my remarks today, I’d like to focus on what Andy cared about and what we at HHS and HRSA care about, too, and that is making sure that every American can access health care – which begins with affordable, accessible health coverage.  

To that end, job one for us in HRSA right now is completing the implementation of the Affordable Care Act.  And I would say to you as someone from a rural area and as someone actively engaged in standing up provisions of the ACA, I personally think that nowhere is this implementation more important than in rural America.  

As many of you are aware, the insurance market has never worked that well for rural families and rural communities, where folks are more likely to have to buy coverage in the individual or small group market and pay more for that coverage, if they could get it at all.

And, I share the belief of President Obama and HHS Secretary Kathleen Sebelius, which is this:  In America, where you live shouldn’t determine your chances for a healthy life.  That’s a principle that I think we should all be able to agree on.

The full implementation of the ACA will improve the situation for everyone by providing needed common-sense reforms to the insurance market and by expanding coverage.  But already the law has resulted in more health care choices, better benefits, a check on rising costs, and higher quality care.  

In a speech just last month, President Obama clearly articulated how the ACA has changed health care in America for the better, in rural areas and around the country.  

• He reminded us that 3.1 million previously uninsured young Americans between the ages of 19 and 25 have now gained health insurance coverage by remaining on their parents’ plan – this includes an estimated 394,000 young adults living in rural areas and in Arizona 69,000 young adults right here, previously uninsured – now insured – because of the ACA.
• The President reminded us that the ACA eliminated life-time coverage limits on caps that affected almost 16 million rural Americans.  Already, more than 2 million Arizonans, including 769,000 women and 570,000 children are free from having to worry about lifetime limits on their insurance coverage, that perverse practice of denying insurance coverage just when an individual may very well need it the most.
• And, in July, he also reminded us that the law has increased access to affordable prescription drugs for 6.6 million seniors by reducing the Medicare Part D “donut hole,” saving seniors over $7 billion on prescription drugs.  In Arizona, that added up to savings of nearly $123 million on prescription drugs for people on Medicare thanks to the ACA, with many of those Medicare beneficiaries residing in rural Arizona.

So what’s next for the ACA and what does it mean for rural America and rural health?

Estimates from a RAND study project that 5.5 million rural Americans who would otherwise be uninsured will gain coverage by 2016 through the expansion of Medicaid eligibility and the creation of Health Insurance Marketplaces.  That’s 5.5 million rural Americans who will gain health insurance coverage!

At HHS, our team recently took a look at the data on uninsured Americans, at those people who will have new insurance options when the Health Insurance Marketplace opens October 1.  The research found that:

• Right now, more non-elderly people are uninsured in rural areas than in urban settings, and the rural uninsured across the nation tend to be poorer than their urban counterparts. The rural uninsured non-elderly are also more likely to be older than 35 and working.  
• The research also confirmed that rural residents per capita are more likely to benefit from the Medicaid expansion than the uninsured in urban areas.

So why are these findings important to all of us in this room?  Well, first, on a per-person basis, rural Americans are in greater need of and stand to benefit more than those in urban and suburban areas from the expansion in insurance coverage.  Second, the demographics of this population reflect a population that faces some serious challenges -- and we’ve got a chance over the coming months to really help them.   

As the Health Insurance Marketplace opens this fall, we see a real opportunity to improve rural health on two key fronts.  First, we’ll be able to get more of the rural uninsured covered, some for the very first time in their lives.  Second, this will help rural hospitals and clinics improve their bottom lines.  By seeing more patients with health insurance, their uncompensated care and bad debt will be reduced.

And these facts – improved health of rural families and improved financial health of rural providers – are personally important to me because I come from a rural town just a bit north and east of here, Devils Lake, North Dakota, population 7,000.  And I worked in that local rural hospital starting in high school, and I knew early on what it meant for people not having to drive 95 miles for health care.  And furthermore, living in a rural community means you know your neighbors.  When you talk about the uninsured in your community, they’re not faceless numbers. They’re people you know.   They work in your stores downtown.  Their kids are in classrooms with yours.  They live next door or a block over.

So now let me take a minute and talk about those people we know, and how the new Health Insurance Marketplace will affect them.  Because this is so important to their health and the economic health of their communities, and because of its importance, each of us has a role to play in making sure that affordable health coverage is within reach for every American.

In Arizona, about a million people, 947,000 to be exact, or about 18 percent of your state’s population, are uninsured and eligible for coverage through the Marketplace.  I’m sure that all of you know a few people who fall into that group.

Beginning October 1st, they’ll be able to sign up for health insurance through the Marketplace.  Enrollment will open that day in Arizona and in every state, with coverage that begins January 1, 2014.  And while each state will have its own set of insurance options, each of the state plans will be accessible through one website:  healthcare.gov.  

Here, at healthcare.gov, rural consumers and others will get a clear picture of what they are paying for before they make a choice.  Here, consumers will be able to make apples-to-apples comparisons of plans.  Here, they’ll be able to learn, with a single application, if they or their family members qualify for a no-cost or low-cost plan – or a new kind of tax credit that lowers monthly premiums right away.  We recognize that computer access may be limited in some rural areas: I mention this so you know that folks can also submit a paper application if they prefer.

All state plans must cover an essential set of benefits, including hospital visits, doctor visits and prescription drugs; and now, discrimination based on gender or pre-existing conditions, like diabetes or cancer -- because of the ACA -- is against the law.  And many, many families and small business owners will qualify for a break on monthly premiums.

For a lot of people, the Marketplace will be a whole new way to shop for health insurance.

Right now, we’re counting down to coverage.  So I’m asking you today to help us educate rural America about the new coverage options that will be available.  You can partner with outreach workers and Navigators who will be on the ground in many of your towns and communities.  Or you can work with your local health centers:  last month we announced $150 million in supplemental funding to boost health centers’ efforts to help enroll the uninsured in underserved areas.

Just last Thursday, we announced $67 million in funds for Navigators in the 33 states with a Federally-facilitated or State Partnership Marketplace.  The Navigators will help consumers learn about their Marketplace and find coverage.  In these grants, we’re asking Navigators to work with individuals with limited English proficiency, people with a full range of disabilities, and vulnerable, rural, and underserved populations.  Specific to Arizona, yesterday we highlighted grants worth more than $2 million to four Navigator organizations and their partners.

We’re also getting ready to provide supplemental funding of just over $1 million to up to 52 Rural Health Outreach grantees to help enroll eligible folks in their communities for coverage.

Those funds will help us, but more needs to be done to make sure we reach every eligible rural person.  We need you to help spread the word that “now’s the time to get ready.”  We need you to engage your networks and your communities to help ensure that no one who is eligible is left out, left behind, or left on the sidelines.  Our collective effort is critical because surveys tell us that many of the people who stand to benefit most from access to health insurance may not know what they are eligible for.

That reminds me of a quote I saw recently in my local paper in Devils Lake from an old friend of mine, a rural health care administrator who said this about the importance of getting the word out.  He was quoted as saying:  “The only thing worse than not having insurance is being eligible for insurance but not knowing about it.”  I think that about sums it up when it comes to getting the word out.  How true is that?

So we have to change that situation, particularly for rural Americans, who, as I indicated earlier, in many respects have the most to gain from affordable coverage.  Right now, as Secretary Sebelius says, it’s “all-hands-on-deck time” in rural America and across the nation.   Yes, this work is a challenge, but it’s an opportunity to recalibrate access to health care for our neighbors and our communities and perhaps even for some of our own family members.  

There are terrific resources you can use when colleagues, patients, friends, and neighbors come to you with questions about enrolling in health insurance through the Marketplace.  And you can guide people to places that have additional answers.

• Urge patients and friends to go to healthcare.gov to learn about the Marketplace and what will be available October 1st.  In Spanish, it’s CuidadoDeSalud.gov. It’s straightforward information about what people need to do to sign up.
• Get the word out through social media.  If you have a Facebook account or a Twitter account, connect to HHS social media channels through hhs.gov.  Then repost and re-tweet the information you find there and as that site is updated.
• For providers, one site to visit is marketplace.cms.gov.  How many of you have been to this website?  There you can download infographics that you can post on your websites; videos you can run in your waiting rooms, patient rooms, classrooms, board rooms and community meeting rooms.  It also has quick visual links called “widgets” that you can put on your e-newsletters, agency websites and consumer sites.  And HRSA is about to add our own website with a “toolkit” of useful resources for providers.  We’ve pulled all our information and guidance to providers and put it in a central location to make it as easy as possible to get the knowledge you need.  We expect it to be ready to post later this month at our existing ACA website.  So if you’re a provider, keep an eye out for that.  

These next few months are the culmination of the most significant advance in health care policy that I personally have seen in my lifetime.  It’s a game-changer, and we’re right at the point of fully engaging it.  Every eligible Arizonan deserves to be insured, and in partnership we can make that happen!

So, that’s the message on enrollment.  But that’s just part of the important work of the ACA.  We are so concentrated right now on outreach, enrollment and education that it’s easy to overlook the other important elements of the ACA, elements that also are changing the way we deliver health care in the United States – especially care to underserved populations and communities, and I want to talk for a moment about those other provisions of the law that we’ve been working on as well.  

The scope of our work at HRSA underwent a massive expansion when the ACA invested billions of dollars in four key HRSA programs:  two programs that were expanded – health centers and the National Health Service Corps, and two that were brand new – the Home Visiting program and the Teaching Health Center program.  I’ll say just a word about these four programs.

With health centers and NHSC, ACA funds followed investments in two programs of these programs through the 2009 Recovery Act, so the combined impact has been strongly positive in terms of increasing access to care for underserved people.  

I’m sure that many of you are intimately familiar with the value of services provided by NHSC clinicians -- these physicians, dentists, psychologists, advanced practice nurses and others who agree to spend at least two years working in an underserved community or site in exchange for federal loan repayment or scholarship assistance.  Well, thanks to the support provided through ACA and the Recovery Act, the number of NHSC loan repayors and scholars nationally has more than doubled since 2008 to about 8,000 clinicians.

How has Arizona benefited from just this one provision of the ACA?  Well, today Arizona has 274 NHSC clinicians, with 234 of them (85 percent) supported by ACA funds.  Of the total number, 86 (almost a third) are physicians.  Particularly important for rural Arizona, 166 of the 274 NHSC clinicians in the state are serving in rural areas.

Of course, many of these clinicians --in Arizona and around the country -- work at HRSA-funded health centers.  Thanks mostly to the ACA – which invested $11 billion over 5 years to expand health center sites and services – health centers have added 4 million patients since the beginning of 2009.  They now serve more than 21 million people each year.  Today, some 1,200 health center grantees operate almost 9,000 clinics in every state and U.S. territory.

Arizona has added 2 health center grantees since 2009 (the number is now 16) and the volume of patients in Arizona’s health centers has grown by nearly 19 percent during that time.  

And since about half of all health centers across the nation are located in rural areas, the boost that the health center expansion has given to health care in rural America is real – and it’s growing.  As a result of the Recovery Act and now the ACA, health centers located in rural areas of the country provided care to just over 7.6 million patients last year; that’s an increase of more than 20 percent since 2009.  Think of that!

Health centers also help provide needed rural jobs.  Data show that rural health centers employ more than 50,000 people; that’s up by 28 percent since the start of 2009.  

So you can see that the impact of the ACA investment in health centers has been positive in increasing access to care, in expanding the range of available services provided, and in creating needed jobs -- in rural America and the entire country.

As I mentioned earlier, the ACA didn’t just expand HRSA’s existing portfolio, it also added to it by assigning our agency responsibility for implementing and overseeing two new programs.

The first initiative made one of the most significant investments in Maternal and Child Health in a lifetime, by creating the Home Visiting program.  This five-year, $1.5 billion investment enables nurses, social workers and others to visit pregnant women, young children and their families in high-risk communities.  There, they provide evidence-based counseling and intervention services known to have improved health outcomes.  In fiscal year 2013, Arizona reports almost 11,000 home visits to date.

The positive outcomes of evidence-based models used in home visits include: improved parental capacity; improved school readiness; reduced maternal depression; and better healthy child development.  Studies show that every $1 invested in home visits returns $9.50 to society.  It’s an important program – talk with your state health department about the needs you see for families and at-risk communities to participate in this program.

The ACA also established a new Teaching Health Center Program to expand medical and dental residencies in community-based training sites.  I’m told that the Wright Center for Graduate Medical Education and AT Still University of Health Sciences’ School of Osteopathic Medicine are supporting family medicine residents through this program.

Research indicates that teaching health centers produce primary care physicians who are three to four times more likely to provide care for underserved populations in community settings than physicians primarily trained in hospital settings.  So, the ACA is not just focused on preparing more providers, we’re also focused on harnessing training opportunities that reflect an important new orientation for the next generation of health care providers.  Some of the Teaching Health Center training sites serve rural populations, like those in West Virginia, Washington and Kentucky.  

Let me shift gears for a moment here.  With the current focus on expanding health insurance coverage, people may not be aware of the ACA’s strong emphasis on encouraging individuals, families and communities to take proactive preventive measures to maintain good health.  And the law also encourages better ways to organize the delivery of health care to improve quality and lower costs.

Many of you are health care clinicians and you know that a lot of the health problems sick patients present with could be wholly prevented, or at least markedly mitigated, through investments in disease prevention activities like screenings, health and wellness promotion, and patient education.  And these activities are a big part of the ACA.

For women, for example, the ACA requires most private health insurance plans to cover recommended prevention and wellness benefits such as mammograms, screenings for cervical cancer, regular well-baby and well-child visits, and domestic violence screening with no cost-sharing.  

Men also have access with no out-of-pocket cost-sharing to potentially life-saving screenings that are covered for all adults:  colonoscopies, flu and pneumonia shots, alcohol misuse screening and counseling, cholesterol checks, immunizations, and more.

For rural populations with historically high rates of uninsurance and lower incomes, these preventive screenings, that many of us take for granted because of our insurance coverage and our incomes, will – in many cases – provide the first opportunity for many rural folks to access these very important services.

I also mentioned that the ACA drive toward better ways to organize care.  To follow that important work, I urge you to stay up with the ongoing efforts of the Innovation Center at the Center for Medicare and Medicaid Services.  Our colleagues at CMS are making important investments, funded by the ACA, that test new models for paying for and organizing care which not only improve outcomes but also help to control costs.  Rural providers are a key part of these activities, whether it’s the rural health centers taking part in the Patient-Centered Medical Home demonstration or the many rural communities funded under the ACA-supported Innovation Challenge.  

More vital work in this field has been taken on by the Partnership for Patients, which seeks to improve quality and reduce patient harm on a national level, and I’m pleased to say that we have a high level of rural participation in that effort.  When it comes to quality and patient safety rural providers can lead.

At the core of the Partnership for Patients are 26 Hospital Engagement Networks, which link with nearly 3,700 hospitals across the country to identify best practices and solutions to reducing hospital- acquired conditions and readmissions.

Dozens of hospitals in Arizona are members of the Hospital Engagement Networks.  They run from some of the biggest hospitals in the Phoenix area to at least two Critical Access Hospitals: Page Hospital in Page and Copper Queen Community Hospital in Bisbee.

As I close, let me return our attention to the task closest at hand, the start of health insurance enrollment in just 40 days, by recalling what President Obama said earlier this month at a press conference: that millions of Americans are going to have a chance to benefit from the gains that come from getting access to health care.

We’ve got a wonderful opportunity to really improve health care in rural communities by reaching out to help as many uninsured Americans as possible sign up for health insurance.  

Thank you for inviting me to be here today and for the important work that you do every day and for what you do going forward to ensure that your neighbors and friends in your rural towns have full access to health care because they have access to health coverage.

Thank you.