Remarks to the Association of Maternal and Child Health Programs

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By HRSA Administrator Mary K. Wakefield

January 27, 2014
Washington, D.C.

Thank you, Sam (Sam Cooper, AMCHP President Elect) for your kind introduction, and thanks to AMCHP for inviting me here today.

It’s nice to be back at AMCHP’s annual conference with all of you again. It’s always energizing to be among colleagues who are so totally committed to the extremely important work of improving the lives of millions of mothers and their children in the U.S. each year.

And I also want to take this opportunity to recognize HRSA staff that are here from the Maternal and Child Health Bureau – please stand. I’m fortunate to be able to work with this terrific team, and especially with Dr. Michael Lu.

As I mentioned, we find ourselves at an exciting time for maternal and child health programs and for the future of the work that you do.  For those of us who have worked in health care our entire professional lives – including many of you in this room – the Affordable Care Act is creating a pivotal shift toward the achievement of real and unprecedented improvements in the health of women and children in this country, in no small part because the law is opening the door to accessing health care services by making access to health insurance a reality.

Now, across the United States, millions of Americans are signing up for quality, affordable health insurance.

As all of you know, the Marketplace’s website had a turbulent takeoff, but since then we’ve been really encouraged by the strong response to coverage availability.  More than 9 million people have either signed up for private insurance through the Marketplace, or have learned they’re eligible for Medicaid, or have renewed their Medicaid coverage. Let me break that 9 million number down a little.

As of January 15, 3 million people have enrolled in private insurance through the Marketplace. And 6.3 million people have learned they are eligible for Medicaid or have renewed their coverage as of December 31.

This doesn’t include the more than 3 million young adults who had already gained coverage because the Affordable Care Act allows them to stay on their parents’ insurance plan until they are age 26.  And those people who already had health insurance now have more reliable coverage than before.

For example, as of January 1, for the first time, women cannot be denied coverage or charged more for insurance just because of their gender.

And insurers can no longer deny health insurance coverage to women because they’re pregnant, or because they gave birth by C-section, or because they’re a breast cancer survivor.

Since the ACA went into effect, 17 million children with pre-existing conditions have been protected from discrimination by insurance companies. And now, no American adult or child with health insurance coverage has to worry about being so sick that they reach an annual limit, then see their health insurance evaporate just when they need it most. 

In addition, millions more women and children have access to preventive services with no co-pay.  So many are finding new prevention and wellness services covered with no cost-sharing on their insurance policies, including for mammograms, screenings for cervical cancer, domestic violence screenings, and other preventive services.

And maternity and newborn care are now required to be covered by every insurer.

Insurance policies are also required to cover  regular well-baby and well-child visits, autism screenings, developmental screenings, immunization vaccines,  and other very important health services.

Many of these are services that have historically been excluded from coverage or were too costly for some people.

In short, the ACA helps to improve the health of women and children not just when they are sick, but also by helping to ensure that they stay healthy in the first place.

Even with these provisions in place, there is still more to be done. The challenges in our health care system that provisions of the ACA were designed to address were decades in the making, and they won't be solved overnight.  But every day more Americans are signing up for insurance and getting the peace of mind that comes with knowing that they can get the care they need without losing everything they've worked and saved for.

In addition to these and other long overdue changes that have been ushered in by the ACA and that strengthen health care, at HRSA we are also working to transform and improve many of our programs to align with these improvements.

Taken together – the ACA and the changes we have under way in our maternal and health programs – we have a great opportunity to leverage these important initiatives in groundbreaking ways.  And much of these new directions are efforts that we’re of course pursuing in partnership with AMCHP and with all of you.

Yesterday many of you heard from Dr. Michael Lu, Associate Administrator of our Maternal and Child Health Bureau, about some of these transformations.

Take, for example, the Home Visiting Program.

The Affordable Care Act included a $1.5 billion investment in the Home Visiting Program over five years. I consider this to be one of the most significant investments in maternal and child health in a lifetime.

It’s significant for a number of reasons, not just because of the financial resources committed to it, but also because it builds off of an evidence base about what we know that works, and because it engages a partnership that includes federal, state, and local entities.

In order to continue to ensure quality improvement as these Home Visiting programs continue across the country, HRSA is committed to providing technical support and collaborative learning.

And, as part of this quality improvement effort, last spring, we launched a Collaborative Improvement and Innovation Network, or CoIIN, to drive quality improvement in Home Visiting – an approach similar to that taken by the CoIIN for infant mortality.

In addition to the targeted focus on quality, we also want to make sure that Home Visiting is well-integrated within a comprehensive system of services for children and families.  Both Home Visiting and the Early Comprehensive Childhood Systems program should play very important roles in driving systems integration for early childhood.

By doing the critically important work of aligning Home Visiting with Community Health Centers, Early Head Start, and Head Start, along with other early childhood programs, we can continue to leverage these assets even more effectively and, in the process, drive important improvements in health outcomes for mothers and children.

And for those of you who are playing an important leadership role in the Home Visiting Program, I really want to thank you for all your efforts.  It’s important that we continue to push out the boundaries of this program to ensure that more families who can benefit from it are not on the outside of this effort, but are being brought into it.  And many of you in this room and your colleagues back home are essential to expanding the reach of Home Visiting to support more vulnerable families through this initiative.   

Well, another way we are leveraging investments and resources to move the needle on health outcomes is by using Special Projects of Regional and National Significance – SPRANS – to enhance the work of the CoIINs that I mentioned a moment ago. 

For example, by bringing the science of collaborative improvement and innovation together, HRSA has leveraged SPRANS funding to help address infant mortality in 13 southern states.

These efforts are having a real impact. By sharing best practices, states are learning from each other and have tracked progress using last-quarter data from vital statistics. That real-time analysis is, as you know, pretty uncommon.

The data show that in southeastern states and states along the U.S.-Mexico border, early elective deliveries have been reduced by 20 percent on average.   Although we can’t definitively say that this was due to this one HRSA initiative to address infant mortality, we can state that the initiative accelerated collaborative improvement and innovations across the states.

Considering that early elective deliveries alone cost the nation $1 billion each year, if we can replicate the results nationally – and we plan to expand our efforts to help reduce infant mortality to a national initiative in 2014 – we can save money in unnecessary inductions and C-sections, and in fewer unnecessary NICU admissions, and of course achieve better health outcomes for mothers and newborns in the process.

Also in 2014, HRSA will be re-competing the Healthy Start Program, which will see the largest changes in its 22-year history through six key features that are directly linked to the goals of the ACA.

First, we will take a “place-based” approach to health care, which means that the program will be accountable not only for its clients, but for the entire community.  Increasingly, we’re seeing and supporting an expanded focus on population health, not just focusing on patients seen in exam rooms, but on the health of people in our neighborhoods or communities.  So Healthy Start Programs, too, will play a greater role as community hubs, working across sectors and systems to address both clinical and social determinants of population health and to achieve greater community alignment and collective impact on infant mortality.

Second, in the Healthy Start Program, this year we will strengthen the focus on quality by requiring core competencies and standardized interventions. 

Third, in lock-step with the ACA’s focus on prevention and wellness, the program will expand its efforts to improve women’s health not just during pregnancy, but before and after as well, and – because the populations served through the Healthy Start program stand to gain so much by having health insurance – we will encourage all those involved to become certified as application counselors for outreach and enrollment. Healthy Start is an ideal program to get information about insurance coverage to vulnerable populations and to get people insured.

Fourth, the program will increase its focus on engaging both parents in the future of the child and on family resilience to address some of the stress that underlies many disparities in birth outcomes.

Fifth, there will be a greater focus on the overall collective impact that Healthy Start Programs have in their communities, given the potential that these programs have to potentially serve as community hubs or organizations that can partner with others to drive collective improvements.

Finally, the sixth area of focus is squarely on accountability, with performance measures and rigorous evaluation platforms to drive improvements.

These are just a few examples of the many ways we are aligning with the opportunities provided by the ACA to adjust and retool our programs, as health reform transforms our health care delivery and service systems, and these efforts will continue across all of our programs.

For example, we will be re-competing the sickle cell program next year as well, and that too will be going through a major change as it ramps up from a handful of demonstration projects to reorient toward a regionalized system of care.

And as we fully implement the ACA, Title V programs will also continue to play a lead role as the signature public health system for maternal and child health populations in all 59 states and jurisdictions, driving improvements and targeting a wide range of maternal and child health issues – from maternal morbidity, to safe sleep, to school readiness, to adolescent preventive services, to medical homes for children with special health care needs, and so forth.

These programs work hand and glove with the investments from the Affordable Care Act. For example, through these programs we can track children and families’ access to health care services through data and surveillance. 

And HRSA, through the investments of both the ACA and Title V, is committed to making sure that the unique needs of women, children and families -- including those with special health care needs -- are at the forefront of our policy and programmatic goals. 

And on this front in particular, I want to voice my full and enthusiastic support for the transformation of the Title V program that Dr. Lu outlined in his remarks yesterday.

At this point, every opportunity to align and fully leverage resources should be a top priority for all of us. No program should be operating in isolation or disconnected from other efforts that target the health and well-being of mothers and children.

For this reason, I have made it a priority for HRSA staff to leverage investments from other programs, both within HRSA and across the Department – including the Centers for Disease Control, the Centers for Medicare and Medicaid Services, and the Administration for Children and Families.

While this is easier said than done, it’s work that is essential, and its success depends largely on what we do to engage other assets that impact mothers, infants and children. And it depends on what you do locally to connect key resources on behalf of the populations we collectively serve.  

I certainly expect our programs to have porous boundaries, not rigid silos of activity, and I look for those opportunities as well. As an example, just last Friday, HRSA and the Administration for Children and Families leadership met together to talk about an ACF program stood up by the ACA to provide support for front-line health occupations training for individuals from low-income backgrounds, and part of the conversation considered ways to make information about that program available through Home Visiting and Healthy Start.

To give you another example, right now Title V programs should play a key role in outreach and enrollment, and in helping children and families navigate the new health systems through care coordination and case management.

To take full advantage of the potential created by health care reform, we need to continue to align Title V programs with the ACA goals of expanding access to care, reducing health disparities, and growing a well-prepared and adequate workforce.

For example, we have all seen how Title V programs played a critical role in expanding Medicaid for pregnant women and the Children’s Health Insurance Program.

Many of you in this room helped to make those efforts possible.

Now, there is a new opportunity for your important leadership once again, leadership that helps to ensure that the populations we care about fully benefit from the ACA.

We don’t expect providers or community organizations to become insurance experts, but we are encouraging everyone to talk with the populations they serve about their health insurance status.  Those who are uninsured or underinsured should be encouraged to visit healthcare.gov to explore the options available to them.

On that website, consumers can find easy-to-understand information on different health insurance plans in their state and make straightforward comparisons of benefits, quality, and rates before they make a choice of plans. 

They can also learn if they qualify for programs like Medicaid or CHIP, or for tax credits to help offset the cost of health insurance. And for Spanish-speaking populations, there is an equivalent website now available in Spanish.

Additionally, when you need a place to direct folks for assistance in signing up for a plan, local Community Health Centers are a great resource – many with trained assisters whose job it is to help those with questions who walk through their doors, not just the patients seen in those clinics. Enrollment continues through March 31, so this window of time is especially important.

For providers, there’s a website that I hope each of you has visited, and if you haven’t please do, let me give you the address – marketplace.cms.gov.  This site is an excellent resource with material that can be easily downloaded – from brochures to PowerPoint slides – information that can be added to your websites, distributed in your workplaces, in classrooms, waiting rooms, board rooms, community meeting rooms, places of worship, and so on.

One other resource is on our HRSA website at hrsa.gov/affordablecareact.  There we have pulled together useful materials for health care providers to make it as easy as possible to get the knowledge you need.

In closing, we have, I think, really unparalleled opportunities to complement and strengthen each other’s efforts to achieve our common goal of improving the health and well-being of women and children, and their families and communities.

HRSA is committed to helping you in any way that we can in your efforts, whether it’s directing individuals to how and where to sign up for health insurance for the first time, to providing supportive services to high-risk families right in their homes.

By fully engaging the historical opportunities we have before us, we can make an unprecedented and lasting difference in the lives of America’s women, infants, and children. 

We look forward to engaging this vitally important work with AMCHP and with each of you.  

Thank you for the opportunity to be with you this morning.