Remarks to National Black Nurses Association

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By HRSA Administrator Mary K. Wakefield

February 6, 2014
Washington, D.C.

Good morning.  Thank you for the invitation.  I want to begin by recognizing the important leadership the National Black Nurses Association provides – not just to support and advance the contributions of its members – but also the work that NBNA does to strengthen the health of the nation.

I’m really pleased to have the opportunity to talk with you – with fellow nurses – about the historic efforts under way through the Affordable Care Act to improve health and health care for individuals and families in America, and why this health reform effort – especially right now, right at this point in time – is so critically important.  

Fortunately, across the country, nurses and nursing organizations widely support the Affordable Care Act.  Members of our profession recognize it as a watershed moment in American health care because the law promotes what so many nurses and nursing organizations have always believed:  that everyone deserves access to affordable, high-quality health care.  That where you live, or what you do for a living, whether you’re a student or you have a job, or what your income is – that shouldn’t determine whether you have access to health care.  This belief isn’t unique to nurses, of course.

Access to affordable health care has long been on the agenda of some great leaders past and present, leaders like Martin Luther King.  Last month at HRSA, we hosted a ceremony to briefly stop and reflect on Dr. King’s dream for America.  And we recalled that in 1966, he said, quote, that “of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

So as I said to my HRSA colleagues last month, as we really begin to deliver on the promise of expanding access to high-quality health care through the Affordable Care Act, I have to believe that – if he were here – Dr. King would support our efforts and align himself with this mission.

At HRSA, we used last month’s event honoring Dr. King as a time to reflect on the extent to which any of us step up – at any given moment – and take actions, large or small, to overcome inequality.

I’m fairly certain that sometimes people wonder why I feel so passionately about achieving health equity and doing my part to make sure people have equal access to health care.

After all, I grew up in a small town in North Dakota, far from the civil rights movement that Dr. King led.

But my home town – Devils Lake, population 7,400 – is about 12 miles from an Indian reservation known today as the Spirit Lake Nation.   My mother taught school on that reservation, and even as a girl, I saw the differences between the two communities.  You didn’t have to look hard or far to see inequity.  It was everywhere – inequity as obvious as the fact that my town had paved streets, while dirt roads ran through the reservation.  I didn’t have first-hand knowledge of the segregation of the South that Dr. King struggled against, but I surely knew what inequality looked like.

As I grew up and left my hometown, those 12 miles came to represent some of the same  unfairness and discrimination that Dr. King sought to overcome, and it helped underscore to me how really important it was – and very much still is – to work to improve the health and well-being of all underserved and disadvantaged people across the country.

That work has rarely taken on the prominence or the opportunity that it has today, right now, in early 2014.  Last summer and fall – just before the online Health Insurance Marketplace website went live – I spoke with many nurse organizations about the healthcare.gov website and our outreach and enrollment efforts.  In fact, last July I traveled to New Orleans to speak with the NBNA’s Presidents’ Leadership Institute.

Well, last fall, as all of you know, enrollment in the Marketplace website experienced a turbulent takeoff.  But now, with the website operational, and features having come together, nurses have an unprecedented opportunity to help ensure that more people are able to get healthy and stay healthy because they have health insurance coverage.   What nurses do from now through the end of March when open enrollment ends will greatly impact whether people in our communities obtain – this year – the security provided by health insurance, insurance that can be life-changing.  

We’re in the midst of an incredibly important health insurance enrollment window in the Marketplace, and this is a critical time for individual nurses – and nursing organizations – to make an almost unparalleled impact on the health of individuals, families and communities.  

So that’s what I want to focus on today, and that’s why I want to tell you more about what we’re doing, and what you can do to address inequality in health that stems from inequality in accessing health care.  But first, let me say a word about the agency I lead, the Health Resources and Services Administration, better known as HRSA, and what we do that supports meeting the health care needs of underserved populations, because it fits hand in glove with the aims of the ACA.  

I’m the first nurse to lead HRSA.  I was appointed to this position by President Obama in part because I am a nurse, and the experience I draw on most every day in my job is my education and experience in our shared profession.

HRSA is known by many as the safety-net agency for vulnerable populations.  Our programs target services to people who are underserved geographically – whether they live in urban, inner-city or rural underserved areas; and medically – whether they have HIV/AIDS or need an organ transplant.

HRSA supports and works closely with nurses – both RNs and APRNs – in many ways, but especially through our workforce training programs, the community health center program, and the National Health Service Corps.

Our annual budget is about $8.1 billion, and our 3,000 grantee partners across the country join with us to further HRSA’s mission to strengthen access to care, build a diverse and culturally competent health care workforce, and improve health equity.

I think my colleagues at HRSA would tell you that one of the most attractive parts of working at HRSA is that we try every day to fulfill Dr. King’s dream for America.  Through our health center and Ryan White HIV/AIDS programs, through our programs to promote rural health and maternal and child health, and through our efforts to promote and expand organ transplants – and so much more – HRSA works to bring greater fairness and equity to health care by providing needed services to the most underserved among us.  

Of course, right now at HRSA we’re focused like a laser on making sure that we help spread the word about the need to get everyone who qualifies signed up for health insurance coverage under the Affordable Care Act.

I know that many of you have already shared information with neighbors, students and service organizations to help people get covered, and your efforts are making a difference.

As of today, more than 9 million people have signed up for private insurance through the Health Insurance Marketplace, or have learned they’re eligible for Medicaid, or have renewed their Medicaid coverage thanks to the Affordable Care Act.  That’s a tremendous number of people who are benefiting already from the ACA, and we are encouraged by the strong response.  To break that down, our latest statistics show that:

• As of January 15, approximately 3 million people enrolled in private insurance through the Marketplace; and
• As of December 31, 6.3 million people learned they were eligible for Medicaid or had renewed their Medicaid coverage.

And this doesn’t include the more than 3 million young adults who’ve already gained coverage since 2010 because the ACA allows them to stay on their parents’ plans until they turn 26.

So, those are the numbers – but who are the people behind those big numbers that can make a person’s eyes glaze over?  In the discussion of millions of people enrolling in and benefiting from the ACA – and millions more who are eligible to enroll but who may not even know it – it’s easy sometimes to forget how the law will have a real impact on real human beings.  We can lose track of the difference the ACA can make, one person and one family at a time.

So let me share with you a story of a person for whom the ACA’s benefits came too late, a story written by two physicians that appeared three months ago in the November issue of the New England Journal of Medicine.  

The story is about a man called Tommy Davis.  The physicians described Mr. Davis and his wife as having no health insurance despite working full-time jobs.

The physicians first met Mr. Davis in their clinic for indigent patients in March 2013, following a visit he made to an emergency room for abdominal pain.  The work done in the ER – an exam, lab tests, and a CT scan – cost Mr. Davis $10,000.  That was an amount equal to his entire life savings.  Once the test results came back, the ER sent Mr. Davis home with a diagnosis of metastatic colon cancer.

By the way, this wasn’t the first time Mr. Davis had been seen in the health care system for worrisome symptoms.  The year before, the physicians wrote, “Mr. Davis had had similar symptoms and had visited a primary care physician, who took a cursory history, told him he’d need insurance to be adequately evaluated, and billed him $200 for the appointment.”

Since Mr. Davis was poor and ineligible for Kentucky Medicaid, by the time of his trip to the emergency room and to see these two physicians he had a fully obstructed colon and widespread disease.  He chose to forgo any treatment.

The authors noted that, “Mr. Davis had an inkling that something was awry, but he’d been unable to pay for an evaluation.  As his wife sobbed next to him in our exam room, he recounted his months of weight loss, the unbearable pain of his bowel movements, and his gnawing suspicion that he had cancer.”

“In fact,” Mr. Davis said to the physicians, “if we’d found it sooner, it would have made a difference.  But now I’m just a dead man walking.’ ”

The authors continue by saying, quote: “However unconscionable we may find the story of Mr. Davis, a U.S. citizen who will die because he was uninsured, the literature suggests that it’s a common tale.

They go on to write near the end of the story that “in discussing (and grieving over) what has happened to Mr. Davis and our many clinic patients whose health suffers for lack of insurance, we have considered our own obligations.”  

“We can familiarize ourselves with legislative details and educate our patients about … health care reforms.  During our appointment with Mr. Davis, [for example], he was unaware … that under the [ACA’s] final rule, he and his family would meet the eligibility criteria for Medicaid and hence have access to comprehensive and affordable care.”  

And I would say that what these physicians see as their obligations – to know the basic provisions of the law and to educate people who could benefit – many nurses would see as an obligation of our profession as well.

The physicians concluded the article by saying that “it is well-documented that our country’s uninsured present with later-stage cancers and more poorly controlled chronic diseases than do patients with insurance.  We find it terribly and tragically inhumane that Mr. Davis and tens of thousands of other citizens of this wealthy country will die this year for lack of insurance.”

I think that the observation by these physicians surely echoes Dr. King’s, that “injustice in health care is the most shocking and inhumane inequality.”

The physicians called on their colleagues to act on behalf of our less-fortunate neighbors and to familiarize themselves with how the Affordable Care Act can help.  I’m here today to do the same – I’m here to call on you, my nurse colleagues, to act.

We all know people like Mr. Davis and his wife – maybe they’re even our friends or family members – they’re people who may work in jobs that offer no affordable insurance options, who may be out of work, or who may suffer from acute or chronic or terminal illness.  They’re people who couldn’t have gotten or afforded health insurance before the ACA if their lives depended on it.

It’s our time now to make sure that, as nurses, we do everything we can to end these types of stories.  We need to make sure that other Tommy Davises and their families across America know that today they have options and how important it is to pursue those options in order to get healthy or stay healthy.

Obviously, and most importantly right now, we need to educate the uninsured.  But we shouldn’t stop there.  We also need to educate the already insured, because the Affordable Care Act has brought significant benefits to those who already had health insurance coverage -- though folks with insurance may not even be aware of it, and may think, wrongly, because they already had health insurance coverage, that the new law didn’t help them.

They may not know that just last month – for the first time – individuals and families gained new consumer protections:

• As of January 1, patients can no longer be denied coverage or charged higher insurance premiums because they have a pre-existing health condition like high blood pressure, cancer or asthma.
• From now on, health care benefits can’t be capped annually. Historically, that cap on insurance coverage has meant that for many people diagnosed with serious conditions, their health insurance coverage ran out just at the moment they needed it most.  Well, insurance companies can’t do that to people now.
• Additionally, no woman in this country can be charged more for health coverage just because she is a woman.  Perhaps some of you were unaware that that was a practice of some insurance companies – but it isn’t now.
• And, here’s another critically important benefit of the law:  Americans no longer have to worry about going without health coverage if they lose their jobs.
• And also effective last month, comprehensive coverage that includes emergency services, maternity and newborn care, prescription drug coverage, and mental health and substance use disorder services now are required of all health plans.

Those are impressive gains in coverage.  But we can’t rest, not with so many people outside this room who don’t yet have the benefit of health insurance coverage.  Perhaps some of you here were on the phone call HHS Secretary Kathleen Sebelius and I made to nursing organizations two weeks ago asking nurses to step up and redouble their efforts.

The Secretary took the time to make that call because she recognizes that nurses already know first-hand the importance of health coverage – and the difference it makes in terms of allowing people to get the care they need, when they need it.  Nurses know that an injury or an illness can – and too often in America does – bankrupt individuals families that don’t have insurance coverage.

The Secretary also is very well aware that nurses’ action is vital because patients and neighbors turn to us for advice and guidance.  In fact, we know from research that people are more likely to trust information about the Affordable Care Act when they get it from nurses and doctors than if it comes from sources like the news media, their employers, or even their friends and families.

And after all, this is one of the things that nurses do best – educating patients in all the different venues where nurses can be found – making sure information about healthcare.gov is available in ERs and classrooms, in public housing and at health fairs; distributed in places of worship and community and board rooms; in hospital waiting rooms and clinics.  Wherever nurses are, I think this information should be available there, too.

Nurses’ engagement is critical because while we’ve made very important strides in getting people covered, today we still have millions of Americans unable to get important health care services – including nursing services – because they’re on the outside of health insurance coverage.  But it doesn’t have to be this way.

To inform your patients, relatives and friends, you don’t have to know all the details about the ACA.  But you do need to know where people can be directed for more information and also to share with them what nurses already know -- the incredible difference in health that insurance makes.

There are five basic ways to help your patients, students and community members apply for health coverage through the Marketplace.  This is the information you can share in speeches and meetings.  This is the material you can tape to exam room doors:
• First, people can go online to HealthCare.gov to shop for coverage 24/7 from their kitchen table, living room or library, or anywhere they can access the internet.

• Second, they can call the toll-free number, 1-800-318-2596, any time day or night.

• Third, they can apply in-person with a trained counselor in their community — for example, staff in our community health centers.  You can find these counselors in local communities by visiting LocalHelp.HealthCare.gov.

• Fourth, people can apply by mail by downloading the paper application from HealthCare.gov.

• And finally, people can work directly through a health insurance issuer, agent or broker.

We already have resources targeted directly to help health care providers communicate with patients and others.  For nurses and other providers, there’s a website at marketplace.cms.gov that has a broad range of resources – from brochures to PowerPoint slides – that you can easily download to use as educational material on your websites and in classrooms, waiting rooms and board rooms.

And at HRSA, we have pulled together our own website of useful resources for health care providers to make it as easy as possible to get the knowledge you need at hrsa.gov/affordablecareact.  

I hope all of you go to these websites to access those materials, download them and share them.

Of course, the Affordable Care Act does far more than expand access to quality health care.  It also gives nurses increasingly important roles and responsibilities in redesigned health care systems, so I’ll spend my last couple of minutes talking about that.

Earlier I mentioned HRSA’s health centers.  The Affordable Care Act invested $11 billion over five years in health centers, which deliver primary and preventive care to 21 million patients at more than 9,000 sites throughout the country.  Health centers provide services to anyone who seeks health care there, with fees adjusted based on patients’ ability to pay.  Since President Obama took office, that patient base has grown by about 4 million people.

To treat those extra patients, health centers used ACA funds to add some 4,500 nursing positions since 2009.  Right now, nearly 18,000 nurses work at health centers across the country, including 4,700 nurse practitioners and more than 500 certified nurse midwives.

And we just recently announced 236 new health center sites which will be stood up this year to provide additional access points for primary care -- along with new employment opportunities for nurses and others.

Also, thanks largely to ACA investments, the ranks of the National Health Service Corps have more than doubled from about 3,600 clinicians in 2008 to nearly 8,900 primary care providers today.  Of that number, nearly 1,600 are advanced practice nurses – that’s nearly twice as many NHSC nurse practitioners and nurse midwives as there were just 4 years ago.   According to self-reports, about 15 percent of the APNs in the Corps are African American.  That’s slightly higher than the 13-14 percent estimate of African Americans in the U.S. population, so this is a very good program that helps African Americans pay down school debt and help meet the needs of underserved communities.  

In case you didn’t know, the NHSC works like this: clinicians get their school loans repaid up to a total of $50,000 in exchange for 2 years of service in underserved communities – and they, of course, get a salary, too.  Many Corps clinicians work in our health centers.

The ACA also recognizes the importance of providing health care where children spend so much of their time, so it extended substantial support to school-based health centers – which rely most heavily on nurses – to ensure that children can stay healthy and are more ready to learn at their highest potential.

And in the area of maternal and child health, the ACA created the Home Visiting program, which puts more health care “boots on the ground” in at-risk communities.  Under this program, nurses, and others work with pregnant women, fathers and young children in their homes in high-risk communities, providing early counseling and evidence-based intervention services to improve health outcomes.  Now more than 500 nurses work in this program –and the program continues to expand in all states across the country.

So these are ACA provisions that have already been implemented and are already making a difference.

Beyond the ACA’s impact on expanding primary care and nursing care in various settings, the law also has improved training for nurses and other primary care providers.

For example, the ACA directed $15 million to nurse-managed health clinics, which train new nurses while delivering primary care to vulnerable populations.

The ACA also allotted $31 million to prepare more primary care advanced practice nurses and $200 million for graduate nurse education programs that prepare APNs for roles in coordinating care.

In addition, while not part of the ACA, the Obama administration strongly supports nurses through a scholarship and loan repayment program similar to the NHSC but that is strictly for nurses.  We call it the NURSE Corps.  More than 2,500 nurses practicing in underserved areas throughout the country have been assisted through this program – either through a scholarship to attend nursing school or through help repaying loans associated with nursing school – and over 700 additional scholars are currently in the education pipeline.  Once they complete their training, they’ll begin their service obligation in an underserved community.  According to our data, 12.3 percent of NURSE Corps nurses are African American.

These and other training investments are critical to help ensure that we have a nursing and health care workforce that is capable of caring for an expanding, and increasingly older population and ready to provide care to those who become newly insured as a result of the Affordable Care Act – people who in some instances will start accessing health care services outside of the emergency room setting for the first time.  These are people who will get treatment earlier because the Affordable Care Act places high value on screenings by requiring insurance companies to provide them at no out-of-pocket costs to the patient.    

For all of us, these are welcome changes.

Before I close, let me give you a glimpse into activities that HRSA is engaged in whose impact will occur over a much longer timeframe than the next several weeks.  I’m talking about our activities to improve health care quality and health professions workforce diversity, and nurses are at the core of both efforts.

First, care quality.  Over the past several years, HRSA has worked with private foundations to promote the development of competencies needed to deliver interprofessional, team-based care.  These competencies include how to practice as team members across health care settings, and how to assess and apply clinical evidence regarding treatment options to facilitate care coordination.

Why is this needed?  Because gaps in health care between care settings and among health care providers put at risk the health of patients while also contributing to inefficiency and increased costs.

As our health care delivery system evolves from a model dominated by acute care to one that more robustly embraces primary care and prevention, nurses should be key players in coordinating the delivery of this high-value, cutting-edge care.

So HRSA is working to promote the delivery of health care by provider teams through interprofessional training of both students and faculty.  About a year and a half ago, we awarded a grant to the University of Minnesota to host a new National Center for Interprofessional Practice and Education.  

This five-year, $12 million initiative supports the development of a more integrated health system of coordinated, collaborative, team-based practice as it becomes the new national norm.  So remember “interprofessional care” and the opportunities it will offer nurses in the future.

Also at HRSA we understand that achieving health equity – which is one of HRSA’s four main goals -- requires a collective effort that focuses on social determinants of health across all disciplines and all sectors, including those outside of health care.  HRSA’s Division of Nursing recently posted on its website a special Public Health Reports supplement titled Nursing in 3D: Workforce Diversity, Health Disparities, and Social Determinants of Health.

The supplement examines work underway to address health disparities and health equity specifically within the context of the social determinants of health – that is, environmental conditions that contribute to avoidable differences in health status, such as relative lack of access to health care, and the availability and affordability of housing and food supplies.

We all need to better understand these environmental challenges that can compromise health status and work to address them through research, practice, public health and public policy.

And at HRSA, we’re trying to do just that.  For example, in our latest Nursing Workforce Diversity grant opportunity announcement (which closed January 24), we said that applicants must include “innovative approaches that use social determinants of health to frame its scholarship, stipend, and pre-entry/mentoring activities.”

The announcement went on to say that these approaches “should … address the larger social and structural forces that impede efforts to diversify the nursing workforce, increase access to quality care, reduce health disparities, and improve health equity.”

Social determinants of health as drivers of inequity and interprofessional care are two of a number of important issues HRSA is working to address.  

But for the next several weeks, we ask you to join us in keeping our full attention on the Affordable Care Act and on what we can do to sign people up for health insurance coverage until this current enrollment period closes on March 31.  I can’t think of a single action we could take that could impact the health status of people more.

People who enroll before March 31 will have insurance through the Marketplace, but the next scheduled enrollment period doesn’t begin again until November 15.  So these next few weeks are so crucial.  Enrollment in Medicaid, however, is ongoing.

This is a truly historic moment, one in which nurses are playing, and will continue to play, a decisive role in improving the health of communities across the country.  

To close, I think it’s worth noting that just last week HHS Secretary Kathleen Sebelius visited Paul Quinn College, a historically black college in Dallas, to promote the benefits of the Affordable Care Act.   There she noted that six out of 10 African Americans may be eligible for Medicaid, CHIP or financial assistance to help pay for health insurance through the Marketplace.  Secretary Sebelius estimated that as many as 6.8 million uninsured African Americans have opportunities today for affordable health insurance coverage through the online Marketplace.

Clearly there is more important work for all of us to do.  On behalf of the U.S. Department of Health and Human Services and as a nurse colleague – I thank you for everything you do to promote the health of the nation today and to ensure the health of America’s next generations.