Remarks to the National Health Law Program

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By HRSA Administrator Mary K. Wakefield

December 8, 2014
Washington, D.C.

Good afternoon, everyone. I’m very happy to be here today to speak with you.  The National Health Law Program is a longstanding “Friend of HRSA,” and so I am especially pleased to have this opportunity to recognize our partnership and to share with you some of the work we have underway at HRSA.  

Perhaps most importantly, I want to thank NHeLP for your strong and unwavering support of the Affordable Care Act.  Across the U.S. Department of Health and Human Services, we deeply appreciate your support of the law – the most important health reform law since Medicaid and Medicare.  And as I will explain shortly, we will still need your help and legal expertise over the coming months.

Your organization and HRSA share the same orientation toward our work: ensuring that low-income, disadvantaged, underserved populations have the same opportunity to get healthy and stay healthy.  And we both recognize that to achieve that aim, people need to be able to access quality and affordable health care.

And, more broadly, we at HRSA recognize what many of you have known – the need to consider the broader context that influences the health of the individuals we serve: that is, the link between social determinants of health and health status.  We’re increasingly working to raise awareness about how characteristics like income or geographic location are related to one’s health because that recognition helps shape federal programs -- like HRSA’s Health Center program and Ryan White HIV/AIDS Programs -- that work for the communities that we serve.  It’s also an important orientation to bring to broader efforts, like expanding access to health insurance coverage, which I know has also been a long-standing priority for NHeLP.

I know that in addition to our shared orientation, our work also overlaps with yours. You work with individuals and families every day who either benefit from one or more of the over 80 programs that HRSA operates or benefit from provisions of the Affordable Care Act.  At HRSA, with a budget of about $9 billion, we engage with and through you -- and about 3,000 other associations and organizations every year – to help meet the needs of underserved populations across the country – from inner cities to the most frontier areas.

As you may know, all of HRSA’s programs – from maternal and child health programs to our rural health investments that coordinate care in isolated and underserved communities – aim to impact and improve the health of communities, and to end health disparities among groups and across geographic areas.

Given our shared focus, there are a number of ways for us to partner together, and I’d like to spend a few minutes talking about how you can provide input through structures and processes, and then I’ll shift over to talk a little more about what we’re doing at HRSA, including activity around the ACA.  As I mention the opportunities to provide input, I’m hopeful that you will be thinking about ways you might want to engage with HRSA on issues you care about.  We have terrific expertise within HRSA but we are always looking for new input from our stakeholders!

One way you can provide us with expert input is by participating in one of the many national advisory committees HRSA has responsibility for.  These committees cover issues ranging from farmworkers’ health to infant mortality, to heritable disorders in newborns and children, and to advising on health care workforce or rural health issues.  In fact, prior to becoming HRSA Administrator, I served on advisory committees both at HRSA and at another HHS operating division, the Agency for Healthcare Research and Quality.  

These committees meet regularly throughout the year – at varying levels of frequency – and meetings are open to the public. And now that many of these committee meetings are virtual, people can participate remotely by serving as a member or as part of the public audience.  For HRSA’s advisory committees, you don’t even need to leave your desk or travel to attend.  Advisory committees explore key health-related issues within their committee charge, and they make recommendations to the HHS Secretary or to the Congress.

If you want to learn more about the Secretary’s advisory committees, you can contact the HHS program you are interested in, and for committees that HRSA is involved with, you can go to our website at hrsa.gov and contact key staff in the Bureau or Office that has responsibility for that issue – such as the Maternal and Child Health Bureau or the Bureau of Health Workforce.  To give you a sense of how all this works, let me share an example.

In terms of their recommendations, the Secretary’s Advisory Committee on Infant Mortality, for example, issued a call in a January 2013 report for a strategy “to increase health equity and reduce disparities by targeting social determinants of health through both investments in high-risk, under-resourced communities and major initiatives to address poverty.”

Now, to all of us, this probably seems like a fairly obvious recommendation. But the link between under-resourced communities and health disparities isn’t always obvious, which is why we’re focusing even more on the underlying causes of persistent disparities – such as poverty or lack of housing.  We also know the recipe for reducing infant mortality – early identification of high-risk pregnant women, early intervention for risk factors such as prenatal smoking, and access to services before, during, and after pregnancy.

In the process, we are also expanding our focus on the use of metrics to measure performance and improve quality.  And, here at HRSA, we are doing just that with the Healthy Start Program.

Healthy Start programs work in some of the nation’s poorest communities to prevent infant mortality by reaching out to pregnant women and new mothers to connect them with health care and other resources to nurture their children. Healthy Start grantees also reach out to various sectors at the local and state levels – housing, education, the environment, and more – to address those contextual obstacles to good health.

So, on the basis of the Advisory Committee’s recommendation and other input, we looked at the Healthy Start program and we asked ourselves, “What more can we do to further address infant mortality in high-risk communities?”  This year, we transformed the Healthy Start program by including strategies to improve quality, expand access to care, and invest in surveillance systems to measure outcomes.

We also asked grantees to do more by better aligning program investments in order to serve 60,000 women and children annually, an increase of about 15,000 over the previous Healthy Start program.

In addition to this, we are also going to begin to capture grantees’ efforts to enroll clients in Medicaid and connect them with the community health care system – and I know this is another important issue for NHeLP.

These are great example of how we couple input from external experts and advisors and also apply practices we have seen to be successful in other health care sectors to our work.

Staying for a moment with the focus on HRSA programs for vulnerable women and children, another program that is emblematic of this Administration’s strong support for women and children is the Home Visiting Program, which was established through the ACA.  This voluntary, evidenced-based program is strongly supported by President Obama, and it’s part of the President’s Early Learning Initiative that he included in his FY 2015 budget proposal.

I think the Home Visiting Program is one of the most significant investments over the past decade in support of prevention and well-being for mothers and children. The program puts more health care “boots on the ground” in at-risk communities to address some of the very social determinants of health that I just mentioned.

Nurses and others work with pregnant women, fathers, and young children in their homes, providing early counseling and evidence-based intervention services to improve health and development outcomes through initiatives that provide information, coaching, and support for parents struggling to meet their children’s basic needs.

The program is now active in all states.  As of September 2013, grantees reported serving a total of 77,000 parents and children in 774 communities across the country.  Through my work, I have met with some of the nurses and the families they serve.  I can tell you that it is a lifeline for these typically young and fragile families, providing an array of information and referrals, from nutritional education to early learning strategies.

The Home Visiting models have been shown to lower domestic abuse and increase parenting skills, economic self-sufficiency and children’s readiness to learn.  And states are working with partners at the local level with community-based organizations and health care providers to achieve these successes.  The program resets some of the circumstances for infants and children and their moms in remarkable and, frankly, essential ways.

As you may know, funding for the Home Visiting Program is set to expire in March 2015, and unless Congress reauthorizes the program, a host of initiatives that have proven effective for strengthening high-risk families will end.  I want to thank you for your consistent support for this very important program.

Earlier I mentioned Advisory Committees as one way to engage with HRSA programs.  Another avenue for involvement is by connecting with local health centers to work together on shared aims at a community level.  All HRSA-funded community health centers have boards that oversee their work, and by law at least half of the board members must be patients who come from the local community.

Other board members include social service providers, community leaders, hospitals, businesses, schools and other community based organizations – so you may become members yourselves. This direct community engagement ensures that the voice of the consumer and the community is heard when new health center policies or directions are established and implemented.

Health centers also perform community health assessments to identify critical needs and resources, so getting involved with these boards is another important way to track and impact community health and support community efforts with HRSA resources.

More broadly, as insurance coverage continues to expand as a result of the ACA, the role that health centers have in the primary care and public health arena continues to evolve, too.  Today, the Health Center Program supports a nationwide network of almost 1,300 grantees that deliver primary care to nearly 22 million patients at 9,200 sites throughout the country. That’s 1 out of every 15 Americans, and nearly 5 million more patients than in 2009.

Moreover, more than two-thirds of health center patients live below the federal poverty line, so health centers provide essential preventive and primary health care services to one out of every four people living in poverty.

Health centers represent the single largest network of health care providers in the country. Their growth over the past 4 years has been driven by the Affordable Care Act, which significantly boosted funding to health centers and pushed a growing trend to integrate public health and primary care – and these previously separate worlds are increasingly viewed as intertwined.

Part of this shift is driven by the ACA’s sharper focus on getting people insurance coverage and building out the infrastructure so that they have additional places to obtain care.  And as our health care systems transition away from quantity of care to one focused on patients’ health outcomes, health centers are evolving into patient-centered medical homes where preventive health care, oral health care, HIV care and mental health services – alongside other services – are all provided under one roof.

For example, in FY 2013, health centers provided mental health services to more than 1.1 million patients and substance abuse services to more than 100,000 patients. They also served more than 1.1 million homeless people and provided enabling services such as case management, transportation, eligibility assistance, and translation services to more than 2 million patients.

So health centers are providing other services beyond health care, and they are addressing social determinants of health to overcome persistent obstacles to care.  And as health centers expand and further connect with community partners, we will be better positioned to address community-based public health challenges.  I’ll say more about this in a minute.

So, bottom line -- health centers, as part of a broad array of local service systems, are increasingly about the health and well-being of the community as a whole, not just individual patients.

And increasingly, health centers are creating referral networks or partnerships with legal service organizations and other non-profits to fully integrate legal services into health care teams.  This is where some of you may be a little bit more familiar with our work.

These collaborations between health centers and legal services organizations can leverage outside groups’ expertise through training for health center staff and volunteers to provide legal referrals or counseling to patients.

In July of this year, for example, we signed a 3-year National Cooperative Agreement worth $300,000 a year with the National Center for Medical-Legal Partnership – a project of George Washington University.  As you may know, the Partnership’s mission is to support an integrated medical-legal approach to health and health care for underserved populations –an approach that can ultimately help improve health outcomes.

Working at the intersection of health care and health care law, the Partnership helps train staff to identify and address the sources of some health-harming social problems – such as unsafe housing conditions, domestic violence, or lack of access to health insurance.

In fact, civil legal aid may be included in the range of “enabling services” that HRSA-funded health centers provide to meet the primary care needs of the communities they serve.  While this enabling service does not come with specific funding, health centers can explore the re-allocation of enabling services funds toward civil legal aid.  It also means that health centers may be able to apply for future enabling services grants from HRSA to support medical-legal partnerships.

And we fully understand the importance of legal aid for access to health care.  For example, HRSA supports a Cooperative Agreement with Farmworker Justice, a non-profit organization that works with front-line health center staff, such as clinicians, outreach workers, promotoras, community health workers, case managers, or front-desk staff.  Farmworker Justice staff help us screen for legal problems related to housing, employment, disability, and other situations that can lead to stress and make health problems worse.

Through partnerships like these, HRSA capitalizes on available expertise to integrate legal services into health care settings.

In addition to the integration of legal services with health care services, health centers are undertaking another important integration effort – one that you may not be familiar with: The integration of primary care with public health.  Part of this shift is driven by a sharper focus in the ACA on keeping people healthy rather than just treating them after they’ve become ill.

And as the focus of our health care system transitions away from quantity of care to one focused on health outcomes, coordinated health care, and social determinants of health – we will be better positioned to address public health challenges such as cardiovascular diseases, injuries, obesity, diabetes and other chronic diseases that are literally crippling our nation and threatening the well-being of future generations.

Entities throughout HRSA are working to strengthen the link between primary care and population health.  For example, our Maternal and Child Health Bureau is working with the Association of State and Territorial Health Officials to expand the integration of primary care and public health through initiatives such as the Million Hearts Campaign, with the goal of preventing 1 million heart attacks and strokes by 2017.

And earlier this year, we signed a cooperative agreement with the National Organization for State and Local Officials worth $2 million over 3 years to help state and local governments address several issues, including:

• implementing the ACA;
• promoting the integration of primary care and public health activities;
• and helping state and local health agencies collaborate on efforts to implement innovative strategies to improve health and achieve health equity – in fact, that’s a central aim of the agreements.

Our focus on public health and community-based health care services extends to the services we provide to Americans who are HIV positive.  As you know, many of the people with HIV/AIDS have comorbidities, are poor, and have a range of other problems that make it very difficult for them to successfully treat their conditions.

To address the array of challenges these populations face, HRSA’s Ryan White HIV/AIDS Program works with cities, states, and local community-based organizations to provide HIV-related services to more than half a million people each year, people who have insufficient health care coverage or too few financial resources to pay for their care and treatment.

Among the many services the program provides are those needed to help people stay in care, such as housing assistance, behavioral health care, and case management – all of which address the barriers that make it difficult for people living with HIV to obtain access to medical care and life-saving treatment.

For example, housing services are critically important for people living with HIV.  At any given time, about 10 percent of people receiving assistance through the Ryan White Program are homeless, do not have permanent housing, or need short-term assistance.  And without a place to live, it’s much harder to prioritize medical appointments, fill prescriptions, or have a safe place to store medications.

As you know, when people are homeless they spend most of their energy on meeting their most basic needs, at the expense of their health.  For example, our data shows that viral suppression was almost 20 percent lower for people who did not have stable housing in 2012. So housing is the key indicator that people are getting and staying in care.

And for a number of HIV-positive individuals, legal assistance is also health care.  Services provided under Ryan White include legal services to eligible HIV-positive individuals to address legal matters directly related to their HIV status – including legal services to ensure access to eligible benefits and address HIV discrimination or breaches of confidentiality that hinder access to quality health care and medications.

This is another example of the overlap between your goals and ours.  And it shows how HRSA focuses not just on the provision of health care services, but also on ways to leverage our assets – and potentially yours – to address social determinants of health.

Before I take some questions, I also wanted to spend some time talking about your efforts to help individuals and families access affordable, quality health insurance through healthcare.gov.

In preparing for my remarks, I looked at your online resources and was incredibly impressed by the attention NHeLP places on outreach and enrollment efforts.

As of today, 6.7 million Americans have already enrolled in Marketplace coverage, and another 9.1 million have enrolled in Medicaid and the Children’s Health Insurance Program.

I want to extend a heartfelt “thanks” to those of you here who in small or large ways have helped people to learn about and sign up for health insurance.

And, as you know, the Marketplace just recently opened again and will continue to accept applications through February 15.  This time around, new enrollees will find the application process for insurance to be simpler, faster, and more user-friendly than it has been:

• It’s simpler because people will enter information just once.
• And it’s faster.  While the length of time that it takes to fill out the application depends on a consumer’s specific situation, for many people the 76 screens they had to click through during the first enrollment period has been reduced to just 16 clicks.
• And as I said, it’s now more user-friendly for consumers. It’s a more streamlined application that has simpler navigation and built-in help along the way.

And wait-times for the national call center have been reduced from several minutes to just seconds as a result of 1,000 new call center operators.  This is great news in terms of helping consumers access insurance.

In the first two weeks of open enrollment that ended on November 28, more than 765,000 people had selected plans for Marketplace coverage, and more than 1.5 million people spoke with one of our call center representatives after an average wait time of just 8 seconds.  So every day, we’re making progress – but it’s still early, and we have a lot more people to help get enrolled; to make sure they stay enrolled; and help them use their benefits wisely.

It’s not just crucial that we help people who don’t currently have health insurance coverage. It’s also important for people who signed up last year and need to make changes for 2015.  Twenty-five percent more issuers have joined the market this year, so folks who are re-enrolling may find more choices.

Even as we make this progress, however, there are still 23 states have yet to expand Medicaid, depriving an estimated 5.7 million people of health insurance coverage.  This is another critical piece of the Affordable Care Act that I know many of you are also paying close attention to this in your home states.

At HRSA, we deeply appreciate your leadership and commitment to improving the health of people across the country.  Thanks so much for the important work you do to help more people get healthy and stay healthy, because at the end of that day, that is what so much of our collective work is all about.