Remarks to the National Rural Health Association

---

By HRSA Administrator Mary K. Wakefield

February 2, 2015
Washington, D.C.

Thank you Jodi (Schmidt) for that introduction…. And thank each of you for taking time away from your work and family and making the effort to be here in Washington, D.C., this week.  It’s a great opportunity to both educate about rural health care and to be educated about policy and programs focusing on rural health.

This Policy Institute is one of my favorite meetings because, coming from a small town myself, the institute has a little of the flavor of a small town.  When all of you come here, it feels like a “rural family reunion” – with occasional disagreements, but always with abiding affection for colleagues that we’ve come to know and respect -- for some of us -- for decades.

Speaking of “family”… I want to take this opportunity to acknowledge an individual you all know well as a “champion of rural health”—HRSA Deputy Administrator Marcia Brand.  While she’ll always be a member of the rural family, this will be her last Policy Institute as a member of the “HRSA family,” as she’ll be retiring from federal service at the end of this month.

Many of you know her best from her time leading HRSA’s Federal Office of Rural Health Policy.  While in that role, Marcia oversaw a period of significant growth at ORHP —with new responsibilities overseeing the Flex program and increased funding for the Outreach program. She got these programs, which are now strongholds in your communities, off the ground.

Marcia also was the driving force behind the creation of the Secretary’s Rural Task Force in 2001, which was the first time HHS had ever done a comprehensive analysis of how the department served rural America.  That initiative gave ORHP a new standing within HHS that it maintains to this day.

There are many other things I could mention that have Marcia’s fingerprints … the Frontier Extended Stay Clinic Demonstration, the Rural Assistance Center, the Institute of Medicine’s Report on rural quality, HHS’ broad engagement with Regional Commissions like Denali, and   the Appalachian Regional Commission ... the list goes on.

Marcia’s work has left an indelible imprint on rural health programs and policy and, on another front, it was at this policy institute meeting about eight years ago that, as Marcia finished with her HHS update, she had some time left.  So, never losing an opportunity, she then delivered what came to be known as her oral health – well, I’ll call it an impassioned soliloquy – whatever you call it, she got the attention of everyone in the room – probably including waiters and people walking by trying to find their hotel rooms.  In those remaining moments, she spoke from the heart about the deleterious effects of rural folks who, because of financial or geographic access problems -- go without oral health services.  And she delivered those comments like a true content expert because, in addition to many other things, she has dental hygienist on her resume.

I was here for that speech and I remember it like it was yesterday.  And, my guess is that there are a number of you in the audience who remember it as well.  For those of you that got her message that day, you’ll be pleased to know that Marcia has worked across HRSA and HHS to keep oral health as a priority issue.

So for all of that, I’d just like to take this opportunity to say, “thank you, HRSA Deputy Administrator Brand.  All of us in your “rural and your HRSA family” so appreciate your long-standing commitment and your stellar contributions to the health – including oral health – of rural America.

Well, this morning, I’d like to talk to you about several issues going on at HHS and HRSA that I think are relevant to improving the health of rural Americans and how we can continue to work together toward that end.  

I want to start by underscoring what no doubt each of you already knows -- that we’re in the final push to get uninsured individuals and families enrolled in a Marketplace Plan in the final days of the 2015 Open Season, which ends on February 15 – now just two weeks away.  That’s not much time left to help change the health circumstances of many rural Americans that are still without coverage.  And I’d like to talk for a moment about why it’s so important for us to engage in this work – from the community to the federal level.  I think this work is important because of the established relationship between overall health and health insurance coverage.

Based on research, you can draw a straight line between the two -- between health status and health insurance.  And that significant linkage is perhaps particularly important for rural populations.

Let’s start with the facts – some of them established by our own research conducted by or supported through HRSA.

First, the opportunity to help rural people get insurance is important because rural America has lower rates of health insurance coverage and higher rates of chronic disease than the population as a whole.

In fact, we know from our own research at HRSA that over the past 20 years life expectancy in rural areas has been consistently lower than in urban areas, and the gap is widening.  We also know that mortality from cardiovascular diseases, injuries, from lung cancer, and COPD is much higher in rural areas than in urban areas.

So getting folks into coverage is a critical step in addressing these long-standing and frankly, unacceptable disparities. This is something that all of us can do something about.

Also important to consider is the fact that rural small hospitals and clinics shoulder the burden of uncompensated care when uninsured individuals seek services.  So enhanced access to insurance coverage means that rural hospitals and practitioners struggling to pay their bills will have more patients able to pay rural providers for the services they receive.

So, for very good reasons, putting a priority on getting people enrolled is vital, and I ask each of you to think about how you can push forward to the end of the open enrollment season -- to talk about it, to write about it, to make sure you have information available so that people currently without insurance know what they need to know in order to sign up in each of your communities.

You may be interested to know that since the second Open Enrollment period began on November 15, we’ve seen – as of a week ago -- more than 9.5 million people across America select a new plan or re-enroll in an existing plan, and a large number of those people signed up from rural areas.

A report last week that looked just at the 36 States in the Federally Facilitated  Marketplace Exchange found that, of the 7.3 million folks who had selected plans, 1.3 million -- or 18 percent of the total -- are from rural communities.  That’s good news.  But to the extent there are folks in your communities who are unaware of the options, who don’t know how to get information or what that information means, this strong showing still isn’t good enough.  Not for my hometown, and I don’t think for your hometown either.  Not when we know the difference that health care coverage can mean to accessing health care.  But, as I mentioned, there’s still a block of time to work with, to redouble our efforts.

And to the extent that it would be helpful to you if we at HRSA partner with you on webcasts, conference calls, joint letters, blogs – anything -- to spur your colleagues to work as hard as they can to reach out with the message of how health insurance coverage can help your communities, we want to do that.  Please let us know if and how we can help.

And do keep in mind that people who are eligible for Medicaid or CHIP -- or whose personal circumstances have changed through marriage, divorce, birth of a child or other major life events – these folks can enroll in health insurance at any time during the year, not just during these designated enrollment periods.

Speaking of Medicaid, I’d be remiss if I didn’t also briefly mention the impact of Medicaid expansion on rural America.  The challenge of lack of access to health insurance is especially acute for states that have not expanded Medicaid – and for the rural communities in those states.

A July 2014 study by the North Carolina Rural Health Research Program found that most rural residents live in states without plans to expand Medicaid.  The study concluded that a complete nationwide Medicaid expansion would go a long way toward narrowing the insurance coverage gap between rural and urban areas.

But no matter of how states handle Medicaid expansion, HRSA has been working in partnership with local rural communities to extend the reach of our collective efforts to help individuals and families access coverage.

On this front, last year HRSA invested $1.4 million in rural communities to conduct outreach and enrollment activities in this current open enrollment period.  And that followed our 2013 investment of about $1.3 million in supplemental funds to our Rural Outreach grantees for outreach and enrollment activities during last year’s initial open enrollment season.  Those funds helped more than 9,000 rural residents sign up for coverage in the first enrollment period.

You can read about the lessons we learned during the first year of rural outreach and enrollment in an article by Linda Kwon, an ORHP staff member, which was published in the winter edition of NRHA’s own Journal of Rural Health.

And to further help all of you in your outreach to rural residents, Sahi Rafiullah, Helen Newton, Linda Kwon and Nisha Patel from ORHP led efforts to produce a new “Best Practices Guide in Rural Outreach and Enrollment.”  We just posted it on the HRSA website just a little over a month ago.  It’s full of great strategies geared to increase rural enrollment that we compiled from people like you and your colleagues – folks who have been working to extend the reach of insurance coverage across rural America.

For example, we’ve learned from several non-profit rural hospitals that they’ve been able to tie their outreach and enrollment activities to meeting their community-benefit reporting requirement.  It’s a great strategy:

• The hospital helps those in their community get the coverage they need  so that rural family after rural family can get healthy, stay healthy, manage chronic conditions, and so on.
• In the course of that, the hospital meets its IRS requirement for demonstrating community need.
• And by getting the uninsured enrolled, the hospital helps improve its bottom line by reducing the number of uninsured and reducing bad debt and charity care.

That really is a win-win situation!

To get a copy of this guide, you can download it by going to the hrsa.gov website and searching for “rural best practices.”

And just last week, ORHP released a new funding opportunity to do more outreach work, as well as support more comprehensive benefits counseling.  What we’ve learned is that a lot of rural folks really need help with a broad range of insurance issues.  ACA enrollment remains front and center, of course, but rural communities also can use these grants to help seniors sort through their Medicare coverage options -- or work with rural veterans to make sure they’re aware of their benefits and options, particularly under the Veterans Choice Act.  We’re planning to award eight grants worth just under $1 million in support of these kinds of activities.

Even as we wrap up this  Marketplace Open Season on February 15, , there are still of course, a lot of other things going on that I think are important for rural America.  Later in this meeting, you’ll hear from some of my HHS colleagues, starting with Jon White, the Deputy Director of the Office of the National Coordinator for Health Information Technology.  With the ongoing move to meaningful use of electronic health records, you’ll hear about key steps HHS is taking in this area and what they mean for rural hospitals and clinics and other providers.  

You’ll also hear from Dr. Patrick Conway, Deputy Administrator of the Centers for Medicare and Medicaid Services.  Patrick will talk about a big announcement from HHS last week focused on Delivery System Reform.  There is an important role for rural health to play in this ongoing discussion about how we can meet some ambitious -- and very important -- national goals laid out by our HHS Secretary, Sylvia Mathews Burwell.

As a native of West Virginia, I can tell you that Secretary Burwell’s rural roots – encompass rural health care issues and she has a keen understanding of many of  the health care challenges in rural areas. But also important, she sees opportunity for rural health.

I recently had a one-on-one meeting with her.  Let me tell you, in just a few short minutes she conveyed a very deep understanding of the issues, talking at length about the Critical Access Hospital in her hometown in Hinton, West Virginia, and how it had recently added a skilled nursing facility, which shored up its finances while also meeting an important local need for the elderly there.

She then talked about the complexities of the Medicare wage index and its impact on rural facilities.  So, in a few brief minutes, she showed a keen understanding of cost allocation for CAHs and the challenge of adjusting Medicare payment for local and national wages.  Tom Morris was with me and – as unflappable as he is – even he was more than surprised at her depth of understanding.

Bottom line:  This Secretary certainly gets it.   As part of that, delivery system reform is a key priority for the Secretary and also for HRSA and, as such, we’re working closely with CMS and other key partners in HHS to ensure a place for rural providers in this important activity.

From your own experience and, as you listen to Jon and Patrick and other speakers during the course of this meeting, you’re hearing and you’re going to hear a lot of discussion about the changes we’re seeing and that are envisioned in the health care system.  And accompanying that, from speakers and likely from each other, you’re going to hear about the need to be creative, to be innovative.

But I would argue that a strong bent toward creativity and innovation isn’t new to rural America.  Certainly when it comes to incentivizing value and care coordination, rural providers and rural systems are and can be leaders.  Since many rural areas have less supporting health infrastructure than in urban areas, rural health care is often, by necessity, creative and efficient.  Rural health care provides laboratories where innovation and collaboration are piloted and then implemented on a larger scale.

We see it played out often in the grant programs we fund out of the Federal Office of Rural Health Policy.  For example, in Missouri, the Citizens Memorial Hospital District has used ORHP funds to collaborate with a behavioral health system and the county health department in order to integrate medical and behavioral health services.   That’s an alignment many urban and other rural stakeholders are interested in pursuing.

In South Carolina, a Flex Program grant is supporting the Abbeville Community Paramedicine Project, a pilot initiative that aims to reduce 911 calls, Emergency Department visits, and hospital readmissions.  These are important areas for attention because of their impact on resources.

In my home state of North Dakota, Catholic Health Initiatives, supported by a Telehealth Network grant from ORHP, has used telemedicine services to expand access to behavioral health services in rural communities in western North Dakota that have seen rapid population expansion in recent years.

But it’s not just the programs that we at HRSA support.  There are a lot of people right in this room who are already developing, implementing, and adopting new ways of delivering care.

We see it in the work of Lynn Barr and the National Rural ACO folks, who have been able to combine their work across some very different geographies to collectively field an innovative ACO.  And we know others are also finding success with this model.  On a related front, we’re hopeful that recent proposed rule changes around patient assignment to include Physician Assistants and Nurse Practitioners may also help as rural providers consider the ACO model.

I could use all my allotted time to cite additional examples.  The point is:  Where better to test out new ideas and think creatively about how to improve health care than in rural America?

You’ll see that emphasis on innovation across the programs supported by the Federal Office of Rural Health Policy, and, yes, you’ll notice the word Federal in there.  We recently formally changed the name of ORHP to add the word Federal to better reflect the broad role the Office plays in working on rural issues across HHS and with a number of other Federal partners like USDA, the VA and the White House Rural Council.

Across the Office’s programs, we’re seeking to leverage the funding to provide rural communities with the tools and resources they need to not only survive -- but thrive.

You can see that in the many programs funded through the Rural Health Outreach authority.  In the past week, we’ve announced a number of new funding opportunities. We have also just announced $2 million in funding for Allied Health Training Networks, as well as $2 million for a new set of pilot grants that focus on Care Coordination.  Later this year, we’ll fund up to $16 million in new Rural Health Outreach grants.

We’re also doing what we can to meet emerging needs in rural areas.  Many of you are aware of the ongoing challenges related to opioid abuse and related overdose deaths that are significantly impacting many rural communities.  This is a highly complicated and worrisome trend in terms of opioid abuse and it is on the list of high-priority concerns for HHS.  In the coming year, HRSA is going to award 15 grants totaling $1.1 million that will allow for the purchase of narcan, an opioid antagonist, and support appropriate training in its use.  Eligible applicants include local emergency response organizations and other non-profit and for-profit entities.  As important as this specific rural investment is, we’ll also be working on other related fronts in this area.

That notion of effectively leveraging our rural grant funding is also evident in the work we do with the State Offices of Rural Health and through the Rural Hospital Flexibility Grant program.   The State Offices and the Flex program have made great strides in getting CAHs to focus on quality through the Medicare Beneficiary Improvement Program, and we’ve now got 95 percent of the CAHs agreeing to take part in voluntary quality reporting.

You see it, too, in the programs across the Office for the Advancement of Telehealth.  We’re particularly excited about the funding of the new Evidence-Based Tele-Emergency Network grant program, where we’re looking at the clinical impact of providing these services in small rural communities.

I would say that the changes in telehealth from 20 years ago until now are about as stark as the difference between a mainframe computer and an I phone. Two weeks ago I visited the Avera E-Helm in Sioux Falls, S.D., to see what I now consider a cutting-edge example of how telehealth can improve health outcomes, expand access, and support small rural hospitals and clinics.  In that particular example, they offer a full suite of services from e-pharmacy to e-emergency and e-consults across six states.  It is a remarkable blend of technology and human capital – both in the rural communities and in their connection to additional expertise in Sioux Falls.

I also want to highlight ORHP’s policy and research work.  The Rural Health Research Centers play a key role in objectively analyzing the issues affecting rural providers, and their findings are critically important to informing key policy discussions that we have within HHS.

For example, we know that some rural hospitals are facing financial challenges, and we’ve seen a number of rural hospitals close in the past few years.  In coordination with our Research Centers, our policy folks are tracking this issue closely.  What we can tell you is that – based on the research -- there is no single issue driving these closures.  Some folks think there is a cause-and-effect link to the ACA, but there’s no evidence to support that.  In some cases, we see communities that may not have the volume to support a full-service hospital.  In other cases, it’s a payer-mix issue that can be related to a State’s decision not to expand Medicaid or to challenges in third-party private reimbursement.  Or it may be due to market forces, given all the consolidation we’re seeing in the industry.  Or to a combination of these factors.

What I can tell you is that we’re continuing to track this issue closely.  We’re going to continue to do a deep dive on upcoming regulations in Medicare and the Marketplace plans to make sure rural considerations are taken into account.  And we’re going to continue to enhance our targeting of programs like Flex and Outreach to help rural hospitals, while also partnering with our colleagues in USDA and HUD on access to capital issues.  

But I’d be remiss if we only thought about the impact of HRSA programs on rural communities by focusing on the Federal Office.  HRSA’s other programs also play a key role in rural America.  Just to give you an example, you can see our impact in the work of the Home Visiting program, a program established by of the Affordable Care Act that seeks to improve health outcomes for women and children by leveraging community resources to make health care, counseling, and information available to at-risk mothers, children, and their families.

In 2014, home visiting services were provided in 321 rural counties, which represent 17% of all rural U.S. counties.  The number of rural counties served by Home Visiting grantees has increased more than 130% since 2010.  There is great need for these services in many of our rural communities, where one in four children currently live in poverty -- the highest rate since 1986 -- and the gap between rural and urban child poverty rates continues to rise.  Both the overall rural poverty rate and the rural child poverty rate have exceeded rates in urban areas for over 30 years.  You’ll hear more about the larger challenges around rural child poverty Thursday from Doug O’Brien of USDA.

The Home Visiting program’s emphasis on community and social determinants of health is also reflected in recent changes to HRSA’s Healthy Start program, which now emphasizes grantees’ efforts to “achieve collective community impact” by playing greater roles as hubs of service delivery to young mothers and their families.   In the past year, we’ve expanded funding for Healthy Start into rural communities and now have 11 rural grantees and 13 others that serve both urban and rural communities.

Finally, you are here in Washington during budget time, of course, and President Obama has just announced his budget proposal for FY 2016.  The President is asking for a $10 billion budget for HRSA in 2016, and his proposals for the agency build on the priorities embodied in the Affordable Care Act:

• The budget improves access to health care in underserved areas;
• It supports health professions training to build the health workforce for the 21st Century; and
• It also proposes new funding for three programs that will have no funding or --substantially less funding-- in FY 2016, programs that are critical to sustaining the nation’s health care infrastructure – Health Centers, the National Health Service Corps, and Graduate Medical Education.

First, the President’s Budget requests a total of $4.2 billion for the Health Center program to maintain this vital source of primary care for underserved patients.  As you probably are aware, almost 50 percent of HRSA’s 1,279 current health center grantees are located in rural America.  Those rural grantees served 7.5 million patients in 2013.

With these requested resources, Health Centers will serve 28.6 million patients, an increase of 1.1 million additional patients, at more than 1,300 health centers operating over 9,000 primary care sites.

The second of the three programs -- the National Health Service Corps -- is critical to bolstering the Nation’s health workforce.  And it’s also a key element in the strategy to improve the delivery of health care across the country, especially for underserved rural and urban communities.

NHSC clinicians help all sorts of people in the underserved communities we all care about – and in dramatically growing numbers under President Obama and the Affordable Care Act.

The number of NHSC clinicians has grown more than two-and-a-half times since 2008, and all of us who have our roots in rural America know very well that one extra clinician can make a world of difference in a struggling rural community.  Across rural America, more than 3,500 NHSC clinicians are currently practicing – that’s a lot of small communities impacted by their service and a lot of health care services that might otherwise not be provided.  That’s largely an ACA impact.

Going forward, The President’s budget proposes $810 million for the NHSC, including $523 million in new mandatory resources, to support an annual field strength of just over 15,000 providers.

The third critical HRSA program emphasized in the President’s 2016 Budget is Targeted Support for Graduate Medical Education.  He proposes $400 million for this new competitive grant program to support 13,000 new physicians over the next ten years in community-based, primary care settings, where most people receive the bulk of their health care.  As you read this part of the President’s budget request, you’ll see a specific nod to the need to focus on community-based residency training in rural areas.

The bottom line is that there is a lot going on, so you are here at a very good time.  I know there are many challenges facing rural communities, but there are also opportunities.  What I’ve shared with you today are some of the things we’re doing to leverage these opportunities.

The Federal ORHP team is one of the best and some of them are here today. I’ll ask them to stand, and if any of you see an unfamiliar fed face, please reach out to them during a break to introduce yourself.  There’s a lot our entire team learns from each of you.

With that, let me extend by thanks to NRHA for your tremendous leadership on behalf of health and health care in rural America.  And thanks to each of you for the critically important work you do back home, and for taking the time to be in Washington, D.C., now.