U.S. Department of Health & Human Services
HRSA Press Office: (301) 443-3376
Remarks to the University of Rhode Island Honors Colloquium
September 18, 2012
Before I begin, I’d like to say a few words about the agency I lead, the Health Resources and Services Administration, which we call HRSA. We are an agency of the U.S. Department of Health and Human Services, alongside agencies such as the National Institutes of Health, the Centers for Disease Control and Prevention, and the Food and Drug Administration.
HRSA has a portfolio of 80 different grant programs. Not all, but most of these programs go toward expanding primary care and extending health services to those who are low-income, medically vulnerable or geographically isolated, need an organ transplant, or live in frontier areas.
Among the programs and activities we support are the following:
Speaking of organ donation, I always ask every group I speak with to consider signing up or help sign people up and become organ donors. This year, we kicked off our “Fifty Plus” campaign targeting people over 50. I’m over 50, and that word “donor” is on my driver’s license. I hope it’s on yours, too, regardless of your age.
Did you know that more than 100,000 people are waiting for an organ, and 18 of them die every single day waiting for an organ? You are never too old, so please get involved. We’ve had college campuses involved, including medical and nursing schools that have helped out.
Well, to deliver health care services through its programs, HRSA has about 3,000 partner organizations. There is virtually nothing that is done by HRSA without state and local government agencies, non-profits and community-based organizations, foundations, clinical providers, universities, research centers and others.
But before I get to health care, let me say a word about one of those 3,000 partnerships – our partnership with URI. It is one of our important partners, of course, a really terrific university that makes a serious commitment to offering affordable and high-quality education to students from all over the world.
I have heard about your innovative Health Studies Major for non-clinical careers in public health, health education and promotion, and health services. We definitely need more people with a broad-based interprofessional education, especially in community-based health care delivery. And this is the sort of academic innovation that we want to keep an eye on and learn from.
HRSA is funding several ongoing grants to the university, including more than $400,000, for example, to support geriatric education centers. We think this sort of partnership is especially important not just here in Rhode Island – where people 65 and over make up almost 15 percent of your state’s population – but for the entire nation, which as you know is going to see a large increase in its aging population in the next decade.
HRSA is also funding $250,000 for advanced nursing education at URI, as well as other funds in loans to nursing students and for student loans in the School of Pharmacy. All by way of saying that URI has been an important partner for HRSA for a number of years.
Other partners in the state that receive HRSA funding for health care workforce training include Brown University, Salve Regina University, Memorial Hospital in Pawtucket, and the State Department of Health in Providence. In fact, thus far in FY 2012, HRSA – just one operating division of HHS – has awarded more than $31 million to 22 grantees in Rhode Island.
Many of HRSA’s programs that support health care education and health care in this state have been strengthened tremendously with the support of President Obama and Congress and through passage of the Affordable Care Act, or ACA. In fact, HRSA is intimately involved as the lead agency or partner agency in implementing 63 provisions of the law.
But when it comes to discussing the Affordable Care Act, there’s been a bit of confusion about it. So before talking about the impact of the ACA on health care and the health status of Americans, I want to share some of the details about the law with you.
As a nurse and as the administrator of HRSA, I have been working day and night to implement some of its provisions. So I’ll share with you from my vantage point why it’s important and what we’re doing. So let’s look back before we look forward. Looking back, the first question most people had about the ACA was: “Why do we need it?”
And the answer was pretty compelling. We needed it because health care was rapidly moving out of financial reach of businesses, individuals and families. And because quality was often fragmented, and access to care was decreasing even as health care costs were rising. All these and other factors had us on a very problematic trajectory.
We had a health insurance market that worked quite well for big insurance companies, but not so well for many American families. For example, insurers could pick and choose to whom they gave insurance coverage – often avoiding people with pre-existing health care problems like diabetes or asthma, often the very people who needed health care coverage the most.
And premiums were skyrocketing even as some health insurers were making record profits. That made it hard – and sometimes impossible – for families to afford the critically important security that health insurance provides.
In fact, tens of millions of Americans were uninsured, and the numbers were continuing to trend upward. And millions more had coverage that didn’t cover critical treatments or preventive care. And those of us who had insurance could lose it if our employer dropped coverage, or we switched jobs, or we retired.
But lack of availability or choice in insurance coverage wasn’t the only problem in health care that the ACA is designed to resolve. The law also supports efforts to improve the quality of health care. There are a number of provisions, but I’ll give you just one to illustrate the focus on care quality.
The Partnership for Patients initiative is an ACA provision and a nationwide, public-private partnership between hospitals, doctors, nurses, pharmacists and other health professionals, employers, and health plans. This effort is designed to improve the safety of health care in America.
The goal of the Partnership is to reduce preventable injuries that happen in hospitals by 40 percent and cut hospital readmissions by 20 percent. That alone would save more than 1.6 million patients from complications that force them to return to the hospital. Are there nursing students in the audience? Well, nurses, of course, are some of the first line of defense in the prevention and identification of infections in hospitals.
Rhode Island currently has 11 hospitals participating in the Partnership, through the Hospital Association of Rhode Island, to reduce all nine Hospital Acquired Conditions – which include various types of infections, injuries, and adverse effects.
So to support the availability of health insurance and insurance choice – and to address cost, quality and fairness – these are among the key reasons why Congress passed and President Obama signed the Affordable Care Act.
If that was the aim, then what does the ACA do? I gave you a quick illustration of one provision aimed at improving quality. Let me quickly walk through its major benefits.
First, there is the Patient’s Bill of Rights that protects patients from unfair insurance practices. For example, before the ACA, insurance companies also could put a lifetime cap on the amount of care they would pay for. Today, as a result of the ACA, more than 100 million Americans no longer face lifetime dollar limits on health benefits.
Prior to the ACA, as I briefly mentioned before, insurance companies could deny health insurance to a child who had asthma or was born with a heart defect. Well, there are about 129 million Americans with pre-existing conditions.
People with pre-existing conditions who tried to buy coverage on their own were often locked out of the insurance market. Most of us in this room aren’t in that circumstance, but a lot of people outside those doors are. For people with potentially fatal conditions, this often meant they couldn’t afford life-saving treatments.
But today, for example, the parents of more than 17 million children with pre-existing conditions like asthma or a heart defect no longer have to live in fear that their kids will be denied health insurance. The ACA has already banned insurance companies from denying coverage to those children, and in 2014 discrimination against all patients with pre-existing conditions, young or old, will be prohibited.
As of April 2012, 166 previously uninsured residents of Rhode Island who were locked out of the coverage system because of a pre-existing condition are now insured through the ACA.
The second way the law helps people is by addressing health care costs and making sure health insurance premiums are spent wisely. Specifically, the ACA created a new 80-20 rule: insurers must now spend at least 80 percent of your insurance premium on health care services or improving care – or they must refund that difference. And the law’s 80-20 rule is helping deliver rebates worth $1.1 billion to nearly 13 million consumers.
The law also requires insurance companies to justify rate increases of 10 percent or more, and it gives states new resources to review and, when necessary, block these premium hikes.
Additionally, the ACA provides special relief for small businesses. In the past, a small business employer paid about 18 percent more for the same health coverage as a big chain store down the street. That made it hard for small businesses to compete and also hard to attract and keep the best employees.
To address this inequity, the ACA gives small businesses tax credits that benefited an estimated 360,000 small employers who provided health insurance to 2 million workers in 2011. And the credit goes up in 2014.
Third, the law also improves access to affordable care. For example, for years, most young adults lost their family coverage when they graduated from high school or college. This tends to be a pretty healthy population, but if they had a car accident or an unexpected diagnosis while uninsured, they or their families could find themselves financially vulnerable trying to pay for the care they needed.
Now, under the law, most young adults – meaning those between the ages of 19 and 25 – who can’t get coverage through their jobs can stay on their parents’ plans until age 26. I suspect that provision covers some of the people in this room. That change has already allowed more than 3 million young adults to get health coverage, including 9,000 young adults in your state. As important as this provision is to young adults accessing care, it’s even more important to their parents.
The ACA also expands access to preventive care. This is not talked about much, but I think it’s incredibly important to focus on wellness, prevention and health promotion.
I spent most of my clinical time in intensive care units, so I know that nurses see every day that many health problems presented by desperately ill patients could be prevented, or at least mitigated, through earlier investments in disease prevention activities like screenings, health and wellness promotion, and patient education. And that – for the first time in our country in a very substantive way – is where the law takes us.
Before the ACA, too many Americans went without this care because it often required expensive co-pays that they couldn’t afford. As HHS Secretary Kathleen Sebelius has pointed out, we need a health care system instead of a sick health care system.
Now, thanks to the ACA, people on fixed incomes don’t have to choose between groceries or a cancer screening. Many recommended preventive services are provided at no out-of-pocket cost to the patient.
That helps people stay healthy and avoid costly hospitalizations. Last year 54 million people with private health insurance – including 195,000 in Rhode Island – took advantage of the law's expanded coverage of preventive services.
And, as of August 1, 47 million women started to become eligible to get greater control over their access to a set of new prevention-related health care services without paying more out of their own pocket.
Each of these improvements that I’ve just mentioned helps to fill gaps in our health care system. But they’re just the beginning.
In 2014, states will create Affordable Insurance Exchanges for families and small business owners who buy their own health insurance. To help increase insurance affordability, tax credits on a sliding scale will be available to middle-class families.
These exchanges will function in a way like Expedia or Orbitz for health coverage. You’ll be able to go to a website and compare all your coverage options in one place. In fact, the ability to do some comparison shopping for health insurance coverage is available for everyone right now, on the healthcare.gov website.
You go there and type in your zip code and it gives you incredibly user friendly information about health plans – their costs and coverage in your community. I’ve looked at it myself and directed other people to it. Prior to that, a person might have a hard time determining what insurance plans were available in their locale and compare them.
All the ACA provisions I have mentioned so far have had a cumulative positive effect on insurance coverage. According to the Census Bureau, the percentage of people without health insurance dropped from 16.3 percent in 2010 to 15.7 last year – and I think it will drop further when this year’s data comes in.
Young adults were those whose insurance coverage benefited the most: the percentage of 19-to-25 year olds without insurance dropped a full two percentage points, from 29.8 percent in 2010 to 27.7 percent in 2011. This represents more than half a million more young adults with health insurance than the year before.
In addition to increasing insurance coverage and improving the availability of affordable services for the young and all working Americans, there are a number of provisions that specifically support access to health care services for senior citizens. For example, again with that focus on keeping people healthy – not waiting to care or cure them after an illness – the ACA makes many key preventive health services available with no co-pay or deductible to people on Medicare.
In the first seven months of this year alone, 18 million Medicare beneficiaries took advantage of the law's coverage of prevention with no cost-sharing. In Rhode Island, more than 128,000 Medicare beneficiaries received preventive services with no out-of-pocket costs last year thanks to the ACA.
Second, the law gives beneficiaries in the so-called “donut hole” a 50 percent discount on their covered brand-name medications. The donut hole is a gap in coverage in which beneficiaries pay all prescription costs out-of-pocket up to a yearly limit.
Thanks to the ACA, more than 5 million seniors in the donut hole have saved an average of $768 so far – or nearly $4 billion – and the law will eliminate the donut hole by 2020.
Third, there are also health care system incentives that may be most beneficial to seniors. For example, and in fact of direct relevance to both patients and providers like nurses, pharmacists, physicians and others, the law encourages and supports health care providers to work closely with other professionals to coordinate care for patients. This is especially important for elderly patients, who often see multiple care providers in environments that are too often fragmented.
Beyond the provisions and impacts that I have just outlined, the ACA will have substantial effects on the delivery of health care services in our nation, and it will obviously affect both patients and providers.
The law has brought about a number of changes to our work at HRSA and many of HRSA’s programs. I would like to share some from the vantage point of my office. For example, in two key HRSA programs – community health centers and the National Health Service Corps – the ACA made enormous new investments to expand access to primary and preventive health care in communities that need it most. And clearly there’s a lot of need out there.
As I mentioned earlier, HRSA’s health center network delivers primary and preventive care – including oral and behavioral health care – to more than 20 million patients.
Our health centers are an essential part of the national safety net because they serve anyone who walks in, regardless of their insurance status or ability to pay. Last year, nearly 40 percent of health center patients had no health insurance.
With the expanded insurance coverage provided by the ACA, we expect the number of people served by health centers to increase dramatically over the coming years. So we expect health centers here in Rhode Island to provide services to many more than the 120,000 patients they served in fiscal year 2011.
As a result of the ACA, health centers here in Rhode Island received more than $24 million to increase the number of patients they serve, expand preventive and primary health care services to keep people healthy, and support major construction and renovation projects.
The law also strengthens support for nurses working at health centers. Right now about 16,000 nurses – including 4,300 advanced practice nurses – work at health centers across the U.S. Since the expansion began in 2009, health centers have added about 3,000 nursing positions, including 800 in advanced practice. And there will be more between now and 2015.
And related to this, out of the overall ACA investment in health centers, the law includes funding to expand school-based health centers, which allow kids – and very importantly, disadvantaged kids – to get care before major health problems take root. Nurses, of course, are the core of school-based care.
As part of the effort to strengthen the primary care infrastructure, the ACA also pays attention to the workforce in programs such as HRSA’s National Health Service Corps.
The Corps places primary care providers in underserved urban and rural areas for at least two years in exchange for paying down their student loans. These clinicians represent a range of disciplines – advanced practice nurses, physicians and dentists, among others.
And financially, the Corps is a great deal. Corps clinicians who work in the very neediest areas can qualify for up to $60,000 in annual loan repayments, and even those who practice in less needy areas get up to $40,000 in loan repayments.
There are 35 Corps clinicians currently working in Rhode Island, and 21 of them are being funded through the ACA. You can find out more about the benefits of joining the Corps from the HRSA website at hrsa.gov.
Another area in which we have a major focus is mothers and children. With that in mind, the ACA created a new five-year Maternal, Infant, and Early Childhood Home Visitation Program. Under this program, nurses, social workers and others visit pregnant women and young children in high-risk communities. There, they provide counseling and intervention services that – based on evidence – are known to improve health outcomes.
The Home Visiting program started here in Rhode Island in 2010 and today is working in six communities (Central Falls, Woonsocket, Providence, Pawtucket, West Warwick and Newport). In Rhode Island, the program incorporates three different models of care – the Nurse-Family Partnership, Healthy Families America, and Parents as Teachers.
These and other evidence-based models funded through the ACA are known to improve health outcomes. Along with other ACA provisions, they are designed to focus on health and also the social determinants that negatively affect the most vulnerable populations – determinants such as poverty, lack of access to care, poor education and job skills, and poor nutrition.
The expansion of these proven models through the ACA also adds to nurses’ ability to contribute directly to the health of families and communities.
Because a number of you in the audience are nurses – or aspiring nurses – I want to say a specific word about support for nursing. Beyond investments in these three key HRSA programs – health centers, the National Health Service Corps, and home visiting – the ACA invests in several programs to educate nurses and place thousands of them in communities where they’re needed most.
For example, the ACA directed funds to Nurse-Managed Health Clinics, which are run by advanced practice nurses and are affiliated with schools of nursing. They train new nurses while delivering primary care to public housing residents and other vulnerable populations.
Another HRSA program – the Nursing Education Loan Repayment Program – has seen its budget more than double since 2009.
Under this program, RNs who work for two years in a facility with a critical nursing shortage can get 60 percent of their school debt paid off. More than 2,000 nurse scholars and loan repayors are now working under this program nationwide.
HRSA also has taken steps to ensure that more nurse practitioners take advantage of the loan repayment program.
As part of the grants, all of the hospitals must partner with local schools of nursing in arranging clinical opportunities.
Earlier I mentioned a strategy to improve care quality through the Partnership for Patients. The ACA also encourages longer-term efforts to improve care quality by looking at ways to educate emerging health care professionals to encourage greater team-based care in the future.
This emphasis arises from the recognition that true health care reform cannot be achieved just by increasing the number or distribution of clinicians. Rather, improving health care also must include efforts to ensure that health professionals are taught to work collaboratively in teams.
The law recognizes that team-based health care is an important model for improving care quality, care coordination, and efficiency because it capitalizes on the knowledge and skills of everyone engaged in delivering patient-centered care.
Earlier this month the Institute of Medicine estimated that $750 billion – or about one-third of total U.S. health care costs – were wasted in 2009 on unnecessary services, excessive administrative costs, fraud, and other problems.
The IOM explicitly mentioned care coordination as a key area to focus on and recommended, among other things, that providers need to improve coordination and communication within and across organizations. Specifically, provider organizations and clinicians need to partner with patients, families and community organizations to develop coordination and transition processes, data sharing capabilities and communication tools to ensure safe, seamless patient care.
That is exactly what part of the ACA aims to achieve, and the programs we are pushing forward align with this vision.
They include, for example, the evolution of community health centers into patient-centered medical homes, where primary care and public health are aligned, and where there is seamless cooperation among providers working in different specialties.
They also include the work that the Center for Medicare and Medicaid Innovation is promoting to improve care, encourage healthier lifestyles and lower the costs of care through the expanded use of preventive health care, better care coordination and reduced inefficiencies.
In fact, this isn’t some abstract concept managed from Washington, D.C. The CMS Innovation center program is funding three initiatives in Rhode Island, including one here at URI, which has received about $14 million to use interprofessional care management teams to teach patients with disabilities how to manage chronic diseases with the aims of better health, better health care, and lower costs.
At HRSA, another area of improvement in patient care involves initiatives that expand interprofessional training. For example, we are working to equip primary care medical faculty – the people who are training the next generation of clinicians – with the skills necessary to train medical residents in these new models and systems of care.
We’d like to see this effort reach virtually all primary care residency training programs over the next five years.
Well, I have described just some of the ways that the Affordable Care Act is reshaping the way health care services are being delivered to improve the health of our nation and the specific role of the agency that I lead in that work.
To keep up with all the many developments regarding the Affordable Care Act, I suggest you bookmark the site: healthcare.gov. It’s updated regularly and has the facts about the law.
The ACA explicitly supports higher-quality, more accessible, and less costly health care, and it’s important for everyone to understand how the law’s provisions affect them.
Thank you for the invitation to be with you today.