Remarks to the 5th Nursing Economic$ Summit

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U.S. Department of Health & Human Services
Health Resources and Services Administration
HRSA Press Office: (301) 443-3376


by HRSA Administrator Mary K. Wakefield, PhD, RN

June 8, 2012
Washington, D.C.

Right now is an especially exciting time to talk about nursing in America, and – as I’m sure is the case for most if not all of you – I’ve never regretted my choice of professions.  From practicing clinical care to teaching to public policy work serving as a chief of staff to U.S. senators, to now as administrator of a federal agency, in each of these very diverse settings my nursing background has served me exquisitely well.

And even as I found an abundance of opportunity to use the knowledge and skills a nursing education brings, as I’m sure each of you has, I think the road ahead for nurses has even more opportunity for the generations coming up behind us.

By that I don’t mean easier work.  Rather, I mean that for nurses there is almost no wrong career door that a nurse can walk through.  A lot of doors are increasingly unlocked and ready for nurses to push open.  Going forward, I see this profession posed to really enter a new and very exciting era in health and health care.

Last year’s Institute of Medicine-Robert Wood Johnson Foundation report on the future of nursing – which I’m sure you are all familiar with – put down an important marker that envisions nurses as leaders building better health care in America.  Clearly, within the profession, we’ve talked about nurses as leaders for decades – that part isn’t new.  But this focus as leaders in building health care and making health care better aligns exactly with what we in this nation need.  And we need it now.

Having nurse leaders at all levels – clinical practice, health care management, academia, public policy and elsewhere – isn’t a nicety for nurses, it’s an absolute necessity for the nation’s health care and for the nation’s health.

To achieve this aim, we need nurses who see the doors that can be walked through and we need the opportunity that comes from other people valuing nursing as a leadership asset and as health care experts.  On that front, I personally don’t think it gets much better than when the President of the United States doesn’t just talk the talk about the relevance of the nursing profession: he walks the walk.  Here are just a couple of many examples I could give.

The President opened a new era for our profession when he named me to head up the Health Resources and Services Administration.  The agency has had a number of physicians at the helm, but never a nurse – until President Obama took office. 

And earlier this year the President selected Marilyn Tavenner – another nurse – to be the acting administrator of HRSA’s sister agency, the Centers for Medicare and Medicaid Services.  I say “acting” because she’s awaiting confirmation by the U. S. Senate.

The fact that the President selected nurses as administrators of HRSA and CMS underscores his recognition of the nursing profession’s contributions and ensures that nursing expertise informs health policy and reform.

We also are supported strongly by HHS Secretary Kathleen Sebelius, who arranged for nurse leaders to gather at HHS Headquarters in Washington on April 30, just before the start of this year’s National Nurses Week celebrations. If you go the website (and search that site for “National Nurses Week 2012”), you’ll find a number of resources developed for the nurses gathering, including a video of the Secretary, a Q & A session I held on Twitter from the White House, and a report that summarizes this Administration’s strong record in support of the nursing workforce.  They’re great resources for you, your colleagues, nursing students and others.

And among my senior advisors at HRSA, nursing is well-represented:

  • Our $2 billion HIV/AIDS Bureau is run by Dr. Deborah Parham-Hopson, a nurse.
  • The Associate Administrator of our Bureau of Health Professions, Dr. Jan Heinrich, is a public health nurse.
  • Our Office of Global Health Affairs is led by Kerry Nesseler. Kerry also is the chief nurse of the U.S. Public Health Service.
  • And the director of our Division of Nursing, Dr. Julie Sochalski, is, as you might expect, another nurse leader at HRSA.

President Obama and Secretary Sebelius both recognize nurses as leaders with critically important expertise to help guide key health care programs and policies, and when we think about the future of nursing, the President’s support for nursing leadership helps set the stage for the next nursing generation and the next set of contributions from our profession.

The careers open to today’s – and tomorrow’s – nurses are many.  And there has been a booster shot full of opportunities brought to our collective doorsteps by the Affordable Care Act, our now-just-over-two-years health care reform law.

I’ll elaborate on some of the key provisions relevant to nurses and nursing care – as well as the reach of the law – in just a moment.  First, however, let me tell you a little more about HRSA.

As HRSA administrator, I oversee an $8.2 billion portfolio of 80 different grant programs.  Most of these programs go toward expanding primary care and extending health services to those who are poor, medically vulnerable or geographically isolated.

Among the programs and activities we support are the following:

  • Over 1,100 Community Health Center grantees deliver primary and preventive care at more than 8,500 sites to about 19.5 million patients annually.
  • The Ryan White HIV/AIDS Program includes 900 grantees that provide top-quality care to more than 500,000 people living with HIV/AIDS.
  • Our Maternal and Child Health block grants to states help 6 out of every 10 women who give birth and their infants.
  • Our health professions training, curriculum development, and scholarship and loan repayment programs strengthen the health care workforce. 
  • The National Health Service Corps places primary care professionals, from a range of disciplines, in medically underserved areas.
  • HHS’s Office of Rural Health Policy bolsters rural hospitals and coordinates health care among rural coalitions.
  • HRSA also funds Poison Control Centers, the National Vaccine Injury Compensation Program, and federal organ procurement and donation systems.

Speaking of organ donation, I always ask every health care provider group I speak with to help sign people up and become organ donors.  Last month 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.  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?  Please get involved.

To deliver health care services through its programs, HRSA has about 3,000 partner organizations.  They are state and local government agencies, non-profits and community-based organizations, foundations, clinical providers, universities, research centers and others.

We support them with dollars and resources.  We oversee their work.  However, it is our collaborating partners who do the front-line work for families and communities.  These partners do the training.  They carry out the research. They provide the care.  So it’s partnerships that are the primary means by which HRSA puts policy into practice.

Many of HRSA’s programs have been strengthened tremendously with the support of President Obama and Congress and through passage of the Recovery Act and the Affordable Care Act, the health care reform law that is changing America for the better.  HRSA is intimately involved as the lead or partner agency in implementing 63 ACA provisions.

As you know, the law is a direct response to a complicated, expensive, frequently unwieldy health care system.  Because the ACA brings about some long overdue and, consequently, pretty dramatic change, perhaps not surprisingly it has its share of critics.

And the skepticism with which some view the ACA has remarkable historical parallels.  In a way, that shouldn’t surprise us – major programs that created a sea change have prompted similar responses.  For example, even though Social Security and Medicare are now widely regarded as successful social programs, each was highly controversial at its inception.

Medicare, for example – which is now a lifeline for millions of elderly Americans – was directly resisted, even by some health provider groups.  But not, I must add, by nurses.  Organized nursing saw its value and was one of the few and the strongest health professions supporters of Medicare, well before such support was in fashion.

And there’s been a lot of confusion and misinformation about the ACA, so I want to share some of the details about the law with you.  As a fellow nurse and as HRSA administrator, I’ve been working day and night with colleagues to implement its provisions; I appreciate the opportunity to be able to tell you about the differences it’s already making and will make going forward.

Let’s start with health care costs.  One of the barriers to getting health care services is often cost, so the law eliminates out-of-pocket co-payments for basic preventive health services and screenings.  Last year, about 86 million Americans took advantage of the ACA’s prevention benefits for Medicare beneficiaries and people with private insurance.

Since the ACA was signed into law, more than 32 million Medicare beneficiaries have gotten at least one free preventive service like a cancer or diabetes screening with no out-of-pocket payment required.  The ACA is about keeping our elderly – and frankly, all of us – healthy or mitigating the impact of serious illness as early as possible.

Moreover, this year women in health insurance plans that are new or have been updated will receive preventive health services that include screening for gestational diabetes, and a range of conditions associated with poor birth outcomes, along with breastfeeding support and domestic violence counseling with no out-of-pocket costs.  Again you see the ACA incentivizing health promotion and wellness.

In 2014, thanks to the ACA, insurers will be prohibited from denying coverage to any American with a pre-existing condition. Until then, the law’s Pre-Existing Condition Insurance Plan is already providing insurance to nearly 50,000 people with high-risk pre-existing conditions nationwide.  That’s peace of mind for the people with serious illnesses, the very people needing it the most – and it’s insurance coverage for people that ensures payment to hospitals, clinics and so on. 

The ACA also enables dependents to remain on their parents’ health insurance plans until they reach age 26.  Through this provision, an additional 2.5 million young adults nationwide are now insured – including many who were previously uninsurable.

Furthermore, the ACA eliminated lifetime caps on health insurance benefits, which relieves a particularly harsh burden on those with disorders that require regular costly therapies.  Researchers studying the impact of this change concluded that 105 million Americans now have improved health insurance coverage thanks to the ban on lifetime limits.  The researchers did not calculate how many bankruptcies will be avoided because of this ACA provision, but the number would be no doubt significant.  And the anxiety about cost that this spares people with very serious ailments is, of course, impossible to estimate.  Among the 105 million Americans for whom lifetime limits have been eliminated are 28 million children. 

Meanwhile, thanks to the ACA, millions of seniors with the highest medication costs have saved several hundred dollars each on their medications.  Information released in late May showed that in the first four months of this year, more than 416,000 people with Medicare saved an average of $724 on prescription meds after they hit the prescription drug coverage gap or “donut hole,” for a total of $301.5 million in savings.  The 2012 savings build on the law’s success in 2010 and 2011, when more than 5.1 million people with Medicare saved over $3.2 billion on prescription drugs:

Additionally, this summer many Americans will find a check in the mail from their health-insurance company.  As a result of something in the ACA called the 80/20 rule, health insurance companies are obliged to spend at least 80 percent of premiums on health care or quality improvements.  Consumers and businesses will receive about $1.3 billion by August from insurance plans that fail to meet this new standard, according to estimates by the independent Kaiser Family Foundation.

To learn more about the ACA and the benefits I mentioned and others coming online, please go to and tell others to do the same.  It’s regularly updated.

Beyond the changes being made in available coverage for individuals and families, the ACA will have profound effects on the delivery of health care services in our nation, and it will obviously affect nurses, who are at center stage in reform.

The ACA expands investments in primary and preventive care programs in which nurses play a vital role.  Its emphasis on keeping people healthy, preventing illness and managing chronic conditions opens up new opportunities for nurses. 

While I spent most of my clinical time in intensive care units, it didn’t take a nursing genius to figure out that a lot of the health problems presented by desperately ill patients could have been wholly prevented, or at least markedly 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 – is where the law takes us.  It takes us to what second-year nursing students and most of your grandmothers and mothers already knew – that an ounce of prevention is worth a pound of cure.  When people talk prevention, they talk about nurses’ knowledge and skills and, more importantly, they’re talking about a healthier nation.

In terms of the ACA and HRSA, there have been changes to many of our programs.  Let me give you a few examples.  In 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.

HRSA’s health center network delivers primary and preventive care – including oral and behavioral health care – to about 20 million patients at more than 8,500 sites.  Our health centers are an essential part of the national safety net because they serve anyone who walks in.

Since President Obama took office, the number of patients getting care at health centers has grown by 2.4 million, mainly due to an $11 billion, five-year investment from the ACA and, before that, $2 billion from the 2009 Recovery Act. 

Additionally, the law 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.

With ACA funding continuing through FY 2014, the number of nurses, nurse practitioners and nurse midwives working at health centers will grow.  So when I look at nursing’s future, I see health center care, which focuses sharply on keeping people healthy and effectively managing chronic illnesses, as a critical opportunity for nurses. 

And related to this, out of the overall ACA investment in health centers, the law includes $200 million 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.  So this is another important interface that the ACA supports, in this case between nurses and children’s health. This investment in schools is particularly important right now in light of high rates of childhood obesity, which place children at higher risk for chronic diseases. 

In addition to strengthening primary care infrastructure, the ACA also pays attention to the workforce in, for example, 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.  Eligible nursing specialties include primary care nurse practitioners, certified nurse midwives, and psychiatric nurse practitioners.  The ACA allocated $1.5 billion over five years to grow the NHSC, placing clinicians in areas with too few health professionals. 

The number of nurse practitioners in the NHSC has more than doubled to 1,750 since President Obama took office.  During the same period, the number of certified nurse midwives rose from 88 to 201.  In the aggregate, before the start of this Administration we had 2,300 or 2,400 clinicians in the field.  In September of last year, because of these investments, we had 10,000.  That’s a lot of new access to primary care services in neighborhoods and towns with previous shortages.  And as a nurse with some rural health experience, I know the difference one nurse practitioner can make in a community.  My 94-year-old mother – who lives in a small town in North Dakota – knows that, too.

Late last year, we made a policy change in the Corps to encourage clinicians to practice in areas that really need their help.  Health professionals who work in the very neediest areas now qualify for up to $60,000 in annual loan repayments, and those who practice in less needy areas can qualify for up to $40,000 in loan repayments.

The NHSC is a great opportunity for health professionals who want to pay down their debt and serve folks who most need care.  To learn more – or to tell others about the benefits of joining the NHSC, I encourage you to go to the HRSA website at and take a minute to look around.  The NHSC is also on Facebook at nationalhealthservicecorps – one word

In addition to the national NHSC program, HRSA operates an NHSC State Loan Repayment Program that provides cost-sharing grants to states to operate their loan repayment programs for primary care providers working in shortage areas.

States that apply for HRSA funds for the program agree to contribute a dollar from their own funds or from donations from public or private entities for each dollar of Federal grant funds.

HRSA released a Funding Opportunity Announcement less than two months ago that for the first time gives state grantees the option to expand eligible disciplines to include registered nurses and pharmacists.  It also expands eligible site types to include critical access hospitals, nursing homes, and state and county mental health hospitals.

You can find out more about these new state-based opportunities by going to and searching for “NHSC state loan repayment program.”  To find out if your state is competing for these grants – and about three-fifths of all states do – let me know and I’ll put you in touch with a HRSA staffer who’ll also know the particular state agency involved in the application process.

The ACA also created a new five-year, $1.5 billion program that assigns considerable responsibility – and new opportunities – to nurses: the 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.  Last year the Home Visiting program got fully under way, and in September HRSA announced an award of $224 million to state agencies to implement it.  States use the funds to support one or more of nine evidence-based home visiting models.

To date, 29 states have selected Nurse-Family Partnerships – one of the models – as the basis for their work.  Nurse-Family Partnerships are a nurse-led home visiting model that partners low-income, first-time moms with maternal and child health nurses.  The expansion of this proven model through the ACA adds to nurses’ ability to contribute directly to the health of families and communities.

But that’s not all the Affordable Care Act does.  Beyond investments in these three key HRSA programs – health centers, the NHSC and home visiting – the ACA also confirms nurses’ role in delivering primary health care by investing in several nurse training and education programs that HRSA administers.  We’ve committed nearly $1.1 billion over the last four years from HRSA alone to educate new nurses, improve the education of today’s nurses, and place nurses in parts of the country where they are needed most.

For example, the ACA directed $15 million to Nurse-Managed Health Clinics under the Nurse Education, Practice, Quality and Retention Program.  These clinics are run by advanced practice nurses and 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 to almost $94 million today.  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.  There are currently ­more than 2,300 nurse scholars and loan repayors working under this program nationwide.

And in response to Secretary Sebelius’ interest in our strengthening primary care services, HRSA has just taken steps to ensure that more nurse practitioners are able to take advantage of this loan repayment program. 

With a steady focus on ramping up access to primary care, in December of last year we released guidance that reserves 50 percent of available 2012 funds to repay the loans of nurse practitioners.  We want nurse practitioners in the workforce as quickly as possible, and this will help them go to school full-time.

Moreover, the Center for Medicare and Medicaid Services, our sister agency, is using ACA dollars to put more advanced practice nurses at the forefront of primary care.  Under the Graduate Nurse Education Demonstration just announced a few weeks ago, CMS will provide hospitals that are working with nursing schools to train advanced practice registered nurses with payments of up to $200 million over four years to cover the costs of their clinical training.  

The ACA also provided $31 million to 26 schools of nursing to boost the number of primary care nurse practitioners and nurse midwives by 600 over five years, again emphasizing the critically important role those two nursing specialties play in expanding the reach of primary health care. 

In addition to greater training opportunities and support from the ACA, nurses are directly affected by the ACA’s promotion of “care coordination,” which is at the core of efforts to improve health care quality and safety and is a working model that nurses frequently lead.  You’ll hear about this in detail from your next speaker, Deb Gardner.  Until recently, Deb headed up our interprofessional training and education efforts at HRSA, so I’ll let her tell you what exciting things are going on in this area.

Suffice it to say that the approach we’re taking on many fronts moves perfectly in sync with the IOM’s report on The Future of Nursing that I mentioned earlier.  The IOM recommended, among other things, the expansion of opportunities for nurses “to lead and diffuse collaborative improvement efforts.” 

Another initiative aimed at improving patient safety and health outcomes that grew from the ACA is the Partnership for Patients – a nationwide, public-private partnership between hospitals, nurses, doctors, pharmacists and other health professionals, employers, unions, patient advocates, health plans, and others 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, in doing so, preventing an estimated 1.8 million injuries and saving 60,000 lives.  The Partnership focuses specifically on improving care transitions by reducing hospital readmissions by 20 percent, saving more than 1.6 million patients from complications that force them to return to the hospital.

More than 8,000 partners have publicly pledged to support the goals of the Partnership.  Over 3,800 hospitals from all 50 States are participating in the 26 Hospital Engagement Networks that were launched in December 2011.

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 – with the critical contribution of nurses. 

The Affordable Care Act gives nurses a platform to create and use ideas to continue pushing transformational care that fully deploys our workforce, that organizes health professionals into highly functioning teams, and that is centered first on the patient and not on providers or on the care system.

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.

I thank you for listening and, most importantly, for all that you do.  I’m very proud to be a member of the profession that you and I share and to be part of your meeting today.  Thank you.

Date Last Reviewed:  April 2017