Remarks to the 2014 American Indian Nursing in North Dakota Conference

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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

May 20, 2014

It is a pleasure to join you to talk about how growing up in North Dakota – and my work as a nurse – provided a solid foundation for my current work as the Administrator of the Health Resources and Services Administration.

From my experience, North Dakota has often been an incubator for health care innovation and collaboration among providers, organizations, and academic institutions.  We are oriented to solve problems creatively and overcome barriers through partnerships.

To be sure, that is what is going on here today. Together, North Dakota State University, Cankdeska Cikana Community College, and the Next Steps Program have developed a robust agenda to address specific hurdles American Indians face when pursuing their educational goals.  This is an extremely important focus and I want to extend special thanks to the conference partners for bringing this group of individuals together.

Achieving equity in access to quality health services begins with having a health care workforce in local communities that is committed to – and capable of – delivering culturally competent care. This is a main reason why those of us in the Obama Administration are working hard to strengthen our federal workforce programs so that they encourage and support health professions students from disadvantaged and minority back grounds.  And we also support schools that are aiming to educate health professions students from varied racial and ethnic backgrounds.

I personally think this is one of the most important things we should be doing to achieve health equity for underserved populations across the nation -- including many tribal communities.  This belief is deep-seated and based on what I observed as I was growing up.  Let me share just a little about that.

As most of you know, I grew up just a few miles from Fort Totten, in Devils Lake, about 10 miles from the edge of an Indian reservation which is home to what in those days was known as the Devils Lake Sioux Tribe; today, it is known as the Spirit Lake Tribe.  

There was something very stark about those 10 miles.  In some respects, it could just as well have been 1,200 miles, separating those two communities — because back then there was very little interaction, very little understanding, very little appreciation of both the strengths and the challenges of the communities and the people on that reservation that started barely 10 miles away.  

I think that on the side of the 10 miles that I was raised on, very little was known about the Sioux culture, social organization or spiritual beliefs.  I probably knew just a little more than others at the time because my mother was a head start teacher at a school on the reservation, so aspects of the work she did as a teacher there would come up in conversation from time to time.

Basically, from what I could tell as a child and as a teenager was that the communities of Fort Totten and Devils Lake were very different communities, very different worlds in which to grow up in and live—a difference as stark as the paved streets you would see in one town and the dirt roads that ran through the other.

And what I would learn over the next decades about American Indians, I would learn in fragments. Even today what I know is a very small part of a much broader mosaic of people and places and cultures that cuts across Native people.

Those differences that I saw as a child growing up in Devils Lake were just as persistent during the early years of my nursing career.  As a young faculty member, teaching at the College of Nursing at the University of North Dakota, there were a handful of students from North Dakota reservations. Working with some of those students was, at times, I’ll be honest, a frustrating experience for me.  And, in retrospect, it was likely even more so for the American Indian students with whom I was working.  

For example, part of my job as a faculty member was to assess each individual student’s application of knowledge in clinical settings, as they delivered nursing care to patients.  

But that was a challenge because, more often than not, when I went to a patient’s room to observe and to work with a Native American student, I rarely found just one—there were almost always two American Indian students, working together to provide nursing care.  It made it hard for me to evaluate what each individual student knew.

Yet what I did not know then, and what I greatly appreciate now, is that what I was witnessing was very similar to what today we are working so hard to create, so hard to drive into health professions training.  And that is the ability of health care providers to work together, collaboratively – not in isolation, not as independent agents, but rather as members of a care team.  

Today we call it interprofessional care.  But I think that what those students were doing was developed from their American Indian culture.  They instinctively attached significant importance to relationships, they had a strong sense of community and support for each other.  This was an orientation rooted in kinship that is defined more broadly in their culture than the one in which I was raised.

At the time, I would not have been able to explain it, but those students were engaging in some of the earliest models of team-based care, a concept that today is becoming more and more standard practice.  It’s such an important concept that we’re now investing millions of dollars to embed it in health care delivery -- to facilitate coordinated care that keeps patients safe.

Later on in my academic career at UND, working in rural health policy, I worked alongside five American Indians – three with their PhDs, two with their master’s degrees.  During that time, from them, I learned more about the stark inequalities and problems facing American Indians on the Northern Plains.  For example, I learned about the rates of morbidity and mortality across tribes that, to me, were simply jarring.

High rates of illness and premature death impacting people just miles from where I lived and worked.  Why?  And what could be done about it?  What could I as one nurse do about it?

Having that perspective, I knew North Dakota – or, for that matter, rural and tribal areas across the country – had serious challenges in access to quality health care.  But I also saw seeds of innovation that were second to none.  So, I took my degree in nursing, and my clinical knowledge, and my faculty experience to Capitol Hill where I had the privilege to work for two US Senators from our great state, Senators Burdick and Conrad.  

Both of these Senators had a keen appreciation for the health care challenges that rural and tribal residents of North Dakota faced in accessing health care – and both of them had a commitment to address flaws in opportunities to educate American Indian Students as well as the compromised health that impacted these populations.

So, while working in public policy, for 2 North Dakotans who cared deeply about challenges facing tribal communities, I learned how to leverage policies and programs to better meet and support the health and health professions education on behalf of these communities.

But none of this was or still is easy – there were and still are chasms of inequity in health status between American Indian and the US General Population – from health care indicators, to college graduation rates, to the numbers of individuals becoming health care providers.  And, every one of us needs to do everything we can to eliminate those disparities.

So, that’s the orientation that I brought to my current position, Administrator of HRSA.  Now let me tell you a little about this agency.

HRSA is one agency within the U.S. Department of Health and Human Services – HHS – and we use our $9 billion annual budget to reach the following four goals:

  • To improve access to quality health care and services
  • To strengthen the health workforce
  • To build healthy communities, and
  • To improve health equity.

These agency goals mirror my own personal goals.  And frankly, they mirror the aims of the nurses in clinical practice and nurse faculty.  Using our resources, we are able to have a significant positive impact on many of the most vulnerable populations.

And now, with the implementation of the Affordable Care Act, the goals of HRSA are reflected across the entire Department.  The long-standing inequity in access to health care for American Indian populations can be significantly reduced through provisions of the Affordable Care Act.  That’s why I want to take a couple minutes talking about them.

Because all of us should be doing everything we can to help get individuals and families in tribal communities signed up for health care coverage.  Having health insurance coverage for individuals and families can mean the difference between illness and health, and sometimes – as data clearly show – even life and death.

And if we care about the health status of American Indian communities then every single one of us has a role in this -- whether we’re nursing faculty, nursing students, practicing nurses, or college administrators.  We have a role because the law benefits the most vulnerable populations.  For example, we know that Native Americans are 4½ times more likely to have chronic liver disease and almost three times as likely to have diabetes, when compared to other Americans.  And life expectancy for American Indians and Alaska Natives is more than 4 years lower than for the rest of the U.S. population.

For those people with significant health challenges, and for the generations that come after them, insurance companies are no longer allowed to turn them down because of these or any other pre-existing health conditions.  As you all know, these and other diseases last a lifetime and they can be very expensive to treat.  Historically, that has meant that some companies put lifetime limits on coverage – denying health insurance just at the point when people needed it the most and when families impacted by serious illness had so many other things to worry about.

But now, whether you’ve had health insurance coverage for 20 years or you’re just getting it now, insurance companies can’t do that -- because of the ACA.  And insurance companies now have to provide coverage for young adults up to age 26 through their parents’ plans.  Also thanks to the ACA, women can no longer be charged higher premiums than men, and now everyone now has guaranteed access to additional preventive services like screenings – without any out-of-pocket cost to that person.  

There are more than half a million American Indians and Alaska Natives who are uninsured – this serious barrier to healthcare, and so a barrier to health, doesn’t have to be this way.  These new insurance options augment health services available through the Indian Health Service to help ensure that people have timely access to needed health care.

As you may know, members of federally recognized tribes can enroll in health insurance coverage through the Marketplace at, in Medicaid, or in CHIP any time during the year.  That’s different than for most other populations.  

So, while you hear about the next enrollment period in the Marketplace beginning this fall – in November – for tribal members, the marketplace is open for business throughout the year.  If you haven’t been to, I urge you to go.

  • Most members of federally recognized tribes will not be required to pay anything for their coverage – no premiums, no copays, no deductibles – due to tax credits made available through the law.
  • You can get – or keep getting – services from the Indian Health Service, tribal health programs, or urban Indian health programs.
  • You can also get services from any providers on the Marketplace plan.

I’m more than glad to count North Dakota among the states that are expanding Medicaid as part of the ACA.  Do you know that if all states that haven’t expanded Medicaid did so – like South Dakota did, for example – the percentage of uninsured American Indians nationwide could be cut nearly in half?

And as more American Indians are covered under private health insurance through the Marketplace, or through Medicaid and CHIP, it means that more people won’t have to delay accessing important health care services.  It also means more third-party payments to IHS, a stronger IHS, and healthier communities – but only if people know about the new opportunities and take the time to enroll.  And this is where nurses can make a difference.

And I personally think this is one of the things that nurses do best – educating individuals, families, neighborhoods, and entire communities about complex issues.  The Affordable Care Act is a win-win.  Patients win and providers win.

As a native of North Dakota, I know that the best form of communication comes from those around us.  Not Washington.  So I encourage you to spread the word about health insurance coverage options.  

You will find resources specifically for nurses and other providers to use at a particular website,, that explain how people can sign up:

  • online through
  • over the phone by calling 800-318-2596.
  • by mail by downloading the paper application from; or
  • directly through a health insurance issuer, agent, or broker.

In addition, we have resources targeted directly to help health care providers.  For nurses and other providers, that website I mentioned at has a broad range of resources – from brochures to PowerPoint slides – that you can easily download to use as educational material on your websites and in classrooms, waiting rooms in the clinics where you get care or work, and exam rooms. You don’t need a master’s degree in health insurance.

Share this information with others. Get creative – work in teams to knock on doors or ask a local grocery store to allow you to staff a table with information. Across the nation, nurses are making a difference in this effort, and they’ll continue to be integral to helping with outreach and enrollment. Helping get the word out about these new options has been some of the most rewarding work I have done.

At the same time that the ACA is increasing access to health care insurance coverage for millions of individuals and families, it is also working to expand access to health care services, though this access isn’t discussed nearly as much, but it’s crucially important for American Indians and other minorities.

Now, members of racial and ethnic minority groups continue to face obstacles to getting the quality, affordable health care and security that all Americans deserve.  They’re more likely to be uninsured and less likely to get the preventive services they need to stay healthy.  

Through the Affordable Care Act, HRSA’s programs to expand access to services and grow the health care workforce have received a significant boost – especially through the HRSA-supported health centers and the National Health Service Corps.

HRSA’s health center program is our principal method of expanding access to quality health care and services.  By law, health centers operate in medically underserved areas.  Fees are charged on sliding scale based on income; no one is turned away due to an inability to pay.  Health centers served 21 million patients in 2012, including more than a quarter million American Indians and Alaska Natives.

In calendar year 2012, HRSA supported nearly 1,200 health center grantees, which operated nearly 9,500 health center clinics, offices and outreach sites across the country.  Of the 1,200 grantees, 32 are dually-funded Tribal and Urban Indian health centers, so called because they receive funds from HRSA and from the Indian Health Service.  The dually-funded health centers operate 183 service delivery sites for their patients.

In North Dakota, four health center grantees operate 13 sites – that’s twice as many as there were when President Obama took office.  These sites served more than 41,000 patients in 2012 – including more than 2,600 American Indians.  

Since 2010, health center grantees in North Dakota have received more than $8.6 million through the ACA to support ongoing health center operations and to establish new health center sites, expand services, or support major capital improvement projects.  

In terms of the health care workforce, Nurses are an essential component of the health center workforce.  Across the country, more than 18,000 nurses work at health centers.  But that number, although growing daily, is still not enough to meet the growing demand for primary care nurses, especially in Tribal areas, which have always had a shortage of culturally competent health care providers.  

One of the primary ways we strengthen workforce and improve access to quality health care is through the National Health Service Corps.  The Corps repays educational loans and provides scholarships to primary care providers – advanced practice nurses, physicians, dentists, physician assistants, behavioral health providers, and licensed clinical social workers – in return for service in underserved areas.

Thanks largely to the ACA, the ranks of the NHSC have more than doubled, from about 3,600 clinicians in 2008 to nearly 8,900 primary care providers today.  These are primary care providers who – in exchange for at least 2 years of working in an underserved area – can have their loans paid back by as much as $50,000 per year.  Or, who can pursue scholarships.  

Of that number, nearly 1,600 are advanced practice nurses – that’s more than three times as many NHSC nurse practitioners, certified nurse midwives, and psychiatric nurses as there were just 5 years ago.

The number of Tribal health care sites that are eligible to recruit Corps clinicians has increased ten-fold – we’ve gone from 60 sites eligible to have NHSC clinicians in 2010 to 620 tribal health care sites this year.  How did that happen?  Because this Administration enacted a policy change that allows tribal sites to automatically become eligible for the program.  What is the result of that policy change?  

Well, at the beginning of 2014, about 370 NHSC clinicians were serving in Tribal sites, more than twice as many as there were four years ago. Each one of those doctors, Nurse Practitioners, dentists and psychologists -- among others -- is making a difference for hundreds of American Indians.  That’s what commitment and policy change can do – and what President Obama’s Administration has done.   

To be sure, this – automatically designating tribal serving sites – has made a remarkable difference in recruitment and retention of providers to IHS-designated sites, but we need to do more to ensure that those numbers continue to climb.  As of September 2013, there was just one NHSC clinician working at a Tribal site in North Dakota – a nurse practitioner at Fort Yates Indian Health Hospital – and two NHSC practitioners who identified themselves as Native American working elsewhere in the state.  

We want to boost those numbers. If you have loans to repay, or need a scholarship to make school affordable, there are underserved areas in North Dakota that could use your help. I encourage you to visit the NHSC Jobs Center on our website at  

In addition, the Obama administration supports nurses through a scholarship and loan repayment program similar to the NHSC but that is strictly for nurses.  We call it the NURSE Corps.

More than 2,500 nurses practicing in underserved areas throughout the country have been assisted through this program – either though a scholarship to attend nursing school or help repaying loans associated with nursing school.  The NURSE Corps field strength at the end of September 2013 included more than 1,400 RNs, 480 nurse practitioners, 120 registered nurse anesthetists, 11 nurse midwives, 6 clinical nurse specialists, and more than 460 nurse faculty.

The number of minorities in the National Health Service Corps and Nurse Corps far exceeds that of the civilian population, which tells us how important these programs are to supporting more minority health care professionals successfully move through school and practice in communities where their heart takes them.  

But we have hardly begun to fill the gap – we know we need to support even more minority dental hygienists, behavioral health care providers, primary care doctors and nurses – and we also know why that is critically important. We know from research :

  • That minority health professionals  tend to serve minority and other medically underserved populations; and
  • That minority patients tend to receive better interpersonal care from practitioners of their own race or ethnicity, particularly in primary care or mental health settings.

Cultural competencies can be taught, but we’re committed to also having a workforce that matches our population’s demographics.

To that end, we are focusing in particular on strengthening a diverse workforce, and of course this includes American Indian/Alaska Natives, who make up 2 percent of the U.S. population but only 0.4 percent of the RN workforce.  In other words, to mirror the ethnic profile of the United States, we would have to increase the number of American Indian/Alaska Native registered nurses by about 54,000.  

To help meet this challenge, HRSA funded 45 awards for a total of more than $11 million in FY 2013 to health professions education programs for American Indian/Alaska Natives, and these funds allowed more than 9,000 American Indian/Alaska Natives to take part in sponsored training programs.

We also support a number of programs that provide opportunities for American Indian nurses, and specifically the Nursing Workforce Diversity, Scholarships for Disadvantaged Students, and Centers of Excellence programs.  Together, these initiatives provided educational support to more than 800 American Indian/Alaska Natives in 2013 pursuing health care careers.

One of these funding initiatives, for example, is a new Nursing Workforce Diversity grant to the University of North Dakota, which plans to recruit American Indian students who are interested in nursing careers and living on reservations here in North Dakota and in Nebraska, South Dakota, Minnesota, Montana, Wisconsin and Wyoming.

And, of course, you all know very well the shortages that Indian Country faces in providing much-needed mental health services – especially given the high rates of substance and alcohol abuse among American Indian and Native Alaskans.  

So we’re very encouraged by the work that is being carried out by the Seven Generations Center of Excellence in Native Behavioral Health – which is also supported by a HRSA grant and is administered by the University of North Dakota – to help Native Americans who are working toward becoming or currently service as mental health professionals.

It’s not enough to enroll young people; we need to make sure they complete their coursework, earn their diplomas, and are ready to enter the workforce.

So in 2012, we began requiring schools winning grants through the Scholarship for Disadvantaged Students program to have at least 20 percent disadvantaged enrollees and 20 percent disadvantaged graduates.  In addition, the program gives additional review points to applicant schools that have higher percentages of minorities enrolled.  

We also revised the program to allot substantially more scholarship funds to each student in an effort to keep them in school and increase graduation rates.  We feel that the extra assistance may make the difference between a disadvantaged student staying in a health professions school or dropping out before completion.  

Beyond expanding access to health care and providing additional training opportunities for minorities, the Affordable Care Act also created new opportunities to bring health care professionals directly to the people and communities that need them most.

So, tribes are benefiting from one of the ACA’s signature programs in support of women and children: the Home Visiting program, a five-year, $1.5 billion program which is one of the most significant investments in Maternal and Child Health in a lifetime.

Under Home Visiting, nurses, social workers and others visit and work with pregnant women, expectant fathers, primary caregivers, young children and their families in high-risk communities.  There, they provide patient education, guidance, and referrals to community services that health strengthen families and improve child and family health.

The ACA carved out a 3-percent set-aside for Tribes, and since the start of the program, 25 tribes, consortia of Tribes, Tribal Organizations, and Urban Indian Organizations have received grants through the ACF totaling $21 million.  

In North Dakota, the Home Visiting project is working with American Indian families at Turtle Mountain Band of Chippewa Reservation and at Devils Lake.

Finally, one thing we have done at HRSA to help build healthy tribal communities and eliminate health disparities among American Indians is to improve the ability of Tribal entities to effectively compete for more of the grants we offer.  

The key words here are “eligible to compete.”  Most of our grants are awarded competitively, and the competition is often quite intense.  So HRSA has placed resources online to help new applicants learn more about the grant process.  It’s part of our commitment to reach out to Tribes and other eligible entities.  

You can access these resources on HRSA’s home page at  If you scroll down the right side of the home page, you’ll see a box we created that’s dedicated to American Indian/Alaska Native health.  Click on the box and you can go to our Grants site, which provides information on specific grants and the full grant process, including tips for writing a strong application and more.  

The AI/AN website also links to important information on health centers, workforce training programs and shortage designations, among other topics.

Before I conclude, I want to make one final point – a point that has the potential to save the lives of those around us. I already talked about how health insurance coverage can do that – now I want to talk briefly about organ donation and transplantation, which HRSA has the responsibility of overseeing.

Last year organ donors enabled 28,000 transplants to occur.  Yet, the national transplant waiting list continues to grow and now stands at more than 120,000.  Every single day across the country, 18 people die waiting for a life-saving organ that – for them – never comes.  

This is especially challenging for American Indians, who suffer from disproportionately high rates of diabetes, heart related diseases, and liver disease – all of which increase the risk of organ failures.  More than 1,300 American Indian/Alaska Natives are currently on the waiting list.  

A Gallup survey we funded in 2012 found that nine out of 10 Native Americans support the idea of donation, but fewer than half have signed up as donors on their driver’s license and for many organs – and age is irrelevant to the ability to donate.  We have organ donors in their 90s.  So what more do you think we can do – or will you do – to help save these lives?

As you may know, one donor can save up to eight lives. If you aren’t already a donor, please visit to learn how to sign up.  And make this a conversation you integrate into your conversations with patients, family members, friends, and neighbors.  

If you’re a student or a patient in a clinic, is information available there about how to donate?  If not, you can get it from our website at  Downloading and sharing pamphlets is pretty easy – and it could be the way you save a life without ever even knowing it.

Well, as a nurse, you can see why I feel so passionate about my work.  Everything that HRSA does drives toward eliminating the differences in the health and well-being that I saw as a child in Devils Lake and during the early years of my nursing career.

But now, we have a set of tools – from insurance coverage to health care setting to more health care providers in places we need them most – and all of that as a direct result of the ACA.  This is an exciting time to be in the business of helping others.  The Affordable Care Act has made possible most of the good work I spoke about to you today.

And none of this would have been possible had America said no to change.  It isn’t easy work – trust me – not from where I sit, nor from the front lines, where folks are working daily to get people in health care coverage and then in to health care.  But, in my nursing career, there has never been anything more exhilarating than having the tools at hand to make the difference in the health of millions of people.  

That only happens, though, if we all “lean in” to this important work.  In our communities, in our places of worship, in our neighborhoods, in our classrooms – tell people about it, and tell them where they can get more information – at

The need to “lean in” is particularly applicable to those of us in the health care field.  The health care system is changing – for the better – which is something we should not only embrace but help to shape.  

Change is happening, but we have a lot more work to do.  An HHS report released May 1 found that about 10,600 North Dakotans enrolled in health insurance coverage through the Marketplace during the open season that concluded March 31.  

That’s progress, but it’s just a fraction of the estimated 68,000 residents who were uninsured and eligible for coverage through the Marketplace at the start of open season.

Many of you have your entire careers ahead of you.  Much of what is unfolding can provide new opportunities for nurses and leverage the profession’s expertise – if we look for them.

Achieving health equity and eliminating health disparities happens only if all of us commit to that goal and robustly act on it.  And remember that while we can achieve a lot on our own, by working together to create solutions – by partnering with others, we can extend our reach.  

As nurses, regardless of where we come from and what has separated us historically, staying in touch with the needs of others is an abiding value of the nursing profession.  It reflects who we are, regardless of where we came from or where our career paths take us.   

I thank you for everything you do to promote the health of the Indian Nation today and for the health of the next generation.  And thank you for the opportunity to spend a few minutes with you today.

Date Last Reviewed:  March 2016