Remarks upon receiving the Victor I. Howery Memorial Award for Outstanding Contributions to Rural Mental Health from the National Association for Rural Mental Health

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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

July 18, 2014
Washington, D.C.

Thank you very much for this award.  And while I am certainly honored to be the recipient, as the Administrator of HRSA, what we have accomplished at that Agency is very much a product – as you might imagine -- of the outstanding work of my colleagues.

All of us at HRSA are fully committed to improving health and achieving health equity by ensuring access to quality health care services, including behavioral health services, and by strengthening the supply, the skill set and the distribution of health care providers, particularly in geographically isolated and underserved communities.

I think of HRSA’s programs and our efforts as vehicles that are designed to disrupt an unacceptable status quo, and to address challenges head on.  How we do this really varies – it may take the form of clearly documenting the disconcerting trends in rural population health status versus their urban counterparts.  It may be reflected in our efforts to get thousands of people off of waiting lists for HIV AIDS drugs, or it may be by launching new efforts to procure more organs, and make them more accessible to more people, and by signing up more organ donors,.

Changing the status quo in these and scores of other areas -- we have a broad portfolio at HRSA – that’s what we work on every day.

And from what I know about the work of Dr. Victor Howery, and his work to direct national public policy attention to the need to improve access to mental health care in rural areas, it looks like shaking up the status quo was his life’s work, too.

In the 1970s, Dr. Howery’s influence on the national level was such that the first recipient of this award, as you surely know, was First Lady Rosalynn Carter.  She, of course, made improving mental health care a key policy emphasis during her time in the White House and, as a woman from rural America, and as First Lady, she knew the need there as closely as anyone.  

The work Dr. Howery and Mrs. Carter collaborated on helped raise awareness about the need for better access to quality health services, with an emphasis on behavioral health care, which at the time challenged the status quo.  Their message wasn’t all that different from our efforts today – working to ensure every American has access to affordable health insurance coverage.

This access is so important because research clearly supports our ability to draw a direct line between health insurance coverage and health status.

Most recently, for example, a study in the Annals of Internal Medicine found that in the 4 years following the enactment of health insurance reform in Massachusetts, that state saw a decline in the number of deaths by 3 percent – even while no similar declines occurred in other states.  Some have speculated that we may see an even larger reduction in deaths over the next few years in other states as a result of the ACA.

The impact that health insurance coverage will have for individuals with mental illness, especially severe mental illness, is likely even greater. We know that individuals with mental illness are likely to have comorbid conditions: a 2011 study found that two-thirds (68%) of adults with a mental health disorder had at least one medical condition, with diabetes and asthma cited as frequent medical problems.

So it’s very important that all of us work in coming months to build on the gains of the past year and ensure that even more rural Americans know about the benefits of the Affordable Care Act and sign up for coverage, especially those who stand the most to gain.

The good news is that over 8 million Americans signed up for health insurance coverage through the Marketplaces and more than 3 million young adults under age 25 enrolled in coverage under their parents’ plans, thanks to the provision in the law making that possible.  And 5.2 million additional individuals have enrolled in health insurance coverage through Medicaid or the Children’s Health Insurance Program since open enrollment began.

But a major challenge we still have to face is that 24 states have not yet expanded Medicaid — and that’s depriving about 5.7 million people of health insurance coverage.  And that’s not acceptable to rural or other communities given the data I shared a moment ago about insurance coverage and health status.

In fact, where the opportunity for people to participate in Medicaid is expanded we can find great gains.  For example, look at what the ACA’s Medicaid expansion provisions already have done for one largely rural state: in Kentucky, the ACA’s expansion of Medicaid eligibility has helped to reduce the number of uninsured individuals there by half.

So let’s imagine if every state expanded Medicaid.  We know that nearly 40 percent of uninsured individuals living in rural America fall below 139 percent of the Federal Poverty Level.  The bottom line is this: States that have yet to expand Medicaid are leaving money on the table that could boost their economies and they’re leaving many of their rural residents without affordable insurance coverage options.

However, even in states that have not expanded Medicaid, we know that more individuals who were in fact previously eligible for coverage through Medicaid have now enrolled in the program, thanks to stepped-up outreach efforts.  For example, in Alabama, Medicaid rolls topped 1 million for the first time.  And across the nation, individuals can enroll in Medicaid all year round, so those numbers will continue to grow.

People also can sign up for Marketplace health care coverage any time during the year – not just during the open enrollment periods -- whenever a life circumstance changes their connection to health insurance, say through getting married -- or divorced -- having a baby, changing jobs, or graduating from college.  And members of federally-recognized Tribes can enroll in and buy health insurance coverage through at any time.

We believe that the improved access to health insurance provided by the Affordable Care Act can largely reduce the long-standing inequity in access to health care suffered by many U.S. population groups – including the 60 million Americans who live in rural areas and the similar number of adults estimated by the National Institute of Mental Health who suffer from a diagnosable mental disorder in any given year.

That’s because the ACA also ensures that no one can be denied coverage because of a pre-existing condition, like a substance abuse disorder.  There are no lifetime or yearly dollar limits for mental health and substance abuse disorder services.  Additionally, women cannot be charged more for insurance coverage than men.  Furthermore, health insurance coverage is no longer tied to one’s job – all of this means that, going forward, people who have been insured -- and people historically without insurance -- will have a better opportunity to get the health care that they need.

And people now have another important access, thanks to the ACA:  Guaranteed access to preventive services like health screenings without any out-of-pocket cost.  Lack of money – historically a very significant barrier – is no longer an obstacle to getting preventive health services that can keep people healthy and can in fact save lives.

In addition -- and very importantly under the ACA -- health insurance plans must offer mental health and substance abuse treatment services at “parity.”  That means that limits applied to mental health and substance abuse services on co-pays, number of visits or care management, for example, cannot be more restrictive than limits on those factors for medical or surgical services.

But even with the successes of the ACA over the past year, we all know that too many Americans still remain uninsured, and the problem is slightly worse among Americans living in rural areas than it is for urban residents.  And rates of uninsurance among people with mental illnesses are higher than among those without, according to a 2011 study.

These circumstances make both Medicaid expansion in states that have yet to do so – and the next open enrollment period for insurance through the Marketplace that begins on November 15 -- extremely important for the populations you serve.

So there’s still a lot we need to do, and I encourage you to continue to get the word out in your communities about the coverage options that are available right now.

Obviously, and most importantly, we need to continue to educate the uninsured about their options under the ACA.

But we also need to recognize that, too often, folks who now have health insurance – many for the first time -- may not be aware of the range of ACA benefits I just discussed.  They may think, wrongly, that preventive services like certain screenings aren’t covered or even wonder why those services are important.  In other words, many of the 8 million newly insured may need guidance on the full range of benefits that health insurance provides.

So to help with this, our colleagues at CMS have created a new website called “From Coverage to Care” to help health care providers  with patients and others on topics that many of us take for granted, but that may be foreign to a lot of Americans, such as:

  • What it means to have health insurance;
  • How to find the right provider;
  • When and where to seek health services; and
  • Why prevention and partnering with a steady source of care is important for good health.

From Coverage to Care is a great addition to the next phase of our ACA outreach.  It’s information that can be made available through schools, board rooms, class rooms, exam rooms, patient waiting rooms.  

I encourage you to go the Coverage to Care site at and familiarize yourselves with those resources.  They’ll be valuable for all of us as we enter this new phase of outreach.

But it is also critical that we continue to ensure that individuals – especially those with mental illness – who are newly insured or receiving new benefits due to health reform know about the services out there.

During my time at HRSA, we have, I think, been partners in your work by stepping up our efforts to focus resources on behavioral health care and on integrating it into our grantees’ delivery of primary care across America.  Of course, those efforts occurred at the same time the ACA and the 2009 Recovery Act funded an enormous expansion of HRSA-supported health centers.

Thanks to the ACA and the Recovery Act, since 2008 health centers have hired an additional 2,600 behavioral health providers.  Those new hires have raised the total number of behavioral health providers working at health centers to 6,500 – an increase of 65 percent over five years.

And it seems likely that those new providers are impacting the way health center clinicians examine and treat their patients.  In 2013, health center clinicians diagnosed 1.6 million patients with depression and other mood disorders – that’s the fourth-highest diagnosis made by health centers nationwide.

The ACA and the Recovery Act also invested heavily in expanding the National Health Service Corps.  The overall number of NHSC providers has more than doubled in five years, from 3,600 in 2008 to nearly 8,900 in 2013 -- providing care for millions more patients.

The expansion has been even greater among behavioral health providers in the Corps -- since 2008, their numbers have more than tripled!  Currently, the NHSC has more than 2,800 behavioral health providers – that’s about one of every three NHSC clinicians in the field as of September 2013.  And almost half of those behavioral health providers – close to 1,300 clinicians – work in rural communities.

Both health centers and the NHSC have close to half of their grantees and assets in rural America, so the expansion of these programs adds considerably to the work that many of you do.  And because behavioral health services in rural areas are often delivered through primary care and other safety-net providers, improving access to primary care by expanding health centers and increasing the number of NHSC providers will improve access to mental health and substance abuse services in rural America.

These accomplishments really mean a lot to the most vulnerable populations, but also to health care infrastructure and community development in underserved rural areas across the country.

For that reason, later this summer, we will award $50 million of funding made available through the Affordable Care Act to help 200 health centers expand behavioral health services and step up their integration into primary care.  

And last month we announced the availability of $300 million to expand health services at health centers.  Grantees may use part of these funds to expand a variety of services, including behavioral health care.

HRSA is also working to ensure that providers and others continue to evolve with new health care delivery models and receive training in critical areas.  Together with SAMHSA, HRSA supports the Center for Integrated Health Solutions, which promotes the integration of primary and behavioral health services to address the needs of individuals with mental health and substance use conditions.

Recently, the Center has been providing an 8-hour training course called Mental Health First Aid to help laypersons and professionals increase their basic knowledge of mental health and substance use issues.  In rural areas, the training helps build a community's capacity to identify mental health and substance use issues early and adds to their ability to intervene and refer a person to existing resources.  More than 500 of these trainings have occurred in rural areas over the past year.

The Center also has available from its website a six-part presentation on telebehavioral health training and technical assistance, along with a number of webinars on integrating behavioral health into the delivery of primary health care.  That website address is:   

I encourage you to get the word out to the populations you serve and the providers you interact with every day about this important resource, as well as the material I mentioned earlier that can be found on the From Coverage to Care website.  

This material should help you and your colleagues as you continue to fulfill your commitment to reach individuals with mental illness, and their families, in rural and isolated parts of the country about the importance of health insurance coverage and accessing preventive and treatment services.

Thank you for what you do each and every day, and thank you again for connecting Dr. Howery to HRSA and to the National Association for Rural Mental Health through this award.

Date Last Reviewed:  March 2016