U.S. Department of Health & Human Services
HRSA Press Office: (301) 443-3376
Remarks to the Edward N. Brandt, Jr. Memorial Lecture in Women’s Health
November 15, 2012
Thank you for inviting me here today, I am very pleased to talk to you about the agency I lead, the Health Resources and Services Administration – or HRSA – our role in promoting women’s health and wellbeing, and our perspective on women’s health and health care services in the context of health care reform and a rapidly evolving health care system.
HRSA is an agency of the Department of Health and Human Services, where Dr. Ed Brandt served as Assistant Secretary of Health from 1981 to 1984. You are all familiar with Dr. Brandt’s work and his lifelong commitment to women’s health. His life stood as a wonderful example of service to others and to improved health for all. It was under his tenure as Assistant Secretary for Health that AIDS was first identified, and he led the nation’s health care agencies’ response to the epidemic.
He is widely recognized for giving birth to efforts in the Public Health Service and HHS that have resulted in the increased national consciousness about women’s health and their health care, as well as health disparities and health equity.
His achievements and honors are too numerous to list. He served, among others, with the Commonwealth Fund, the Robert Wood Johnson Foundation, the Kaiser Foundation, the Oklahoma State Medical Association, the American Medical Association, the Food and Drug Administration and the Institute of Medicine of the National Academy of Sciences.
At HRSA today we continue to push forward the work that Dr. Brandt championed, and throughout government we’ve had a very strong ally in the President. In March 2009, President Obama signed an Executive Order creating the White House Council on Women and Girls. The purpose of the Council is, in the President’s words, "to ensure that each of the agencies in which they're charged takes into account the needs of women and girls in the policies they draft, the programs they create, the legislation they support."
The recognition of the importance of women and girls by the President is not purely symbolic, it has provided steadfast support to the work we’ve been carrying out at HRSA and HHS for the health of women, young and old.
But before continuing, I want to make sure everyone is aware of the many different programs HRSA is responsible for. Our mission is to improve health and achieve health equity through access to quality services, a skilled health workforce and innovative programs.
You may know that HRSA is often called the safety net agency, charged with ensuring access to high-quality, culturally effective, primary care for all Americans. But not everyone knows that HRSA has a portfolio of 80 different grant programs, and that most of these programs benefit women who are low-income, medically vulnerable or geographically isolated by expanding primary care and extending health services to them.
Our budget of $8.2 billion provides grants to 3,000 partners in state and local agencies, non-profit organizations, hospitals, clinics, colleges and universities, and more. Among the programs and activities we support are these:
Our Community Health Center network delivers primary and preventive care at some 8,500 sites to over 20 million mostly low-income patients each year. In 2011, Health Centers served more than 9 million women age 15 and older – that’s more than 3 out of every 5 (62.1 percent) of all health center patients in that age group.
Our Ryan White HIV/AIDS Program’s 900 grantees provide top-quality health care to more than half a million people living with HIV/AIDS, a third of whom are women. Women now represent one-quarter of all diagnoses of HIV infection in the U.S. And more than half of all new HIV infections among U.S. women occur among African Americans.
Our Maternal and Child Health Bureau’s block grants to states support access to comprehensive perinatal care to improve the health of women before, during, and after pregnancy. The block grants help 6 out of every 10 women who give birth and their infants. Overall, MCHB focuses on integrating strategies to reduce maternal morbidity and mortality to promote primary preventive health services for women.
Our National Health Service Corps provides scholarships and loan repayments to encourage primary care professionals from a range of disciplines to serve in medically underserved areas. Of the nearly 10,000 Corps clinicians currently in the field, three out of four are women. Among other benefits, the Corps supports female providers by offering various resources and webinars related to women’s health and up to 35 days of maternity leave without incurring any extension of their service.
In the health professions, HRSA’s training, curriculum development, and scholarship and loan repayment programs strengthen the health care workforce. Our Bureau of Health Professions programs provide policy leadership and grant support for health professions workforce development — making sure the U.S. has the right clinicians with the right skills, working to provide high-quality and culturally and linguistically appropriate care.
Its programs promote women’s health by supporting the development of a health care workforce that aligns the composition and distribution of health care providers with the needs of individuals, families, and communities, and encourages the use of interdisciplinary health teams to improve the efficiency and effectiveness of care.
HRSA also houses the HHS Office of Rural Health Policy, which serves as the Department’s chief voice on rural health issues and advises the Secretary on rural health policy. The Office also runs a number of state and community-based grant and technical assistance programs to help HHS better meet the health care needs of rural areas, where more than 27 million women live.
Finally, the fulcrum of our efforts to improve the health and wellbeing of women is HRSA’s Office of Women’s Health, which promotes an integrated approach to women’s health across the lifespan. This Office coordinates activities with every HRSA component and leads our collaborations across HHS, taking into account social, economic and environmental contexts through collaborative activities.
I will talk in more detail about some of these activities and their impact on women’s health shortly, but first I would like to give you an overview of what health care reform through the Affordable Care Act, or ACA, has done for the health and well-being of women in our country.
Simply put, as HHS Secretary Kathleen Sebelius recently said, “this is probably the most important women’s health law in nearly 50 years.” It is generating not only a monumental shift in the way we approach health care for women and mothers and their children, it is also expanding access to health care services for all Americans – men and women – at a rate not seen since the creation of Medicare and Medicaid.
First and foremost, with the understanding that health insurance coverage is a critical factor in making health care accessible to women, the ACA prevents insurers from denying coverage to women because they’re pregnant, they gave birth by c-section, they’re a breast cancer survivor, or they’re a victim of domestic violence.
The ACA also helps to make prevention affordable. And as it now stands, starting in 2014, women will no longer be charged higher insurance premiums than men just because they’re women. The law also requires most private health insurance plans to cover recommended prevention and wellness benefits such as mammograms, screenings for cervical cancer, flu and pneumonia shots, regular well-baby and well-child visits, and domestic violence screening with no cost-sharing.
HHS estimates that thanks to the ACA, 47 million women will receive guaranteed access to these and other preventive services without cost-sharing for many policies renewing on or after August 1, 2012. Eliminating such barriers as copayments, co-insurance, and deductibles will increase access to services that improve the health of women and their children. The association between prenatal care and improved maternal health and birth outcomes – with which most of you are familiar – is but one example. Access to preventive services against heart disease, the number one killer of women in the United States, is another.
Furthermore, the ACA recognizes the need to take into account the unique health needs of women throughout their lifespan. As you know, a person’s health is influenced throughout the lifespan by factors such as sex, gender, racial ethnicity, culture, environment, and socio-economic status. For example, women's life expectancy overall is about five years longer than men’s, but this often comes at the expense of increasing disability and lower quality of life. Only 38 percent of women over 65 report being in excellent or very good health.
Researchers are discovering the critical roles that sex – being male or female – and gender identity play in health, wellness, and disease progression. The discoveries being made through the study of women’s health and sex differences are key to advancements in personalized medicine for both sexes.
Women represent about 70 percent of the American population age 65 years and older. Almost all participate in Medicare. The 24.7 million women who have coverage through Medicare can now receive additional preventive services without cost-sharing, including an annual wellness visit, a personalized prevention plan, mammograms, and bone mass measurement for women at risk of osteoporosis. In the first nine months of 2012, more than 20 million people with original Medicare got at least one preventive service at no cost to them.
The ACA also clearly recognizes that children’s health is linked directly with women’s health. There is a growing body of scientific evidence that suggests a host of chronic childhood diseases such as asthma, autism, and obesity, as well as chronic adult diseases such as heart disease, diabetes, and cancer, may trace their origins to maternal health.
So the ACA is promoting women’s health by improving children’s health by, for example, providing preventive services for children without co-pay, or prohibiting companies from denying insurance coverage to children with pre-existing conditions.
You may also recall that soon after President Obama’s first inauguration, he signed in February 2009 a re-authorization of the Children’s Health Insurance Program. Thanks to that and passage of the ACA, health insurance has expanded to 3.7 million more children and young adults. The law also allows youth and young adults to remain on their parents’ health insurance plans until age 26.
At HRSA, we’ve been heavily involved in the implementation of health reform, and we lead or partner in the implementation of many ACA provisions. This work has complemented our ongoing commitment to the goal of expanding access to affordable, high-quality health care services for women and children. We have made great strides in expanding access to primary health care for women and children over the past four years through virtually all our programs. I just want to mention a couple of examples.
Under President Obama, the health center system has seen its patient base grow from 17 million to more than 20 million – again, 60 percent of those patients are female.
In the National Health Service Corps, African American physicians today represent 17 percent of Corps physicians, exceeding their 6.3 percent representation within the national physician workforce. Hispanic physicians represent 16 percent of Corps physicians, nearly three times their 5.5 percent representation in the national physician workforce. Given the racial disparities implicated in infant mortality, growth in the diversity of the NHSC translates into substantial new access to primary care services for populations at greatest risk – clinicians who are conversant in their cultural and linguistic traditions.
As you know, with healthy women come healthy children – and vice versa. First and foremost on this front is prenatal health. Babies of mothers who do not get prenatal care are three times more likely to have a low birth weight and five times more likely to die than those born to mothers who do get care. The United States still suffers from a notable infant mortality rate, particularly in terms of disparities and across populations.
In a proactive focus on this crucial public health issue, last June Secretary Sebelius announced that the Department will be working over the next year to formulate America’s first-ever national strategy to address infant mortality. Among other things, we’ve set a national goal to bring the percentage of all preterm births down to 11.4 percent by 2020.
In this long and difficult challenge, the Healthy Start program is an initiative mandated to reduce the rate of infant mortality and improve perinatal outcomes through grants to project areas with high annual rates of infant mortality. The program began in 1991 with grants to 15 communities with infant mortality rates 1.5 to 2.5 times the national average. In 2010, 104 Healthy Start projects were providing services in 38 States, the District of Columbia and Puerto Rico.
Also, we are joining with our partners in the 13 southern states with some of the country’s highest infant mortality rates to build a Collaborative Improvement and Innovation Network to engineer collaborative learning and accelerate improvement and innovation across states to reduce infant mortality. Common strategies that are very important in this collaborative work include reducing pre-term deliveries, providing preconception and inter-conception care, and promoting safe sleep and smoking cessation.
The other side of the mother-baby health and wellness link is the health of the mother. There is wide consensus now that to reduce infant mortality in this country, we have to first improve the health of women and girls before they get pregnant. The link between women’s health before, during and after pregnancy, and the health of their babies is indivisible.
We know, for example, that an African-American woman is nearly three times as likely to die from childbirth as a non-Hispanic White woman, and an African-American baby is still more than twice as likely to die within the first year of life as a non-Hispanic White baby.
With respect to closing the maternal mortality gap, we need to do a number of things, including ensuring the safety, quality and access of patient-centered health care services, influencing social determinants, reducing racial, ethnic and income disparities, and increasing health equity. This is because much of women’s health has to do, among other things, with genetic predisposition, behavioral patterns, social circumstances, and environmental exposures.
In this area, access to care has been expanded by the ACA’s creation of the Maternal, Infant, and Early Childhood Home Visiting Program, which provides $1.5 billion over five years to send nurses, social workers and other trained home visitors to meet with pregnant women and young children who live in high-risk communities. There, they provide counseling and evidence-based intervention services that are known to improve health outcomes.
The Home Visiting program is now under way nationwide in more than 450 counties, 5 territories and 38 major urban areas – including New York, Los Angeles, Detroit, Seattle, Dallas and Denver. Last spring, 10 states received nearly $72 million in grants to expand their home visiting programs. States can select multiple models of interventions. The most common models are Healthy Families America, used in 37 states, and Nurse-Family Partnerships in 31 states.
There are many other programs we fund at HRSA and HHS to advance the health care of women. I would like to mention just a few:
The Bright Futures for Women’s Health and Wellness Initiative develops and evaluates a variety of evidence-based consumer, provider, and community tools for women across their lifespan. Tools have been developed in English and Spanish on physical activity and healthy eating, emotional wellness, and maternal wellness.
HHS earlier this year launched Strong Start to help reduce preterm births. Through this initiative, the Center for Medicare and Medicaid Innovation will award grants to health care providers and coalitions to support the testing of enhanced prenatal interventions.
The Healthy Weight Collaborative, another ACA-funded initiative, shares and spreads evidence-based, team-oriented clinical and community interventions to prevent and treat obesity for children and families. It is using new approaches that link primary care, public health and community resources to bring fresh ideas and effort to prevent and treat obesity in America. In the second phase of the Collaborative, 2 of the 10 teams integrated a women’s health focus into their work.
Another area of prevention in which we are investing considerable effort is domestic violence. This is a critical public health issue and a social determinant of health. One in four women, and one in five teen girls in the United States report experiencing physical or sexual partner violence. Injuries due to domestic violence increase the risk for asthma, cancer, hypertension, depression, substance abuse and poor reproductive health outcomes.
The Health Care for the Homeless program helps grantees train medical providers identify past and current exposure to violence among child and adult patients. Protocols and procedures are in place to identify abuse, neglect, and violence. And the Intimate Partner Violence and Perinatal Depression Project offers a series of pre-recorded webinars based on topics in a Toolkit that will be released soon. We are also integrating violence prevention guidelines, reporting requirements, or training with a number of our programs, including Ryan White Part D, Area Health Education Centers, the Graduate Psychology Education Program, and the Preventive Medicine Residency Program.
In addition to the ACA, one section of HRSA’s Ryan White HIV/AIDS program – called Part D – is the Children, Youth, Women and Families component, which provides family-centered primary medical care for women, infants, children and youth with HIV-AIDS and their families. Part D awarded more than $68 million to more than 100 organizations in 2010, providing care and other services to more than 53,000 women age 13 or older. Part D organizations also play a very important role in preventing mother-to-child transmission of HIV.
Another activity of the Ryan White Program involves Special Projects of National Significance, which develop innovative models of HIV treatment in order to quickly respond to emerging needs of clients. Two current projects are focusing on enhancing access to quality HIV/AIDS care for women of color and retaining them in care. Another is focusing on engagement and retention of quality HIV care for transgender women of color.
And you may have heard of a relatively new initiative called Text4baby, an educational program led by the National Healthy Mothers, Healthy Babies Coalition that provides pregnant women and new mothers with information they need to take care of their health and give their babies the best possible start in life. Women who sign up for the service receive free text messages each week, timed to their due date or the baby’s date of birth. HRSA is a promotion/outreach and evaluation partner of Text4baby.
One of our efforts to expand access to quality patient-centered care for women in high-risk and underserved communities involves supporting community health workers such as Promotoras de Salud. Many Promotoras are women because, as you know, women are often the health care decision-makers in their families and communities. Promotoras primarily work in Latino neighborhoods, providing health education and emotional support. They also monitor public health challenges and offer a vital link for communities where access to primary care is often scarce.
Several of HRSA’s components support community health workers in the form of training, technical assistance, special projects, and support for state and local initiatives. There’s a good reason for this: A 2007 study by our Bureau of Health Professions found that the most frequent health issue for which community health workers were used was – not surprisingly – women’s health and nutrition, followed closely by child health and pregnancy/prenatal care and immunizations. This finding underscored the importance of community health workers in the overall provision of care for women and children.
These and other evidence-based models funded through the ACA are known to improve health outcomes among women. Along with other ACA provisions, they are designed to focus on health and also the social determinants that negatively affect the most vulnerable women – determinants such as poverty, lack of access to care, poor education and job skills, and poor nutrition.
There are many more programs HRSA supports – too many to list here – in support of women’s health and the health of their children, which run through everything we do, touches all the activities we support, and is an integral component of the work we do at HRSA. Now let me pivot to the overall health professions workforce.
The growth in the number of people with health insurance coverage will, of course, increase significantly the demand for services. And that, alongside a steady demographic shift in our population that will see growing numbers of seniors needing more health care services for a longer time, will require a sustained and sizable growth in our nation’s health care workforce.
At HRSA we are working to grow that workforce in a number of ways. For example, the number of clinicians in the National Health Service Corps today, nearly 10,000, is close to triple the number in the field when President Obama took office, thanks to ACA and the Recovery Act.
I told you earlier that most NHSC clinicians are women. In fact, the front line of primary health care is largely composed of women. In general, women are not under-represented in health occupations, in fact they dominate most health professions. But it is worth noting that while the percentage of women in health professions requiring the most education, like medicine and dentistry, is growing, that number is not yet equal to the percentage of women in the general population. That is one disparity we need to address.
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 – noted that health care delivery is shifting from a model dominated by acute care to one focused on primary care and care coordination. Such a system will require a sufficient, well-skilled, and effectively deployed workforce.
HRSA is meeting this challenge by increasing program support to the primary care nursing workforce. Doing so will require a well-supplied pool of faculty. The IOM report noted this need as well and recommended doubling the number of nurses with doctorates. This is being addressed through the lifting of the cap on funds in Title VIII for doctoral education, as well as through increases in funding for the nurse faculty loan programs.
In fact, HRSA’s Bureau of Health Professions administers a selection of programs that contribute to the growth of the health care workforce. These programs support interdisciplinary programs in public health, programs to strengthen the primary care and geriatric workforce, scholarships for disadvantaged students, and loans for health professionals, among others.
Support for training programs covers a wide range of professions, from the Personal and Home Care Aide State Training Program, to the Nursing Assistant and Home Health Aide Program, to the Patient Navigator Outreach and Chronic Disease Prevention Program. And for those who work with elderly populations, we support a number of Geriatric Education Programs.
The Bureau also supports Area Health Education Centers, which provide continuing education programs on women’s health-related topics such as domestic violence, maternal and child health, breastfeeding, breast and cervical cancer, and prenatal health.
The IOM recommendations I just mentioned also promote the regular collection and publishing of health care workforce data. Providing a proactive approach to this important need, the ACA established the National Center for Healthcare Workforce Analysis, which is housed within HRSA.
The Center is working collaboratively with other government agencies and external groups to build a data reservoir across the health professions to track the supply, demand, and need for health workers – and to make that information available in a timely fashion to influence and shape the policy debate on health reform implementation.
It is worth noting that many of our data and reports will include breakouts by sex. For example, our professions diversity report will include data on the percentage women in each of 32 health professions and how that number has changed over the past decade. We will also report on new graduates by occupation. This occupations report will also have data on the percentage of women in 60 health occupations for 2008-10.
Obviously, research and data are also useful to improve our understanding of health care needs, health care services delivery, and training outcomes. To achieve these aims, HRSA produces the Women’s Health USA Databook, which is now in its tenth edition. This data book is updated every year using current national-level data to highlight emerging health issues and trends. Data is analyzed by sex, race/ethnicity, geographic location, and age, among other factors. Furthermore, this publication is a free resource – available online on our website.
Another important example of how we use women’s health data at HRSA is our set of State Women’s Health Profiles, which provide insight into how our Title V agencies are incorporating and tracking women’s health-related needs. The online Profiles are based on the 2010 Title V Needs Assessments, and have been used in academic and other teaching settings to help students learn more about Title V.
Further, a focus on women’s health is a priority in several of HRSA’s rural health research projects. These projects are addressing rural-urban perinatal health outcomes; quality of obstetric care and perinatal safety in rural hospitals; and the impact of race and rural status in cervical cancer screening practices.
Of course the priorities and goals of our work – from increasing access to care, to growing the workforce, to incorporating prevention into our vision and programs – are operating within the context of a health care system that is rapidly changing.
In this new environment, team-based health care is an essential element for improving quality of care, delivering patient-centered services, and keeping costs in check. In other words, improving health care also must include efforts to ensure that health professionals are taught to work collaboratively in teams and that health care settings are designed to deploy an effective use of a complement of health care providers.
The importance of this approach was reinforced recently, when the IOM estimated that $750 billion – or about one-third of total U.S. health care costs – was wasted in 2009 on unnecessary services, excessive administrative costs, fraud, and other problems.
The IOM explicitly mentioned care coordination as a key focus area and recommended, among other things, that providers need to improve coordination and communication within and across organizations. Specifically, the IOM said that 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.
To achieve this necessary shift in our business models requires both health professional educators and clinical leaders working together across disciplines to create appropriate training and care models.
These team-based care models can improve patient safety and health outcomes. For example, one of our sister agencies in HHS, the Agency for Healthcare Research and Quality, in September completed a unique nationwide program that showed that a combination of teamwork, the best clinical practices, and a strong commitment to safety reduced the rate of central line-associated bloodstream infections in intensive care units by 40 percent.
This and other successful evidence-based models of team-based care challenge us to identify new ways to educate the health workforce to deliver care that has quality and safety – and their requisite attributes of care coordination and team engagement – at its core.
To further this aim, HHS recently announced a continuing HRSA grant to the University of Minnesota Academic Health Center to be the site of a new Coordinating Center for Interprofessional Education and Collaborative Practice. The center will facilitate movement of the health care delivery system to one characterized by integrated care and services. It will act as a one-stop resource on interprofessional education and practice that also supports research, data collection, and analysis.
This new five-year, $4 million initiative will pilot projects at 11 affiliated academic sites around the country. As just one indication of how groundbreaking this initiative is, four private philanthropies have committed an additional $8.6 million to support the Center’s projects.
And just as models of interprofessional collaboration gain more attention and acceptance, so too does the idea of including a greater emphasis on women’s health in overall efforts to encourage collaborative education and treatment models.
One example is a new HRSA report that addresses integrating women’s health into curricula across five specific health professions programs: medicine, oral health/dentistry, baccalaureate nursing, pharmacy, and public health. Both women’s health and interprofessional collaboration are top priorities in health education, and improvements will contribute to dramatic health benefits across the population.
All this gives you an overview of some of the ways that HRSA is working for the health of all women and their children, and how we are working to strengthen and enhance the primary health care programs that serve them, alongside the training, education, information, resources, professionals, and policies that deliver these programs.
Another way to look at this is, as Secretary Sebelius put it, is to say that “women have a powerful opportunity to make a difference as champions of healthy communities and as everyday practitioners of preventive care.” Health care reform and the work of countless partners and stakeholders across the country are providing that new opportunity.
The values driving our work are central not only to the goals of expanding access to care, reducing health disparities, and growing a well-prepared and adequate workforce – they are central also to the Affordable Care Act itself, through which much of the foundation for an effective national strategy to improve the health of all Americans has already been laid – and which will only be further strengthened between now and 2014.
Our goals are supported by the President of the United States, by Secretary Sebelius, and by me and other members of the administration.
I thank you for inviting me to be with you today.