September 12, 2003
Phoenix, Ariz. 

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Thank you for inviting me to be with you today.  Before I begin, I’d like to recognize George Hardy of ASTHO, and Patrick Lenihan of NACCHO for their dedication to the cause of public health in America .
 
It’s wonderful to be in Phoenix with so many of HRSA’s state, county, city and territorial partners in protecting and improving the health of the American people.
 
Today I want to talk about our shared concern and responsibility for the state of public health workforce.  I want to tell you about HRSA’s efforts to improve public health preparedness through the counter-bioterrorism programs we oversee and through HRSA’s new Ready Responders initiative.  And I want to discuss ways HRSA can aid the work of ASTHO and NACCHO members and the resources we have to help you.
 
But let me begin by telling you where we are in administering the President’s Health Center Expansion Initiative, one of HRSA’s most important responsibilities now and for many years to come.  There’s an opportunity for public entities to get more deeply involved in providing health center services and I want to talk about that, too.
 
So far the President’s expansion plan -- 1,200 new and expanded health centers that will serve an additional 6 million patients annually by 2006 -- is proceeding ahead of schedule.  In 2002 we thought we did great when we exceeded our targets by funding 171 new health center access sites and expanding capacity at 131 centers – 41 sites beyond our goal.
 
And we’re also going to surpass the goals we set for 2003 of 90 new access grants and 80 grants to expand medical capacity.  Two weeks ago Secretary Thompson announced his intention to fund 204 grants worth $56 million to open new centers, boost service expansion at existing centers, and implement health disparities collaboratives.  With those grants, we will exceed the 2003 target for expanded medical capacity by seven and pass the new access grant target by an even dozen.
 
And we fully expect that our 2003 expansion grants will continue the unprecedented gains in service delivery achieved in 2002, the first full year of the expansion initiative:
 

• Health centers served more than 11.3 million patients last year.  That’s an increase of more than a million patients over the 2001 figures, and close to double the annual average increase during the years 1998-2001.
  
  
• Total patient encounters grew from 40.3 million to 44.7 million – that’s 4.3 million more encounters over the year.
  
  
• Health centers treated more uninsured patients, more Medicaid patients, more minority patients, more patients below 200 percent of the poverty line, and more dental patients.  The number of dental encounters in 2002 increased by 557,000 from the year before, rising to almost 3.8 million.  Increasing dental care at health centers is a priority at HRSA.
  
  

President Bush has asked Congress for an additional $169 million for health centers in his FY 2004 budget, which would increase funding to a record $1.6 billion.  The President’s 2004 budget proposal would take us to the halfway point toward his goal of 16 million patients served annually by health centers in 2006.
 
While I’m talking about the expansion of the health center system, I want to mention here an element of the legislation that offers an opportunity for public entities – such as city or county health departments, public universities or hospitals – to get directly involved as health center grantees.
 
The health center legislation offers up to 5 percent of grant funds each year to these public entities, and gives them a break on health center governance rules regarding personnel structure and policies to ease their participation.  In FY 2002, only 3 or 4 percent of health center grantees were public entities, so there’s room for growth here.
 
Public entities that win health center grants usually establish a separate governing board that meets legal composition requirements.  The public entity and the board then apply for the grant as co-applicants.   A memo of understanding is included in the application that explains the relationship between the public entity and the governing board and the roles each will play.
 
What I say to all of you who head public entities is this:  You may convene an effort to get people and organizations together to expand access to health care, but decline a direct role in service delivery.  You may be a partner in the drive to expand access by working with health centers to coordinate health care services.  Or you may, if you choose, decide to become a health center grantee yourself.
 
If you opt for this third path, the 5 percent ceiling offers a solution to the barriers posed by the legislation's governance requirements.  And our people at the Bureau of Primary Health Care can help guide you if you decide to follow that path.
 
One of the major challenges of the health center expansion, of course, is the need to hire thousands of health care professionals to staff the new and expanded centers.  We estimate that health centers may need up to 36,000 new staff to meet the President’s targets, including more than 11,000 clinicians.   The reform and expansion of the National Health Service Corps – the second of the Presidential initiatives HRSA is responsible for -- plays an integral role in our staffing plans, since many NHSC clinicians serve at health center sites.
 
But we also need to develop new recruitment and retention strategies, improve existing ones, and work with residency and educational training programs to get the people we need.  We welcome your help and advice on meeting these goals.  The situation is challenging, true – but it also expands opportunities for health care professionals who want to serve America .
 
On broader workforce issues, HRSA shares your concern on the need to infuse the public health workforce with new blood, and we have taken steps to get more talented young professionals into our ranks.
 
Soon after Secretary Thompson asked me to become administrator at HRSA in March of 2001, I remember reading agency staffing forecasts which warned that many of our most experienced employees would be eligible to retire in coming years.  We knew we had to act decisively to attract the best and the brightest to HRSA’s mission of expanding access to quality health care for all Americans.
 
So we established the HRSA Scholars program and recruited the first class of scholars in November of 2001.  We’ll soon welcome our third class.  The program recruits between 45 and 60 people in each year’s class, with the goal to nurture their professional development and retain them as productive professionals on staff for years to come.
 
The cornerstone of the Scholars program is a year-long training curriculum that each Scholar must complete.  We offer Scholars learning experiences in several HRSA bureaus and offices, shifting them to new assignments every three months.  The training emphasizes the acquisition of the skills and knowledge   Scholars will need to help HRSA meet future challenges, and includes courses in grants management and project officer functions.
 
After they successfully complete the year-long curriculum, the scholars enter a probationary period that leads eventually to permanent career slots.
 
HRSA also offers a fellowship program in collaboration with the Association of Schools of Public Health (ASPH) and a training program with Johns Hopkins University that gives Masters of Public Health graduates and students work experience at our agency.
 
Our partnership with ASPH offers people who have received an MPH within the previous five years a one-year fellowship in a HRSA bureau or office, with a chance for a one-year extension.  The program also offers three-month summer internships for students pursing a public health degree.
 
Since 2000, 29 fellows and 39 interns have participated in the program.  This past June, we accepted 8 fellows and 4 interns.  Many past fellows have moved on to public health careers in academia and government – including at HRSA and the National Institutes of Health.
 
The Johns Hopkins agreement, called the Student Career Experience Program, offers health policy students in the university’s Masters of Health Sciences program a year of work experience following a year of academic study.  Students pursuing the MHS in Health Policy degree at Hopkins must secure that year of work experience to get their degrees.  One of the benefits of the program for HRSA is that it gives us a chance to “try out” these people to see if they fit well with our goals and mission.  The number of students is relatively small – usually between 3 and 6 per year – but about half of the students who enrolled in the program since 1997 are still working at HRSA or HHS.
 
That’s what we’re doing inside HRSA to plan for future workforce needs.   I know, too, that we’re working with some of you on broader workforce issues.  HRSA’s Office of Rural Health Policy has sponsored a NACCHO analysis of rural public health agency workforce and needs that is set to be published in the November issue of the Journal of Public Health Management and Practice.   In the same area, HRSA is working with CDC’s Office of Public Health Practice to evaluate the use of public health performance standards in rural public health agencies.  The project is almost finished and we should have that information for you soon.
 
Additionally, HRSA now can help providers that want to hire foreign-trained physicians in medical residency programs who are here on J-1 visas.  Normally those individuals are returned home when the residency ends.  The Department, through HRSA, has assumed a new role acting as an “Interested Government Agency” to sponsor applicants for a waiver of the J-1 visa requirements.  If these doctors want to stay in the U.S., the State Department and the Immigration and Naturalization Service are willing to waive the ”return home” provisions of the J-1 visa if the physician is willing to serve in a Health Professional Shortage Area or a Medically Underserved Area.  Secretary Thompson recognized the need for HHS to take on this role to support recruitment and placement of physicians in underserved areas of the country, particularly rural areas.  The Department published regulations about its new role last December.  HRSA has the responsibility to accept these waiver applications and issued application procedures this past spring.
 
One certain thing public health professionals of the 21^st century will have to tackle is disaster preparedness.
 
HRSA’s National Bioterrorism Hospital Preparedness Program, launched last year, is a core element of the federal government’s response to the challenges posed by the September 11 attacks and the anthrax terrorism that followed.
 
The program is structured to develop and sustain “surge capacity” at hospitals sufficient to handle mass casualty events.  It almost goes without saying that our hospitals – together with health centers and other first-responders -- will play a critical role in both identifying and responding to any potential terrorism attack or infectious disease outbreak.
 
In 2002, states used first-year funding to develop needs assessments and plans for dealing with a potential epidemic involving at least 500 patients in their state or region.  Planners looked at quarantine and decontamination needs and the capacity of hospital labs to diagnose and report possible bioterrorism agents and forward high-risk specimens correctly.  They outlined procedures for the immediate receipt and distribution of antibiotics and vaccines made available from federal sources.  They covered communications among hospitals and emergency responders.  And they discussed emergency drills and personnel training.
 
Earlier this month Secretary Thompson announced half a billion dollars in FY 2003 hospital preparedness grants. These funds will support investments identified last year in the state plans.  2003 funds -- and those in future years -- will pay for more hospital beds; the development of an isolation capacity; and the establishment of hospital-based pharmaceutical caches.  Funds will be used to identify additional health care personnel who would be called on in an emergency “surge,” and to provide personal protective equipment, extra mental health services, and trauma and burn care.
 
As all of you know, hospital preparedness funds go to states, but HRSA was careful to make sure that those resources don’t stay at the state level: 80 percent of the funds must go to local hospitals and clinics, health centers, EMS centers and the like.  And we specified in the program guidance that participation in the advisory planning committee must include officials from local health departments, hospitals, health centers and clinics.
 
We have heard complaints from local officials that the money is not getting down to them in sufficient amounts.  And we have read the General Accounting Office report on hospitals’ shortcomings in building capacity to respond to a bioterrorism incident.  On that latter count, we feel that hospitals, states and localities have made much progress since that report was written using data from early 2002.  And on the first count, we urge patience and remain hopeful that state funds will indeed reach local levels as planned as the program matures.  States were forced to gear up very quickly to pull together stakeholders, write plans, and establish priorities.  That they have done so in an environment of troubled state budgets while responding to the public health threats posed by SARS, monkeypox and the West Nile virus is a tribute to them and their staffs.
 
We also think it likely that the impressive response by state and local health officials to these sudden public health threats was in part due to the planning and coordination encouraged by the hospital preparedness grants.
 
HRSA also is responsible for administering a new “Bioterrorism Training and Curriculum Development Program,” which provides continuing education and training for health care professionals already at work and adds bioterrorism curricula in medical education.
 
I’m happy today to announce $26.5 million in FY 2003 competitive grants under this program.  The continuing education grants total $22.3 million and go to grantees in 19 states; the curriculum development grants total $4.2 million and go to 12 states.  Most of the grants were won by major academic health centers, many of which have designed partnerships with local and state health departments to do the training. 
 
The Metropolitan Chicago Healthcare Council is a good example of the broad-based coalitions encouraged by these grants.  Its members include the Chicago Department of Public Health, the University of Illinois Colleges of Nursing and Pharmacy, several major hospitals and health systems, Access Community Health Network -- a network of clinics that serves vulnerable populations -- and the Illinois Retail Pharmacy Association.  To expand Chicago ’s surge capacity and ability to respond to emergencies, the MCHC plans to train about 6,000 primary care practitioners, nurses, pharmacists and mental health professionals.
 
The Denver Health and Hospital Authority is another excellent example. Denver Health’s partners include the Colorado State Dept. of Public Health and Environment, multiple federal agencies, local Community Health Centers and several Colorado universities.  The partners plan to train 4,000 health professionals in the first year of the grant and 5,000 in year two.
 
The President has proposed $60 million for bioterrorism training and curriculum development in FY 2004, with the goal of providing continuing education for 38,000 health care professionals over the 2003-04 period.
 
I’m also pleased to announce 11 grants for another element of HRSA’s counter-bioterrorism arsenal, our poison control incentive grants.  Those grants, worth about $1.5 million, to go poison control centers and universities in 11 states to improve services and boost collaboration among poison control centers and local public health agencies.
 
All of these counter-bioterrorism grants will be posted on the HRSA web site at www.hrsa.gov.
 
The programs I’ve just discussed, of course, were passed by Congress and signed by the President.  But we’ve also taken an independent effort at HRSA to boost the nation’s emergency preparedness – and improve medical care to underserved Americans at the same time – by enlisting medical professionals in an elite corps we call the “Ready Responders.”  As of today we have almost 50 Ready Responders on staff; we hope to have that number up to more than 70 by the end of the year.
 
We created the Ready Responders in the weeks following the 9-11 attacks.  HRSA and our sister federal agencies immediately scrambled to send Commissioned Corps employees trained in disaster relief to New York, the Pentagon, and to the crash site in Pennsylvania.  To a person, they reacted heroically to the challenges they faced.
 
But in our struggles to identify and mobilize these individuals within HRSA, we recognized that we needed to build a better way to respond to future disasters that may strike us.   And we wanted to coordinate that effort with HRSA’s ongoing push to provide more direct health care to our neediest fellow Americans.

Fortunately, HRSA already had a structure in place to get health care professionals to areas of greatest need – the National Health Service Corps.   We just needed a framework that would enable us to rush clinicians to disasters, whether natural in source or induced by the cruel natures of those who hate freedom.

Like other NHSC clinicians, the Ready Responders serve in health centers and remote sites where underserved people need greater access to quality health care.   But they also commit to a rigorous training regimen twice a year and are always on call to respond in times of emergency.

To our mind, the Ready Responders creates winning scenarios on several fronts:
 

• Because Ready Responders are members of the Commissioned Corps and paid by HRSA, hospitals, health centers and clinics in the most underserved parts of the country get free health care professionals on site.
  
  
• By eliminating some administrative positions and putting the resources into the Ready Responders, HRSA put more health professionals in service to America without increasing our budget.
  
  
• The Ready Responders themselves gain invaluable new training and expand their professional capabilities.
  
  
• And the nation knows that its government can respond to the worst possible events by sending in the highly trained, highly qualified health care experts.

We pray, of course, that the training the Ready Responders have received will never be tested.   But America is more secure, more confident and better able to confront the challenges of the 21st century because they have it.
 
A few minutes ago I referred to tight state budgets.  You at the state and local levels may have more colorful terms for the budgets you’re wrestling with.  We know from our health centers and our other grantees that uncertainty over Medicaid revenue has been and remains a major concern.   HRSA works with our colleagues at CMS in several ways to see that our grantees receive appropriate reimbursements for the eligible patients they serve.
 
Lately we’ve been working with state and regional primary care associations on state-specific strategies to ease the burden on new health centers seeking certification for Medicaid reimbursements.  CMS has been very responsive to us and even developed an expedited process and streamlined forms to help the new centers.   And at the Primary Health Care All-Grantees meeting HRSA convened at the end of June, CMS sent a contractor to answer questions new grantees had about the certification process.
 
HRSA also works with CMS by commenting on reviews of waivers and amendments to State Medicaid and SCHIP programs.  Our aim in doing so is to make sure that HRSA-funded providers who serve a large number of low-income persons are not negatively impacted by the proposed changes.
 
Additionally, CMS supports the Third-Party Reimbursement Training HRSA sponsors to educate our grantees on how to obtain appropriate Medicaid and other reimbursements.  This training began last year, and so far we have held sessions in 31 states.  We hope to provide sessions in all 50 states by the end of 2004.   CMS helps by coordinating with State Medicaid Agency personnel on upcoming training sessions.
 
Our reason for providing the training is this: When health centers and other HRSA-supported providers get appropriate reimbursements from third-party sources – Medicaid, Medicare, SCHIP and commercial insurance -- then these grantees can use more of their HRSA funds to serve the uninsured.  That, in turn, lessens the burden at the local level on hospital emergency rooms, local health department clinics and other safety-net providers.
 
Before I go, I need to mention a change in organization at HRSA that we feel will improve the way we interact with our far-flung grantees.  Earlier this year, we changed the name of our Office of Field Operations to the Office of Performance Review.
 
More important than the name change was the change in its function.  No longer will our outstationed employees act as project officers for health center grantees.  All of that work will be done at headquarters, just as it always had been done for HRSA’s other grantees.  Now and in the future, we want our Performance Review staff to focus on what the name says -- reviews of grantees’ performance.  These reviews will include community-wide and even statewide examinations of grantees, with the intention of identifying what works in service delivery and what impediments to success need to be removed.
 
We’re giving Performance Review staff in the regions their own budgets and a charge to provide technical assistance to help grantees quickly find solutions to problems they may face.  We want to empower regional managers to provide TA from knowledgeable local sources if available, so that the help arrives quickly to grantees without anyone from headquarters slowing things down.
 
Besides identifying where TA is needed, we expect that the reviews will uncover program trends and lead to policy recommendations that staff in the Office of Performance Review will bring to the attention of HRSA’s senior leadership on a regular basis.
 
Let me close today by again thanking you for the invitation to speak here today.  I hope in the future to be able to spend more time with ASTHO and NACCHO members, and I invite your leadership to visit me at HRSA’s offices in Rockville .  My door is always open to discuss the public health issues that affect all of us.
 
Thank you for listening.