Honors Colloquium 2012 – "The Affordable Care Act and The Future of U.S. Health Care"

good evening welcome to the second night of the 2012 honors colloquium healthcare policy healthcare change i should say health politics and money thank you for braving what they’re saying might be bad weather we’re thrilled you’re here and I know you won’t be disappointed just to do a few housekeeping details the restrooms there are two unisex bathrooms out in the in the lobby and then downstairs the doors that you would take if you’re going upstairs to your to your left would be the men’s room and to the right would be the ladies room and exits there’s three exits in the back to on the front and the front on the side and two in the back on the side here ok so at this point I’m very pleased to introduce the interim dean of the College of Nursing dr. Mary Sullivan who will be introducing our speaker tonight dr. Mary Wakefield thank you thanks Mary I am real to introduce dr. Wakefield who is the administrator of the health resources and services administration called her saw an agency of the US Department of Health and Human Services dr. Wakefield leads hearses efforts to fill in healthcare gaps for people who live outside the economic and medical mainstream the agency uses its eight point two billion dollar annual budget to expand access to quality healthcare in partnership with healthcare providers and health profession training programs dr. Wakefield brings to her saw a rare mix of high-level experiences in three worlds she has worked as a nurse in both urban and rural health care settings she was chief of staff in the 1990s to sue senators from North Dakota Kent Conrad and Quentin Eric and she has been a healthcare scholar and university administrator she joined hertha in 2009 from the University of North Dakota where she was associate dean for rural health at the school of medicine and health sciences dr. dr. Wakefield scholarly credentials also are evident in her election to the Institute of Medicine and selection as a fellow of the American Academy of Nursing most notably she served on the IOM committee that produced the landmark report to err is human and crossing the quality child chasm dr. Wakefield is a native of Devils Lake North Dakota she has a Bachelor of Science degree from nursing from the University of Mary and Bismarck masters and doctoral degrees in nursing from the University of Texas Austin she speaks tonight with the title the affordable care act in the future of us healthcare please join me in welcoming dr. Wakefield thank you very much it’s just a delight to be with you this evening and and I’d ask if for the folks who are listening from right here in this room how many of you have been through my hometown Devils Lake North Dakota but 010 shocking too okay I was afraid I was going to come to Rhode Island for the first time this part of Rhode Island and no one would know where I was from but there you have it two people in the audience it’s a it’s a special delight to be here in part because while I’ve been to the airport in Providence before I’ve never been outside really of that town so I’ve had the opportunity to do a little bit of driving and what is an absolutely beautiful state what a gorgeous setting what a gorgeous setting for this university as well I wanted to just ask and this will be probably the last question or one of the last questions I asked how many nursing students or nurses do we have in the audience ends up ok great special shout out to each of you because i am a nurse’s was indicated by dr. Sullivan and and I’m of course very proud of my profession as we all are whatever profession we pursue so for those of you that might be nursing students welcome to the ranks it’s a I don’t think he’ll ever look back and wonder why it pursued this particular degree I certainly have not before I begin and really talk about the Affordable Care Act and its impact both on health care delivery systems but also talking about its impact on health on the health of the nation that’s at least as important and I would say even more important than thinking about the Affordable Care Act and its impact on health care delivery because at the end of the day it’s really all it’s all about what we do to influence the health status of Americans across the United States in rural and urban communities everywhere before I get into that conversation though about the Affordable Care Act I want to talk with you a little bit about the the agency that I

operate and it is as was mentioned and operating division of HHS the US Department of Health and Human Services so my boss is US Secretary of Health and Human Services Kathleen Sebelius and my operating division is a little bit less well-known than some of the other operating division so for example some of you might be very familiar with NIH you’re at least we’ve heard of it FDA Food and Drug Administration maybe centers for disease control and prevention well those are some of the other operating divisions Indian Health Services those are sort of the sister agencies if you will to the health resources and services administration our agency isn’t quite as well known perhaps as some of those and I say it’s like the old a vez car commercial some of you are old enough to remember it and it’s you know we’re not first but we try hard or something like that so we’re not as well known as the others but we try harder at her saw her so though is slightly larger than a number of the other operating divisions so I think it’s worth your knowing something about what we do on behalf of the health and health care of the American public the health resources and services administration and I want to talk for just a minute about it give it a little bit more of a sense of the agency because I’m going to end up talking about what we’re doing in this agency in implementing some of the provisions of the Affordable Care Act and my guess is that some of the provisions i’ll be talking about you may never have even heard of and so that’s why tonight might be an important conversation an important time how to tell you a little bit about some of the things that you’ve not heard about so the health resources and services administration is this big this big is it’s about an eight point two billion dollar agency so not in the millions but in the billions of dollars that’s how big this part of the agency is it has a complement of about 80 80 80 different programs with that focus that was mentioned in the introduction on ensuring access to high-quality healthcare services for underserved populations that’s really the mission most of our programs most of those 80 programs are designed to help vulnerable underserved populations well what would make a population underserved would make a population vulnerable it might be their health status so for example we have the Ryan White hiv/aids program that’s a vulnerable population we have certainly the population that we provide services for or individuals who are donating organs we oversee the organ donation and transplant system in the country so that’s a vulnerable population obviously we also have programs that are designed to meet the needs of economically vulnerable populations people who are low-income who are poor who are uninsured and who are geographically vulnerable so who reside in parts of the country that might be very rural not unlike North Dakota or very or even frontier so that when i say vulnerable populations or medically underserved those are the populations that most not all but most of our programs address the 80 programs that we support have probably four or five that i think are worth highlighting specifically and and so let me just briefly mention them to you and as i mentioned some of those programs have been impacted directly by the Affordable Care Act so a little bit later I’ll come back to them to them and tell you how they’ve been impacted we are responsible for so just to give you a few examples of some of those 80 programs at her saw we’re responsible for 1100 community health centers across the United States so those community health centers receive funding from taxpayer dollars that flow through the federal government and then go back into local communities to provide primary care preventive health services to anyone who watched through the door so they might have insurance and they might not they might be on Medicaid they might not they might be a veteran or somebody who’s homeless might be a schoolteacher with health insurance the point is a community health centers are responsible for delivering primary and primary and preventive care and they serve anyone regardless of their ability to pay if you can pay something than you do it might just be ten dollars when you walk in the door or five but if you can’t pay anything then you are still obliged to be seen that’s our contract if you will with community health centers I mentioned to you that we have 1,100 community health centers across the country this is an important program because it was resourced up markedly through the Affordable Care Act something you probably don’t know about it but as i’ve mentioned i’ll talk more about later we’ve expanded it a lot those with the enactment of the Affordable Care Act so while we have 1100 community health center sites across the nation we are

health centers across the nation we actually have 8,500 sites think about that footprint across the United States 8500 locations where you can go to get healthcare services do you know some of them are mobile vans and they might be parked in a church parking lot that’s what some of those sites are some of those community health center sites are three or four storey bricks-and-mortar state-of-the-art clinics and all things in between and do you know how rhetorical question do you know how many patients are seen right now in those community health centers across the United States 20 million people get their care and those numbers have increased in the last few years with the expansion through the Affordable Care Act infusion of resources in the community health centers program with those that infrastructure that safety net infrastructure has seen an additional three million people in just the last couple few years so those and we expect those numbers to continue to increase over time but that’s part of the primary care prevention focus of the Affordable Care Act as I mentioned not always talked about couple of other programs oh I should just mention too that we of course have community health centers for those of you who are actually from Rhode Island originally you might be interested to know that we have community health centers of course right here in this state they’re received some of that funding I was just talking about we’ve got them in Wakefield it’s a town I’d like to visit we have them in North Kingstown and we have health centers in Providence in fact in your state we have 48 community health centers in this state you might not have known it but there they are and and in those particular locations other programs that we operate through the health resources and services administration just mention a few others I sort of mentioned to you the Ryan White hiv/aids program that is a program that supports 900 clinics 900 grantees across the united states that deliver health care services individuals with HIV and AIDS they provide top quality high quality healthcare services and how many people do they serve they serve about half of all the people in the united states that have been diagnosed that have HIV and AIDS so we serve about a half a million people across those 900 sites her saw also supports the maternal child health block grant program that puts resources into Rhode Island puts resources into places all across the United States every state and what’s the footprint of that program so again this little no one part of the federal government her son and but what the story I’m telling you is look at the footprint so not so well known but you start to see really in a very palpable way how what we’re doing in Washington and the programs were implementing directly influence the healthcare down the street down the highway from where we are right now so on the maternal child health black pants that go out to States those through those resources we actually touch the lives of six out of every ten women that give birth in this country and their infants you’re screening etc that are supported through the resources it flow to states are we also at her saw responsible for Health Professions training I’ll say a word more about that in a little bit and for scholarship and loan repayment programs one of our programs in particular was also impacted by the Affordable Care Act the National Health Service Corps program that’s a scholarship and loan repayment program for oral hygienists if they were pursuing that career for a dentists for behavioral mental health care providers for physicians primary care physicians that is and for primary care nurse practitioners primary care pas and so on so the National Service Corps is a program that places those primary care providers in underserved areas in exchange for paying for some of their schooling by either paying off their loans or giving them a scholarship to go to school do we also have the office of rural health policy for the entire HHS department that’s located in her saw and it’s really responsible for strengthening the health care the rural health care infrastructure in rural communities across the you we have an office of rural health in your state so it’s just another way that we touch Tetris state then in general and a magnitude of other programs including poison control centers so if somebody’s ever had to make a phone call or is that a friend who’s that a call at poison control center we hope to support those the next the national vaccine injury compensation program and the federal organ procurement and transplant donation systems as I mentioned and speaking of organ donation and before I sort of start now to shift into some of a little bit more look closer to home a comment about the University of Rhode Island and then into the Affordable Care Act I always sort of like to make a pitch about organ donation we work with college campuses across the country we work with all sorts of different

organizations to try and increase the rate of donation in the country this year there’s hardly a person in this room that would meet this criterion but this year we kicked off a new program called 50 plus and that’s to really target people our age 50 that might be some of your grandparents for those of you who are sitting in the room to really target people who are 50 or older and to let them know that they more often than not are eligible donors a lot of times when people hit their 70s or 80s even 90 they think whoops too old to donate and do you know what sometimes you can have a much healthier 75 year old and maybe some of you sitting in this off in this room right now at least hypothetically speaking so so the point is we’ve got a big gap between the need that is more than a hundred thousand people waiting in the United States for an organ and we’ve got 18 people that die every single day because an organ is not available to them so it’s serious I’ve got donor on my license car my license driver’s license and I’ve had it there for probably decades now and so we asked all of you to think about getting involved too never too old never too young to think about that program well to deliver our services through her saw we do our work through about 3,000 partners local health departments state health department’s hospitals clinics universities just like the University of Rhode Island that’s how our agency does its work we’re very much a bridge between federal government and putting resources into local communities to better meet the health care needs of those individuals and families and communities one of our important partners is of course this University the University of Rhode Island really a terrific university that has made a serious commitment to offering affordable and very high quality education so congratulations to you and to all of the students that are enrolled here and we have been funding this university for quite a while we have a number of ongoing grants that come right into the University including for example more than four hundred thousand dollars it goes just specifically to gret to geriatric education to geriatric to a geriatric Education Center just to give you an example you can imagine that that’s a pretty important investment because in Rhode Island and across the United States as you well know the demographics are changing and so people here in your state people aged 65 and older make up about fifteen percent of the state’s population we’re focusing like a laser on making sure that we’ve got the infrastructure including healthcare workforce to meet the needs of our aging population here in this part of the United Nation elsewhere as well we also have about a quarter of a million dollars and funding into the into advanced education nursing education at the University of Rhode Island we also put money into student loans for the school of pharmacy students school of loans into the nursing school and probably have some other funds coming into the university that I’m not even aware of we of course of other resources that go into a many other universities and healthcare facilities in the state of Rhode Island well that’s sort of a background on cursa health resources and services administration anticipating that maybe it didn’t know a whole lot about that but let me take your attention now right to the Affordable Care Act the reason why I really did want to start out by telling you about her says because as I indicated a lot of the programs in the health resources and services administration have been impacted markedly strengthened by provisions of the Affordable Care Act and in fact the health resources and services administration another little known fact of all of the divisions of HHS there’s only one division one operating division then had more of the provisions of the Affordable Care Act for which they were became responsible only one that has more responsibility in terms of numbers of provisions than her son and that’s CMS the Centers for Medicare Medicaid Services CMS so they’ve got the lion’s share of responsibility persa has a second largest set of responsibilities in terms of provisions we’re responsible responsible for implementing about 63 provisions of the law and we co-lead about another 15 so we’ve got a pretty significant role and as a nurse and as the administrator of the health resources and services administration I can tell you that since the day the bill was signed into law by President Obama we have been working fast and furiously to implement all of the provisions for which we have responsibility and so with that I’ll share from my vantage point a little bit about about what it is we’re doing but let’s step back for just a second and think for a minute about why that conversation occurred initially about the reasons that this law was needed that is why such interest in reforming health care just a few years ago let’s look back for just a minute and then we’ll look forward to what we’re doing the answer is back a few years ago we’re really quite compelling and that is that we needed to look quickly at reforming health care because

health care was rapidly exceeding or moving away from the financial reach of individuals and families and businesses in the United States was route of becoming rapidly out of the financial reach of large swathes of the American public and we healthcare reform was also important because we were certainly aware of variation in hair quality fragmented care so there were opportunities and real need to improve care quality so that it would consistent in in its delivery regardless of where you receive that care small town Devils Lake North Dakota Providence Rhode Island so there was clearly there were clearly gaps in care quality there was a mention of the Institute of Medicine reports that some of you might be familiar with and I sat on the committee that produced those err is human and crossing the quality chasm they laid out in pretty clear a narrative but significant gaps we have and not just gaps in quality but compromises to patient safety people actually being harmed when they were seeking to be helped through medical errors so challenges with care quality in some parts of the other country sometimes even within the same health care facility high quality care on one floor less so on the other so you had this almost a paradox highest quality of care that you could find in the world in some respects and then in other respects that didn’t hold true at all so those were problems and decreasing access to care all of those rap together had us on a very problematic trajectory we also had a health insurance market that worked quite well for health insurance for the for the companies themselves but didn’t work so well for a lot of families across the United States so for example insurers could pick and choose who they would provide health insurance coverage to their choice their choice they would often avoid no surprise covering people that would have that would have pre-existing conditions do you no fault of their own this might be a child born with a congenital heart defect and might be somebody who develops asthma when there are 14 years old it might be somebody who develops diabetes when they’re 21 years old or a mental health illness so so insurance coverage historically was often avoided by companies for people that had health care conditions that required access to health care services so in other words the people who needed the most we’re standing on too frequently outside of being able to get access to health insurance coverage and even then premiums were skyrocketing health insurance premiums were gone through the roof even as health insurers many of them were making record profits so that made it hard and really sometimes impossible for families to afford health insurance coverage and for businesses to provide it as well so you saw this consistent uptick in numbers of individuals across the country year after year who are uninsured for part of the year or uninsured uninsured consistently those numbers weren’t holding steady they weren’t decreasing they were going up it was a trajectory that was just unsustainable in fact as you know tens of millions of Americans were uninsured and the numbers as I said continuing to trend upward a little millions more had coverage but that coverage didn’t prove I didn’t cover preventive health care it didn’t cover a health promotion activity and screenings for example it might cover for example only critically a critically important treatments high-cost treatments if you will and for those people who might switch their jobs or retire those individuals could lose their health insurance coverage so lack of choice in health insurance and lack of availability and health insurance was a big problem in health care that the Affordable Care Act was designed to reset to address the laws I mentioned also supports care quality and there are a number of provisions that are designed to address a quality of care I’ll just give you one in the Affordable Care Act just want to make the point there are many partnership for patients that’s one of the provisions that comes out of the Affordable Care Act and it is it is a nationwide initiative that’s underway it’s a public-private partnership that involves pharmacists nurses doctors hospitals clinics across the united states that are participating it involves employers and health insurance plans and others and the whole focus of the partnership for patient initiative is designed to improve the safety of health care so that people aren’t harmed when they enter our health care delivery system but that they’re safe that that they receive high quality and safe care the goal of the partnership in other words then is to reduce preventable

injuries to reduce preventable injuries that historically occur far too frequently in the United States and and as a major area of not just cost to an individual’s health sometimes and often excuse me sometimes resulting in patient deaths so preventable error resulting in a patient’s death but also long-term harm lost days from work in other instances illnesses that people go home with rehospitalizations etc so so preventing injuries preventing preventable injuries is a big area of focus and one of the ways that we come at it through the Affordable Care Act is through this partnership for patients that involves not just as I said the federal government but partners across the United States what’s the goal the goal is to reduce preventable injuries and hospitals across the country by forty percent and to cut hospital readmissions by twenty percent that alone would save more than 1.6 million patients from complications complications that for example force them to return to the hospital and Rhode Island currently has 11 hospitals that are participating in this Affordable Care Act provision they’re participating in the partnership through the hospital association of Rhode Island and and they’re focused on reducing 99 specific hospital acquired conditions and those conditions include various types of infections and injuries and adverse effects so that’s the focus then of the Affordable Care Act is very much on ensuring access to healthcare services through insurance access but it’s also focused on care quality as I mentioned and also trying to drive a health care costs down well what the Affordable Care Act does that’s the reason why we’re here in terms of the Affordable Care Act being considered and enacted into law and some of what its its purposes were designed to address then what is that we’re doing now in terms of implementation of various provisions well let me mention some of those to you and let me just start with our non hers of provisions and then I’ll go to the her supervision first they embedded within the Affordable Care Act and by the way some of what I’m talking to you about tonight is not what to hear about necessarily when you’re talking to folks or you’re listening to news casts or radio talk shows etc but there but the provisions I’m talking about tonight are extremely important nevertheless so one of the provisions you may not have heard talked about is a patient Bill of Rights that protects patients from unfair insurance practices some of them practices I was talking about just a couple of minutes ago so for example before the Affordable Care Act the insurance companies could put a lifetime cap they could cap put a ceiling on the amount of care that they would pay for you regardless of whether or not you had a condition that had high costs associated with it there could be limits on the amount of insurance that and care that they would pay for today as a result of the Affordable Care Act more than 100 million Americans no longer face lifetime limits on health benefits also prior to the Affordable Care Act as I mentioned briefly insurance companies could deny health insurance for people with pre-existing conditions do you know how many people there on the United States with pre-existing conditions pretty close to 130 million people might not be anybody in this room but you don’t have to go real far outside the doors and this campus to probably find people that have pre-existing conditions so people with pre-existing conditions who would try to buy health insurance coverage on their own whereas I said often locked out of the insurance market and sometimes these are individuals with potentially fatal conditions that required life-sustaining treatment so this isn’t about accessing a health care that was optional this was for some people a matter of life and death but today for example the parents of more than 17 million children across the United States with pre-existing conditions like heart defects for example no longer have to live in fear that their children will be denied health insurance coverage the Affordable Care Act has already banned health insurance companies from denying coverage to those children in the United States so that’s one of the things just one of the things that the Affordable Care Act is done and intranets and that’s preventing insurance companies prohibiting them from denying a health insurance coverage for children with pre-existing conditions in 2014 that provision extends to all ages so already covered our children and it extends to all ages young or old any discrimination against any age a category of an individual of any age category with a pre-existing condition would be prevented as of 2012

so of april of this year you have about 166 previously uninsured residents of rhode island that were locked out of the coverage system because of a pre-existing condition who now have access through the Affordable Care Act so in real ways right here numbered in scores of people already impacted just by that first phase of that provision the second way that the law makes sure that it helps people is by helping to address health care costs and making sure that health insurance premiums are spent wisely so the Affordable Care Act created something and boy your eyes are going to glaze right over when I say this but it’s an important provision they’re all everything is important that I think that I’m talking about tonight and but ensuring with you but this one your eyes will glaze over when i call it the 8020 rule so the Affordable Care Act has a new 8020 rule that says to insurers insurance company you must now spend eighty percent of the insurance premium that you receive and health insurance coverage on services or unimproved care or if you spend less than that you need to refund the difference you need to refund the difference so eighty percent of premiums that are paid by employers or if you’ve got your own health insurance coverage has got to go to providing a coverage for you for health care services to you or to improve the care that you receive not to infrastructure of the not beyond twenty percent not to the infrastructure for example or salaries of ceos infrastructure of the company and so on so that that rule is now helping to deliver rebates the summer the rebates already started to go up for companies that were charging or excuse me that were violating that 8020 rule rebates started to be paid back to individuals and to employers this summer and what are those rebates worth about 1.1 billion dollars that’s how much money flows back to individuals who’ve been paying premiums when in surance companies were out of compliance with that role additionally the Affordable Care Act provides special special relief for small businesses in the past this will certainly make sense I’m sure to anyone who comes from a small business I do my parents owned a small business and I worked in it it’s a little small crop dusting business as a matter of fact no I wasn’t a crop duster but I was out there flagging fields that’s something that only the older folks in the audience would probably know about because they don’t put teenagers out in the field anymore waving a flag with a plane that’s lined up buying you and coming straight down that that field a line up on you and release all sorts of herbicides and pesticides and you’re kind of hoping that you know you don’t get paid quite a whiff of that but depending on which direction the winds blowing that day who knows um but I digress the the but my point was I come from a small business family so I’ve got a sense of what providing an insurance coverage and purchasing insurance coverage for your family small business is all about in the past a small business and small business employer paid about eighteen percent more for the same health care coverage that a big chain store might pay just a few blocks away that made it really hard for small businesses to compete it made it hard for them to compete because they were paying more for insurance that means that they’d had left money to pay for other things and it made them it hard for them to compete even on the insurance that they provided to their employees if they weren’t being able to provide the same level of services but somebody else three blocks away was able to provide those services that put them at a real disadvantage so to address that inequity the Affordable Care Act and small businesses tax credits that have the potential to benefit an estimated 360,000 small businesses that provide provided healthcare coverage for example to about 2 million workers just last year in 2011 so there are also provisions not just for individuals and families but for small businesses as well the law of course also improves access to affordable care for young adults and I wanted to especially mention this particular provision to you this one I think you probably might know about it historically for a lot of young adults they would lose their health insurance coverage when they graduated from high school when they graduated from college if Care Act change that for millions of young adults across the country up to the age of 26 so historically as I said if they had a caught if they were uninsured they had a car accident they came down with a pretty significant illness and there were 25 years old while they were uninsured their their families would be stuck with those often pretty significant bills or they might not as a young adult uninsured beginning the health care services preventive health care services that they would want to be able to access so under the law most young adults meaning those between the ages of 19 and up to the up to age 26 who historically couldn’t get coverage can now get coverage through their parents plans until the age of 26

and I would suspect that some of the people in this room may well be benefiting from that particular provision that change has allowed more than 3 million young adults across the united states already to get health insurance coverage so when you ask what’s happening with the Affordable Care Act my guess is a lot of people may not even know that what they’re able to get as prevail in terms of access to coverage health screenings without co-pays etc a young parent who just who gave birth maybe six months ago to a child with congenital heart defects etc they may not even know that some of their coverage is now available because of the Affordable Care Act so 3 million young adults under the age of 26 with that coverage now how many right here in Rhode Island about 9,000 about 9,000 young of adults in Rhode Island have already benefited from that coverage well let me shift off of insurance coverage and put on and say we’re too about illness prevention and health promotion one of the best-kept I’d call it a secret but one of the things I’d say it’s not so well known about the Affordable Care Act is that it focuses like a laser on keeping people healthy in very significant ways we wouldn’t begin doubt the time to talk about the various provisions that are designed to ensure that people have access to primary health care services and that barriers are reduced to individuals staying healthy are taking advantage of immunizations health screenings and but I can tell you as somebody who practiced as a nurse for a number of years practice a good part of that time in intensive care units I can tell you from personal experience that a lot of the patients that I saw and and that I took care of on those evening shifts were patients who presented with illnesses that were preventable but patients whose life lives often hung by a thread because those illnesses weren’t prevented so something like high blood pressure that went unabated year after year that resulted in a significant stroke for example so the Affordable Care Act while not talked about in that context very often has a number of provisions that really move upstream certainly takes care of people when they become ill but really recalibrates the focus to focusing on keeping people healthy in the first place so how does it do that well it does that in a few different ways first of all it helps people stay healthy and by providing access to health care screenings and preventive services that are not provided at no out-of-pocket costs so no barrier in terms of being able to access many recommended preventive services that means that people don’t have to choose they don’t have to choose between getting a mammogram a colonoscopy a vaccination and immunization and paying for rent for example or paying for groceries or paying for something that their children a child needs that really we think helps people stay healthy and avoid costly hospitalizations last year 54 million Americans with private health insurance took advantage of those the laws expanded coverage for preventive health services including 195,000 people right here in this state so those provisions are already being rolled out and and going forward while we’ve implemented a lot of provisions already there of course many more to come the insurance exchanges that are being stood up in 2014 and a number of other provisions as well just for the sake of time let me just make the focus real quickly just say a word about Medicare and straight into the health resources and Services Administration’s a responsibilities a couple of specific provisions Medicare I’ve talked a lot about carat coverage for kids and young adults a little bit for families and so on but in addition to increasing access to insurance and health care services like preventive health services and improving the availability and affordability of the of health care there are a number of provisions that are specifically designed to address the needs that maybe some of your grandparents have in terms of access to health care services health care services in other words for senior citizens so for example the Affordable Care Act makes many of the key preventive services that are important some of the examples I just gave a minute ago available with no copay or deductible to people on Medicare and in the first seven months of this year alone so from January through July and the about during that period of time about 18 million Medicare beneficiaries took advantage about the laws coverage of preventive health services that is getting preventive health services with no out-of-pocket costs associated with it in Rhode Island you had more than 128,000 participants in the Medicare program that received preventive

services with no out-of-pocket costs over the course of the last year there are other provisions to we were on a trajectory to close what’s referred to as the doughnut hole right now the most recent add in is a discount on covered brand-name medications of fifty percent discount on covered brand named medications and thanks to the Affordable Care Act there are now more than about five million seniors that fell into the doughnut hole had coverage and then lose it for a period of time get coverage again at sort of the catastrophic and when their prescription drug costs are ratchet up markedly and as a result of the Affordable Care Act if they said more than about five million seniors in the donor and that doughnut hole have already saved an average of about seven hundred and sixty eight dollars and by 2020 that doughnut hole is eliminated entirely so this has direct impact than on Medicare beneficiaries or what their out-of-pocket costs are both for preventive health services already and for prescription drug coverage so important on critically important especially in terms of polypharmacy and coverage of drugs for that part of the population seniors tend to take a multiple chronic conditions and take a lot of drugs to treat those conditions well let me take you now straight into the health resources and services administration what we’re doing there with some of the provisions of the Affordable Care Act beyond the benefits that I just outlined the there are a few key provisions that are have markedly changed our work inside the agency that I lead and and have changed many of hearses programs I’ll just take off two or three one of them the community health centers program mentioned it already second one I’ll mention the National Health Service Corps a program that’s designed to help support students in health professions of careers and then the third one if I get to it is at the home visiting program so I’ll say just a word about the very significant investments that the Affordable Care Act is made in those programs to primarily expand access to primary care and to preventive health care services very much in the communities that need it the most so as I mentioned earlier our community health centers network delivers primary care and preventive care it includes oral health behavioral mental health services substance abuse services in a lot of the community health centers not just the traditional health services you might get when you go into a traditional clinic where you might go into an exam room and what you get there is a traditional set of medical services our community health centers are really cutting-edge and in this way they’re in many ways actually but they’re certainly cutting-edge in this way they are comprehensive they tend to be fairly comprehensive in the set of services that they provide so when you walk through the door of many community health centers in the United States you can get traditional medical care let’s say from a family nurse practitioner or from a family physician you can also get oil health care from an oral hygiene dental hygienist and a dentist you can also often get mental health services treatment for substance abuse for example or other two different chronic conditions and you can get referrals to sub specialty care that’s part of the that comprehensive set of services that are typically available through community health centers so as I mentioned our health centers an essential part of the safety net expanded markedly through the affordable care act as a matter of fact the the Affordable Care Act put over between 2010 and 2015 here at through the end of 2014 about 11 billion dollars into the safety net infrastructure to allow us to ramp up again that investment in keeping people healthy investing in primary care and preventive health so so when I say that the Affordable Care Act not much talked about but incredibly having an incredible ability to impact health in the country it’s because of the expanded focus not just caring for people after they become sick but actually keeping them healthy in the first place so so that large investment was made in the in the community health centers program again caring for people regardless of their ability their insurance status or ability to pay and health center is right here in Rhode Island provide services to probably about a hundred and twenty thousand patients are seen across just your health centers and we expect with these investments not just in Rhode Island but across the united states that that availability that access to primary care services is going to continue to expand as a result of the Affordable Care Act as a matter of fact Rhode Island received more than 24 million dollars to enable your community health centers to see more patients to deliver more primary care services along along the lines of what I just described the law also for those who are nurses here quick shout-out for nurses though I also provide lots of new opportunities through those community health centers for physicians for pharmacists for

nurses for social workers and others but just use nurses as an example the we now have about 16,000 nurses working in those community health centers across the United States and that includes 4,300 advanced practice nurses that is nurse midwives and nurse practitioners and so on and since those expansions have began as also the Affordable Care Act that is at pushing out of that primary care infrastructure focusing on keeping people healthy we’ve added three thousand nursing positions in that infrastructure and they’ll be adding more as we continue to expand that part of the safety net even even more substantially well that’s the safety net infrastructure in terms of places to go for healthcare services what about the workforce that you see when you get there well we’ve got lots of changes in a number of our workforce programs but the one I wanted to mention specifically is the National Health Service Corps this is a program that as I said repays Scott repays loans where gives you scholarships to attend medical school to attend a nurse practitioner program and to become a dentist exit and a range of other disciplines that can be pursued in exchange for service in an underserved rural or urban community and financially the National Service Corps is really a great deal pay attention to this so if you’re in the National Health Service Corps if you’re if you are apply and you are admitted to the National Health Service Corps you can have sixty sixty thousand dollars of your loans paid back at six thousand but sixty thousand in exchange for two years of service in an underserved community that doesn’t that means you’re getting 60,000 back and loan repayment but you’re also getting your salary of course as a new practice saying fill in the blank primary care provider so pretty substantial funds and people can continue and get additional loan repayment up to about 160 thousand dollars so think about the cost of medical school today or dental school it’s running right in that vicinity of 150 160 thousand dollars and so this is a vehicle for people who are to attend school through scholarships loan repayment and then engage in service on in exchange we’ve got National Service Corps clinicians working in your state right now we’ve got 35 of them working here as a result of the Affordable Care Act 21 of those 35 are here as a result of the Affordable Care Act think of the difference that one physician one physician assistant one social worker makes to a community every single one of them sees thousands of people over the course of a year so so coming through their doors so clinicians make a huge difference and that investment through the Affordable Care Act makes a big difference in terms of ensuring that we’ve got access to providers in our most rural and urban underserved areas and as a matter of fact we have more than doubled the number of National Health Service Corps clinicians across the United States when I started we had about 2,400 in the field what do we have about right now as a largely as a result of the Affordable Care Act and before at the Recovery Act we’ve got about 8,600 think about every one of those clinicians that are making a difference in a in an underserved community if they weren’t there there might not be anybody there or there might only be one doctor there for example and now they might have to another area the last one that I wanted to give you an example of and by the way the Affordable Care Act invested 1.5 billion dollars in the National Health Service Corps not just to supply more providers but to help distribute them to the areas that need them the most in the United States and you’re benefiting many of your communities are benefiting from that right now the last program that I wanted to mention the home visiting program that the home visiting program now works it is here and you in the state of Rhode Island has resources coming to it from the Affordable Care Act and is working in a number of communities Newport west warwick and central falls providence a pocket in a cup and at least one more and in Rhode Island your home visiting program looks like this just like the rest of the United States the Affordable Care Act and uses an asset of evidence-based models to deliver health care services and support services to women with infants in high risk communities notice that I said evidence-based so this isn’t oh we’re going to apply for a grant and we’re going to use any model and we’re going to sort of try something out and hope that it works this is saying if you in your community or you and your state are willing to choose from one of nine evidence-based models models that have been shown to produce health outcomes improved health outcomes for women and children if you’re willing to choose one of these as a state and invest those resources the federal government through the Affordable Care Act is moving those resources into your state and I just ticked off some of the communities where those resources are going right now so the state of Rhode Island is selected three of those nine evidence-based models and their proven models as I said that are known to improve health

outcomes incredibly important because they focus not just on the health of say a young mother but they also focus on social determinants of health job skills and domestic violence not just the health needs of the mother and the health needs of the infant but also some of those other environmental characteristics that need attention as well education poor nutrition and so on it’s not just about that medical needs it’s frequently about some of those other characteristics as well and the expansion of these proven models to the Affordable Care Act puts resources right on the ground that are as I said proven to work it’s not talked about very much with the Affordable Care Act but the example I just gave you isn’t the only one of evidence-based provisions in the Affordable Care Act there are a number of them we’re basically the provision is structured in a way that says you know what we’re using research we’re pivoting off of research so for those of you that are in healthcare careers you might be very familiar with evidence-based medicine or evidence-based health care let me say there’s also something called evidence-based policy and so in evidence-based programs that are being rolled out and the example that I just gave you is is just such an example well the last area that I just mentioned is that within the Affordable Care Act there are many provisions on even how we deploy our healthcare workforce not just producing more not just helping to distribute them to high need areas but also investing in competencies of the next generation of health care providers and one of the areas that we’re focusing a lot of attention is on interprofessional team approaches to care on care coordination as a matter of fact some of you might have read an article that appeared just within the last week that talked about and that estimated that about 750 billion dollars about one-third of US healthcare costs this is an institute of medicine report were wasted in 2009 so huge amount of money wasted being used inefficiently for unnecessary services an excessive administrate the administrative costs fraud and other problems some of what the Institute amount of meadows identified as a core catalyst for some of those wasted dollars going into health care poor care coordination so you see a lot of provisions in the Affordable Care Act that are focused again like a laser on team approaches to care on coordinating care and moving away from fragmented healthcare services that that too often impacted even patients health outcomes in addition to being to driving up health care costs so for from our vantage point in the health resources and services administration we’ve got a range of different health workforce programs and a number of them were driving now toward focus on embracing team approaches to care both in the educational environments and universities like this one but also in the clinical practice environments we’re focusing on physicians we’re focusing on nurses we’re focusing on pharmacists other health care providers as well and we’re doing that by using the tools of the Affordable Care Act well that gives you a rundown on a number of the provisions I actually have more but I’m going to stop because I’ve talked quite a bit and I want to take a breath sometime and and actually just bring this part to a close but but wanted at least give you that sense of them a number of the major provisions those are just some of the ways not all by a long shot and not even all of the ways that the hearses involved in the Affordable Care Act but what it ought to tell you pretty clearly is the areas of that that the Affordable Care Act focuses on in terms of reshaping health of the nation and reshaping health care at the end of the day it’s very much about the health of the nation and from my vantage point where I sit at the helm of my age and see much of it is about investing resources to keep health to keep people healthy frankly for probably really in at this magnitude certainly for the first time in my lifetime have we ever seen an effort to move the needle and recalibrate so that our focus in certainly includes care for individuals when they become ill the very best care that we can give them consistent high quality care and access to it but investing on the front end to keep people healthy families healthy in the first place so the Affordable Care Act in all those different ways explicit supports high quality care accessible care and tries to make it very cost much more cost-effective for individuals that need health care so if that’ll stop right there and I think we’ll take questions with whatever time we have left Oh water thank you you’re a good man thank you if you have questions for dr. Wakefield you can see the instructions on your screen if you’re

using a computer or some device with a web browser you can submit responses that whole mcom forward slash 2012 hoc o or you can text Wakefield and your message so the word Wakefield and then the message to the phone number 37 607 here’s the first question what are some of the challenges you expect to encounter in implementing the Patient Protection and Affordable Care Act it’s a good question so we’ve already as I mentioned in my remarks you’ve already been extremely busy implementing provisions already and I gave you a lot of examples of people in my number try to quantify the impact of some of the provisions that we’ve already been been rolling out in terms of insurance coverage expanding our community health center infrastructure and so on but so some of the challenges I’d say we’re already past because we were moving very rapidly to stand up those provisions many of them that had deadlines so even within the law there were deadlines for certain activities for certain provisions to actually occur that meant that for those of us who work in government there we were moving at a very very rapid clip to get those provisions and programs implemented as quickly as possible I think one of the challenges that that that I’ve seen in addition to just not enough time in the day because this is pretty much is for me at least and for a lot of the people with whom I work it’s very much felt like a 24-7 a set of activities a lot of good work to get done and a real commitment and a passion to get it done as quickly as possible because we knew that people’s lives were being impacted in favourable ways that soon as those provisions were implemented examples that some of the examples I’ve already given you but I’d say that one of the challenges that I that I think from my vantage point we encounter is that folks are not so familiar with some of the provisions that I even shared with you this evening that’s what I find when I’m out talking about the Affordable Care Act didn’t know that there was a healthcare.gov website that I could go to and that I could put in my zip code first type in my state and then put in my zip code and then up would pop up all the health insurance policies that are available to me right now in my zip code where I live or where my aunt lives or where my friend lives didn’t know that that resource was even available in presented data presented in a way that maybe for the first time you could even understand because you could compare insurance policies in terms of cost and coverage etc so the challenge is how much people know or don’t know about some of the provisions some folks may not even know that they’ve benefited from the provisions that have already and unfolded and that they’ve directly benefited from so I think one of our big challenges is explaining as we go along what’s available when it becomes available and so that’s why when we’re out and about and we have the opportunity to talk to audiences I certainly tried to do just that to make sure that people know about the availability of the resort of resources that are there right now and those that will be coming online over the course of the next year or so so big challenge communication the next question is preventive care is arguably neglected by health care providers because it’s less profitable than conventional medicine do you think this solution it is to find a way is to find a way to more effectively monetize preventable care government subsidies or to educate individuals to improve their health through lifestyle changes such as diet or exercise yeah such a great question too so and preventive care sometimes sometimes I think folks may not know how important it is to have screenings certain types of screenings so some of its just innate human behavior it’s I didn’t realize that I should have had that fill in the blank done and now maybe say colonoscopy and maybe the the colon cancer that I’ve developed could have been picked up a year ago had I known that I was at high risk for colon cancer because of family history or that i was in an age group now where I should be getting these on and at certain intervals colonoscopies on certain intervals had I only known I would have done that or i would have participated in and preventive care except there was a copay and you know what it was a copay that I couldn’t afford so I didn’t get that preventive care whatever that preventive care was so so I’d reframe the first part of that question a little bit to say that preventive care is neglected for diff for different reasons one was it covered by insurance companies too was there a high I was there an out of play if it wasn’t covered or if there was a high out-of-pocket copay was that a deterrent or three was it a lack of information about what preventive screenings you

should be getting in your age category for example or what vaccinations you should be getting for example so so I think those would be some of the factors that contribute to historically some of those factors were trying to take off the table but historically would have contributed to a lack of access to preventive health services educating individuals incredibly important so and I didn’t even talk to you about about the first lady’s let’s move campaign and then some of the provisions of the Affordable Care Act specifically that focus on healthy weight we’re operating one of them right out of the right out of the health resources and services administration we’re working in partnerships with teams across the country focusing on healthy weight which means diet exercise but using evidence-based models remember I told you the affordable care act as a pivot off evidence and this is one of the areas where we’re doing that to best practices where we don’t have evidence evidence where we do have it and the our healthy weight collaborative so we stood up in sites across the country aren’t just being conducted by and through traditional healthcare providers it’s also with teachers with parents with parks and recreation departments with other stakeholders businesses that have an interest in healthy communities so educating individuals to improve their health through lifestyle changes absolutely high priority and we’re investing by working with communities across the country through some of the Affordable Care Act provisions it’s extremely important before we get to the next question just want to remind you that you can also fill out the cards and they will come to the coordinators and will enter it on the screen so not only can you text and use the web but you can also fill out the cards and someone will pick it up and we’ll put it on the screen next question is what is her so doing to focus on preconception health of young women did that come from a nurse or physician our pediatrician I should have said or an ob/gyn GOG any one of the three okay a pediatrician right yeah so this pediatrician could actually answer that question I only know this because I had a quick opportunity to talk with them a little bit before though we’re not talking about this topic the as I mentioned earlier on the health resources and services administration has responsibility for the maternal child health block grant program and for a number of different programs that directly impact the health of infants children pregnant women women who want to become pregnant etc we have really shifted our focus what I was taught when I was a nurse in terms of the health of women and infants was very siloed it’s okay today you’re pregnant so now your health the status of your health begins today the day that you learn you’re pregnant that’s when I’ve got to pay very close attention to the status of your health and all the way to your pregnancy you deliver that infant and done finished with that it’s just a segment of health nothing to worry about nothing that occurred before that would influence very much your health as during your pregnancy nothing that would occur afterwards other would tie into that pregnancy that you had and the preconception health is really a not new for pediatricians today or new nurses today but it would have been new for me and that is to say a lot of what is healthy or not about the health of that pregnant woman and the infant that they and the infant that they bear is a result not just the care they received while they were pregnant but the care that maybe their mother received the care that they received in their health condition and their nutrition when they were not 23 years old and pregnant but three years old and 13 years old and so with our resources through a number of our programs we’re really focusing on preconception health of young women not just when they conceived not just when they’re pregnant but actually what their health status is long before that because we’re starting to see clearly characteristics of an individual’s health and that emerged long after as a result of and linked to and health status social determinants of health that occurred much earlier in their life span so that’s really that that new orientation that our programs are complemented programs have taken on we’re embedding that in our Healthy Start program which delivers health care services to underserved populations across the country through a number of our programs but that’s a that’s a pretty simplistic version of it and you could give a much better one than I did i just gave but the point is as i said when i was studying i would have been looking for nursing we would have been educated almost exclusively not entirely but almost exclusively on the health of that woman during their pregnancy and now that’s not the case at all we’re

looking at how well that infant does based on maybe how what that mother’s health status was when she was 13 and links between was that sort of in the ballpark kind of next question how does the AC address that the other end of the spectrum end-of-life care so that’s a good question about palliative care hospice care our the the health resources and services administration doesn’t provide services in those particular areas really most of what we do is focus on on primary care services we invest early in geriatric education centers and probably some of those centers would be looking very much at training and end-of-life health care services but for at least at least for our part of the agency I couldn’t speak to that because that’s not an area that we’re focused on specifically sorry we’re a little bit more on the ambulatory care side of the equation how does that 8020 rule get monitored and is the provision saying that eighty percent of an individual’s premium must be spent on the individual eighty percent must be spent on healthcare services for the individual or on improving the quality of care that the individual receives monitored by the by CMS by the Centers for Medicare Medicaid Services and through their contractors so what impact do you expect the Affordable Care Act to have on physical therapy practices that’s a great question and certain certainly issues around coverage of physical therapy people who could access physical therapy services because they would now have affordable accessible health insurance coverage so you might expect that because of that people who might have forgone access to needed physical therapy now having coverage would be able to take advantage of those services and so that would probably be one of the most important on potential outcomes that is actual coverage for people who historically might have needed the service couldn’t forget it because insurance was out of reach and a follow-up our physical therapist included in the National Health Service Corps they are not oh no they say but they’re not there but but there a couple of things that I’d say about that the we did just last year so for the physical therapists in the audience which must be back there on last year so we have lots of different disciplines that are interested in being able to participate in the National Service Corps and you heard me describe the types of providers that can participate and that we define primary care and that sounds pretty broadly not just family medicine or not just family nurse practitioners but also oral health services and behavioral mental health services the so we’ve got lots of different providers and disciplines that have asked whether or not they could be included so they’re there we wouldn’t begin to have the resources to be able to cover all health care providers that’s for sure but what we did you last year is we we asked the employers the prospective employers what do you need what do you need so for those health professional shortage areas those clinics those community health centers rural health clinics and so on that are eligible to hire a National Health Service Corps clinician and if that clinician would come and work for them that clinician then would get that it would for example be able to take advantage of loan repayment and we asked those employers what do they need so we got a list of about seven or eight of the highest need disciplines one of them pharmacists the other registered nurses neither of which had been covered or work are covered currently in the National Service Corps program so what did we do we took our resources that we put into states we’ve got one part of the National Service Corps program it’s called the state loan repayment program Rhode Island participates in this program right now your state is putting 125 thousand dollars into the state loan repayment program we federal government are matching it so state loan repayment requires a state match states can choose to participate or not if they choose they can decide if they want to hire in place not hire excuse me but place and repay loans for pharmacists or registered nurses so those are the two new categories that are now available through that loan repayment program and it was as a result not because of some mr. off-the-cuff decision that we made but rather really querying the prospective employers to see what their needs were so we just opened that up the states don’t have to expand those categories to include pharmacy for example pharmacist for example but they can if they choose to so those would be

two new ones so the point is it is a little my point is to say not there now but but but we’re constantly trying to understand what the greatest needs are in underserved communities and meet those needs thus the recent change and we’ll continue that why do you believe that most individuals or some individuals oppose the affordable healthcare act as a whole while supporting individual sections and what can professionals in the medical field do to help inform their patients about the reality of the bill well the information about the the lie think is extremely important because we want to make sure that everyone is eligible for any of the provisions that I talked about already or will be eligible to participate for example in health insurance exchanges in 2014 know that they’re eligible we don’t want anyone who could benefit from health care to not realize that that bed there that that health care is now available to them as a result of the Affordable Care Act so for us communication information is extremely important and it will become more so as those as state health insurance exchanges are stood up a beginning 2014 so so communication is extremely important health care providers are critical that website i mentioned earlier healthcare gov i can’t tell you how often I’ve been on it and how often I’ve sent people to it health care all one word that website is updated constantly and as I mentioned you’ve got state-based information there it’s not just generic information it’s talking about provisions that are available right within your community or in your state as these as provisions roll out there might be specific to your state like where is a health center community health center located for example and so that kind of information is available and that’s where providers can probably help the most to make sure that their patients and their communities not just their patient but because healthcare providers tend to be leaders in their communities that their communities are aware of the provisions of the Affordable Care Act why do I think that there’s an opposition will be Gary I’d say you can look back to any major almost any major major and legislate major laws that were implemented in the United States I can’t think of any of the major ones that that I’d reflect on right now that didn’t have a lot of diverse opinion expressed about them Social Security lots and lots of back and forth very diverse opinions about whether or not Social Security when it was first enacted was the right thing to do Medicare back in 1964 1965 some health professions associations opposed Medicare when it was first enacted they’re not they’re not professions that oppose Medicare now you can think about people who are age 67 69 with that insurance coverage that prior that in the early 1960s didn’t exist it was hotly contested in 1965 hotly contested so so enactment of major laws this is not unique to the Affordable Care Act it certainly has been characteristic of laws that were enacted historically and I also think that there’s a lot of misinformation and there’s confusion about some of the provisions of the act of the Affordable Care Act and that probably contributes to that at two at least two certainly questions and in some cases if it’s misinformation opposition and then everyone does have different opinions about about different provisions so so that’s sort of human nature that we don’t all agree on absolutely everything so what one last question thank you all for your questions we received many to select from dr. Wakefield what do you see is the next big step in healthcare chain a lot of innovation unbelievable innovation so for those of you that are thinking about healthcare it’s um be ready for change it’s make sure those your seat backs and trays are in a locked and upright position because we are taking off it’s a it is a time of lots of opportunity we’ve got a toolbox that we’ve been given that allows us to move in New in different directions and that we have from from how we’ve engaged health and healthcare historically and we’re seeing innovation emerging all across the country we are supporting innovation through our son Drew center on innovation in in the Centers for Medicare Medicaid Services we’ve got phenomenal new innovative care models that are being tested right now and they’re grassroots they’re coming out of communities this is not Washington DC saying here’s what you need to do to model this this unless it’s an evidence-based model and we know what works and the home visiting would be an example of that but we’re asking for a lot of innovation and models that are being constructed at local levels Center for Medicare Medicaid Services just

funded about oh maybe about a hundred and seven new initiatives across the united states that harness telehealth technology harness telemedicine field community health care providers not just the traditional healthcare providers but are putting people right out in the community and focusing and intensely on illness prevention health promotion I think some of them at well I’m not exactly sure so I won’t continue that that sentence but looking at reconfiguring the way we deliver healthcare so what’s happening where we’re seeing in communities across the United States re-engineering of healthcare delivery some of that being supported of course a lot of it by the Affordable Care Act a lot of it but a lot of it emerging almost even separate and apart from what the Affordable Care Act has underway so folks who are sitting around the table and saying we see opportunity to improve the way we’re doing our work harnessing electronic health records harnessing health information technology working in teams enhancing efficiency and effectiveness tracking patient outcomes in a more consistent way using research to inform our performance improvement so lots and lots innovation and I’d say the next big step in health care lots of change a good change so does that suffice okay because it’s really hot up here let me thank you very much thank you so much dr Wakefield for a very informative talk I think I speak for everyone that we all feel much more informed to the various provisions of the Affordable Care Act so thank you very much next week we’re going to be changing gears a little bit our speaker will be Captain Robert to Sato of the United States Public Health Service and he’s the director of the division of civilian volunteer medical resort Reserve Corp and he’ll be discussing how health politics and money affect participation in public health initiatives and disaster preparedness I hope you can join us thank you very much