NATIONAL ADVISORY COUNCIL ON MIGRANT HEALTH
Washington, D.C., January 30-31, 2006

• Printer-friendly minutes from January 30-31 meeting (Acrobat/PDF)

On this page:

• Minutes from January 30
• Minutes from January 31
• Attachment I, Listing of subcommitee members
• Attachment II, Action items
• Attachment III, Draft recommendations to the Secretary, HHS
• Attachment IV, Subcommitee recommendations

Council members present: Wenceslao Vasquez (Chair), Robert Scott, Jr. (Vice Chair), Rosita Castillo-Zavala, Susana Castro, Enedelia Cisneros, Rogelio Fernandez, M.D., Anne Kauffman Nolon, John McFarland, D.D.S., Diana Sanchez, Robert Nimmo, Jr., Gilbert Walter, and Karen Watt.
Council members not present: Edward Colon-Quetglas, Guillermo Martinez, and Gloria Reyes-Garcia.

Federal staff present: Jean Hochron, M.H.P. Office of Minority and Special Populations (OMSP); Marcia Gomez, MD, Designated Federal Official (DFO), OMSP; Theresa Foster, HRSA; Louise Wagner, HRSA; and Gladys Cate, OMSP.

Audience:
Monday, January 30: Elaine Alvarez, BPHC/OMSP; Rebecca Ashery, BPHC/OMSP; Marquita Cullom-Stott, BPHC/DSCA; Regina Douthard, HAB/Global; LaVerne Green, BPHC/OMSP; Richard Jackson, BPHC/OMSP; Helen Kavanagh, BPHC/DSCA; Gladys Perkins, BPHC/OMSP; Lynn Spector, BPHC/DPD; and Brenda Coakley, Migrant and Seasonal Head Start Collaboration Office.

Tuesday, January 31: Rebecca Ashery, OMSP; Marco Beltran, Migrant and Seasonal Head Start Collaboration Office; Oscar Gomez, Farmworker Health Services; Helen Kavanagh, BPHC/DSCA; Annette Nelson, OMSP; John Ruiz, National Association of Community Health Centers; and Bobbi Ryder, National Center for Farmworker Health.

MONDAY, JANUARY 30

New Member Orientation and Government Ethics Training
Gladys Cate, Public Health Analyst, OMSP
Marcia Gomez, MD, DFO, OMSP
Theresa Foster, Ethics Personnel Security Officer, HRSA

Ms. Cate welcomed Council members to the meeting, expressing appreciation for their attendance. She then introduced Dr. Marcia Gomez, Designated Federal Official for the Council.

Ms. Cate first called attention to the 30th anniversary of the Council in 2006, to be discussed later in the meeting, and briefly explained HRSA’s support to the Council and its role, based on the Public Health Service Act 330, in advising the Secretary. The National Advisory Council on Migrant Health’s (NACMH’s) web site presents all past Council recommendations, meeting minutes, and member contact information. She then explained that the Council’s 15 members represent 12 governing boards of health centers, including 9 users; the other 3 individuals are qualified by training and experience in the medical sciences or in the administration of health centers. Council members present at the meeting had received a notebook of information at the meeting with a member roster, a map showing the geographic representation of members and other information. Ms. Cate expressed pride in the good representation by women, doctors, dentists, social workers, lawyers, and farmworkers on the Council. Ms. Cate then reviewed how Council members are recruited and approved, the Council’s Executive Committee and four subcommittees, the frequency of meetings (at least two face to face and two conference calls a year), and the process by which the Council develops and sends recommendations to the Secretary and receives his responses.

Ms. Cate then turned to a number of logistical details, including forms that Council members are required to fill out at the beginning of their term or annually; a credit card for their use while traveling on Council business; and issues relating to air travel, salary, and reimbursement. She then introduced Theresa Foster, who reviewed Council member responsibilities as Special Government Employees (SGEs), following up with a video that illustrated the many ethical issues that SGEs must handle correctly in working for the Federal Government. In general, SGEs must avoid any conflicts of interest, although waivers may be possible under certain circumstances. SGEs must also fill out a financial disclosure form annually or whenever there is a change in circumstance. Their notebook of information included a section on ethics rules for SGEs.

Call to Order and Welcoming Remarks
Karen Watt, Vice-Chair, standing in for Guillermo Martinez, Chair
Mr. Martinez was unable to attend the meeting, so Ms. Watt called the general Council meeting to order at 9:10 am. She first reviewed and asked for additions or corrections to the agenda. She mentioned that Dr. Elizabeth Duke will not be able to attend the meeting on Tuesday afternoon, and she will send her Senior Deputy Manager. Ms. Watt also noted that one of the main reasons for holding one meeting a year in Washington, D.C. was to take advantage of the presence of senior HRSA leaders.
Welcome: Ms. Watt then formally welcomed both Council members and members of the audience and asked them to introduce themselves and where they were from and explain why they were there at the table.
Introduction of Council members:
• Enedelia Cisneros is a migrant farmworker in Texas, Ohio, and Michigan in the harvest of apples, pickles, and peppers and works with migrant families as a promotora. She is also a board member of Migrant Health Promotion. She wishes to make a difference by getting migrant workers the health services they need.
• John McFarland has been interested in migrant health since the 1970s and loves his work. Since 1972 he has served as a dentist for one of the earliest migrant health centers (MHCs), which is located in Fort Washington, Colorado, in the very agricultural South Platte Valley. He also works for the National Network for Rural Health Access, a group of dentists who mainly practice in MHCs.
• Diana Sanchez is a user/board member and former migrant worker and entering her fourth year on the Council. To new members, she noted that membership involves a great deal of work, but they will feel satisfaction in being the voice of their community.
• Rogelio Fernandez, a new Council member, is a practicing physician in central California, whose family emigrated from Mexico when he was 1 year old to settle in the small farming community of Parlier. He attended local public schools, Fresno State University, and the University of California–Irvine for medical school, returning to Fresno to do a residency in family medicine, combining tertiary care in a local hospital and with work in a clinic in the small community of Selma. Dr. Fernandez then returned to Parlier to work the past 15 years in another small clinic, serving as medical director for 9 years and now as an associate medical officer. He considers it an honor to serve on the Council and hopes to serve in any way he can.
• Robert “Bobby” Nimmo is a board member/user for Green County Health Care and former family farmer in eastern North Carolina. He has served on the Council for a year and noted for new members that, although there is a lot to get used to in its work, he has found it interesting. Green County is very agricultural with a large migrant population and H2A labor. His use of H2A labor originally led to his position on Green County Health Care’s board and later on the Council.
• Robert “Robbie” Scott, Jr., is an attorney who works for a legal clinic that provides free legal service to low-income people in central Washington. Most of his clients are seasonal migrant workers. He is president of a local health clinic and has served on the Council for three years.
• Karen Watt has served as Vice-Chair of the Council and is a fruit grower in western New York in the “fruit belt” near Lake Ontario. She employs both migrant and full-time workers. Ms. Watt has served on the board of the local health center, which runs two migrant clinics.
• Anne Kauffman Nolon has served for 30 years as CEO of Hudson River Health Care, which has 13 sites north of New York City. Her organization started as a community health care program and later added health care for migrants, homeless, and public housing residents. Her first love is migrant health. She grew up on a farm and loves agriculture and considers it an honor to serve on the Council and work for those who put food on the table.
• Gilbert Walter is the executive officer of a community health center (CHC) in Bridgeton, New Jersey, that serves 20,000 farmworkers, many of whom are migrants. Southern New Jersey is an area that is still recognized as “the Garden State” with a great deal of farming and migrant workers. He welcomed the new members to the Council.
• Rosita Castillo Zavala is a new member of the Council from eastern Washington. She has lived there for 20 years and is part of a family of migrant workers. She is a U.S. citizen who works for her county as a social worker and has also been on the board of the Yakima Valley Farmworkers Clinic for more than 10 years. She is an advocate who knows that she can always return to pick apples if she needs to.
• Susana Castro, also a new member, is a nurse who was born in Lima, Peru, and became a U.S. citizen as a freshman in college. She serves on the board of the Community Health Partnership of Illinois, which provides health care for migrant workers through several satellites of Community Health Partnerships of Illinois in the state. She is honored to serve on the Council.
• Wenceslao Vasquez was born in El Salvador and moved during the civil war to California, where he worked as a farmworker for years, in the process learning how important the farmworker community is and how hard they work. He has served 13 years on the board of a CHC with 12 medical clinics located in northern Sacramento. He welcomed everyone, especially the new members.
• Marcia Gomez is the Designated Federal Official (DFO) for the Council and welcomed everyone to the meeting, which has a long agenda. She noted that members had asked for more time for discussion, and she has attempted to accommodate. She explained that Guillermo Martinez had indicated he would be unable to attend the meeting and apologized for not being able to make it there.

Ms. Hochron also welcomed other attendees in the room (listed above), who also briefly introduced themselves.

Change of guards: Ms. Watt introduced Mr. Vasquez as the new Council Chair, and Mr. Scott as the new Vice-Chair, whereupon Ms. Nolon asked that Ms. Watts and Mr. Martinez be congratulated for their past service as Vice Chair and Chair, respectively, and how well they had served, to which the other members applauded.
Ms. Hochron then introduced Michele Snyder and Dr. Donald Weaver, part of the leadership team at the Bureau of Primary Health Care (BPHC), who had been invited as part of an effort for Council members to meet with key HRSA staff.

Welcome to Maryland
A. Michelle Snyder, Associate Administrator for Primary Health Care, BPHC
Michelle Snyder began by noting that her training in clinical psychology and law had been good training for her work on migrant health. She grew up in a multigenerational family whose ethic was that one should give back to the community and care for people in need. She believes her career has followed this tenet. Migrant issues are interesting and important, and she often asks herself, “how well do care for them?”
HHS Secretary Leavitt had called her the other day to express his personal appreciation for the more than 30 years of the Council’s impressive work and that to come. She hoped that Dr. Duke would thank them in person on Tuesday as well. They all look forward to the Council’s recommendations to help them put “boots on the ground,” giving the BPHC strategic direction from the field. She encouraged Council members to work very hard on their recommendations and thoughts to the Secretary.

She noted tough challenges that lay ahead. The Council must think about strategic directions against the backdrop of reduced Federal and state budgets. Congress is now considering Medicaid reform and reduction of dollars for health care; funding will certainly not increase. In an environment of reduced funding, how does one provide culturally competent quality care? A new government report on progress in reducing health care disparities notes that, many disparities have shrunk, but not for the migrant community.

The BPHC is currently funding 135 migrant primary health care programs nationwide, of which 17 are migrant voucher programs and 118 are jointly funded with CHCs. The BPHC has met the 8.6 percent mandatory funding set aside for migrant/seasonal farmworker populations. In 2004 CHCs served 675,000 migrants and their families, mostly Hispanics/Latinos; however, 80 percent of Hispanics/Latinos have incomes at or below the poverty level and 54 percent are uninsured. All these numbers show progress that is worth celebrating, but much more needs to be done.

Ms. Snyder then discussed progress on the President’s Initiative to create 1,200 CHC sites, including 14 new access points, 15 expanded medical capacity grants, four mental health, and six oral health sites.

People may talk about what are important goals, but actual funding shows what is important to them. In 2006 funding for expansion of health centers was significantly less than requested, resulting in fewer funding opportunities in the coming year. The BPHC will fund the 88 new access points announced last year as well as a second round of applications for expanded medical opportunities—particularly for special population set asides for migrant farmworkers and homeless—in a process that starts next week. Significant issues in this second round, however, are the low number of applications and their poor quality. She challenged the Council to encourage interest in their communities and generate applications.

Ms. Snyder thought the Council should consider the strategic implications of preparation for the Administration’s position on reauthorization for the consolidated health center program. They should consider what aspects of the law should be reviewed and provide input at the beginning of the process. She reviewed a number of ideas for the Council to discuss:

• Is the legal definition of migrant farmworkers correct?
• How can mandatory funding allocations be met?
• What are the challenges of serving this population in terms of quality and the type of care needed?

The Council can make both long-term strategic and short-term practical recommendations. The Government works incrementally, so the Council should look at what in the short term can be pushed, that is, what steps, as well as strategies in the long term to guide decision making.

The BPHC is committed to supporting the Council and working with members to improve quality and access to health care for migrant and seasonal populations as well as all special populations. Dr. Weaver, her deputy, is working on a quality initiative whose theme is “raise the bar and close the gap.”

Clinical Measurement of Migrant Health Care
Dr. Donald Weaver, Deputy Director, BPHC, then spoke to the Council primarily on clinical measurement of migrant health care. Health care is a business—the business of caring. It is also fragile, especially for the disadvantaged. All health care is local, so he thanked Council members for contributing their on-the-ground perspective, which is invaluable in helping Washington make decisions. Even though not everything the Council recommends will result in the desired government outcome, due to other competing voices, he urged Council members to make sure they have been heard.

At the clinic level, migrant health care has come a long way; MHCs now serve as a frontline foundation in health care with significant successes, such as making medical records portable and ensuring that children of migrant workers are not over- or under-immunized.

In the future, they hope to build on the past, for example, health disparity collaboratives. They want to take a systematic approach to chronic disease prevention and prenatal and perinatal care, including encouraging use of often overlooked preventive measures. They have achieved results and now are trying to better document how they are helping to raise the quality of health care and closing the gaps. They seek assistance from the Council on (a) increasing the efficiency of measuring health care for what is a challenging population to measure, while minimizing the burden on clinics, to show results in high-quality care that will help leverage funds and (b) systematically retaining and recruiting high-quality staff.

Ms. Snyder and Dr. Weaver then answered a number of questions from Council members:

• To Dr. McFarland’s question on including dental care in primary health care, Ms. Snyder responded that the decrease in funding for oral health was simply due to a lack of funding. The BPHC had to choose between continuing long-term funding for existing primary health care programs and funding new mental/dental/drug programs.
• Dr. McFarland expressed frustration that MHCs had achieved impressive results, actually lowering costs for other medical services, for example, emergency room visits; yet, migrant health does not realize the savings from its efforts. Ms. Snyder agreed with this point—Congress currently does not give credit to those programs that save money by making that money available for reinvestment by the programs doing the saving.
• Mr. Scott asked what the new health disparities report says about Hispanics. Ms. Snyder did know that, except for birth weight, the gap between Hispanics and other populations has increased. Ms. Hochron promised to print out one full copy of the report and hand out copies of the executive summary of the report to Council members later that day.
• Ms. Nolon noted that the Expanded Medical Capacity (EMC) funding announcement would come out next week, which is too fast for any changes to be made. There are reasons applications are not flowing in very fast. Migrants and other special populations have trouble jumping through the many hoops required in funding applications. She urged the BPHC to think creatively and add flexibility to the process. Lowering the threshold to 1,000 was a good step, but she suggested that going lower, even to 500, would allow programs to get 100,000 to do some decent outreach and get migrant workers and families into primary health care. She also suggested that the second round allow MHCs to expand access through a voucher program. All these approaches could increase the number of applications. Ms. Snyder said the BPHC had looked at and was not opposed to such options and may be able to handle the funding process differently in 2007, including giving some relief in terms of the cost per patient. The main aim now is to get applications for the money available so it is not lost to migrant health.
• Mr. Walter then asked HRSA to reconsider its figure of 54 percent on the number of migrant workers who are insured, saying that the figure is deceptive, mainly reflecting Medicaid coverage for children and pregnant women and almost no one else. HRSA has struggled over these figures, Ms. Snyder noted. The agency really only has gross data. In addition, it is important for them to show Medicaid portability.
• At this point, Brenda Coakley in the audience referred to an article by Andrea Weathers (2003) entitled “Health Services Use by Children of Agricultural Workers: Exploring the Role of Need to Care,” (Pediatrics Vol. 3, no. 5). This research shows that migrant families with insurance do access services like others and that areas with unidentified farmworkers are not part of the data.

After a short break, Wenceslao Vasquez reopened the meeting by asking Council members to formally approve the agenda for the meeting. Mr. Scott moved that the discussion on the HHS Secretary’s response to FY 2005 Council recommendations be moved to 3:30 pm that afternoon, which the Council approved. The agenda was then also approved unanimously. The Council then also unanimously approved the minutes.

Reports from Bureau of Primary Health Care/Office of Minority and Special Populations (OMSP)
Jean Hochron, MHP, Director, OMSP
Marcia Gomez, MD, Senior Advisor on Migrant Health, NACMH Designated Federal Official (DFO), OMSP

FY 2006 Budget Overview: Ms. Hochron asked the Chair if she could report not only on the FY 2006 budget, but also information relevant to concerns about Uniform Data System (UDS) data that Mr. Walter had raised earlier. She offered to make copies of some charts on the UDS data over lunchtime to hand out to Council members, which would help clarify some of the issues.

Although the Federal fiscal year begins in October, the budget is not usually approved by then. This year, the BPHC found out its budget five months into the budget year. The health care budget totals $1.7 billion. The President had asked for a $300 million increase, but only received $66 million more. Compared with other programs, this was actually quite good, but the program cannot grow as desired. Much of the increased funding ($56 million) must go to the 88 new access points already committed to last year. Only $10 million is left, therefore, in new funding. None of the new access points are for migrants.

The new budget total for 2006 ($1.8 billion) by law must be distributed as follows: 80 percent for CHCs and 20 percent to two to four special populations. Of the 20 percent, migrant and homeless populations receive about 9 percent each and public housing populations receive 1 percent.

Use of the funds for migrant health presents a great challenge. For practical reasons, it is important to get these funds out, and the mechanism for expanding medical capacity, compared with new programs, such as dental health, is already in place.

Ms. Hochron had attended the Migrant Stream meeting in Portland, Oregon, the previous weekend, where she encouraged various groups represented there to spread the word, especially to pockets of migrants who have received few grants, and generate applications for this funding. Although it is difficult to write Federal applications, this round should be somewhat easier as there is an 80-page limit and no special data are required to establish need. Applicants may show need for migrant health, homeless health, or a combination.

She emphasized that, although the second round of funding is primarily for medical capacity expansion to provide more primary care, if this expansion involves such services as outreach, mental health, oral health, or substance abuse to the expanded population, it is acceptable to include these services, although they must be explained and justified. The second round, however, is definitely not intended for expansion exclusively of such new types of services.

Applicants are required to expand the number of new recipients by 1,000 or 10 percent of total patients, whichever is fewer. New patients can be migrants, homeless, or both. Applications targeting exclusively migrants or homeless will be first in line, so applicants who previously applied for both populations should consider reapplying for either one or the other population. Migrant patients who are only present in the area for a short time count for an application. A health center may expand its scope of service by establishing a relationship with another health center in the area. Guidance on applications is expected very soon. Applications should be turned around within a 30–45 days. Grants should be funded by the end of September 2006.

Ms. Hochron concluded by saying that the great danger in not soliciting enough applications is that it will be more difficult to demonstrate need for funds in the future. It is a critical long-term strategy, therefore, to solicit more applications to maintain funding for migrant health.

Mr. Vasquez then asked for questions on her budget report:

• Ms. Nolon wondered if funding for homeless would run out sooner and hurt applications that combine funding for the homeless and migrants and also whether previous applicants should apply again. Ms. Hochron noted that a few of the 88 new access points are for the homeless. Applicants must make a strategic decision on whether to combine the two populations. It is good strategically, in any case, to be sure to establish need. Ms. Hochron also said it cannot hurt to apply again as the applicant may be able to do a more thorough job, resolve inconsistencies, beef up information, and double check numbers.
• Ms. Hochron affirmed for Ms. Coakley in the audience that expansion can include services to migrants that are not already provided in primary care, for example, pediatrics.
• A number of Council members then asked questions on eligibility to which Ms. Hochron made the following remarks: First, applicants will not need to document the eligibility of the migrants for whom services will be provided. She agreed that whether the applicant needs to change how funding is used if the need established by the applicant changes was a matter of accountability and a good question. All CHCs are required by February 15 each year to report on demographics, such as age, gender, income, and insurance status of patients, as well as fiscal information about the programs. If migrant health care increases for a program, for example, from 25 to 35 percent of funding, the BPHC would change its accounting for that money to 35 percent. This practice began last year for several programs and this year will be done for all jointly funded programs. In the long term, if the community experiences a great deal of movement, the budget should be recentered, but this has not happened yet.
• Dr. McFarland wished to confirm with Ms. Hochron that applicants may include funding for some oral health as a line item. She replied that it was possible, for example, to hire a dentist as part of the total expansion, but it must be justified well; the bulk of funding, however, must go to medical care.

Ms. Hochron then turned to a discussion of 2004 UDS data on 675,000 farmworkers and families. Of these, 40 percent are under 20 years of age and more than 50 percent are women. Not surprisingly, many are Hispanics and many are poor. The greatest surprise in the data is the relatively high rate of insured, which can probably be explained by the high number of children who are eligible for Medicaid.

Ms. Nolon suggested that these numbers should be recalculated for probable regional differences. She also pointed out that some clinics may just guess about the rate of insurance among their patients. Ms. Hochron agreed that clinics should be encouraged to ask questions on insurance and fill out UDS forms better.
Dr. Gomez then spoke on a number of topics regarding the Council’s work, reminding Council members on the language of the Public Health Service Act 330, which mandates the Council to advise the HHS Secretary and HRSA Administrator solely on funded MHCs and migrant and seasonal farmworkers, not other issues. Many of the Council’s recommendations have been taken, for example, having regional coordinators for MHCs. She noted that the bureaucracy can be slow, but little steps have indeed been taken on health centers and service provision for migrants. Other issues, such as portability, may take longer for the Government to address. She advised Council members to look at what is really happening at health centers and state their real concerns to the Secretary. Council members, whether board members or users, are the experts, so they should emphasize what they know. She also added that Council members would receive later that day a CD entitled “HIV/AIDS along the U.S.-Mexico Border.”
Responding to Council requests, Dr. Gomez and other BPHC staff had attempted to limit the number of presentations during the current meeting. Today, Council members would hear division directors’ reports and about the portability study by Mr. Clark from the Centers for Medicare and Medicaid Services. Tomorrow, they would hear a Department of Labor report on the National Agricultural Workers Survey (NAWS) and reports from Central Office Grantees and Regional Stream Coordinators.
Dr. Gomez noted that data presented reflect the first year in which data are specific to migrant health; they have some kinks, but were the best they can generate. It is important for the Council to think about how to improve such data in the short term, regarding who is reporting and how.
She asked if the Council wanted to consider the definition of migrant and seasonal farmworkers. If so, how should it be changed? How different are such workers from other migrating populations? The Council should decide whether to open this “can of worms” which is being discussed and will continue to be discussed by many people.

Council Discussions
Review approved roles of Council’s subcommittees: Mr. Vasquez, Chair, and Mr. Scott, Vice Chair, led a Council discussion of its subcommittees, asking (a) should there be subcommittees at all, (b) how should they be defined, and (c) how should work between Council meetings and conference calls be organized? Council members made the following remarks:

• Ms. Watt noted the good work of the subcommittees in the past and how difficult it was to do the work as a committee as a whole; she moved to continue the subcommittees.
• Dr. Gomez reiterated a concern raised in the October 2005 conference call about getting subcommittees to work before Council meetings. What level of effort can be expected? Is it reasonable to expect Council members to do more, given their other responsibilities? The BPHC cannot offer administrative support, except for conference calls.
• Ms. Nolon liked past subcommittee work and results on the different topics, but thought the Council could handle their work or by meeting separately for three to four hours at Council meetings. It is too difficult for her to integrate subcommittee work into her daily schedule.
• Mr. Walter agreed with Ms. Nolon’s points; breaking out into subcommittees at Council meetings was a good approach, but chairs of subcommittees should call their members beforehand so data and information needed for discussions can be brought to meetings. He suggested having a preliminary meeting to make Council subcommittee meetings more efficient. He also asked that they receive relevant documents before the meeting.
• Mr. Walter also thought presentations at Council meetings should be further limited, to which Dr. Gomez reiterated the difficulty of both limiting presentations and responding to Council requests for reports on various topics. All had considered the report by Mr. Clark, the only non-HRSA speaker, to be important. She asked for their continued feedback on how to limit presentations. Mr. Scott stated that he did not have access to much of the information presented to the Council and needs to be able to ask questions about it. Subcommittees should hold conference calls immediately before meetings to make them more efficient.

Council members then reviewed subcommittee memberships to better distribute new members and assure appropriate placement of those with specific knowledge. To this end, the Council approved the switch of Rogelio Fernandez from the Public Policy and Advocacy subcommittee to Migrant Health Services, so he could replace a past member who was a clinician, and of Rosita Castillo-Zavala from Migrant Health Services to Public Policy and Advocacy. The Council further approved placing Enedelia Cisneros and John McFarland on the Executive Committee.

Planning public hearing: The Council then turned to discussion of a public hearing at the next Council meeting in San Antonio, Texas. Council members made the following comments:

• Ms. Nolon believed that the National Center for Farmworker Health (NCFH) was the best organization to organize the hearings. Its director, Roberta Ryder and her team should arrange the hearing.

Action item: Dr. Gomez agreed to contact Ms. Ryder on organizing the hearing.

• Several Council members applauded the last public hearing, which placed consumers and providers at the front of the hearing room to provide testimony, making them feel more comfortable than if they address a panel of Council members on the stage.
• Ms. Nolon urged and other Council members agreed that questions for local presenters be consistent with those asked at hearings elsewhere, enabling comparison of input from the different regions. The questions have been broad so should not limit feedback.
• Council members further agreed that the hearing consist of three separate panels of (a) community leaders, (b) migrant farmworkers, and (c) migrant health providers, who would present their thoughts for 45 minutes each.

Action item: Dr. Gomez will send Council members the questions asked of presenters at past hearings in Tarrytown and San Diego and ask for their feedback.

• Ms. Coakley in the audience offered to send the Council health-specific data from her organization on Head Start and migrants, for example, the numbers of Head Start centers by state and the state of migrant children’s health.

Action item: Dr. Gomez will send the Council a pre-press publication from Ms. Coakley on Head Start and migrants.

Action item: The Council will give Ms. Coakley some time at a future meeting to discuss the issues she has raised today to the Council.

Ceremony for the Council’s 30th Anniversary: Anne Nolon began by noting that she has been invited this semester to be a visitor at George Washington University (GWU) to work with Sarah Rosenbaum and Peter Shin, who are doing research on community health centers. She has discussed with them several ideas on highlighting migrant health this year, kicking it off with celebrations of the 30th anniversary of the Council in 2006 at its San Antonio meeting and culminating with the 45th anniversary of the migrant health movement in 2007. Not much has been done so far, but she reviewed a number of proposals for recognizing these anniversaries:

• Publishing a monograph consolidating Council recommendations and achievements
• Publishing a book or picture book identifying past and present leaders in the migrant health field
• Producing a migrant health video, using footage from a past video on the 30th anniversary of the migrant health movement, to show at the San Antonio celebration
• Arranging to highlight migrant health at the Geiger-Gibson Symposium next year by holding a panel on migrant health history, focusing on one center and some of the leaders to show what it has meant to get to this point, as well as a speaker, such as Bob Ross, who is very well known for investing in migrant health
• Making a business case for migrant health to augment support for migrant health by getting business leaders interested
• Creating and pushing a small research agenda at GWU.

She concluded by saying that all Council members were welcome to assist in any of the above efforts. Ms. Sanchez and Dr. Gomez had already expressed interest. It would be wonderful if they are only able to accomplish one or two of the above ideas.

The Council then broke for lunch.

Presentations by BPHC’s Divisions

Mr. Vasquez opened the afternoon meeting by introducing five BPHC division directors and a few of their staff members. Each director then presented details on their respective programs:

Elizabeth Handley, Director
Division of Policy and Development

Ms. Handley described the three division branches and their work:

The Policy Branch has a number of activities:

• Helps clarify from an administrative perspective how health centers can change their scope
• Works with the Division of State and Community Assistance, providing perspective on expectations for emergency preparedness
• Currently discussing what changes to consider in reauthorization, including looking at Council recommendations
• Works with other Divisions on reimbursement issues.

The Health Center Expansion branch addresses the issues of expanded medical capacity, new access points, service expansions. The Health Center Systems branch handles other programs such as radiation exposure and screening, black lung, and Native Hawaiian guidance.

Ms. Nolon and Mr. Walter expressed concern about opening up the reauthorization bill for change, because then anything might be changed. Ms. Nolon expressed particular concern about changes that might occur in the 8.6 proportionality and consumer board representation requirement. Mr. Walter thought it might be good to work on the definition of agricultural and seasonal worker, as huge changes have taken place in the industry, but not if it means losing gains already made. He asked if there was another level where the definition could be examined.

Ms. Handley replied that the division is collecting ideas on what needs changing and tweaking, but does not know what the Administration would say. She guessed there would be considerable opposition to changing the consumer board and governance requirements. It was anyone’s guess what would happen to proportionality.

Thomas Coughlin, Principal Program Manager, representing John Cafazza, Jr., Director, Division of Health Center Management

Mr. Coughlin’s Division interacts frequently with Ms. Handley’s Division, which manages applicants; his Division, in contrast, interacts with grantees. Contrary to its name, the division does not manage health centers, but monitors organizational compliance with statutes; assists organizations in growing stronger, improving quality, and becoming more stable; and is responsible for a few other programs, such as black lung clinics, radiation exposure and screening, and Native Hawaiian healthcare improvement.

The Division is composed mainly of project officers who interact with a great variety of health centers, including migrant. Mr. Coughlin then listed his Division’s Operations branches: Northern, Northeastern, South Central, and Southwestern. The Division monitors two categories of activities:

• Formal activities include applications; conditions placed on grantees, including progress; and post-award activity assessments. All three of these types of activities give project officers opportunities to interact with grantees, including through site visits and performance reviews.
• Informal activities include frequent contacts by telephone and e-mail, all-grantee meetings, and additional site visits to the extent possible. All project officers have visited projects, and more than half of the health centers have received such visits. Beyond monitoring, the division also provides assistance: informing grantees of opportunities to do a better job and assisting health centers with problems.

In terms of scope, the division is responsible for 990 health centers and other primary care service grantees. Each project officer has about 20 grantees to monitor, which is a heavy, but manageable load. The grants represent a total of $1.5 billion serving 13 million people at more than 335 sites—an astounding network of health centers nationwide—and the number is growing. He hopes they will reach 1,000 CHCs soon. In conclusion, Mr. Coughlin noted that each of the division’s branches provides competent expertise to grantees. Project officers receive special training to understand migrant needs and are quite prepared to deal with a range of issues.

Ms. Nolon then asked about any division of technical assistance (TA) to encourage MHCs to apply for funding. She also noted the difficulty applicants would have understanding the nuances of the second round of applications. Ms. Hochron noted that the division has already provided funds for such assistance. She had recently met with representatives of Central Office Grantees at the Western Stream Conference to encourage applications. In addition, a conference call is planned very soon for potential applicants.

Cephas Goldman, DDS, Director
Division of State and Community Assistance

Dr. Goldman first noted that his division focuses on technical assistance and training and manages and administers Cooperative Agreements, including Primary Care Associations. Cooperative Agreements specific to the migrant population are described well at tab 6 of the Notebooks provided to Council members. The division has two contracts: the first with Managed Care Solutions (MCS), which has a pool of consultants to send out at the request of other Divisions to health centers in need of on-site TA and training in management, governance, etc. The seven Cooperative Agreements also work very closely with his division to provide TA. A health center with issues may need a variety of TA, so the Division can pull on the current Cooperative Agreements and the MCS contract.

The Division also coordinates development of the BPHC’s emergency preparation and response plan and its implementation. There is still much to be learned in this area. The division works closely with other divisions on emergency preparedness, including with Ms. Hochron to mainstream the process for special populations.

Dr. Goldman then described the division’s Special Assistance Unit, which pools resources for special assistance to health centers in trouble and works closely with project officers to help develop a successful recovery plan. The division also has a contract with Capital Link, which provides consultations and TA on capital needs. The division has few resources and little flexibility in this area, but Capital Link can help centers to research other resources and develop business plans.

To ensure that its work is on target and efficient, the Division carries out a needs assessment to identify duplications and gaps. The division is currently focusing its TA resources on administration, clinical, public health, promotion, outreach, and environmental issues. The Division tries to get a lot of input on TA and receives feedback from current grantees. The Division is gearing up for the reauthorization, so it is particularly interested in getting good feedback on TA needs.

In the future, the division will focus on the return on investment of HRSA resources, efficiency, and its core functional areas:

• Maintaining and strengthening health center programs
• Surveillance, that is, getting information and feedback on the environment
• Health center growth, focused on expanded medical capacity for special populations
• Work force, in terms of retention and recruitment
• Collaboration and partnerships with external parties, for example, on emergency preparedness
• Clinical quality
• Health disparities
• Leveraging and enhancing revenue.

In general, the division is trying to emphasize the theme of getting input from the real world.

In response to Ms. Nolon’s question on funding this year for the Healthy Communities Access Program (HCAP), Dr. Goldman said that there was no more funding for HCAP this year. They are waiting for Administration instructions, but a phase out is being discussed. Ms. Nolon stated that a more consistent standardized performance review is needed for HCAPs, as they vary widely; their evaluation has not been standardized and, therefore, is not respected.

Dr. Goldman stated that PCAs and Primary Care Offices (PCOs) had met together to increase collaboration. The division is struggling to develop a baseline expectation on collaboration and integration of activities of the PCOs and is working to provide some guidance for them.

Mr. Walter noted that when PCAs and PCOs do not have exact figures, they will insist on using surrogate figures for migrant populations of 50 percent insured and 50 percent below the poverty line. Dr. Goldman said Council members should give their feedback on PCOs to Jean Hochron now on this, as the division is working on a strategy for dealing with PCAs and PCOs.

Marilyn Biviano, Director
Division of Clinical Quality

Ms. Biviano began by saying that her division supports and enhances the provision of high-quality clinical care within the national system of Federally funded health centers. The Institute of Medicine’s (IOM) definition of quality, involves safe, effective, patient-centered, timely, efficient, and equitable care. Her division carries out program activities that, to a limited extent, address these elements. She highlighted three program activities, represented by the division’s three branches. Under the Federal Tort Claims Act, the Malpractice Insurance and Risk Management Branch provides malpractice coverage for “deemed” health centers and free clinic volunteers. The branch also provides risk management continuing education and an accreditation program. About a third of health centers are JCAHO accredited. The Evaluation and Quality Assessment Branch is responsible for the Sentinel Centers Network, which analyzes the quality of and disparities in health center care, as best they can with the limited data available, of a network of 67 health centers and 350 delivery sites that handle 1.5 million patients a year. The Division also conducts in-depth studies of health disparities collaboratives evaluations. A third major program activity is a national quality improvement training effort in the past six years to improve the capability of health centers to deliver quality care of four types of health disparities collaboratives: disease (e.g., diabetes and hypertension), prevention, access and redesign of patient flow, and community systems (e.g., prenatal).

She noted that 90 percent of CEOs they contacted had said that the quality of care is improving, but that they did not have the capability or funds to track health outcome information, such as expensive double data entry. The division discussed these issues with HRSA’s Administrator, who wanted to see an effort that will improve the quality and track outcomes for all patients and health centers. So the division has proposed building on the collaboratives and developed a number of strategies to increase clinical quality:

• Institutionalize health care quality in HRSA’s Health Center Program and support infrastructure
• Establish clinical quality measures and track health disparities and health outcomes for all centers and all patients
• Establish incentives for quality
• Develop and disseminate best practices and annual health disparities and health outcomes reports
• Provide TA and training to health centers in clinical quality improvement.

At this point, Dr. McFarland noted that the division’s efforts had resulted in making the CHCs and MHCs some of the premier health delivery systems in the country. It was a huge undertaking to get 400,000 people on the registry, and he applauded the work of the division.

In reply to Mr. Scott’s request for examples of health disparities, Ms. Biviano said health disparities occur both within health centers and across their population. Addressing such disparities involves comparing special populations with the main population base and trying to get the same health outcomes across the board. Special populations do not have the same access to health insurance and could be a surrogate measure for socioeconomic, racial, and ethnic disparities, which are difficult to track.

Action item: Ms. Hochron will distribute to all Council members copies of the executive summary of the health disparities report, which lays out the most prominent disparities.

To Ms. Nolon’s question on how the division proposed to maintain enthusiasm and quality of reporting for TA on a local basis, Ms. Biviano noted that the division has touched about 75 percent of the health centers. If the effort is nationally focused, however, one is not building state infrastructure for quality. PCAs could have a more significant role, for example, by doing an annual state report to show their state Medicaid agency what the health centers are doing. This may help get more funding for the centers, which are keeping patients out of the hospital and avoiding more extreme results. Ms. Nolon said state infrastructure was still limited, especially in terms of handling data, and that more Federal assistance was needed on resources and standardization. Ms. Biviano said the division is proposing standard core performance measures, looking closely at the registry that is in place now, and going out for procurement for a registry that will require interoperability with the practice systems and include the patching that is needed to avoid double data entry.

Dr. McFarland noted that the most positive effort of the division has been the collaboration that has invigorated health centers, which has involved a lot of clinical input. The division needs to keep the process going, as it is so important in building the system.

Mr. Walter noted that there should be a reasonable outcome-based measurement system so the division may ensure use of a chronic care model and evaluate outcomes. A lot has been done, but there must be a faster way to achieve clinical quality, he said.

Gene Migliaccio, DrPH, Director
Division of Immigration Health Services

Dr. Migliaccio said that his division works with the special population of detained migrants and undocumented workers. Government involvement in this area, which dates back to 1891 and health efforts on Ellis Island, is now the responsibility of HRSA. His division manages a Federally funded health center system at 15 facilities, mostly on the border, which handle 25,000 individuals a day and 260,000 individuals a year, 20 percent of whom are paroled. Of the total, 40,000–50,000 eventually become citizens.

He expressed pride in these health centers, which must address often-chronic health conditions, including dental, mental, and medical, such as diabetes, hypertension, etc. Their patients receive probably the most sophisticated treatment they have ever had. The centers handle a great deal of infectious diseases, particularly tuberculosis (90 cases in 100,000). He noted that the Migrant Clinicians Network is one of their most important partners.

Responding to Mr. Scott’s question on detained migrants in state correctional facilities, Dr. Migliaccio said the division manages this special population like an HMO. It inspects its facilities, which are all triple accredited externally, including through JCAHO.

Ms. Nolon asked whether the division’s data on the health status of illegal immigrants are accessible to the public. Dr. Migliaccio said their data are all in the public domain and passed on to the Homeland Security Department. The division works jointly with the Centers for Disease Control on tuberculosis. The division supports the Advisory Council on Elimination of TB. His division can provide some good data on the 260,000 people who go through their health system. Council members interested in knowing more about their data and information technology may call him at 202-732-0100 and ask for Gene, as his last name is difficult to pronounce.

Responding to a question from Ms. Castillo Zavala, Dr. Migliaccio said that his Division cares for 900 unaccompanied minors under 18 years of age, essentially as refugees. They provide them health care as well as the assistance of psychologists, a psychiatrist, and a great deal of telepsychiatry. The division, in fact, uses a great deal of Telehealth in its work. The division purchases $35 million of local primary health care through some 80,000 claims a year. Many of their patients are Hispanic, and many are in detention; most want to stay in detention and work their way through the system, rather than returning to their home countries. Many are migrant workers, but he was unsure of the percentage. Division contact with these individuals usually averages 28 days.

Presentation on the Medicaid Portability Study
William Clark, Director of State Program Research, Office of Research Development and Information, CMS

Mr. Clark began by saying that his seven-person office is responsible for researching the $350 billion-a-year Medicaid program on only a $3 million budget, so they are very limited in what they can do. Traditionally, his Office’s work has been to evaluate Medicaid waiver programs. The division also constructs Medicaid research data files, so he was very interested in the earlier discussion of the CHC registries. If the division had the Medicaid identification number for those in the registry, they could examine people’s use of managed and non-managed health care. Most of the Office’s budget is devoted to keeping the production of Medicaid research data “alive,” which costs $600,000 a year. The Office transforms routine state data provided through the Medicaid Statistical Information System (MSIS) into data by service, rather than payment, and aggregates it at the individual level, adjusting for differences among state program definitions.

The national data system now covers 1999–2002 and includes data per person from all 50 states. One of their goals is to get the data presented, used, and published to increase its value. Some researchers are beginning to work with the data, for example, the Academy for Health Services Research, American Public Health Association, and Gerontological Society of America. Given the division’s limited resources, it tries to leverage resources in this way.

The division also administers 17 managed-care contracts for dual-eligible beneficiaries under one contract, generally targeted to frail elderly. The problem is coordinating Medicare and Medicaid for the best value. If joined, there is plenty of funding for necessary and improved quality of care services as well as additional benefits for care coordination and provision of services in the home. The program has come a long way: there are 40,000 dual beneficiaries in Minnesota, Wisconsin, and Massachusetts since 1997.

The Medicare Advantage Program has a new program called the Medicare Advantage Special Needs Plan for what are essentially Medicare Managed Care programs targeted to dual eligible beneficiaries and people institutionalized or having special chronic conditions. This is a way to bring more Medicaid agencies into the mix and encourage them to contract with these Medicare Advantage plans to build more unified health plans across the nation.

In 2003 Mr. Clark prepared a report to Congress on farmworker access to Medicaid, but as of 2006, it has not been released and is still in clearance. Mr. Clark is feeling optimistic about its release, but different views on its contents still must be reconciled. HRSA, along with other agencies, will have a chance to review the report, but it is important to have something reach Congress.

Section 404, which is a provision of the HRSA Reauthorization Act and not part of regular Medicaid law, said the department should study the problems of access and barriers to portability and identify possible solutions across several areas: demonstration waivers, interstate compact agreements, demonstration activities, public-private partnerships, potential for a national family migrant coverage legislation or policy, and others. The legislation mandated consultation with stakeholders: state governments, expert researchers, MHC communities, farmworkers, farmworker unions, growers, shippers, packers, that is, a broad spectrum of people and institutions involved in the issue. There was no money for a study; he did have help from Renee Rosenbaum of the University of Michigan on background.

On November 2, 2003, a conference was held in Washington, D.C. for representatives of stakeholders. It was the first time many of them had been in the same room. At the conference, Mr. Clark was able to hand out a background paper, which Council members received from him and on which the report to Congress had been based. He had realized that it is people who make things happen, not reports, that it did not matter what the final report said. Ideas on portability could be developed now. The meeting demonstrated that there were ideas floating around that could be developed regarding portability and eligibility that were within the power of the community health center movement itself: some do involve Medicaid, some involve states working together to plan better together, and some involve grant projects that would take a long time to implement.

The Council then asked Mr. Clark what he thought the Council should recommend to the Secretary. Mr. Clark said that it was not appropriate for him to make such suggestions, but he noted that interstate compacts could be applied to migrant health. He mentioned the Interstate Compact Agreement on Medicare Assistance as a model. If there are three migrant streams, perhaps there could be three compacts: West Coast, East Coast, and one for the South. He emphasized that much could be done now on such ideas. For example, based on the background paper, people could easily approach foundations that fund projects in different regions—for example, the Colorado Foundation and the California Endowment—for funding to develop compacts in their regions.

Dr. McFarland mentioned an organization that finances development of such compacts. It would take $2 million to set one up in each region within an average two-year window. It is clear that states are willing to dialogue, but are also concerned about making permanent new categories of eligibility given limited dollars. Texas and Michigan, however, once came close to having an agreement, and Wisconsin independently decided to accept Medicaid cards from other states. So, state interest does exist. Hurricane Katrina also serves as an important precedent in terms of allowing portability under emergency circumstances. A basic limitation of the Medicaid statute is that it does not allow portability from one state to the next and requires specific contracts with providers in neighboring states, which makes it difficult for Medicaid beneficiaries. One idea would be for CHCs, possibly in collaboration with state Medicaid agencies and contractors, to work with companies such as Molina, which has Medicaid managed-care contracts in several states, so farmworkers could use their coverage in multiple states.

Mr. Scott asked whether anything was being done on reducing residency requirements. If farmworkers come for work, they can be deemed residents, but states do not because of the increase in costs it brings. Mr. Clark said that states have some flexibility, but it really sounds like a regulatory issue.

Dr. Gomez then noted that the frustration for Council members is that they have such a limited role in advising the Secretary. Mr. Clark replied that it is all a question of money. Perhaps Council recommendations could point out how efforts on portability could save money. If Medicaid served many more migrant and seasonal workers, states theoretically would benefit from Federal participation in more than 50 percent of the cost. If the law is in place to do some of this and states have the prerogative of expanding Medicaid to special populations, it would be a cost-effective strategy for states to serve this special population when more money would be available from the Federal government and it would reduce states’ uncompensated care costs.

Ms. Nolon noted that the Council’s June 2005 letter advised the Secretary that residency requirements should not be allowed to be a barrier. Hurricane Katrina refugees used Medicare cards in other states. If this problem can be overcome in an emergency, such as Katrina, it can be done at any time. Congress could have made Medicaid work among states, but has not. The Council should think proactively on recommendations to push the Government along.

Mr. Clark noted that so much could have been done on the report by the time that HRSA reviews it, it may not be helpful if HRSA makes things difficult. His Office would simply like to get the report out. Dr. Gomez asked the Council to consider recommending to the Secretary to spur the report getting to Congress. She urged the Council to focus on what it is able to do, to be efficient, and not take too much on.

Breakout into Subcommittees

The Council then broke down into separate subcommittees, which met for the remainder of the day.

TUESDAY, JANUARY 31

Presentation by Central Office Grantees/Stream Coordinators
Graciella Camarena, Program Director, Capacity Building Assistance Team, Migrant Health Promotions
James O’Barr, Migrant Health Stream Coordinator, NE Region

Ms. Camarena had been asked to present information on the six Central Office Grantees (COGs). She first acknowledged representatives of those COGs attending by conference call, including Kim Kraft, Terry Mountain, and Shelly Davis, and, in the audience, Bobbi Ryder, Oscar Gomez, and John Ruiz. The COGs consist of six national nonprofit organizations:

• Farmworker Health Services (FHS) is dedicated to improving the quality of life for farmworkers in collaboration with local communities and their existing healthcare systems, focusing on program evaluation and consultation, training, and information exchange.
• Farmworkers Justice Fund (FJF) seeks to improve living and working conditions of migrant and seasonal farmworkers and engages in litigation, administrative and legislative advocacy, coalition building, training, clinical assistance, and public education.
• Migrant Clinicians Network (MCN) addresses the unique health care needs and barriers of migrant and seasonal farmworkers through leadership, innovation, collaboration, and support to healthcare providers committed to serving migrant and seasonal farmworkers.
• Migrant Health Promotion (MHP) strengthens communities to improve health of migrant and seasonal farmworkers, acknowledging community leaders who are trained as health educators and advocates.
• National Center for Farmworker Health (NCFH) works to improve the health of farmworker families through innovative application of human and technical resources, providing extensive leadership development and training, including a number of conferences and workshops, and provides network support, development, and expansion.
• National Association of Community Health Centers (NACHC) promotes the provision of high-quality comprehensive health care that is accessible, coordinated, culturally and linguistically competent, and community directed for all underserved populations.

All COGs are available to help migrant and community health centers to recruit and serve migrant and seasonal farmworkers effectively.

Ms. Camarena highlighted that, in the last year alone, the COGs provided more than 9,000 TA encounters serving 138 migrant health grantees at more than 500 sites, trained more than 11,000 health center staff, worked directly with 72 potential new sites for health centers, distributed 350,000 copies of culturally competent health education materials, and hosted 345 workshops for migrant health providers nationwide.

HRSA funding allows migrant organizations to leverage funding from other sources to serve migrant workers and their families and MHCs. Many CHCs do not receive 330 migrant specific funding, but see a significant number of migrant workers and other mobile patients and need COG assistance to serve them. HRSA’s investment was over $2 million in TA to migrant health, and COGs raised an additional $4.6 million, more than tripling HRSA’s investment. COGs are clearly bringing resources to migrant health in a time of limited Federal dollars.

Referring to a memo that had been handed out to Council members, Ms. Camarena then reviewed recent trends in migration:

• Growing numbers of Central American and indigenous migrant workers
• Growing numbers of guest worker programs
• Growing sense of apprehension about state and Federal immigration law. Immigration enforcement has created a nearly insurmountable barrier to health care for many migrant families who have members with a different legal status.

These trends present certain challenges for farmworkers, who are themselves changing. MHCs and their allies must stretch further to be culturally competent, ensure that guest worker programs take health care into account, and keep health centers from becoming or perceived as becoming immigration agents.

She then reviewed recent trends in caring for special populations:

• Concern is growing that MHCs will lose out in the fight for diminishing Federal and non-Federal resources.
• Serious flaws in the migrant health grant application process discourage migrant grant applications by applying CHC standards to the migrant population. This includes (a) the increasing difficulty of describing migrant farmworkers due to the lack of consistent, high-quality local data, for example, the inflated insurance rates among migrant workers in UDS data and (b) the increasing difficulty of reaching migrant farmworkers, who are geographically and culturally isolated and mobile; therefore, (c) farmworkers delay care in order to work, thereby becoming expensive to serve. This should be reflected in the grant application process.
• Enabling services, such as outreach, are always the first to be cut when funding is reduced, despite their critical importance, given rapid changes in the farmworker community and in public policy.
• There have been attempts to skirt Federal law that requires a portion of Federal dollars to be set aside for health centers for migrant health.

The above trends raise challenges, the greatest of which is sustaining and perhaps increasing funding for MHCs.

Ms. Camarena then reviewed trends in HRSA-funded TA and resources:

• Many new access points funded in the past 5 years have tremendous TA needs, because otherwise highly competent healthcare providers do not know how to serve the truly unique farmworker population.
• Proposed cuts in the Medicaid program in the next 5 years threaten to undo many of the gains made by funding of these new access points.

The challenge that these trends present is that COGs are themselves at risk of losing funding. Continued TA from COGs is vital for the success of migrant health programs. She concluded by saying that Council support for continued funding of the COGs would be greatly appreciated.

Ms. Camarena and other representatives of COGs then answered a number of questions from the Council:

• In answer to Mr. Scott on the threats to COG funding, Oscar Gomez said that the COGs face two kinds of competition for dollars: (a) with other organizations during the next open competition for COG funding in July 2006 and (b) with other special populations seeking funding, due to decreased dollars available for CHCs.
• Ms. Ryder added that COGs follow a standard process, but have been told to expect funding of fewer COGs. Instead, their business will be consolidated under one or two COGs at funding levels that are now uncertain.
• Ms. Hochron noted that open competition is part of the regular funding cycle for COGs. There is no separate appropriation for TA, which comes instead out of dollars for health centers; this creates a tension between funding for direct services and for TA. The difference this year, however, is that there will be no new funding. The migrant health COGs are unique, compared with other special populations. She believed that the situation will stimulate good collaboration among the COGs, for example, by collaborating on printed materials, etc.
• Replying to Ms. Nolon’s question on the rationale for COGs, Ms. Ryder reviewed their history. Farmworkers are hard to reach and serve and are underinsured. Only 20 percent of the population is now served. Barriers existed at the administrative level, which is why the COGs were needed. The COGs began with one group, the East Coast Migrant Health Project, which evolved into two additional groups, the Farmworker Health Services and Migrant Health Services, recognizing the differences between health promotion and education and outreach services. Given the wide geographic spread of migrant farmworkers, the COGs later evolved from three to six organizations, each with specific expertise.
• Mr. Scott asked when decisions on funding for COGs would be made. Ms. Ryder said the application phase would take 60 days, followed by a review process. Decisions on funding would come later this summer. Michele Snyder had reassured Ms. Ryder that the proportion of dollars would be maintained for the cooperative agreement for COGs and TA, so funding will depend on how much funding is in the pot. Council members discussed when it was best to make a recommendation to the Secretary on funding for COGs, that is, now or in May. Ms. Watt urged them to make a recommendation during the current meeting.
• Mr. Scott asked the COG representatives about the increased number of guest worker programs. Mr. Gomez replied that they were mostly in the Southeast, for example, in North Carolina and Florida. Ms. Ryder mentioned Thai workers coming to Washington State and other southeast Asian workers coming to the Central Valley of California. Ms. Castillo Zavala mentioned a thousand Laotians working in California, who are being treated badly, which affects the local communities and displaces other farmworkers.
• Mr. McFarland noted that immigration was raising new problems, but was not sure how it would play out. Undocumented workers may increase in number, and they will have problems getting urgent and routine dental, mental, and medical services, even in California, where services are abundant. The situation—not unique to California—underscores a vicious trap: funding exists but is not working for applicants. The nation has a collective responsibility to grow the migrant health program, but has not increased access.

At this point, Ms. Camarena concluded the conference call, and James O’Barr, Migrant Health Stream Coordinator, NE Region, described for the Council the work of the Migrant Health Coordinators. He referred Council members to a map at tab 5 in their notebooks, which lists the seven regions that the coordinators cover as follows:

• Northeast: Connecticut, New Jersey, New York, Maine, Massachusetts, and Pennsylvania
• North central: Kentucky, Maryland, North Carolina, Tennessee, Virginia, Washington, D.C., and West Virginia
• Southeast: Alabama, Florida, Georgia, and Mississippi
• West Coast: (Northwest with two coordinators) Washington, Oregon, and Idaho; (Southwest) California (one coordinator) and Arizona, Nevada, New Mexico, and Utah (one coordinator).

Mr. O’Barr then reviewed how the migrant farmworker population has changed with the years. It is still largely made up of people of color and the uninsured. They have no continuity in health care, compared with the settled population and continue to be difficult to serve. The ethnic background of migrant farmworkers, however, has changed with time. For example, African-Americans once dominated migrant workers in the Hudson Valley, and now most are Mexican or Jamaican. Migrant farmworkers, in general, have changed from “black” to “brown”; from speaking mainly English to mainly Spanish; from being citizens to being undocumented workers. Border crossing is becoming increasingly difficult, expensive, and dangerous, which affects who will “settle out.” Agriculture has also changed; small farms are experiencing increasing stress, leading to more stress on farmworkers. At the same time, migrant farmworkers are shifting to day labor, responding to increases in nursery, greenhouse, and dairy work across the country. They are also increasingly taking seasonal construction work.

The migrant health coordinator positions were established due to the unique challenges of providing healthcare to highly mobile, linguistically diverse, and poor populations of migrant farmworkers. This has dictated the structure of the migrant health program. Mr. O’Barr noted that the migrant health movement, known for its innovation, responsiveness to need, and flexibility, had really given birth to the community health movement.

Once the need for field coordinators was recognized and agreed on, two ombudswomen were appointed to serve as the voice of the farmworker movement in Dr. Gaston’s office with three coordinators across the country. This worked well on the East Coast, but the coordinators were handling too large territories, so the network eventually evolved to include seven coordinators. A coordinator for the center of the country is still missing. Some states not covered, for example, Ohio, have asked for assistance from nearby coordinators, for example, the NE Region.

Only 20 percent of farmworkers receive health care. Farmworkers are dispersed across the country and can be close or very far from migrant health centers. Some farmworkers have simply not yet been identified. More effort is now being taken to identify these farmworkers and how to serve them. It appears to be the nature of the nation’s health system that healthcare cannot be assured for those who are difficult to serve.

Mr. O’Barr then reviewed trends in migrant health care in the field. At first, the coordinators were given great freedom in defining their jobs, which consisted of everything from technical assistance to research to identifying the underserved. In 2001, however, the President’s Initiative led the coordinators to specialize in new access points and getting funding for expansion of medical capacity. With the end of the President’s Initiative, the coordinators are now looking at what comes next.

With elimination of the Office of Migrant Health in the BPHC, the coordinators will become more important, because they are out in the field dealing with the programs and are serving as the BPHC’s main links in the field. It is important to remember that funding usually means direct services, but enabling services make direct services work.

Mr. O’Barr concluded by reviewing a number of trends in migrant health:

• The number of unserved and uninsured migrant farmworkers will increase.
• The overall numbers for insured are deceptive, for example, some Native American migrant farmworkers receive insurance in Canada.
• The insured have problems too, for example, children eligible for SCHIP do not necessarily receive services.

He wanted to impress on the Council that the needs assessment in the grant process makes it difficult to apply. In addition, changes are needed so MHCs can apply for dental, mental, and other services besides medical, which the current EMC does not encourage.

Presentation on the National Agricultural Workers Survey (NAWS)
Daniel Carroll, Office of Policy Development and Research, Employment and Training Administration, U.S. Department of Labor (DOL)
Mr. Scott introduced Mr. Daniel Carroll, who spoke on the purpose and findings of the National Agricultural Workers Survey. He referred to two handouts, one with information from a slide show and the other describing findings from the ninth NAWS (2001–02); his office is now working on the tenth report. DOL has worked with the National Institute of Occupational Safety and Health (NIOSH), part of the Centers for Disease Control (CDC) since 1999 to collect data on agricultural workers.
NAWS is a national survey of farmworkers in crop agriculture that is based on a random sample and includes currently employed field workers in crop agriculture, which means that the survey is biased to healthy workers, because they have work and, therefore, income. The sample size varies depending on the needs and budgets of Federal partners: about 2,250 yearly in 1989–98; 3,300 in 1999–2005; 2,150 in 2005; and 1,500 in 2006. The recent decrease in numbers is due to budget constraints. To date, 42,821 interviews have been conducted through September 2004.

NAWS has its roots in the Immigration Reform and Control Act of 1986, which required the Secretaries of Agriculture and Labor to determine the demand for and supply of seasonal agricultural service workers. Several agencies designed the questionnaire, which provides information for many Federal programs, such has HHS and Head Start.

The findings of NAWS are used by four large Federal migrant programs to estimate populations eligible for these programs: DOL’s National Farmworker Jobs Program, HHS’s Migrant Head Start and Migrant Health programs, and the Department of Education’s program on Migrant Education.
NAWS data are useful in surveying occupational health and injuries for CDC/NIOSH, pesticide exposure and safety training for the Environmental Protection Agency, and counties with large numbers of migrant and seasonal farmworkers in preparation for the Decennial Census by the Bureau of the Census.
Mr. Carroll then reviewed a number of findings from the ninth NAWS report. First, on agricultural injuries:

• Each year, 64,000 farmworkers are injured while working.
• The work-related, lost-time injury rate is 8.2 workers per 100 full-time farmworkers
• Farmworkers have higher injury and fatality rates than all other U.S. workers.
Of 1.8 million agricultural workers:
• 4.7 percent have dermatitis on the hands, 2.1 percent on the face, and 1.9 percent on other areas, including the torso and legs
• 6 percent have musculoskeletal problems in the back and 5 percent have them in their shoulders, neck, and upper extremities.
• 36 percent have used health care in the United States in the past two years
• 41 percent have never seen a dentist in their life.

Mr. Carroll concluded by noting several potential health supplements to be prepared on (a) work factors associated with workplace mental health, (b) occupational injury (modified resumption of an earlier supplement), and (c) alcohol consumption and depression.

The Chair then permitted John Ruiz of the National Association of Community Health Centers (NACHC) to speak for several minutes on a number of topics.

Mr. Ruiz said that he would review a number of trends relevant to migrant health. First, immigration law should be monitored on the number of undocumented workers. He recommended that the Council:

• Notice penalties for assisting undocumented workers
• Assure that health centers continue to be exempt from these penalties
• Monitor the proportional allocation for programs, recommend realignment of resources in the 2006 reauthorization to link resources with needs, and resist moves to “one size fits all” formulas for funding regions, which vary in need
• Consider whether to discourage use of electronic records in migrant health programs
• Examine whether it is possible for undocumented workers to receive health care, as appears to have happened in the aftermath of Hurricane Katrina, for example, in Florida.

Mr. Walter then asked about the threat posed by undocumented workers, who now receive healthcare under a policy of “don’t ask, don’t tell.” Mr. Ruiz said that national health information infrastructure under construction will lead to widespread electronic health records and a patient locator system. The Council needs to keep an eye on how to capture undocumented workers through this system and consider how to deal with the issue when it comes up. Do they want to facilitate listing of undocumented workers on this electronic record or protect patient confidentiality? These questions are being raised not only at the Federal, but also state level.

After a short break, Council members briefly discussed the last set of recommendations that the Council had sent to the Secretary, who had sent various recommendations on to the appropriate divisions. The Secretary had responded to their last recommendations, saying “I have sent your recommendations to the appropriate agencies within the Department for evaluation and analysis.” Ms. Watt noted that one of the recommendations that came out of her subcommittee meeting was that they wanted to see the results of that evaluation and analysis.

Action item: The Council would like to see the results of evaluation and analysis performed of their last set of recommendations to the Secretary by HRSA.

Some members expressed frustration that they had not received more response to their recommendations. Mr. Scott noted that, while it is frustrating in the short term, it is difficult to know the impact of their recommendations in the long term; other groups may pick up on them, so he preferred to be guardedly optimistic. Ms. Nolon noted that they had succeeded in getting Michele Snyder, the BPHC chief, and Dr. Weaver, the Deputy, to their meeting, and will keep hope alive that Dr. Duke will come this afternoon. The Council should not shrink back; they should have the expectation that the Secretary will meet with them. She was pleased with the BPHC’s attendance at their meeting that week and said “We are making them migrant sensitive, and that’s one of our goals.”

The Council then broke into subcommittees.

Breakout into Subcommittee Meetings
[Lunch]

Continuation of Subcommittee Meetings

Entire Council Discussion
Robert Scott, Vice Chair

The Council reconvened from subcommittee meetings to hear subcommittee reports and to begin to develop recommendations for the Secretary. The Chairs of the subcommittees then presented what they agreed should become recommendations to the Secretary.

After discussing the various proposed recommendations, the Council decided that it would attempt to write two sets of recommendations for the Secretary: one short set to send to him immediately and the other set to be discussed and revised at their meeting in San Antonio, TX in May 2006.

At this point, the Council learned that the reason that Marcia Gomez had not been able to attend the meeting that day was that her sister was very ill and they just learned that this person had died that day.

Action item: The Council decided to compose and send a letter of condolence to Marcia Gomez on the loss of her sister.

Closing Remarks
Stephen Smith, Senior Advisor, standing in for Dr. Elizabeth Duke, Administrator, Health Resources and Services Administration

Mr. Smith works with the Administrator and Deputy Administrator in helping them to run the agency, which is in the business primarily of making grants, scholarships, loan repayments, etc. He said he greatly enjoyed having Dr. Duke as his boss; they have worked together for some 8 years. It is a complex agency, and her job is to understand its mission and inspire its staff to move forward. Their mission in migrant health is to remove the word “plight” from “farmworker” by ensuring their access to care through targeted grants. Mr. Smith himself has worked for HHS for 30 years; his strength is that he knows how the government operates and what it can accomplish. Dr. Duke and he both need to hear their input, but it is important to remember that the HHS has some 200 advisory committees, of which 16 are for HRSA. They get great value from their advisory committees, because they stretch the agency to where they need to be. If the Council has something to say, say it in their recommendations. They will take them very seriously.

Mr. Scott asked Mr. Smith’s opinion on trends and challenges in migrant farmworker health, to which Mr. Smith responded in detail:

Migrant health is part of the big picture of providing access to quality health care across the nation, which also includes other migrant workers. The agency is working hard to expand the population served. This year’s expansion will be small, but they are working to reach the mandated set aside. He also discussed a government-wide effort to implement the President’s New Freedom Commission on transforming mental health. Many Governmental entities are involved, including HHS (CDC, NIH, HRSA, Office of Aging), and other Departments one might not expect, such as the Department of Justice (due to mental health issues of 25 percent of prison populations), Department of Transportation (due to transportation problems of people with disabilities), Department of Labor (due to employment transition programs), the Veteran’s Administration (which has its own medical system), and others. At a high-level meeting that morning, it had been decided that this multiagency effort should select four of 140 separate proposed actions to focus on in 2006. These are suicide prevention, integration of primary care and mental health, financing issues, and mental health in emergencies and disasters. They will emphasize the expansion of mental health services. In the future, there should be opportunities for MHCs to acquire mental health professionals. Mr. Smith also briefly discussed planned agency work this year on barriers to access to healthcare.

Ms. Nolon raised the reauthorization bill at this point. It is important to retain the requirement for consumer boards, which are important in guiding health centers. Proportionality is also important in funding migrant health. The high number of uninsured migrant farmworkers is placing strains on communities. With a per unit basis of $150–200, health centers cannot reach out to thousands of new users. She urged that the threshold be dropped from $1,000 to $500 in order to encourage a higher flow of applications in the second round of funding this year. She noted that a low number of applications by no means indicate a lack of need. Mr. Smith appreciated hearing her comments and said he would pass them on to Michele Snyder.

Dr. McFarland reiterated earlier comments on the importance of including dental, mental, and other services in comprehensive primary health care, to which Mr. Smith responded saying that HRSA had done a great deal to increase the number of patients served, but was way short of what was needed. Fewer than 2 million have been served of the 14 million in need. They would like to see increased funding for oral health; there have not been cuts in other oral health programs yet and even an increase for HIV/AIDS patients. Although they have not been able to expand oral health, they hope they can do so in the future.

Entire Council Discussion on Draft recommendations to the Secretary, continued
After Mr. Smith left, the Council returned to its discussion of immediate recommendations to the Secretary, separating out four specific recommendations from a list developed by the subcommittees. They discussed and refined the phrasing of these four and also decided to restate them in their recommendations to be generated from their meeting in San Antonio in May. Karen Watt then moved that the Council approve the four recommendations, which was seconded by Ms. Sanchez and Mr. Nimmo. In discussing the motion, several members asked that one or two members continue to wordsmith the recommendations.

Action item: Mr. Scott and Ms. Nolon will continue to improve the wording of the recommendations and send a draft copy to all for final approval.

The Council also discussed the addition of a recommendation urging HHS to increase the number of in-house oral health programs in migrant health centers to at least 75 percent. The motion was amended to allow for the addition of this fifth recommendation. The Council then voted unanimously to approve sending the five recommendations to the Secretary as soon as a final version was approved by all Council members.

The Council then turned to discussion of the 30th Council Anniversary celebration in San Antonio and other logistical issues for their next meeting in May.
Ms. Nolon asked for ideas on finding a sponsor for the entire event. Ms. Ryder agreed with Ms. Nolon on having presentations separate from the hearing on areas in the region with many farmworkers. Ms. Ryder said she could recommend a number of people who could make such presentations.

The Council then asked Ms. Ryder to take on organization of the public hearings at the meeting. Ms. Ryder said she would accept the responsibility of carrying a request to the COGs to help organize the public hearings. She said that Tarrytown was one of the best achievements she knew of in redesigning testimonials at public hearings. The Council agreed that they would like to replicate that process in San Antonio.

Council members then discussed how to schedule their meeting and the public hearings, given the meeting’s association with the farmworkers conference from May 20–24. After lengthy discussion, they agreed to meet on Saturday and Sunday, May 20–21, using the preceding Friday, May 19, for travel. The public hearing would take place on Sunday afternoon, May 21 so that farmworkers attending would not have to take a day off from work. Monday, May 22, was left relatively open, as Ms. Nolon and Mr. Walter were committed to offering a pre-conference workshop for farmworkers that day. It was agreed that other Council members could spend part of the day on some kind of field trip to learn about local migrant health issues. They could then attend at least the first day or so of the farmworkers conference, including the planned celebration of the Council’s Anniversary on the evening of Wednesday, May 24.

The Council also agreed to have a presentation by Ernesto Gomez on interstate compacts and a further update by Mr. Ruiz. Any further ideas for presentations for the May meeting should be sent to Dr. Gomez, who will be working in April on the meeting agenda.

Ms. Cate then briefly discussed various aspects of reimbursement for Council member expenses from the current meeting. Council members should save all receipts, except for meals, which are reimbursed through a per diem payment, and attach them to the reimbursement form, which should be sent to Ms. Cate as soon as possible, but no later than 10 days from that day. Council members should call her with any further questions.

Several Council members then expressed gratitude to Gladys Cate, Marcia Gomez, and Jean Hochron for their contributions in organizing the meeting.
Ms. Sanchez moved to conclude their meeting, which was seconded, and passed unanimously. At 3:50 pm, Mr. Vasquez adjourned the meeting.

ATTACHMENT I

SUBCOMMITTEE MEMBERS

EXECUTIVE COMMITTEE:
Wenceslao Vasquez (Chair)
Robert Scott
Enedelia Cisneros
John McFarland
Marcia Gomez, DFO

MIGRANT HEALTH SERVICES:
Enedelia Cisneros (Chair)
Edward Colon-Quetglas
Guillermo Martinez
John McFarland
Rogelio Fernandez

ACCESS, RESOURCES, AND FUNDING:
Gilbert Walter (Chair)
Wenceslao Vasquez
Robert Scott
Gloria Reyes-Garcia
Susana Castro

PUBLIC POLICY AND ADVOCACY:
Anne Kauffman Nolon (Chair)
Diana Sanchez
Karen Watt
Bobbie Nimmo
Rosita Castillo Zavala



ATTACHMENT II

ACTION ITEMS

From the January 30–31, 2006 session of the
National Advisory Council on Migrant Health
• Dr. Gomez agreed to contact Ms. Ryder on organizing the public hearing in San Antonio, Texas, in May 2006.

• Dr. Gomez will send Council members the questions asked of presenters at past hearings in Tarrytown, NY and San Diego, CA and ask for their feedback.

• Dr. Gomez will send the Council a pre-press publication from Ms. Coakley on Head Start and migrants.

• The Council will give Ms. Coakley some time at a future meeting to discuss the issues she has raised today to the Council.

• Ms. Hochron will distribute to all Council members copies of the executive summary of the health disparities report, which lays out the most prominent disparities. (Completed)

• The Council would like to see the results of evaluation and analysis performed of their last set of recommendations to the Secretary by HRSA.

• The Council decided to compose and send a letter of condolence to Marcia Gomez on the loss of her sister that day.

• Mr. Scott and Ms. Nolon will continue to improve the wording of the recommendations and send a draft copy to all for final approval.

ATTACHMENT III

Draft Recommendations to the Secretary of Health and Human Services

1) Support the reauthorization of the Health Center Consolidation Act.
2) Included in this act are sections of major import to Migrant Health Programs. Retaining the community-based boards is of utmost importance to maintaining community input, identifying the needs of the population on a local basis, and continuing control. Proportionality, definition support, and support for environmental assessment should also be considered.
3) The council supports continued provision of training and technical assistance provided through Central Office Grantees.
4) In order to expedite the timely release to Congress of the Farmworker Access Study mandated by the Health Care Amendment of 2002, the Council asks the Secretary to accelerate review of the Study by all government entities, including HRSA, so it can go directly to Congress on its final release. As we await release of the Farmworker Study, actions can take place that can help to create access for farmworkers in migrant health centers. One such action is that the Secretary designates FQHCs as out-of-state providers, so that those services for insured MSFWs may be billed.
5) HHS should increase the number of in-house oral health programs in migrant health centers to at least 75 percent to provide comprehensive primary oral health care to migrant and seasonal farmworkers and their families.

ATTACHMENT IV

Subcommittee Recommendations
(For discussion at the next Migrant Council meeting in San Antonio, TX, May 2006)

Access, Resources, and Funding
1. Support reauthorization, including maintaining current government definition of farmworkers, and gather compendium of definitions and analyses, legal comment to be better informed so can respond in future.
2. Study MUA/MUP designation.
3. Designate migrant health centers as HPSAs under the provisions for designated medical facilities and be designated with a HPSA score of at least 15 in order to ensure eligibility for appropriate HPSA resources.

Migrant Health Services

1. Increase the number of in-house oral health programs in HHS to at least 75% in order to provide comprehensive oral health care.

Public Policy and Advocacy

1) Convene a meeting with the Council on an annual basis to hear findings and recommendations by the Council on behalf of MSFWs.
2) Support reauthorization of the Health Center Consolidation Act. Included in this act are sections of major import to Migrant Health Programs. Retaining the community-based boards is of utmost importance to maintaining community input, identifying the needs of the population on a local basis, and continuing control. Also consider proportionality, definition support, and support for environmental assessment.
3) Adopt population-specific strategies to increase funding for MHCs and special populations. EMCs should be modified in the following manner: reduce the threshold patients to 500; allow for flexibility in use of funding, i.e., service expansion; allow MHC to utilize the voucher program as a methodology; and expand access and capacity.
4) The council should express the necessity of the migrant-specific support system: encourage opportunities to study the ROI of the COGs, the migrant coordinators, enabling services, and the Advisory Council itself.
5) Initiate a MOU with national agricultural and grower groups to encourage collaboration on migrant health.
6) Reconvene the bi-national health commission work group to deliberate on improving the quality of access to health care for farmworkers.
7) Issue a letter to Medicaid directors highlighting existing Federal rules and regulations that are to be in place and augment access to health care for farmworkers.
8) Immediately release to Congress the farmworker access study mandated by the Health Care Amendment of 2002 and for expedited review by all government entities, including HRSA, so the study can go directly to Congress on its final release. As we await release of Farmworker Study, actions can take place that can help to create access for farmworkers in migrant health centers. One such action is that the Secretary designates FQHCs as out-of-state providers, so that those services for insured MSFWs may be billed.