NATIONAL
ADVISORY COUNCIL ON MIGRANT HEALTH (NACMH)
Meeting
October 17-18, 2007
Lake Buena Vista, Florida
Meeting Participants
Council Members: Karen Watt (Chair),
John McFarland (Vice Chair), Frances Canales,
Rosita Castillo, Susana Castro, Enedelia
Cisneros, Edward Colon-Quetglas, Michael
DuRussel, Rogelio Fernandez, Roberto Gonzalez,
Anne Kauffman Nolon, Christina Ramos,
Diana Sanchez, Gilbert Walter
Council Members Not Present: Robert Nimmo
Federal Staff: Marcia Gomez, M.D., Designated
Federal Official (DFO); Gladys Cate, NACMH
Staff Support; Jean Hochron, Director,
Office of Minority and Special Populations
(OMSP)
Public:
CALL TO ORDER AND WELCOMING REMARKS
The Chair called the meeting to order
at 8:30 a.m. In her introductory remarks,
she recalled that her first Council meeting
was marked by anger and frustration. Four
years later, the current Council is vibrant
and assertive, with a strong sense of
direction and potential.
The Vice Chair remarked that the Council
has a good balance of clinical and administrative
expertise, which is reflected in its recommendations.
He noted that one of the Council’s
most important functions is to hear testimony
from those it is supposed to serve.
The Council reviewed and approved the
agenda for the meeting and then reviewed
the minutes of the July meeting. Susana
Castro moved to approve the minutes. Diana
Sanchez seconded the motion, which carried
by unanimous vote.
BUREAU OF PRIMARY HEALTH CARE (BPHC),
OFFICE OF MINORITY AND SPECIAL POPULATIONS
(OMSP)
- Jean Hochron, Director, OMSP
- Marcia Gomez, M.D., Senior Advisor
on Migrant Health, NACMH Designated
Federal Official, OMSP
Dr. Gomez welcomed Council members and
thanked them for attending the meeting.
She noted that the informal dinner the
previous night provided a valuable opportunity
for Council members and staff to get acquainted
and relax before two days of intensive
work.
Dr. Gomez provided an update on special
populations, based on the presentation
she prepared for the East Coast Migrant
Stream Forum. She noted that Uniform Data
System (UDS) reports show that the number
of migrant and seasonal farmworker (MSFW)
patients seen at health centers has increased
every year since starting to document
this number for all Migrant Health Programs
in UDS in 2004. In 2006, the Migrant Health
Program served 759,000 patients. Slightly
more than half of the patients were female,
although there are more men than women
working in the fields. The vast majority
of the MSFW patients (94 percent) are
Hispanic/Latino. The patient population
consists primarily of young adults (age
20-44) and children age 19 and younger,
including a large number of young children
from birth to age 6. Slightly more than
half of the patients are uninsured, and
nearly all (98 percent) are below 200
percent of the Federal poverty level.
Dr. Gomez acknowledged the Council’s
important role in increasing access to
health services for this vulnerable population.
Dr. Gomez reviewed the grant awards for
Fiscal Year (FY) 2007. She noted that
18 Expanded Medical Capacity (EMC) grants
and 27 New Access Point (NAP) grants were
awarded for Migrant Health. Thirteen of
the NAP grantees had not previously received
Migrant Health funding, and three were
funded under the President’s High
Poverty Initiative (PI/2).
Dr. Gomez stated that the NAP Program
Information Notice (PIN) for FY 2008 was
released on September 28. She emphasized
that NAP grants are an important vehicle
for increasing services to migrant populations,
and she encouraged Council members to
assist qualified organizations in developing
and submitting applications, which are
due on December 18. Dr. Gomez noted that
all applications for Special Populations
would be reviewed together during the
Objective Review process.
Dr. Gomez informed the Council that the
Central Office Grantees would present
a “Migrant Health 101” workshop
at the Eastern Stream Forum. The workshop
was designed to provide new staff of Migrant
Health Centers with an overview of the
population, issues, history, and legislative
expectations of the Migrant Health Program
and the types of training and technical
assistance that are available to Migrant
Health grantees. Dr. Gomez noted that
the workshop at the Eastern Stream conference
would be a 90-minute pilot version; the
full three-hour workshop will be presented
at the Midwest Stream Forum in December.
Dr. Gomez reminded Council members that
they are welcome to submit comments on
draft PINs issued by the Bureau of Primary
Health Care (BPHC). Three draft PINs were
recently issued: general overview of scope
of project, including definition of sites;
expansion of target population; and specialty
services. The comment period for these
PINs was extended to October 19. Dr. Gomez
urged Council members to submit comments
as individuals and as a group regarding
the potential impact of these PINS on
MSFWs and to solicit input from their
boards and CEOs.
Dr. Gomez informed the Council that BPHC
would be conducting a pilot study to evaluate
and make informed decisions about the
services that are provided to targeted
populations. She expressed concern that
few migrants had volunteered to participate
in the study, and she urged Council members
to work with their constituents and boards
to ensure that the migrant population
is represented.
Dr. Gomez provided a brief overview of
the realignment of the BPHC. She reminded
the Council that the Bureau now has three
offices that report directly to the Associate
Administrator: the Office of Minority
and Special Populations; the Office of
Quality and Data; and the Office of Policy
and Program Development. Below the offices
are four divisions: Eastern Division;
Central Mid-Atlantic Division; Western
Division; and Division of National Hansen’s
Disease Programs. Dr. Gomez noted that
the Division of Immigration Health Services
moved to the Department of Homeland Security
on October 1.
Dr. Gomez discussed the nomination and
appointment of new Council members to
replace Gil Walter, Anne Nolon, Edward
Colon, and Karen Watt, whose terms expire
in November. She stated that the nomination
package was submitted to the Secretary,
and she was hopeful that appointments
would be made by November 25. Dr. Gomez
noted that if the new candidates were
not appointed by that date, the departing
members’ appointments would be extended
by 120 days. Dr. Gomez assured the Council
that the new members would be as well
qualified as those who were leaving and
would bring strengths of their own. She
noted that the legislation stipulates
that at least 12 must be members of the
governing boards of migrant health centers
or other entities assisted under section
330(g) of the Public Health Service Act.
Of such twelve who are members of such
governing boards, at least nine must also
be patients. The remaining three Council
members must be individuals qualified
by training and experience in the medical
sciences or in the administration of health
programs. Geographic and gender balance
are also important considerations. Responding
to a question, Dr. Gomez confirmed that
existing members could be reappointed
for another term if nominations were rejected
and there were no other candidates with
similar qualifications.
The Chair noted that Council members could
help to identify good candidates, and
Jean Hochron stressed that the Office
of Migrant and Special Populations (OMSP)
relies on Council members to do so. Ms.
Hochron urged Council members to encourage
potential candidates to consider serving
on the Council. She also noted that all
Council meetings are open to the public,
and former Council members are always
welcome to attend.
Dr. Gomez informed the Council that, as
of the next cycle, nominations must be
submitted nine months in advance. She
stated that she would distribute information
on the 2008 nominating process to Council
members in December of this year. Responding
to a question, Dr. Gomez clarified that
nominations are only discussed internally.
Ms. Hochron noted that the only comments
regarding MSFW issues in the draft PINs
were from Susana Castro and Bobbi Ryder.
Ms. Castro submitted questions regarding
voucher programs, such as where and by
whom services would be provided, and how
voucher sites would be defined for migrant
populations. Ms. Ryder’s comments
expressed concern that as Federally Qualified
Health Centers (FQHCs) expand the scope
of their services, they may lose their
focus on services for MSFWs. Ms. Hochron
stated that OMSP would ensure that policymakers
were aware of these issues. John McFarland
asked whether the comments received to
date addressed all of the issues that
would be of concern to MSFWs. Anne Nolon
stated that she had submitted comments
through the National Association of Community
Health Centers (NACHC), in which she emphasized
the importance of being able to “grandfather
in” necessary services that are
already provided to support primary care.
The Chair suggested that these issues
could be addressed during the committee
meetings.
- ACTION ITEM: Dr. Gomez will send
information on the 2008 nominating process
to Council members in December of this
year.
WELCOME TO FLORIDA
- Andrew Behrman, M.B.A., President
and CEO, Florida Association of Community
Health Centers, Inc.
The Chair and Dr. Gomez welcomed Mr.
Behrman and thanked him for accepting
the invitation to address the Council
on behalf of the Florida Association of
Community Health Centers (FACHC). Dr.
Gomez noted that the Migrant Regional
Coordinator for the Southeast Region,
Erin Sologaistoa, is based at the FACHC.
Mr. Behrman welcomed the Council to Florida.
He stated that the Migrant Regional Coordinator
position is a critical aspect of his organization’s
work, and he commended Ms. Sologaistoa
for her efforts on behalf of MSFWs in
Florida and throughout the region.
Mr. Behrman informed the Council that
there are more than 40 FQHCs in Florida,
with more than 220 access points. Last
year, these centers served more than 700,000
patients, in approximately 2.8 million
encounters. Approximately one-fourth were
Medicaid patients, and slightly more than
half were uninsured. Mr. Behrman noted
that MSFWs account for a substantial number
of health center patients in Florida.
Mr. Behrman stated that agriculture is
the second most important industry in
Florida, generating $6.2 billion annually.
Florida’s nine-month growing season
is one of the longest in the country,
and its farmworker population is the third
largest, after California and Texas. In
2000, Florida had 286,000 MSFWs, 60 percent
of whom were migrants. Mr. Behrman noted
that MSFW populations are shifting as
priority crops change. He displayed maps
showing that the delivery areas for Migrant
Health Center and Community Health Center
grantees are well distributed throughout
the State and closely mirror the distribution
of the MSFW population.
Mr. Behrman outlined numerous challenges
to Florida agriculture. Chief among these
is the rapid pace of farmland being sold
for development. Florida’s population
is now the fourth largest in the country,
and the housing boom of the past decade
has led to dramatic increases in land
prices. As a result, Florida is losing
150,000 acres of farmland each year. Mr.
Behrman cited other concerns, including
the loss of citrus crops to disease and
hurricanes and the impact of immigration
reform and anti-immigrant sentiments.
Mr. Behrman described challenges facing
rural health and migrant health care in
Florida, including workforce shortages,
specialty care, and transportation. Workforce
shortages are particularly acute. Nearly
one million people in 67 geographic regions
of Florida are medically underserved,
including 13 entire counties. Fourteen
counties in Florida do not have a single
pediatrician, and 33 counties do not have
an obstetrician/gynecologist. Mr. Behrman
stressed the need to develop incentives
for medical students to go into primary
care. He noted that Florida now has six
medical schools, but the number of residency
programs has not increased in ten years,
forcing medical school graduates to complete
their training elsewhere. As a result,
Florida imports 90% of its new physicians,
half of whom received their education
in other countries.
Specialty care is a serious barrier because
of the high cost of malpractice insurance
and low Medicaid reimbursement rates.
In addition, many specialists require
patients to present a Social Security
card. Transportation is a barrier due
to high insurance costs, which can run
to $9,000 per van. Mr. Behrman noted that
transportation to specialists is particularly
difficult.
Mr. Behrman noted that pesticide exposure
is an area of concern, because in the
past pesticides were treated as an agricultural
issue. Florida’s new Surgeon General
is more clinically oriented and has worked
extensively with the migrant population;
as a result, the Department of Health
is likely to become more involved in treating
pesticides as a public health issue. Mr.
Behrman identified several areas of concern,
including weak laws requiring growers
to inform workers about pesticide risks
and safety measures, and limited enforcement
of existing laws.
Mr. Behrman outlined a number of problem
areas for migrant health in Florida. These
include high rates of HIV/AIDS among young,
male MSFWs, lack of early access to prenatal
care, lack of dental and mental health
services, and domestic violence. Mr. Behrman
was particularly concerned about the lack
of dental services, especially regular
care for children.
Mr. Behrman identified several trends
in the MSFW population, including increasing
numbers of young males and increasing
numbers of indigenous speakers. At the
same time, there are fewer migrant labor
camps, which leads to housing shortages.
Mr. Behrman stressed the need for linkages
between housing and health services for
MSFWs.
Mr. Behrman summarized a wide range of
State-level activities to support farmworkers
in Florida. An Interagency Farmworker
“Focus Group” made up of all
State agencies with jurisdiction over
farmworkers helps to build a community
of collaboration. The State of Florida
Family Health Line is a toll-free line
that farmworkers can call to report any
kind of abuse, with the call routed to
the appropriate agency for investigation.
A MSFW Joint Legislative Commission was
created under Governor Bush to address
farmworker issues, and an interagency
group is working to revive this under
the current Governor.
Mr. Behrman described FACHC’s programs
to support MSFW patients. FACHC provides
pesticide training for FQHC clinicians
in agricultural areas, in partnership
with the Farmworker Association of Florida
and the National Farmworker Health and
Safety Institute. It conducts cultural
competence and MSFW identification training
for FQHC clinicians, staff, and board
members. It conducts trainings, regional
meetings, conference calls, and information
sharing to build a network of outreach
and health promotion workers. It conducts
Section 330 training to increase the number
of migrant health centers in Florida and
expand existing centers. In addition,
the FACHC website (www.fachc.org) includes
a dedicated section that provides information
for farmworker patients, advocates, and
clinicians.
Mr. Behrman described FACHC’s role
in Florida’s Medicaid reform program.
He explained that Florida has had a Medicaid
demonstration project for the past five
years, with a requirement of local matching
funds. FACHC complained because FQHCs
provide primary care for many uninsured,
but Medicaid funds were provided only
to hospitals. He noted that a key element
of FACHC’s argument was the importance
of a medical home for MSFWs. When FACHC
demonstrated that FQHCs could generate
the 47 percent local matching funds, the
State agreed to provide funding for CHCs.
Mr. Behrman stated that 19 counties participated
in the program initially, and this year
27 counties will participate. He assured
the Council that FACHC would continue
to do everything possible to keep the
needs of MSFWs in front of legislators.
He then opened the floor for questions.
Michael DuRussel asked if the large number
of seniors in Florida impacts health centers.
Mr. Behrman replied that seniors currently
represent a small percentage of patients
seen at FQHCs. Some FQHC doctors have
geriatric experience, but the primary
focus is on serving adults and children.
Rogelio Fernandez noted that in California,
most doctors gravitate to urban areas,
making it difficult to recruit for rural
areas. Mr. Behrman stated that most rural
areas in Florida are within an hour of
an urban area, making it easy for clinicians
to commute. The situation is more serious
in the Panhandle. Mr. Behrman expressed
concern that recruitment and retention
would be a challenge for the two FQHCs
that recently opened in that area.
Anne Nolon raised the issue of funding
mechanisms for uninsured and undocumented
patients, such as the States Children’s
Health Insurance Program (SCHIP), and
asked whether Florida has a parallel program.
Mr. Behrman replied that undocumented
children are covered through SCHIP, but
it is not automatic. All FQHCs participate
in the State low-income pool that covers
all uninsured patients, including those
who are undocumented. Funds are provided
to each FQHC, based on their uninsured
population; however, they must provide
local matching funds. Mr. Behrman noted
that Florida is under a Medicaid 1115
waiver.
Responding to a question regarding workforce
development, Mr. Behrman stated that FACHC
is working closely with the Area Health
Education Center (AHEC) to promote health
careers to high school students and to
promote primary care to medical students.
He noted that medical schools in Florida
have always been strong proponents of
primary care. FACHC is working with the
medical school at Florida State University
to get medical students committed to FQHC
sites.
John McFarland noted that oral health
and mental health are not included in
the studies that generate statistics on
key diagnoses. As a result, the leading
diagnoses tend to be identical in every
State, while oral health and mental health
are always the top service gaps. He also
expressed concern that many health centers
lack Health Professionals Shortage Area
(HPSA) status, making it difficult to
recruit physicians and dentists. Gil Walter
noted that wealthy retirement communities
are often located in close proximity to
very poor communities, which skews the
data for HPSA scores. Mr. Behrman proposed
designating every FQHC as a HPSA, based
on the fact that approval, as an FQHC,
is contingent upon a documented need for
service.
Ms. Hochron commended Erin Sologaistoa
for her advocacy on behalf of farmworkers
and thanked Mr. Behrman for sharing Ms.
Sologaistoa with the Migrant Health program.
The Chair thanked Mr. Behrmann for his
excellent presentation.
COUNCIL MEMBERS’ DISCUSSION
Reflections of 2007
The Chair noted that the Council had become
more skillful in crafting effective letters
with very specific recommendations. Regardless
of how the recommendations are formally
received, the Council now has a better
understanding of how to work through the
system to advocate for its positions.
She then invited Council members to share
their thoughts about what the Council
has accomplished during the past year,
and what it still needs to do.
Anne Nolon stated that she was thankful
and proud to have been part of the Council
during such a challenging time to carry
the banner for migrant health. She was
also grateful to have been able to participate
in the Farmworker Study, and she noted
that the Council had provided important
support and input at every stage of the
Study.
Rosita Castillo stated that her participation
in the Council had helped her understand
the work of health center executives,
which was not always clear to her as a
Board Member. She expressed concern about
the many farmworkers in Washington who
move to urban areas to do construction
and restaurant work. They are unable to
bring their families with them due to
the high cost of living, many are becoming
homeless, and they no longer qualify for
migrant health services.
Karen Watt expressed her appreciation
for the opportunity to visit the DuRussel
farm during the meeting in July. This
visit clearly demonstrated the impact
that one family can have when there is
a commitment to making things work.
Diana Sanchez agreed that the visit to
the DuRussel farm was a powerful experience
that reminded her how much work is involved
in bringing produce to market. She was
especially impressed by the program that
DuRussel Farms conducts for teachers and
staff of the local schools.
Highlights of Past Recommendations
Anne Nolon informed the Council that she
had compiled a history of the Council’s
recommendations and the corresponding
legislative actions over the past ten
years. She highlighted three occasions
when the Council provided important input
on policy issues: when it met with Donna
Shalala; when it recommended that migrant
populations be included in the SCHIP legislation;
and when it voiced its support for the
Farmworker Study.
Gil Walter stated that the Council does
have an impact and has been successful
in keeping the focus on migrant health
issues. He noted that the Council’s
recommendations regarding migrant health-specific
grants administration have been well received
at the administrative level at HRSA and
BPHC, and the NACHC responded favorably
to the Council’s actions pertaining
to the Farmworker Study. Mr. Walter remarked
on the impressive number of EMC and NAP
grants for migrant health this year and
asked Dr. Gomez how this compared to previous
years. Dr. Gomez responded that the number
of migrant health grant awards was significantly
higher in 2006 and 2007 than during the
first three years of the Presidential
Initiative, and she credited the Council
for this achievement.
Plans and Goals for 2008 and Beyond
Anne Nolon identified a number of issues
for the Council to address in future recommendations,
including eligibility requirements under
the Deficit Reduction Act; the impact
of immigration raids on farmworkers’
access to health care; the emerging issue
of full-payment and private insurance
coverage for health center services; health
information technology to enable MSFWs
to access their personal medical records;
and mechanisms to ensure the quality of
services provided through voucher programs.
She stressed that the Council could play
an important role in advocating for demonstration
projects linked to the findings of the
Farmworker Study.
Gil Walter urged the Council to continue
its work related to the Farmworker Study
and migrant health PINs. Future recommendations
should address the documentation requirements
of the Deficit Reduction Act; the impact
of increased immigration enforcement on
access to health services; and workforce
shortage issues. He expressed concern
that many areas that have high numbers
of farmworkers are not served by the National
Health Service Corps (NHSC) because they
do not qualify as HPSAs.
Michael DuRussel identified universal
health coverage as an important emerging
issue and suggested that the migrant health
system could serve as a model. John McFarland
noted that a previous testimony regarding
health care reform suggests that there
is strong public support for a single
payor system, but there are many obstacles.
Gil Walter noted that young, healthy populations
such as MSFWs improve the overall risk
pool for insurance. He suggested that
the Council look at ways to expand the
SCHIP model to include migrant children.
Committee Assignments
Dr. Gomez asked whether the committee
assignments reflected the balance that
the Council wanted in these areas. After
a brief discussion, the Council agreed
to keep the current assignments for this
meeting, since committee members were
familiar with the issues.
REVIEW OF RECOMMENDATIONS DRAFTED
AT PREVIOUS MEETING
The Chair noted that the recommendations
drafted in July had not been sent to the
Secretary and were therefore still open
for discussion. Prior to breaking into
Sub-Committees, Council members reviewed
the draft recommendations listed in the
minutes of the July meeting.
The Chair confirmed that a letter requesting
a meeting with the Secretary at the February
2008 meeting in Washington, D.C. was sent
on September 20, but there had been no
response to date. Anne Nolon asked whether
a senior official at HRSA or BPHC could
advocate on the Council’s behalf.
Gil Walter stated that his Congressman
was very interested in farmworker issues.
He offered to write a letter to request
his help; he also offered to circulate
a draft of his letter to other Council
members for their comments.
- ACTION ITEM: Gil Walter will request
his Congressman’s help in scheduling
a meeting with the Secretary. He will
circulate a draft of his letter to other
Council members for their comments.
REPORT BACK FROM COMMITTEES
Migrant Health Services
Committee chair John McFarland reported
that the draft recommendation regarding
expansion of the NHSC would address the
HPSA issue. The committee proposed the
following additional language for the
recommendation drafted in July:
The Advisory Council realizes that the
expansion of the NHSC requires increased
funding, which is a function of the Congress.
However, the Council feels that strong
support from the Secretary and the President
would enhance NHSC expansion.
The committee proposed a new recommendation
related to workforce development:
In the realm of workforce development,
the Council recommends that the Secretary
incentivize health profession training
programs to promote primary care, including,
as examples, family medicine, general
dentistry, and behavioral health.
Gil Walter commented that the NHSC does
not serve well the need of farmworkers
and questioned whether the expansion of
the NHSC would address the HPSA issue
in areas with mixed demographics. He suggested
that the recommendation include language
to promote a HPSA methodology that ensures
that priority is given to special underserved
populations, including migrant and seasonal
farmworkers.
Anne Nolon suggested developing a special
process to determine HPSA rates. The process
would be based on Medically Underserved
Population (MUP) status and would not
include the doctors serving at the FQHC.
Access, Resources, and Funding;
Public Policy and Advocacy
Gil Walter reported that the two committees
had begun to revise the joint recommendations
they drafted in July to include more action
language. The committees also discussed
two new recommendations. The first would
address the documentation required by
the Deficit Reduction Act to obtain services
through Medicaid; the second would focus
on advocacy for SCHIP.
Time constraints prevented the Council
from discussing all of the proposed changes.
The Chair suggested tabling the discussion
until the second day of the meeting. Dr.
McFarland and Ms. Nolon, as committee
chairs, agreed to continue working on
the recommendations from these committees
so that the Council could discuss them
the following day.
OVERVIEW/EXPECTATIONS FOR TESTIMONY
- Erin Sologaistoa, Migrant Regional
Coordinator, Southeast Region; Florida
Association of Community Health Centers,
Inc.
Ms. Sologaistoa thanked the Council
for their time and work and stated that
she was honored to facilitate the public
hearings. She informed the Council that
her goal was to develop three strong
panels, with balanced representation
in terms of geographic location, roles,
and other factors. The members of each
panel had been asked to identify their
successes, their challenges, and one
change that would help to address those
challenges. Following the panelists’
statements, the floor would be open
for a question and answer session with
the Council. If time allowed, the panelists
would take questions from the audience.
Anne Nolon complimented Ms. Sologaistoa
on having assembled three full panels.
She noted that audience participation
had not been included in previous hearings
and expressed concern that this could
take the focus away from health issues.
Other Council members agreed, and audience
participation was removed from the agenda.
Responding to a question, Ms. Sologaistoa
stated that her primary role as a Migrant
Regional Coordinator is to increase the
quality of care and access to health care
for MSFWs in a four-state region. In addition,
she is involved in the development of
new PINS, she helps to create linkages
between organizations, and she provides
advisory services to Midwest region.
Karen Watt asked whether transcripts
of the testimony would be posted on the
OMSP website. Jean Hochron replied that
the BPHC Web site had been revised, and
the new site does not provide detailed
information on programs for Special Populations.
Responding to a question, Ms. Sologaistoa
stated that while she had observed an
overall decline in outreach services,
more than half of the migrant health programs
in the region have outreach programs.
The Chair thanked Ms. Sologaistoa for
her presentation and reminded the Council
that they would meet at 8:30 a.m. to review
their draft recommendations prior to the
hearing.
The Chair adjourned the meeting for the
day at 5:00 p.m.
RECAP OF ISSUES PRESENTED BY PANELISTS
The Chair called the meeting to order
at 8:30 a.m. She opened the floor for
discussion of the issues raised during
the testimony panels.
Outreach/ Promotora Issues Panel
Susana Castro said she was surprised and
reassured by how many of the panelists’
comments reflected the Council’s
recommendations, especially related to
outreach and specialty care.
Edward Colon stated that this was the
best testimony he had heard during his
four years on the Council. He appreciated
the fact that the panelists were both
forthright and outspoken.
Frances Canales found the testimony inspiring
and noted that the issues affecting MSFWs
are the same everywhere, especially those
related to outreach.
Enedelia Cisneros noted that the testimony
showed the importance of a comprehensive
model that incorporates the full range
of services, including transportation.
She stated that clinics that are open
one day a week force migrants to choose
between work and health, and the work
of promotoras is wasted if transportation
is not available.
Rogelio Fernandez noted that the testimonies
underscored what the Council had been
discussing this year. He remarked that
clinic access and manpower shortages were
recurrent themes.
Gil Walter stated that outreach workers
are a cost-effective way to provide the
many small, but essential, services that
are required for migrant health care.
He noted that one panelist from Florida
was the sole outreach worker for nine
health centers; by comparison, his organization
has five outreach workers for nine centers
because the State of New Jersey pays for
those services. Mr. Walter emphasized
the urgent need for Federal grants to
fund enabling services.
Rosita Castillo felt that the panel sent
a strong message about expanding the concept
of outreach to include bringing providers
to the patients. She suggested that models
that work, such as the use of air cards,
should be expanded to other areas of the
country, and she stressed the need for
systems that would enable migrants to
access health records and services.
John McFarland expressed concern about
rising anti-immigrant sentiments and stated
that this was the first time he had heard
a reference to the “war against
migrants.” Other Council members
shared this concern and discussed the
issue of serving undocumented patients
in migrant health centers. Dr. Gomez noted
that FQHCs cannot turn patients away and
do not need to document their patients’
immigration status to obtain Federal funding.
She proposed that BPHC provide more training
for FQHCs regarding documentation requirements.
John McFarland expressed concern that
some issues that seemed to have been resolved,
such as recruitment and retention, were
coming back. The expansion of health centers,
combined with a reduction in the NHSC
and a smaller number of primary care health
professionals, makes it difficult to fill
positions.
Clinical Issues Panel
Rogelio Fernandez asked how health centers
could bill for services provided outside
of their clinic, such as the nurse practitioner
who travels to migrant camps to see patients.
Gil Walter responded that billing policies
vary by State. CHCs in New Jersey can
bill up to eight hour per week for services
provided outside of a licensed facility.
Mr. Walter noted that Medicaid only requires
that encounters be documented. Medicaid
services do not need to be provided in
a licensed facility, because many States
do not license health centers. Anne Nolon
noted that offsite billing is approved
for Medicaid clients in New York, but
not at the full rate. She felt there is
no reason not to give centers the full
rate.
John McFarland commented that mobile units
are poor sources of revenue, because they
are expensive to operate and most do not
bill for services. This is an important
issue when considering funding for health
centers. Mr. Walter stated that some States,
like New Jersey, provide reimbursements
that can help to fund mobile units and
other services, but most States do not
embrace farmworker populations. He reiterated
that mobile units, case management, outreach,
and other enabling services that are essential
for migrant health are not sustainable
without Federal grant funds.
John McFarland noted that the dentist
and the psychologist on the panel echoed
the need for oral health and mental health
services. He stressed that the number
of providers is nowhere near the level
that is required to handle the caseload.
Rosita Castillo remarked that needs would
always be greater than resources. She
reiterated a panelist’s comment
regarding the need to educate the world
about the importance of migrant health
services and the fact that health centers
save money. She suggested holding community
fundraisers for services such as mobile
units.
Administrative/Policy Panel
Gil Walter called attention to the panelists’
comments about the need for Migrant Health
grant guidance and expanded services grants,
which echoed the Council’s recommendations.
Susana Castro noted that many panelists
identified recruitment and retention as
key issues at their centers.
Michael DuRussel noted that some panelists
describe a “one-stop shopping”
model of service delivery. He stressed
the need for mechanisms to transfer medical
records so that migrant health centers
do not have to recreate the wheel.
Next Steps
The Chair asked Council members to comment
on how the panelists’ testimony
would impact the Council’s recommendations.
Anne Nolon replied that the testimony
supported many of the issues that the
Council already had on its list. However,
the testimony called attention to the
urgency of addressing recruitment and
retention. Council members discussed mechanisms
to increase recruitment, including revising
the HPSA scoring methodology and expanding
the NHSC.
DISCUSSION OF RECOMMENDATIONS
AND LETTER TO THE SECRETARY
Anne Nolon led the discussion of the draft
recommendations. She began by stating
that the Central Office Grantees had suggested
forming a joint workgroup consisting of
HRSA staff, Central Office Grantees, and
migrant health leadership to review administrative
issues in grant applications. Specific
issues would include reinstating the needs
assessment worksheet that is specific
to MSFWs, including requirements in the
grant application that would ensure that
grantees receiving funds for migrant health
are providing the full range of services
needed by this population, and reinstating
services expansion grants that include
dental health, mental health, and outreach,
health promotion, and translation services.
She reminded the Council that the presentations
by Migrant Health Promotion and the Michigan
Primary Care Association at the July meeting
emphasized the importance of ensuring
that reimbursement rates at all FQHCs
include outreach and health promotion.
Gil Walter proposed an introductory statement
for this recommendation, which would state
that the Council had heard recurring expressions
of concern from farmworkers and health
center workers around the country that
the current grants administration does
not provide adequate resources to migrant
health services.
Anne Nolon stated that the recommendations
should also address the need for smaller
grants to support planning and infrastructure
development, and the importance of encouraging
smaller health centers to apply for NAP
or expanded services grants to meet the
needs of MSFWs.
Council members suggested various versions
of a recommendation to revise the HPSA
scoring mechanism. Anne Nolon suggested
that the Council identify the key issues,
with the final wording to be developed
after the meeting.
The Council reviewed a draft of the letter
to the Secretary, which was prepared by
Gil Walter and Anne Nolon. Council members
discussed the overall flow of the letter,
identified key issues, and proposed specific
language in a number of areas.
After some discussion, the Council divided
the draft recommendations into high priority
items that would be finalized for this
letter, and others that would be addressed
at the February meeting. Anne Nolon and
Karen Watt agreed to finalize the letter
and the recommendations.
- ACTION ITEM: Karen Watt and Anne
Nolon will finalize the letter to the
Secretary, including the recommendations
that will be submitted at this time.
REMARKS FROM DEPARTING MEMBERS
Dr. Gomez invited each of the departing
Council members to share their thoughts
on the future of the Council and to identify
the issues that the Council should address
in its recommendations.
Mr. Walter stated that the testimony presented
at this meeting summarized his experience
on the Council over the past four years.
Although migrant health does not seem
be a priority at higher levels, there
is still passion on the level of the people.
He noted that the BPHC had responded positively
to the Council’s recommendations,
and the Farmworker Study was conducted
after many attempts. He expressed his
appreciation for the opportunity to serve
on the Council and thanked Dr. Gomez and
Gladys Cate for their hard work and support.
Dr. Colon noted that when he graduated
from medical school, he served with the
NHSC and was assigned to a migrant clinic.
He did his job, but he was not aware of
the problems related to the health delivery
system. Being selected to serve on the
Council after his retirement was a great
honor, because it made him aware of the
many problems faced by farmers, farmworkers,
and health care providers, which were
similar across the country. Dr. Colon
expressed concern that, as a nation, we
have not done what we could do when it
comes to migrants, and he called for a
more humane vision of the work that is
involved in migrant health. He emphasized
that money will not solve all of the problems.
The Council must keep a long-term perspective,
because it will take time to attract,
recruit, and retain talented people. Dr.
Colon thanked Dr. Gomez and Ms. Cate for
their help and support at all times.
Anne Nolon also thanked Dr. Gomez and
Ms. Cate for the support they provide
to the Council. She stated that serving
on the Council was the greatest opportunity
of her long career health care policy
and administration, because it enabled
her to view policy issues at close range.
She emphasized that serving on the Council
is the highest position that a health
advocate can hold in this country because
it is recognized in the law and provides
direct access to the Secretary. She urged
Council members to continue to work hard,
to be proud of their work, and to take
advantage of their power.
Karen Watt stated that it was an honor
for someone from the farming community
to serve on the Council, and she appreciated
the opportunity to work on such a vibrant
body with so many different people from
across the United States. She praised
the Council for keeping the Secretary
aware that migrants are an important group,
and she expressed concern that the pervasive,
anti-immigrant mood of the country could
be a greater challenge than providing
health care.
Dr. Gomez thanked the departing members
on behalf of the Secretary, HRSA, and
the entire Department of Health and Human
Services and acknowledged the contributions
of each departing member. Dr. Gomez stated
that she had never seen a more hard-working
group, and she hoped they would continue
to make their expertise available to the
Council.
AGENDA ITEMS FOR FEBRUARY 2008
MEETING
Dr. Gomez informed the Council that the
May meeting would be held in Puerto Rico
on May 5 and 6, with travel on May 4 and
7. She reminded the Council that the next
meeting would take place on February 4
and 5 at the Parklawn Building in Rockville.
Council members agreed that it would be
acceptable to travel on a Sunday for that
meeting.
Dr. Gomez reiterated that the letter inviting
the Secretary to meet with the Council
had been sent. She was waiting to hear
if the Secretary would meet with the Council
in Rockville, or if he would prefer for
the Council to meet with him at his office
in Washington, D.C.
Dr. Gomez emphasized the importance of
having a detailed agenda for the February
meeting as soon as possible. Karen Watt
stated that the Executive Committee could
work on that. She suggested that the meeting
with the Secretary should be based on
the issues raised in the previous two
letters from the Council.
Dr. Gomez reminded the Council that this
was the first meeting for FY 2008. The
remaining meetings for this fiscal year
would be in February and May. The first
meeting for FYO9 would be held in conjunction
with one of the migrant stream forums.
LOGISTICAL INFORMATION
Gladys Cate reminded Council members to
submit their expense reports as soon as
they return home. She assured them that
honorarium/salary payments would be processed
to be deposited to their bank accounts
as soon as OMSP receives the necessary
documents from them. Ms. Cate asked Council
members to inform her immediately if and
when they change bank accounts.
The Chair adjourned the meeting at 4:00
p.m.
ACTION ITEMS
- Dr. Gomez will send nominating information
for 2008 to Council members in December
- Gil Walter will write a letter requesting
his Congressman’s help in scheduling
a meeting with the Secretary and will
circulate a draft to other Council members
for their comment.
- Karen Watt and Anne Nolon will finalize
the letter to the Secretary, including
the recommendations that will be submitted
at this time.
|
