Remarks to the University of Pittsburgh
School of Public Health

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Prepared Remarks of Claude Earl Fox, M.D., M.P.H.
Administrator, Health Resources and Services Administration

University of Pittsburgh School of Public Health
Pittsburgh, Pa.

February 13, 2001

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Introduction

It is a pleasure to be here at the University of Pittsburgh’s Graduate School of Public Health. I want to thank Professor (Gordon) MacLeod for giving me this platform to discuss some of my ideas about the current and future challenges facing those of us in public health.  

I’ve spent my entire professional life working in the field of public health -- as a health officer at the state, regional, and now the federal level. For certain, those of us who make public health our life’s work start with a strategic advantage. The health of the nation is on everyone’s lips – from politicians to everyday citizens who worry about the future of their own health care. And, through the years, we’ve enormous success.

In 1900, long before any of us were born, the average American could expect to live only 48 years.  Today, that average American lives to be about 77. Also, we’ve seen many of the gaps in our system closed. Polio, diphtheria, tetanus, rubella are conquered. Infant mortality is down, childhood immunization is steadily moving up, and prevention messages are more popular and widespread than ever.

Yet, despite the progress, there are still many challenges that must be faced. And, as graduate students in public health, you will play a key role in how we as a Nation shape the health policies that will guide us through the 21^st century. This morning I would like to explore some of those challenges with you, but let me begin with a brief discussion of the role my agency plays in preserving the Nation’s health.

HRSA’s Role

HRSA is known as the “access agency,” because expanding access to health care to all Americans is one of our two goals – the other being working to eliminate health disparities among Americans. We are a $6.2 billion-a-year agency that does many things to promote access to quality health care, but we are best known for four main programs.  

First, we support community-based health centers and clinics in more than 3,000 communities.  These clinics provide preventive and primary health care services to more than 9 million people – two-thirds of whom are from minority groups, a third of whom are children. 

Second, our Ryan White CARE Act programs are -- after Medicaid -- the largest single source of federal funds for HIV/AIDS health care for low-income, uninsured and underinsured Americans.

Third, HRSA’s maternal and child health block grants to states fund an array of services that help women during and after pregnancy and their children after birth. These programs reduce infant mortality, immunize infants and work to reduce adolescent pregnancies.  

Fourth, our health professions programs are known nationwide for their success in promoting greater diversity in the professions and encouraging students to serve communities in need after graduation.

Taken together, all that we do at HRSA lays the foundation for what we call the Nation’s health care safety net. We work with states and local communities to put in place a network of programs and services to meet the needs of the Nation’s most vulnerable citizens.

Challenges in Serving the Uninsured

In maintaining the nation’s safety net for the uninsured, we face many challenges, including:

·        the increasing demands for financial support,

·        the need to ensure that public health professionals work in specialities and geographic areas where they are needed most,

·        the creative use of information technology, and

·        the ever present need to cooperate and collaborate through viable partnerships at the national and local levels.

All of you probably read the good news released in October: that the number of uninsured people across the United States actually fell from 44 million to 43 million – the first decline in 12 years.

The decline occurred among all major ethnic groups.  Still, the challenge of the uninsured remains.

Access to coverage remains a problem for far too many Americans.  Uninsured people are three times more likely to go without medical care as those with insurance, 50 to 70 percent more likely to need hospitalization for chronic conditions such as diabetes and pneumonia, and four times more likely to rely on emergency rooms for their health care.

Finances

Financial support for safety net providers has always been tenuous.  Securing sufficient resources to serve the medically underserved is an annual struggle.  And it remains so today.

But in this area we have some encouraging news. President Bush has said that he is committed to the strengthening the the Nation’s health care safety net. In fact, he has said that he favors additional financial support  for community health centers that would enable them to double the number of people they currently serve. He also has encouraged health centers to partner with local hospitals, providers, and managed care organizations to ensure a stable health care delivery system in the communities being served.

And under the topic of finding ways to pay for health insurance for all who need it, I’d like to mention a brand-new HRSA initiative called the Community Access Program.

This effort will help communities build partnerships among health care providers to deliver more and better care to their neediest residents. Grantees in 23 States were awarded up to $1 million each in fiscal year 2000 to build integrated health care systems among local partner organizations, all of which are committed to expanding health services to the uninsured.  In the fiscal year 2001 budget, funds for CAP will grow to $140 million. This program will make it possible for local residents to receive services such as primary health care, mental health and substance abuse counseling, and dental and pharmacy assistance.

In addition, last year our State Planning Grant program awarded one-year planning grants totaling $13.6 million to 11 states.  State officials and their partners will use these funds to develop plans for providing uninsured citizens access to high-quality, affordable health insurance similar to that available to government employees.

Our hope is that these states develop plausible, affordable plans that can serve as models for other states seeking to extend full health coverage to their citizens.  We’re very optimistic about this effort and we urge public health officials to be engaged in the crafting of the state plans.  

Workforce

Another challenge we face in maintaining the safety net is making sure we have a well-trained workforce able to meet future demands.

HRSA contends that health services to some of our neediest populations will improve when doctors, nurses, medical technicians, and mental health and substance abuse counselors look more like the patients they serve.  And they should have the cultural competence to understand the values, norms and habits of the communities they serve.  

HRSA invests more than $300 million annually in loan and scholarship programs to increase the diversity of the health professions workforce and to make sure that those we train are willing to serve in places where services are scarce. This is critical because we could spend millions of dollars to build more clinics or even give everyone an insurance card, but it would do no good unless we had in place an adequate supply of health care professionals to provide the needed care.

To increase our understanding of critical workforce issues and their impact on the entire health care system, we’ve recently released several important publications that explore these issues in great detail.

The most significant is our new State Health Workforce Profiles -- a first-ever report that provides valuable data on the supply and demand for physicians, nurses, dentists, and some 20 other health care professionals in the 50 states and the District of Columbia. These profiles give states an early warning system to help them uncover potentially critical shortages before they occur.

A companion piece to the state profiles is our Public Health Workforce Enumeration that includes information on public health workers in eight occupational categories and 55 occupational titles. This data was collected from state and local public health authorities in 57 states and territories.

We hope that state and local officials will use this information to identify and address health workforce gaps and make informed policy and funding decisions for the future.

Information Technology

A third challenge to the health of the safety net reflects our willingness to embrace and use new information technology.  Here I’m speaking of computers that make it possible to quickly share essential public health information among partners and of video and audio equipment that lets doctors check on distant patients from the convenience of their own offices. 

In our work to improve public health and publicly funded health care, the collection and analysis of health information and the construction of reliable health data systems is a central concern.  Data collection and sharing are essential because our ultimate success as guardians and promoters of public health is directly linked to our ability to persuade government officials and the public that the funds we seek are essential to the well-being of their communities.

Legislators and taxpayers want to see returns on their investments.  They want problems identified and they want proof that the money they spend solves real problems.  That’s where data collection – and the need to share it – comes in.

Good data provide verifiable, objective measures for determining the best use of public health dollars and public funds that provide patient care.  The more broadly we share data, the richer the picture we’re able to paint of the general health of the communities we work in.

In public health, ‘dollars follow data.’  I’ve said it so often it’s like a mantra, but it’s true.

None of us can escape this reality -- before you can start any new programs or expand old ones, you’ve got to have reliable evidence of needs and achievements.  Anecdotes won’t cut it.

Another way we can work smarter is by taking advantage of video and audio equipment that transmit images via computers. The technology we have now can use these computer tools to bring high-quality distance learning to the desktops of health professionals nationwide.  It can be used by medical professionals to instantly share x-rays with far-off colleagues.  Or it can be used by dentists, doctors and nurses to do “virtual” checkups, exams and diagnoses of patients who can’t make it to the hospital or clinic.

And public health providers can use this distance-learning technology to ensure that county staff have the latest information needed to address public health functions.

New technology is changing every aspect of life – and its impact on medical care is especially strong.

So the question is: How can you use it to improve the delivery of health promotion and disease prevention services?

The amount of medical information available in a free society is remarkable.  Some segments of the population may be puzzled by a glut of seemingly contradictory information, while underserved groups have access to very little.

It is a primary responsibility of public health experts to continually scan the horizon for the latest, best medical science.  Then we must make sure the information is distributed to all who can benefit from it.

Surgeon General David Satcher has challenged all of us to shorten the time that occurs between the discovery of new science and its use in actual practice.  Estimates are that two years elapse between discovery and use.  We can do better.

And so can you.  Schools of public health should make the dissemination of new scientific findings the cornerstone of their continuing education efforts.

Roles of Government in Public Health

Creating a health care agenda whether at the national or local lever is always a dynamic exercise, with changing tactics and players at every turn. As soon as you think you have one problem solved, another is sure to crop up to take its place. One day you win over a longstanding adversary, the next day you encounter a new one -- more forceful and powerful than any before.  In this field, all you can count on are constantly changing priorities and demands and a future that rarely follows any predictable path.

In health promotion and disease prevention, leadership is crucial at all levels of government.

At the local level, where health services are delivered and follow-up occurs, government best educates the public by tailoring public health campaigns that respond to the needs of each community.

At the state level, officials and lawmakers must make sure that health education and disease prevention activities penetrate all areas of the state.  State legislators must be asked to provide appropriate resources, since we know these activities make a great difference.

And the federal government must ensure that all health-related agencies give proper attention and allocate necessary resources to health promotion and disease prevention activities. And to make sure these activities are up-to-date and reflect the latest knowledge, government needs to appropriate adequate dollars for research.

Can government have a dramatic impact on Americans’ health?  Of course it can.  One need only look at how public health campaigns in our lifetimes have changed America.

Take for example: the campaign to immunize 2-year-olds.

In the mid-1980s, childhood immunization rates in most states were about 60 percent.

But since 1993, immunization rates have reached all-time highs, with 90 percent or more of America's toddlers receiving the most critical doses of children’s vaccines by age 2.

In addition, reported levels of disease were at or near record lows in 1998.  For the most critical childhood vaccines, vaccination levels are nearly the same for preschool children of all racial and ethnic groups, narrowing a gap that was estimated to be as wide as 26 percentage points a generation ago.

Why was the immunization campaign so successful?  Because it relied on a partnership of public agencies and private organizations to reinforce the message.

In fact, one partner -- the service organization Kiwanis -- made it their central theme.

In 1992, Kiwanis launched a public-service radio series that was distributed to stations throughout North America.  The slogan of the campaign, "All Their Shots, While They're Tots," urged immunization of children by age 2.  The radio campaign was supported by a billboard and poster program with the same theme.

The federal government strengthened this public-private partnership by making 30-second TV and radio spots endorsing the Kiwanis campaign.  And now immunizations are at all-time highs.

The point in all this is that government can’t promote healthier living and disease promotion by itself. 

It’s always going to take organizations like Kiwanis or Mothers Against Drunk Driving in the fight to prevent needless car accidents to advance the ball further down the field.

Private organizations -- and academic entities like your own -- bring irreplaceable power, drive and resources to public health campaigns.

A Future of Promise

No doubt, the future of public health is full of uncertainty and challenge, but it is also filled with promise.

With tremendous past success on our side, we have every chance to make even greater progress in the 21st century.

As you move forward in your careers, here are a few guiding principles:

·        insist on being at the table when key decisions are being made that impact the health of your communities,

·        work to eliminate the differences between the medical haves and have-nots,

·        continue to inform and influence the debate, making sure that health policy is built on fact, not fantasies, and;

·        make quality your guiding force.  

With all of working together to build a quality health care system that is open to all, we make it possible for all our citizens to live happier, more productive lives.

  

 

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