As the newsletter goes to press, this fall's fiscal fights already are underway in the US Congress. The current series of battles — over spending and budgets, a potential government shutdown, and the debt ceiling — is reminiscent of the sequestration article in the January 2013 Nursing Education Policy e-newsletter
While the January article described the ongoing congressional maneuvers, the underlying showdown is about the role of government in acting against inequality. A policy that tackles inequity and is a target of one of the current congressional clashes is the implementation of the health care reform law — the Patient Protection and Affordable Care Act
(PPACA) — that aims to provide insurance to the 15 percent (41 million) of Americans who otherwise wouldn't have it.
Equity and advocating for access to quality health care for all is the first health policy priority described in the NLN Public Policy Agenda 2013-2014
. It states, "[f]undamental to the nursing profession and the NLN is the principle that all individuals must have equitable access to comprehensive health and wellness care addressing all medical conditions, including mental health and substance use disorders."
Nondiscrimination by extending insurance coverage to expand access to care to all US citizens is a key goal of PPACA, making it the most significant social justice reform in health care since the 1965 creation of the Medicare and Medicaid programs. An examination of PPACA reveals a law that is nurse-centric in its perspective and values. PPACA promotes better health care, better care experience, and lower cost of care by driving best practices toward organizing those delivery systems that reflect the signature of nursing care: actively patient-centered and holistic in health homes, coordinated care between health care settings and among team-based providers, and focused upstream on wellness and prevention.
The House of Representatives attempt to abort PPACA is playing out in proposed legislation on the nation's fiscal year 2014 spending budget, which began October 1, and in a bill to raise the nation's debt limit in order to pay for the federal programs and services already supported and authorized by Congress. The nonpartisan Congressional Budget Office (CBO) recently warned that lawmakers and President Obama have been slashing the wrong kind of federal spending to avoid unsustainable levels of debt in coming decades (http://www.cbo.gov/publication/44521). In particular, CBO reported that implementation of PPACA would reduce deficits and that repealing it would increase deficits.
For the past two years, the House and the White House have been budget-cutting defense and non-defense discretionary (NDD) programs, the latter were mentioned in the July 2012 NEP article "What Is Sequestration and Why Does It Matter to Nursing?"
. Cuts to NDD programs over the years have been exacerbated by the continuation of the sequestration deal forged two years ago. The CBO report showed that the discretionary trimming has resulted in reductions in areas that are not shaping the projections of future debt. Moreover, since 2011, NDD spending has been in line for annual cuts over nine years and, most importantly, the deficit is down and plunging. Yet, the House is insisting that the sequestration cuts stay in place rather than accept a "proposal for a mix of higher taxes on wealthy people and some corporations and cuts in future entitlement spending."
The NLN participates in NDD United
, a coalition of more than 3,200 organizations standing together to demand an end to sequestration. NDD United reflects the nursing holistic perspective, acknowledging that by coming together organizations can make their voices heard in demanding a balanced, bipartisan solution to replace sequestration.
The NDD holistic view is not unlike the "Health in All Policies" technique that views health as fundamental to every sector of our economy. Recent research shows that many factors outside of health care have a huge impact on health. From agriculture policy that influences the food on our dinner table to national environmental decisions that put us at risk for various disease vectors, every choice we make brings us closer to, or moves us further from, our national health goals. Therefore, every policy, large and small, and every decision, personal and political, must take into consideration its health outcome. No compromise should be reached without analyzing its health footprint. From transportation and education to energy and trade, every political decision has a health benefit or cost, which must be weighed.
NDD United has developed effective resources that nurse educators and students can easily access to raise awareness about sequestration effects. The NDD United video "No More Cuts" explains the sequester in simple terms and against the backdrop of a user-friendly animated video here
. Communication tips about sequestration are available here
. The NDD United advocacy toolkit is accessible at: http://www.nddunited.org/#!toolkit/c1wfv
FROM THE STATES . . .
Bill to Expand Use of Nurse Practitioners Fails in California
After a fierce lobbying battle, an effort to ease the shortage of primary care doctors in some California communities by allowing nurse practitioners to operate more independently came to a grinding halt in the state legislature. Introduced by Senator Ed Hernandez (D-West Covina), the bill would have allowed nurse practitioners to practice without the direct supervision of a physician.
The proposal failed in committee. It came under fire from the California Medical Association, which teamed with some specialists and labor unions to mobilize lobbyists, engage doctors across the state, and even dedicate Twitter accounts as it waged its campaign against the bill. Jockeying over scope of practice has intensified this year as California prepares for full implementation of the new national health care law, which will bring an influx of newly insured patients.
The bill's supporters pointed to a shortage of primary care providers in rural and inner-city areas. A 2009 study by the California HealthCare Foundation, an Oakland-based grant-making and research group, found that only 16 of the state's 58 counties had enough primary-care doctors. According to proponents, allowing nurse practitioners to set up their own practices could alleviate those gaps in care.
Physicians said the bill made no assurances that independent nurse practitioners would work in underserved areas. They argued that letting the practitioners, who have fewer years of education and clinical training than doctors, work without oversight would put patients at risk. Dr. Paul Phinney, president of the medical association, said "California's nurse practitioners should be working more closely with physicians, not independently."
Hernandez changed the proposal to authorize nurse practitioners to work autonomously only in certain group settings, such as hospitals or clinics. However, groups such as AARP and the American Association of Nurse Practitioners pulled their support in response, not wanting the revised proposal to become a model for other states.
But the California Medical Association remained the bill's biggest obstacle. In the first half of the year, the doctors' association spent nearly $1.2 million lobbying on scope-of-practice bills and other similar legislation. The group also has given more than $500,000 in campaign contributions; lawmakers sitting on committees that oversee health and professional licenses received more than $100,000 of that money.
Seventeen states and the District of Columbia allow nurse practitioners to work autonomously. Catherine Dower, associate director of the Center for Health Professions at UC San Francisco, said data and research from those states "show that the quality of care is the same as, if not better than, doctors' and that safety is not compromised."
Clearing the Hurdles to Nurses' Academic Progression
The latest issue of Charting Nursing's Future, the Robert Wood Johnson Foundation series of policy briefs, examines the challenge of boosting the share of nurses holding baccalaureate and doctoral degrees. The brief identifies a variety of barriers to overcome and spotlights programs around the nation that promote nurses' academic progression. These programs include universities and community colleges collaborating to form unified curricula; employer incentives to encourage nurses to return to school for higher degrees; RN-to-MSN degree completion programs that allow registered nurses without baccalaureate degrees to study for master's in nursing degrees; and others.
The Case for Academic Progression: Why Nurses Should Advance Their Education and the Strategies that Make this Feasible can be found here.