Health Care Reform Bills Approaching Floor Action
The Senate Finance Committee reported out its long-awaited health care overhaul proposal on October 13. In trying to get bipartisan backing, Chair Max Baucus (D-MT) had worked for months with a group of six Finance Committee members. (The "gang of six" comprises Baucus, Jeff Bingaman (D-NM), Kent Conrad (D-ND), Mike Enzi (R-WY), ranking member Chuck Grassley (R-IA), and Olympia Snowe (R-ME).) One Republican, Olympia J. Snowe of Maine, voted for the bill. The rest of the committee's Republicans reiterated their opposition in the committee report.

As it now stands, the main provisions of the Finance Committee's bill requires individuals to get health insurance coverage, establishes a health insurance exchange enabling individuals and small businesses to comparison-shop for coverage, reforms the private insurance system, expands Medicaid to include those earning up to 133 percent of the federal poverty level, and — as an alternative to the public plan option included in the House and the other Senate committee's (Health, Education, Labor and Pensions [HELP]) bills — establishes state-based cooperatives to compete with private health plans. The $856 billion cost of the bill is "within President Obama's target of $900 billion."

Moderate Democratic senators have stopped short of endorsing the Baucus plan, and several said they were unwilling to commit to helping their party overcome a potential Republican-led filibuster. The plan has also failed to gain support from liberal Democrats and Republicans. Before legislation can move to the Senate floor, the bill that emerged from the Finance Committee will be melded with the HELP bill. In explaining what will follow, Senate Majority Leader Harry Reid (D-NV) said, "The first amendment will be a composite of the HELP Committee bill and the Finance Committee bill, working with the White House. And we will see if we can get 60 votes on that. If we can't get the 60 votes we need, we'll have no alternative but to do reconciliation." The strategy of reconciliation is controversial and considered risky, but it could prevent a Republican filibuster and allow the bill to reach the full Senate for a yes-or-no roll call vote needing only a simple-majority vote for passage.

Meanwhile in the House, Democrats are divided over how to proceed. Liberals are advocating for bringing health care reform to the floor as quickly as possible, and centrists are pressing for a delay until the Senate acts on its version. Representative Henry Waxman (D-CA), chair of the Energy and Commerce Committee, indicated that he was putting off indefinitely a markup to complete action on outstanding amendments to the House health care legislation, H.R. 3200. Waxman denied that he was bowing to pressure from undecided committee members, many of whom are part of the Blue Dog Coalition, a group of fiscally conservative Democrats. Representative Anna Eshoo (D-CA), an adviser to Speaker Nancy Pelosi (D-CA) and a member of the Energy and Commerce Committee, said the panel's final markup was delayed in part to consider new amendments that Democrats want to offer to respond to constituents' concerns and to proposals that President Obama outlined in his September 9 speech to Congress. Among the proposals being considered are pilot programs and other measures intended to curb or discourage medical malpractice lawsuits. In its present form, H.R. 3200 already has a provision allowing incentive payments for states that institute malpractice reforms, and Pelosi has said she expects the final bill will retain that provision.

Representative Jim Cooper, (D-TN), a longtime Blue Dog and among the many centrist members who want to let the Senate act first, explained that he and other Blue Dogs consider it politically unwise for the House to vote on a bill that includes provisions the Senate is likely to omit. "We want it to fit within President Obama's budget guidelines, and not add one dime to the deficit," Cooper said.

While Eshoo and other Pelosi advisers said that no final decision has been made on whether the House will take floor action first or wait for the Senate, Louise Slaughter (D-NY), chair of the Rules Committee, cited the long-held reality that guides the timing of House votes: "When we have the votes, we are going," she said.

(As we go to press, we received this alert from Congressional Quarterly's "CQ Today Midday Update":
"House Democratic leaders introduced their long-awaited health care overhaul package; the nearly 2,000-page legislation aims to extend health coverage to 96 percent of all Americans once it is fully implemented. It contains a public insurance option that would have the government negotiate rates with health care providers, along with a mandate that individuals obtain coverage and that businesses offer it. It would be financed in part by a surtax on the wealthiest Americans. Early indications were that Democrats across the ideological spectrum were lining up behind the main health care measure, which was assembled by Speaker Nancy Pelosi, D-Calif., and her team. Republicans, as expected, uniformly denounced the legislation. Not a single GOP member is expected to vote for it.")

Harkin New Chair of Senate HELP Committee
On September 9, Senator Tom Harkin (D-IA) accepted the chairmanship of the Senate Health, Education, Labor and Pensions (HELP) Committee. Harkin, who succeeds the late Senator Edward Kennedy (D-MA), indicated that his priorities for the fall — the health care, student loan, and food safety bills — follow the agenda set largely in motion under Kennedy's leadership. He called his new role a "daunting prospect" but also a "great honor" to serve and carry on the legacy of Kennedy.

Harkin has made his mark on many HELP issues. As an advocate for workers and people with disabilities, he was the driving force behind the original Americans with Disabilities Act and its reauthorization. He chaired the committee's working group on prevention and public health, which was responsible for the section relevant to those issues (Title III) in the committee's health reform bill, the Affordable Health Choices Act, approved in July. He expects to have the panel's bill to overhaul the student lending industry marked up and reported to the Budget Committee by October 15 (the House passed its version of the legislation [H.R. 3221] on September 17). In addition, having been asked by Kennedy to take charge of food safety, Harkin said he wants to have that bill ready to go this fall as well.

On health care, Harkin said he will work closely with Senator Chris Dodd (D-CT), but he pledged to keep Dodd in charge of the panel's role in negotiations. Those negotiations have reached a critical juncture and, while Dodd has been a willing negotiator, he has indicated that the time should come when Democrats must stop chasing recalcitrant Republican votes. Moreover, Harkin has made it clear that he would not support an upending of the HELP bill.

        Volume 6, Issue 5
          October 2009

Health Care Reform Bills Approaching Floor Action

Harkin New Chair of Senate HELP Committee


Government Affairs Action Center


NY/NJ Bills Revive Debate on Education Standards for Nurses

Both the New York and New Jersey state legislatures are considering bills that would require all newly licensed RNs to obtain BSN degrees within 10 years of initial licensure. The bills — S4051/A2079B in New York and S620/A3768 in New Jersey, commonly referred to as the "BSN in 10" proposals — recall initiatives dating to 1965 that attempted to raise the minimum educational level of practice in nursing to BSN. The current proposals neither call for the BSN as the minimal requirement for entry into practice nor do they advocate for the closing of ADN or diploma programs, but they have sparked a heated discussion of the issue once again.

(The NLN's Reflection & Dialogue, "Academic/Professional Progression in Nursing," was developed in response to this proposed legislation and that in other states that has revived the question of educational preparation for nursing practice.There is a growing consensus among nurse educators, legislators, and colleagues in service that our current system of nursing education has not provided enough opportunities and incentives for associate degree and diploma program graduates to pursue baccalaureate and master's education, and for baccalaureate graduates to obtain advanced degrees.)

Concerns have been raised about what passage of the bills would mean for nursing schools in New York and New Jersey that, like the rest of the country, already are turning potential candidates away because of faculty shortages. Other major concerns include the fate of ADN and diploma programs, and the monetary burden that could be placed on nurses to fulfill the BSN requirement.

Proponents of the proposals say that the new requirement would ensure that nurses in New York and New Jersey are equipped to handle the ever-increasing complexity of patient care. Furthermore, some in favor of the bills say that, to remain viable and equally competitive in the health care arena, nursing needs to make the baccalaureate degree the minimal requirement for maintaining licensure.

The measures in both states cover the same general points, requiring new graduates of AD and diploma programs to obtain their BSNs within 10 years of the date of initial licensure, and providing a grandfather clause for nurses who already are licensed and for those who are enrolled in nursing school before enactment. For the nurse who cannot complete the degree requirement in the allotted time frame, the bills also provide options to request an extension and be granted a conditional registration.

Each bill gives similar reasons for enacting the legislation. New York's bill notes that higher patient acuity, advancing technology and procedures, and complex patient care, along with shorter lengths of stay, are creating a greater demand for nurses' skills. It also cites research studies that "clearly demonstrate the added value of additional education in relation to improved patient outcomes." One study, it states, found that "each 10% increase in the number of baccalaureate-prepared nurses results in a 5% decrease in surgical patient deaths." The language in New Jersey's legislation similarly references studies comparing patient outcomes with nurses' educational background.

According to the National League for Nursing's 2007 statistics, New York and New Jersey have more ADN programs than BSN programs, and since 1987, the number of ADN programs nationally has steadily risen. Through legislators in both states have offered assurances that passage of their legislation would not change this situation and that nurses will continue to be able to enter the profession through ADN and diploma programs, the call for higher educational requirements seems implicit. With respect to health care's increasing complexity, New York's bill S4051 states, "Other countries are responding to these changes by requiring the baccalaureate degree as an entry requirement for nursing licensure, while other professions are demanding master and doctoral degrees as their entry point." In addition, New Jersey's S620 states, "it is the sponsor's intent that currently licensed nurses also seek to advance their education and training." If passed, the New York law would take effect immediately; New Jersey's law would take effect after 90 days.

California Court Strikes Down Minority Preferences for Health Scholarships

A California court has ruled that a state scholarship program for health-care professionals can no longer give preference to members of certain racial or ethnic minority groups. The 1996 law creating the program said the scholarships were intended mainly for minority students entering the health professions. Later that same year state voters approved a constitutional amendment prohibiting state and local agencies from granting racial, ethnic, or gender preferences.

In a decision issued this month, California's Superior Court for Sacramento County held that favoring minority applicants conflicted with the 1996 constitutional amendment, and that the program should therefore operate without regard to applicants' race. A statement issued by the Pacific Legal Foundation, a legal advocacy group that brought the lawsuit challenging the scholarship preference, characterized the case as "statutory cleanup" intended to ensure no state laws conflict with the 1996 amendment, known as Proposition 209.

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