Rolling Out Reform Despite Political and Legal Challenges: The Tug of War for Public Opinion

Wildly popular provisions in the Affordable Care Act have rolled out and have already been felt by consumers, including extending coverage for adults to stay on their parents insurance until age 26, filling the Medicare part D “donut hole” (millions of seniors received checks for $250, a first phase in closing the donut hole), and making it illegal for insurance companies to impose lifetime limits on anybody or to deny children insurance coverage for preexisting conditions. Over the next 6 months, we can expect  more provisions to be rolled out, including a national, voluntary insurance program for purchasing community living-assistance services and supports (CLASS program); requirements that chain restaurants and food sold from vending machines disclose the nutritional content of each item; a phasing-in of more Medicare Part D subsidies and discounts; increased funding by $11 billion for community health centers and by $1.5 billion for the National Health Service Corps over 5 years; and new programs to support school-based and nurse-managed health clinics. The question for all of us is how will advanced-practice nurses (APNs) fit into this picture?

Partisan opposition began on the reform legislation before the ink on the bill had time to dry. Twenty-two states are challenging the constitutionality of the individual mandate because it requires all Americans to have some form of individual health insurance or pay a tax by 2014. Opponents claim this individual mandate interferes with American liberty in that the federal movement oversteps its taxing authority by requiring all citizens to purchase a product (insurance). The opposition is captured by Congressman Steven King (R-IA) who described the healthcare reform as a “cancer” which needs to be “ripped out completely, lock, stock and barrel, root and branch, no vestige left behind, not a DNA  particle retained.”¹ Even as states make their way through the court system with their constitutional challenge, almost all of the 22 states that have filed a lawsuit are simultaneously enacting the reforms. Moreover, according to Senator Ron Wyden (D-OR), states can opt out and develop their own innovative plans to expand coverage,² rendering these lawsuits nothing more than political theater. This battle will likely shift to the courts since some states will try to stall, duck, opt-out, or obstruct the intent and spirit of reform measures. Constitutional scholars agree that the Obama administration insurance mandate will be upheld and remain the law of the land even though the legal challenges of the mandate are expected to continue and may end up in the Supreme Court.

A late summer Kaiser Poll tracking public opinion found that 53% of Americans were not sure what is in the reform law.³ To that end, First Lady Michelle Obama and Administrator for the Health Resources and Services Administration Mary Wakefield, PhD, RN, convened the nation’s nurses to enlist our support in helping the public accurately understand the legislation. They held a conference call earlier this fall for the entire nation’s nurse workforce to thank them for their early and strong support of health reform and to explain how the legislation protects consumers. The first lady and Dr. Wakefield encouraged nurses to explain to patients that none of their Medicare benefits would be cut and that, in fact, the bill expands Medicare benefits. As of September 2010, all prevention visits, including an annual physical, immunizations, and all cancer screenings, will have no co-payment or deductibles. Dr.  Wakefield addressed the nursing faculty shortage and how the healthcare reform legislation will provide assistance for students in several areas, likely those seeking PhDs and DNPs. There will also be more funding opportunities for students who are able to work in underserved areas (with loan forgiveness), as well  as increased funding for APN-run nursemanaged health centers. Mrs. Obama expressed her enormous respect for the nursing profession and told a story of how the nurses provided comfort to her as a parent when her daughter had meningitis. She encouraged all of us to recommend nursing as a second career to our friends who may be struggling with this economy. She also tells young people who she meets on her campaign to combat childhood obesity to consider a career in nursing. We have a very strong advocate with a shared interest in health promotion in our first lady, and she uses her platform to promote the nation’s health.

Many aspects of the reform will remain uncertain until administrative decisions are made and the rule-making process within the Department of Health and Human Services (DHHS) is completed.  Core decisions are left to the discretion of the secretary of DHHS, and many will be made at the agency level. For example, as the accountable-care organizations are rolled out, it is not yet clear who will be included in them, whether or not they will be purely capitated (fixed amount-per-member instead of fee-for-service), and how APNs or a new care-transition benefit would play out. Moreover, many of the insurance reforms and financing mechanisms will be implemented at the state level. There are a number of antitrust issues that need to be clarified by the Federal Trade Commission as health systems integrate. The main incentive in the bill is to coordinate care; however, mergers that eliminate competition in communities could create monopolies and lead to price-fixing.  All of these issues will require clear guidance before practices invest in financial and delivery-integration structures.

Still, this uncertainty creates colossal opportunities for us as APNS to insert ourselves into a re-imagined health system. Attention is now on the regulation-writing phase, and we APNs must be vigilant and aware of how these rules are conceptualized and crafted at the state and federal levels.

There is no question that the reform legislation levels the healthcare marketplace for middle- and low-income Americans as our inequalities have grown wider. Still, there is massive misinformation and confusion about the many aspects of this bill. It is like a giant root ball that cannot be understood without untangling and pulling apart each root. When reform provisions are described to the public in soundbites and outside of the context of the larger root ball, it generates misinformation and fear. Voters have a hard time getting their heads around what will be required in order to have insurance available to 32 million more Americans, improve the quality of care, and lower healthcare inflation, all at the same time. Tangled up in this root ball are disparities and inequalities that are worsening in the United States. Passions run high on issues such as the role of large corporations, special interests, and the profit motive in health care; fear around changing the status quo; and, most divisive of all, the role that federal government should have in health care.

What really happened in the reform bil is that power was shifted away from insurance companies and placed squarely with consumers. It also, to a lesser degree, begins to shift financial risk away from payers (Medicare) and onto delivery systems. As accountable-care organizations and healthcare homes take shape, we could see healthcare-delivery systems organizing to make care more integrated or even extending the DRG to 30 days post hospitalization. This delivery model will ensure that the frail elderly have far more support when they leave the hospital than a ride home!

A Menu of Actions for APNs

Regardless of your political stripes, all of us have a responsibility to promote APNs as important members of any healthcare team and that we can and should be in the center of it, moved away from the margins. Most importantly, three of the national nurse practitioner (NP) organizations are developing a single joint-policy agenda to unify and strengthen the NP message on reform measures. So, we can applaud NAPNAP, ACNP, and NONPF for having the foresight and commitment to collaborate on this level. You have a menu of options to help you express your commitment to what you do every day to contribute to the forward movement of APNs. The most important is to expand our APN role beyond the clinical sphere. If what you are doing is not shared with the public, policymakers, and/or institutional decision-makers, we are not propelling the APN movement forward. Recall that the public trusts nurses more than other health professionals, so we have a duty—covenant really—to shape a humanistic, patient-centered system.

Begin an effort to address a clinical problem at your worksite.

Write letters to editors about health-policy topics important to you; limit letters to about 500 words.

Seek out health-related task forces/advisory boards in your community or state.

Join national and state APN organizations, and put your name forward if you want to serve on a national advisory board within your area of expertise (eg, palliative care, HIV, etc.).

Be sure your APN practice is measuring the quality and volume of care being delivered.

Consider working on a campaign for a state or national congressional candidate.

Send financial contributions to candidates you support.

If you are practicing in one of the 23 states with a restrictive nurse-practice act, join the state legislative or policy committee to address strategies to modernize your state nurse-practice act.

Mentor young people into careers in nursing.

Be sure you are not accepting a role or circumstances that are too confining, ie, that do not allow you to practice as an APN at the highest level of professional nursing practice. Or, as Chuckie Hanson would say, “be sure you keep the ‘nurse’ in nurse practitioner.”

Finally, the founder of the modern NP movement, Dr. Loretta C. Ford, offers some strong and sage advice for us at this moment: “You are the next generation to whom the torch is now being passed. We have moved you toward independent and autonomous practice nationally. We are also leaving you with the most fertile environment in the history of health care, exemplified by monumental changes in healthcare reform. This is an unimagined opportunity for imagineering, engineering, and leadership for NPs. Don’t disappoint us!”