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CNE Objectives and Evaluation Form appear on page 288. Melisa Paradis Janelle Wood Mary Cramer A Policy Analysis of Health Care R e fo rm : Implications for Nurs e s E E C U T I V E SU M M A RY Since taking office, President Obama has urged Congress to m ove rapidly and advance a plan that is consistent with the eight principles he considers essential for improving the U. S. health care system. Three major policies associated with the current discussions surrounding health care refo rm universal cove ra g e, preve n- t i ve care, and improving efficiency and quality are anal y ze d. O ve rall, the Obama plan fo r health refo rm has the potential to improve health care access and quality for all Ameri c a n s d ra m a t i c a l l y. The Obama refo rm holds many o p p o rtunities for nu r s e s, especially for APRNs, FNPs, and B S N s. This is a crucial time for nu r s e s to become active participants in our health care refo rm. Nursing input is needed at the individual, commu n i t y, and fe d- e ral leve l s. MELISA PARADIS, BSN, RN, is a Graduate Student, University of Nebraska Medical Center, College of Nursing, and works at Children s Hospital and Medical Center, Omaha, NE. JANELLE WOOD, BSN, RN, is a Graduate Student, University of Nebraska Medical C e n t e r, College of Nursing, and is a S u p e rv i s o r, Nebraska Medical Center, Omaha, NE. PR E S I D E N T OB A M A M A D E health care re f o rm a major focus of his campaign. Since taking office, he has u rged Congress to move rapidly and advance a plan that is consistent with the eight principles (see Table 1) he considers essential for i m p roving the U.S. health care system. Several former pre s i d e n t s, including Roosevelt, Kennedy, Johnson, Cart e r, and Clinton have taken part in health care re f o rm and Obama seems to be following in their footsteps (Daschle, G re e n b e rg e r, & Lambre w, 2008). He is relying on the expertise of key Congressional leaders, most especially the late Sen. Te d Kennedy (D-MA) and Sen. Max Baucus (D-MT) to lead the eff o rt, and the implications of what is being proposed will have a significant impact on health pro v i d e r s, most especially nurses. The purpose of this policy analysis art i c l e is to discuss the pros and cons of t h ree major policies associated with the current discussions surrounding health care re f o rm. We will discuss some implications for MARY CRAMER, PhD, RN, is Associate P rofessor and Department Chair, University of Nebraska Medical Center, College of Nursing. N O T E : The authors and all N u r s i n g E c o n o m i c $ Editorial Board members reported no actual or potential conflict of i n t e rest in relation to this continuing nursing education article. nurses so that they can make more i n f o rmed decisions and pro v i d e input re g a rding the emerg i n g changes that will affect them and their patients. Unlike an analytic re v i e w, a policy analysis weighs the available information on issues to arrive at an inform e d judgment (Prinz, Cramer, & Englund, 2008). The three major p roposals we will focus on transect Obama s eight principles and the Baucus White Paper (Baucus, 2008): (a) ensuring health care coverage for all Americans, (b) focusing on preventive health c a re, and (c) improving health c a re efficiency and quality. Background The uninsure d. Most Americans (80%) have some form of insurance either through their e m p l o y e r, an individual plan, or a public program (e.g., Medicare, Medicaid); however, 45 million Americans still lack coverage. Over the past decade the unins u red ranks have increased steadily (Health08.org, 2008; Kaiser Family Foundation, 2008; Shi & Singh, 2008; Statehealthfacts.org, 2008; U.S. Census Bureau, 2009) and most especially for adults under age 65 (16.1% in 2000 to 19.7% in 2007) (Kaiser Commission on Medicaid and the Uninsure d 2005; Kaiser Family Foundation, 2 0 0 8 ). Most of the uninsured are in families with at least one worker, and they are self-employed or 281

Table 1. Obama Principles to Transform and Modernize the U.S. Health Care System 1. Guarantee a choice of health plans and physicians, allowing people to keep their own doctors and plans. 2. Make health coverage affordable by reducing waste, fraud, high administrative costs, unnecessary tests, and services and other inefficiencies that provide no health benefit. 3. Protect families financial health by reducing premium growth and other costs, and protect people from bankruptcy due to catastrophic illness. 4. Invest in prevention and wellness through public health efforts to reduce high-cost conditions such as obesity, sedentary lifestyles, and smoking, and by guaranteeing access to preventive treatments. 5. Allow portable coverage and do not deny coverage because of pre-existing conditions. 6. Set the nation on the path of coverage for all Americans. 7. Improve patient safety and quality of care by putting proven safety measure, incentives, and technology in place to reduce unnecessary variations in patient care. 8. Maintain long-term fiscal sustainability by reducing cost growth, improving productivity, and adding extra venue sources. work for small businesses that cannot aff o rd to provide employee insurance. These problems have been exacerbated by the declining e c o n o m y. More o v e r, existing public programs have major coverage gaps. For example, Medicaid eligibility differs from state to state and generally does not cover lowincome, childless adults without disabilities (Daschle et al., 2008; H e a l t h 0 8. o rg, 2008; Obama, 2008). Without insurance, people are less likely to receive preventive care for chronic conditions and this leads to increased emerg e n c y room use and hospitalizations for avoidable health problems. Once hospitalized, the uninsured are m o re likely to die from pre v e n t a- ble conditions (Daschel et al., 2008; Health08.org, 2008; Kaiser Family Foundation, 2008). Caring for the uninsured is costly. The Institute of Medicine (2001) estimates $130 billion is lost each year due to untreated illnesses among the uninsured. Emerg e n c y room visits by the uninsured cost the average American family $900 per year in increased pre m i u m s (Obama, 2007). C h ronic illness. C h ronic illnesses related to unhealthy A Policy Analysis of Health Care Reform: Implications for Nurses lifestyle choices also comes with a high price tag in terms of dollars and lost years of health. The federal government spends less than four cents of every health care dollar on disease prevention, even though 80% of the risk factors involved in leading causes of death are behavior re l a t e d ( L a m b re w, 2007). This is the debt society pays by utilizing 78% of all health care dollars to tre a t c h ronic illnesses (Bodenheimer, Chen, & Bennett, 2009). When combining treatment expendit u res with lost pro d u c t i v i t y, the United States lost $1.3 trillion in 2003 due to the impact of lost workdays and lower employee p roductivity (Milken Institute, 2007). If the United States re m a i n s on its current path, it is pre d i c t e d that by 2023 we will lose an estimated $22.2 trillion annually due to chronic illness. However, if re a- sonable improvements are made in prevention and management of c h ronic disease, then as much as $218 billion in health care expenses can be avoided each year, re p resenting a cost savings of 27.1% (Milken Institute, 2007). System inefficiency and quali - t y. The United States spends more than any other country in the world on health care, yet we rank 37th in overall quality (Daschle, 2007, 2005; Orszag, 2008). The U.S. system has been characterized as fragmented and ineff i c i e n t. T h e re is no central guidance or decision-making mechanism to e n s u re a seamless continuum of c a re; thus, patients often receive a lower quality of care due to underuse, overuse, and/or misuse of health services. Patients typically receive only about half of the re c- ommended services, whether for p reventive care, treatment of acute conditions, or treatment of chro n- ic conditions (Orszag, 2008). C o n c o m i t a n t l y, our re i m b u r s e- ment system promotes overuse of s e rvices by re w a rding pro v i d e r s who order more technologically intensive pro c e d u res and serv i c e s. P roviders who might invest time to develop a chronic disease management program to reduce the need for office visits would actually lose money under our curre n t system (Keenan & Kline, 2004). F i n a l l y, the U.S. system encourages misuse of services because t h e re has been little emphasis on comparative effectiveness re s e a rc h for drugs, technology, and pro c e- d u res. Policy Analysis To address these issues, a C o n g ressional plan for health care re f o rm will almost certainly focus on universal health care coverage, p reventive health care, and some f o rm of centralized decision making to improve efficiency and quality in the system. We will examine some of the pros and cons for each policy. Universal Coverage Obama has asked for a plan that maintains and stre n g t h e n s existing forms of coverage, but one that also reaches those not currently covered. Options include expanding Medicare to persons 55 years and older and bro a d e n i n g Medicaid to include all persons below the poverty level. To re a c h 282

A Policy Analysis of Health Care Reform: Implications for Nurses those not currently covered by a public or private plan, a new public insurance plan would be cre a t- ed that Obama labeled as the National Health Insurance Ex - c h a n g e. This new program would be similar to the Federal E m p l o y e e Health Benefits Pro g r a m ( F E H B P ), which is a group of private health plans off e red to federal employees and members of Congress. Like the FEHBP, the National Health Insurance Exchange would off e r c o m p reh ensive benefits, aff o rdable premiums, easy enro l l m e n t, p o rtability and choice, and the security of never losing coverage. For those who couldn t aff o rd it, the government would pro v i d e some form of financial help (e.g., refundable tax credit, sliding fee scale) (Daschle et al., 2008; H e a l t h 0 8. o rg, 2008; Obama, 2008). These actions would create a single market where people and small business owners could select from existing private plans or the public options. Mandates would re q u i re that all employers o ffer a plan and that everyone participates in a plan. P ro. P roponents believe universal coverage that includes a new public plan will drive competition, lower costs, and impro v e q u a l i t y. Developing larger purchasing power with a new public plan would help keep insurance prices in check by forcing them to be more cost conscious. It would i m p rove access to primary health c a re for all Americans, many of whom are currently denied care due to pre-existing conditions or based on costs. And it would be a major step forw a rd in re d u c i n g health disparities by incre a s i n g access among vulnerable, unders e rved populations. It would d e c rease costly emergency ro o m visits and encourage Americans to use preventive and health maintenance services, thereby re d u c i n g hospitalizations and future medical costs. There would be gre a t e r t r a n s p a rency in health care and that would increase patient autonomy because patients would have a greater choice over insurance plans and health care pro v i d e r s (Daschle et al., 2008; Obama, 2008; Ve s e l y, 2009). Tr a n s p a re n c y within the insurance industry would also allow the public to see how money is spent, including administrative and provider fees, which would keep insurers honest and innovative. C o n s. Expansion of health c a re on the scale that is pro p o s e d by Obama is estimated to cost $634 billion over 11 years (Ta y l o r, 2009; Ve s e l y, 2009). The costs would almost certainly be paid f rom increased taxes such as on e m p l o y e r- p rovided health insurance benefits. Expanding Medicare and Medicaid would further add to taxpayer burdens. The insurance industry arg u e s that a new public plan cre a t e s unfair competition, putting them at a disadvantage and eventually out of business which would lead to a single-payer system. Physicians and health care org a n i z a- tions argue that universal coverage would lead to tighter payment c o n t rols that negatively impact their reimbursement, alre a d y viewed as inadequate under M e d i c a re and Medicaid. A major concern of universal coverage is the shortage of primary c a re providers available to meet the demand. It has been argued that universal coverage will actually reduce access to primary care by e v e ryone based on the sheer numbers seeking care from a limited number of providers. Many believe that universal coverage reduces the degree of ownership that individuals have if they are guaranteed coverage. T h e re would be a sense of entitlement to an array of elective pro c e- d u res. More o v e r, universal coverage offers no plan for addre s s i n g the problem of those who, under our current system, are already eligible for public or private programs but who fail to obtain coverage. For these people, access will be unchanged (Glied, Hartz, & G i o rgi, 2007). SERIES Preventive Care Obama is focusing part of his health care re f o rm on pre v e n t a t i v e c a re based on the belief that i m p roved preventative care for patients with chronic diseases is not only cost effective, but also can help sustain and improve an i n d i v i d u a l s quality of life and reduce the rate of complications (Dettori et al., 2005; Maciosek et al., 2006). Obama has pledged to i n c rease spending on pre v e n t i v e c a re and support managed care p rograms that promote care coordination, disease management, and evidence-based practice (EBP) guidelines (Obama, 2008). To achieve this, the payment system must transform to re w a rd primary c a re providers for spending time and re s o u rces on disease pre v e n- tion and early interv e n t i o n s. Medicaid coverage for pre v e n t i v e medicine must be increased and insurance deductibles for scre e n- ings and physicals must be reduced. Recently, Congre s s a d d ressed this issue by passing The American Recovery and Reinvestment Act of 2009, which includes an additional $1 billion for public health pro g r a m s focused on disease pre v e n t i o n. The Act also includes $1.1 billion to extend information technology that streamlines care between p roviders and improves access to EBP guidelines, both of which will help improve the management of chronic disease (Office of Management and Budget, 2009). P ro s. P roponents believe preventive care will lead to cost savings. It is predicted that pre v e n- tive care will create a five dollar saving for every dollar spent on p revention within 5 years (Robert Wood Johnson Foundation, 2008). The American Recovery and Reinvestment Act will incre a s e funding to the Centers for Disease C o n t rol and Prevention (CDC) to implement more communitybased preventive measures and p rograms that reach a broad segment of the population, there b y i n c reasing the potential to impact 283

lifestyle problems that lead to costly chronic disease tre a t m e n t s (CDC, 2009). C o n s. Opponents argue that making preventive care more available will not change the health habits of Americans. C h ronic diseases and patient outcomes are behavior related and p roviders question the influence that education can have on population behavior. Providers are reluctant to take accountability for individual patient actions. It is argued that the existing U.S. health care workforce is inadequately trained for pre v e n t i o n, most especially physicians. Physicians would re q u i re additional training on community re s o u rc e s and how to incorporate these programs into their treatment plans. F i n a l l y, opponents believe that reimbursing for pre v e n t i v e c a re will re q u i re a major re s t ru c- turing of the health care payment system. They argue that shifting a focus to prevention would cre a t e additional barriers to primary care and potentially disrupt payments for insurance companies and health care org a n i z a t i o n s. Improving Efficiency and Quality To improve efficiency and q u a l i t y, Obama and others discussed the need to create a centralized decision-making agency to advise and/or regulate the U.S. health care system in much the same way the Federal Reserv e B o a rd influences the nation s finances. Obama believes that a centralized decision-making authority or agency could improve system efficiency by acting as an independent and expert entity to contain costs and maximize quality through promoting best practices, examining cost-eff e c t i v e n e s s re s e a rch to develop guidelines for insurance coverage, regulating the public insurance pool, and protecting the public intere s t s (Daschle et al., 2008; Edward s, 2009; Orszag, 2008). Great Britain, for example, has the National Institute for Health and Clinical A Policy Analysis of Health Care Reform: Implications for Nurses Excellence that is responsible for i n f o rming the public on the use of new and existing tre a t m e n t s, d rugs, and pro c e d u res. The board makes its decisions based on clinical re s e a rch, expert opinions, and p rofessional organizations (Daschle et al., 2008). The Obama administration also wants to improve quality and e fficiency by using more technology and/or checklists to ensure a d h e rence to EBP guidelines to cut down on inappropriate care (Daschle et al., 2008; Moffit, 2008). A centralized agency/authority would emphasize cost-eff e c t i v e- ness re s e a rch of drugs and pro c e- d u res to improve efficiency and save costs, and there would also be a greater focus on pay for perf o rmance based on health outcomes and results versus the number of services and pro c e d u re s p rovided. A transformed system would focus on using proven safety measures based on comparative e ffectiveness re s e a rch and that extend across care settings to i m p rove efficiency and re d u c e costs. P ro s. C reating a centralized agency or authority could impro v e the quality of health care by ensuring that EBP is fully implemented in all settings and geographic locations, which will lead to better patient outcomes. This would be a significant achievement because c u rrently health care providers in some parts of the United States comply with EBP guidelines more than 80% of the time, but in other a reas of the country the perc e n t- age of compliance with EBP is as low as 20% (Daschle, 2008). A centralized health authority or agency is projected to re d u c e f u t u re growth in health care costs by 30% by decreasing inappro p r i- ate care (Daschle et al., 2008; E d w a rds, 2009; Moffit, 2008). A centralized agency or authority that promotes the use of EBP may also lead to gre a t e r emphasis on the structural indicators of nursing care that have been shown to improve patient safety and assure a higher quality of care. The public has long been conc e rned with how the RN short a g e will affect the care they receive in the hospitals as evidenced by the spate of state legislative pro p o s a l s to mandate safe RN staff i n g ( B u e rhaus, Staiger, & Auerbach, 2003; Cramer, Nienaber, Helget, & Agrawal, 2006; Hodge et al., 2004; R o t h b e rg, Abraham, Lindenauer, & Rose, 2005). Thus, a centralized authority would more likely engage in promoting stru c t u r a l m e a s u res of nursing care based on the abundance of re s e a rch linking the amount of RN care pro v i d e d (RN hours per patient day, RN to patient ratios) and enhanced RN education (baccalaureate degre e s ) to improved patient outcomes (Aiken, Clarke, Cheung, Sloane, & S i l b e r, 2003; Aiken, Clarke, Sloane, Sochalski, & Silber, 2004; Needleman, Buerhaus, Mattke, S t e w a rt, & Zelevinsky, 2002). In addition, structural measures to i m p rove the work enviro n m e n t (physician-to-nurse communication, nurse-empowered decision making) would also re c e i v e g reater attention. C o n s. Opponents are wary of any centralized authority dictating decisions on health care, fearing that decisions will be made based only on cost effectiveness. Focusing re s e a rch for only the coste ffective treatments may decre a s e re s e a rch for new cures because until a cure is found, this re s e a rc h is not cost effective. Funding for nursing re s e a rch may be furt h e r limited if funding is based solely on cost effectiveness. Patients may lose autonomy in making decisions about their treatment o p t i o n s if a central authority/agency d e v e l- oped guidelines for coverage based only on cost-effective tre a t- ments. Health care providers are opposed to anything that furt h e r limits their autonomy to individualize care for their patients using the treatment they believe is best ( M o ffit, 2008). F i n a l l y, many have arg u e d that there is not enough re s e a rc h 284

A Policy Analysis of Health Care Reform: Implications for Nurses to define best practices in several a reas, nor is there a global means to disseminate new inform a t i o n. The silo type computer systems used by most health care systems do not communicate eff e c t i v e l y between organizations, and are not designed to automatically update providers on changes in best practice guidelines. Summary and Implications Overall, the Obama plan for health re f o rm has the potential to i m p rove health care access and quality for all Americans dramatic a l l y. The costs will be significant, but not necessarily more than the costs already incurred with curre n t system inefficiencies. This is not to discount legitimate concerns yet be a n s w e red about how to pre s e rv e p rovider and patient autonomy and ensure an adequate workforc e p re p a red for primary care and prevention. Cert a i n l y, nurses need to be informed and participate in the dialogue on behalf of themselves and their patients. The Obama re f o rm holds many opportunities for nurses. Advanced practice re g i s t e re d nurses (APRNs) will be in high demand as primary care pro v i d e r s and as case managers for the burgeoning number of persons with c h ronic conditions. APRNs are uniquely suited for both ro l e s because they are familiar with the c a re continuum and they have developed EBP practice models for transitional care that can i m p rove care quality and patient outcomes (Naylor, 2006). Federal and state legislation must first re c- ognize APRNs as primary care p roviders for the medical home so that reimbursement is a financial incentive for APRN practice. To meet the demand for APRNs, colleges of nursing will need to increase the number of students admitted to graduate programs (including post-master s d e g ree certificate), and that means i n c reased financial supports fro m state and federal governments to bolster faculty salaries, help students with tuition, and pay for the added costs of re s o u rces to accommodate increased numbers of students (Rother & Lavizzo-Moure y, 2009). Colleges of nursing will want to examine how best to use their limited re s o u rces for faculty and clinical sites to meet the demand. This may mean inc reased simulation experiences and distance technologies. It might also mean that colleges eliminate specialty programs (e.g., neonatal APRN) in favor of prim a ry care programs, especially the family nurse practitioner (FNP) programs that care for patients from birth to old age. P o s t - m a s t e r s FNP certificate programs can crosstrain specialty APRNs for primary care. National c e rtification boards (e.g., American Nurses Credentialing Center) could re-examine how to facilitate the crosswalk from a specialty certification to FNP. Interd i s c i p l i n a ry education for physicians and APRNs will be more import a n t than ever to ensure communication among a primary care team. SERIES Table 2. Ways for Nurses to Become Involved in Health Care Reform Individual Level Community Level Federal Level Join your professional organization. Email your Congressman. Phone your Congressman s staff. Write a letter to your Congressman. Write a one-page policy brief. Write a letter to your local newspaper. Start a grassroots letter writing campaign. Write a letter to your professional organization. Join an Internet blog. Start a writing campaign at your local hospital or health care organization. Call local/national radio talk shows. Vote B a c c a l a u rea te degree nurses (BSN) will also play an import a n t role in Obama s plan to incre a s e p reventive care. The BSN nurse is educated in public/community health and management, and is well suited to fill roles as case m a n a g e r, discharge coord i n a t o r, patient educator, and public health nurse. Public health departments may find increased funding s u p p o rt from the Obama administ r a t i o n s emphasis on pre v e n t i o n and there may be greater demand for public health nurses. The BSNp re p a red public health nurse will be called on to find ways to collaborate with colleagues and bring health care into the communities, engaging both individuals and businesses in health pro m o t i o n and disease management. If employers are re q u i red to offer a coverage plan to employees (or be assessed a penalty for non-part i c i- pation), there may be re v i v e d i n t e res t in occupational health and employee wellness pro g r a m s, again well suited to the BSNd e g ree nurse. 285

Tr a n s f o rming the U.S. workf o rce to meet the incre a s e d demand in preventive and prim a ry care will mean that government must strategically dire c t funding toward generic baccalaureate programs to help them i n c rease enrollments. The BSNd e g ree nurse is educationally prep a red for prevention and management, and more importantly the BSN is an essential pipeline for advanced practice. Curre n t l y, associate degree nursing (ADN) p rograms are growing faster than the baccalaureate programs, yet the ADN is less likely to matriculate beyond the 2-year degre e. Indeed, the North Carolina Center for Nursing found that 80% of all N o rth Carolina nurses who received advanced degrees also graduated from a baccalaure a t e d e g ree program for their initial nursing preparation (Bevill, C l e a ry, Lacey, & Nooney, 2007; U.S. Department of Health and Human Services, 2004). The Obama re f o rm plan will mean that payment methods that re w a rd quality health care rather than procedural-based payment will need to be enhanced. Nurses can provide strong input into these developments so that funding will increase for community and education-based services, and so that nurses are adequately reimbursed for the services that they provide. Nurses in all settings will play a pivotal role in the development and acceptance of new forms of health inform a t i o n technology including electro n i c documentation, consultation, patient education, and patient monitoring. Nurses will also have an expanding role in collecting, analyzing, and re p o rting health care quality data. This will re q u i re acceptance of EBP practice guidelines and active participation in re s e a rch and quality assurance p rograms. This is a crucial time for nurses to become active part i c- ipants in our health care re f o rm. 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