Make What the Supreme Court Upheld a Reality by Empowering All Providers
This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Matthew D. McHugh, PhD, JD, MPH, RN, CRNP, is an assistant professor of nursing at the Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, and an RWJF Nurse Faculty Scholar.
By upholding the Affordable Care Act, the Supreme Court’s landmark ruling has allowed health reform to continue to move forward. But the promise and potential of health reform depends on having a robust, well-trained workforce that can meet the demands of a changing health care system, an aging population, and newly insured Americans with increasingly complex health care needs.
More than ever, the recommendations from the Institute of Medicine’s (IOM’s) report The Future of Nursing: Leading Change, Advancing Health will be critical to achieving the goals of health reform. For example, this defining moment provides an opportunity to redefine roles to take advantage of the fullest extent of all providers’ capabilities to improve health system efficiency and meet the health care needs of the population.
The first recommendation from the IOM report is that nurses should practice to the full extent of their education and training. Many of the Affordable Care Act’s provisions rely on the health care workforce, particularly the primary care workforce, working in new and expanded roles. Whether it is implementing new models of integrated care, providing much needed care to previously uninsured Americans, or delivering guaranteed preventive services and essential benefits, meeting the coming demand for primary care will require “all hands on deck”—every provider working at their fullest capacity. Although advanced practice nurses are one way to grow the primary care workforce, their ability to fully participate has been limited by legal barriers that restrict them from practicing up to the level they have been trained and often requiring physician oversight.
States and payers, including the Centers for Medicare and Medicaid Services, need to empower advanced practice nurses to practice to their full professional scope so that all patients have access to high quality care providers. Advanced practice nurses are and have always been trained as autonomous providers—not extensions of physicians who oversee them. Limitations of scope of practice and physician oversight are artifacts of policy.
There is little evidence supporting a quality or safety rationale for restricting their practice or requiring these constraints. Rather, advanced practice nurses have demonstrated patient outcomes and patient satisfaction levels that are as good as or better than physician colleagues. Furthermore, they have shown that they work best in interdisciplinary teams rather than hierarchies.
As it stands, the practice and policy environment in many states and organizations has providers—both physicians and advanced practice nurses—not using their skills and training to the fullest extent or matched to the most appropriate patients.
This is not a rational utilization of the health care workforce. In a rational health care system, patients expect to get convenient appointments with appropriately trained providers whose training matches the problem. To make this a reality for all patients, a combination of scope of practice reforms, delivery system structures and models of care, and structures and processes in the production of the primary care workforce are necessary.
The Affordable Care Act goes a long way in many of these areas but there is still a long way to go in others. Empowering all providers to do what they have been trained to do will be a critical step in making all that the Supreme Court upheld a reality.