RWJF Health Policy Fellow Notes Absence of Nurses during Final Health Reform Negotiations

    • August 18, 2010


Problem: Nurses are trusted and liked by the general public, and even by politicians, but often they are overlooked or not valued by people in power. As a result, nurses—who comprise the largest group of health care professionals in the country—tend to have little say about health care policies, even though they have unique insights into how to improve the nation’s health care system.

Background: Margaret C. Wilmoth, Ph.D., R.N., F.A.A.N., a professor of nursing at the University of North Carolina in Charlotte, had always wanted to learn why health care policy is so often divorced from the practice of health care. She got that opportunity—and then some—this year as a Robert Wood Johnson Foundation (RWJF) Health Policy Fellow.

On January 4, Wilmoth—an expert in psychosocial oncology and a Brigadier General in the United States Army Reserve—arrived for duty at the office of the Speaker of the House of Representatives during one of the most heated health care debates in history. Her start date came just days after the Senate had passed landmark legislation to overhaul the health care system and provide tens of millions of people new access to health insurance coverage. In November, the House had passed its own version of the health reform bill. Senior lawmakers, including Speaker of the House Nancy Pelosi, were beginning the latest round of negotiations when Wilmoth showed up for work.

As an aide to Wendell Primus, Pelosi’s senior policy adviser, Wilmoth spent long days and nights in the Capitol Building watching lawmakers iron out differences in the House and Senate health care bills. She also met with stakeholders and reported back to Primus, who then relayed the information to Pelosi. “It was an incredible opportunity to watch the congressional leadership determine how to accomplish the goal of health reform,” she says.

One of the first—and most striking—things Wilmoth noticed during the reconciliation process was the relative absence of nurses in discussions about the pending health care legislation. Physicians were often consulted before provisions were nailed down, but the same was not true for nurses. It was as if physicians had season passes to the negotiations, and nurses were begging for a ticket.

Nurses, she realized, may be well-liked and trusted, but they are not valued by people in power. As a result, nurses have relatively little say in key decisions about health care policy—even though they are the largest group of health care professionals in the country.

“It’s great that people like us,” she says. “But if we can’t articulate our value to key decision-makers, then we will continue to be liked but not valued.”

Wilmoth’s observations were underscored in a recent poll conducted by Gallup for RWJF. It found that opinion leaders view nurses as one of the most trusted sources of health information but see them as having less influence on health care reform than government, insurance and pharmaceutical executives and others. That’s mainly because nurse leaders are not perceived as important decision makers or revenue generators compared with doctors and do not speak in a single, unified voice on national issues, the survey found.

Nurses, however, should have more influence on health policy, planning and management, the majority of survey respondents said. Wilmoth agrees. To do that, she says, nurses need to translate their value to patients and to the health care system in a language everyone can understand: dollars and cents.

Solution: To accomplish that, Wilmoth says nurse researchers need to provide more evidence about the ways nurses improve patient outcomes and contribute to cost savings, and nurse educators and leaders need to amplify that data.

That is what Wilmoth has tried to do as an RWJF Health Policy Fellow in the Speaker’s office. During the health care reconciliation process, Wilmoth used what little data are available to advocate for a greater role for nurses in the health care system. “I tried to put nursing in the forefront as best I could,” she says. “I was always asking, ‘How does nursing fit into this policy? Where are the nurses?’”

She used data to buttress talking points about nursing that she sent to the Speaker. And she used data to persuade policy-makers to keep proposed nursing-related provisions—particularly those that created new funding streams for nurse education programs and created new job opportunities for nurses—in the new health care reform law. She also called on policy-makers to recruit more nurses into positions of influence, as speakers at events, as members of panels, and as appointees to federal and state boards.

Now that the health reform bill has become law, Wilmoth is working with executive-branch agencies and other stakeholders to ensure that nursing-related provisions are properly implemented and adequately funded. She is organizing meetings between the executive and legislative branches of government to discuss nursing-related and other provisions in the health reform law. She is advocating for another bill that would ensure that cancer patients are entitled to meet with a nurse at specific points along the treatment trajectory to learn about their care. And she is advocating for inclusion of a study that will document the value of that care both in terms of health outcomes and in economic value.

Meanwhile, she’s pondering her future. A nurse educator, Wilmoth hopes to find a position in academia or in another setting that will enable her to play a pivotal role in shaping nursing education so that nurses can play a greater role in influencing health care policy. “How does nursing education need to change so we can meet needs of delivery system? If we can’t talk about how we contribute to bending the cost curve, we’re not going to be relevant.”

RWJF Perspective: The RWJF Health Policy Fellows program places health professionals and social and behavioral scientists at the nexus of health science, policy and politics. Conducted and administered by the Institute of Medicine (IOM) of the National Academies since 1973, the fellowship provides health care professionals with hands-on policy experience in the most influential legislative and executive branch offices.