Health Care Reform Law Begins to Have Effect on Nursing

    • March 31, 2011

One year after Congress passed the Affordable Care Act (ACA), there are subtle yet palpable signs of change in the nursing profession.

Changes in federal loan programs are allowing more nursing students to go to school on a full-time basis, which means they will be able to enter the workforce sooner and help curb a looming shortage of nurses that threatens to undermine patient care.

Ten health clinics around the country that are managed by nurses received a total of $15 million in federal funding, which will increase access to primary care services for thousands of low-income patients who might otherwise go without needed preventive services and treatment.

A group of nurse midwives in Minnesota was able to fight back state legislation that would have substantially cut payments for their services.

“The health reform law contains provisions that will produce more nurses to meet increasing demands for health care, prepare more highly-skilled nurses to better meet the needs of an aging population with more complex health problems, and create opportunities for nurses to participate in and lead efforts to redesign the nation’s ailing health care system,” said Susan Hassmiller, Ph.D., R.N., F.A.A.N., Robert Wood Johnson Foundation (RWJF) senior adviser for nursing. “But we need broad system and culture change as well.”

Many of the law’s provisions that directly or indirectly relate to nursing have not yet taken effect, but health care professionals and consumers are beginning to see early signs of its potential impact on nursing and nurses and the patients they treat.

One provision that has been implemented allows nursing students to receive higher loan amounts from the federal government. These federal loan limits had not been adjusted for a decade despite the increasing cost of higher education, causing a widening gap between the cost of attendance and financial resources available to students and depressing enrollment. Nursing students will now have access to loan amounts that are more on par with the current cost of training, according to Suzanne Begeny, Ph.D., R.N., director of government relations for the American Association of Colleges of Nursing.

Another provision authorized up to $50 million in funding for nurse-managed health clinics, $15 million of which has been allocated to support 10 nurse-led clinics—serving some 94,000 patients—around the country.

Medicare payments for services provided by certified nurse midwives will rise by 35 percent; certified nurse midwives will now receive the equivalent of physician pay for Medicare-covered services.

The complex, wide-ranging and controversial law also called for increased Medicare payments for primary care services provided by nurse practitioners, clinical nurse specialists, physician assistants and other health professionals; the removal of a cap that limited spending on doctoral nursing programs to help build the ranks of the nation’s nursing professors; and the creation of opportunities for nurses and nursing advocates to serve in leadership positions.

In addition, the law sets aside money to test the effectiveness of pilot clinical initiatives that rely on highly skilled nurses. Among these are initiatives that send nurses to the homes of first-time low-income mothers to teach them about health during pregnancy and early childhood; help chronically ill older people continue living in their own homes; and support health clinics serving people in low-income communities.

There have been indirect effects on nurses and nursing as well.

Last June, Aetna, Inc., a major insurer, changed its policies regarding credentialing and reimbursement for nurse practitioners. It now recognizes nurse practitioners as primary care providers and reimburses them for their services.

Nurses and nursing are also beginning to move out from the shadow of other health professionals, observers said.

The law identified and defined nurse-managed clinics as critical safety-net providers for millions of people, an unprecedented move that makes it easier for these types of clinics to raise funding, get reimbursed for care, and earn recognition as medical homes, according to Tine Hansen-Turton, J.D., M.G.A., executive director of the National Nursing Centers Consortium.

“It really put nurse-led clinics on the map,” agreed Jamie Ware, M.S.W., J.D., policy director at the consortium. “Community-based health clinics in general struggle to keep funding coming in, and nurse-led clinics are no exception. But decision-makers are beginning to realize that nurse-managed clinics are at the forefront of providing care to vulnerable populations, as is evident by the federal definition and the $50 million” in authorized funding.

The law’s attention to nurses and nursing has also raised awareness about the role nurses play in health and health care as well the research they conduct to improve the system, Begeny added. “It gave nurses another national platform to showcase their work and explain how it impacts the cost and quality of care.”

Still Too Early to Predict Reform’s Full Effect on Nursing

But observers said it is still too early to predict the full impact of the law because the provisions with the greatest potential to directly influence nurses and patients have yet to take effect.

Many key provisions—such as a pilot program to make certain advanced practice registered nurse training programs eligible for reimbursement through Medicare and the addition of millions of new patients to the insurance rolls—won’t kick in until 2012 and beyond.

And much of the new funding for nurse education and other nurse-related programs that was authorized by the law has yet to be spent.

The law reauthorized new discretionary funding for nursing workforce development programs under Title VIII of the Public Health Service Act, the primary source of federal funding for nurse education programs. But members of Congress—tied up for months in budget battles—have yet to appropriate most of those funds.

Indeed, at a time of fiscal austerity, it appears that cuts—rather than hikes—may be in the offing. Lawmakers in the House and Senate have not reached agreement on spending levels for nurse education programs for Fiscal Year 2011.

Meanwhile, President Obama introduced a budget proposal last month for fiscal year 2012, which begins in October. The president’s budget would increase funding for Title VIII programs and nurse-managed clinics. It also includes a modest increase for nursing research. But the president will have to negotiate with Congress before spending plans for next year can be put in place.

Winifred Quinn, M.A., Ph.D., senior legislative representative at AARP, urged Congress to fund nursing workforce and education programs at the full amounts authorized under the health reform law.

“For consumers to have access and the choice of high quality health care providers—and to have a highly skilled nurse when and where we need one—it is imperative for the nursing provisions within the Affordable Care Act to be funded at the levels that it identified,” she said.

To ensure that happens, nurses and their allies need to take a stronger advocacy role, Hansen-Turton added. “We know from experience that unless decision-makers are reminded and urged to keep nurses and nursing in mind during discussions about health care, nurses sometimes fall to the wayside. Nurse practitioners need to knock on the door to get in.”

To learn more, visit the Center to Champion Nursing in America—an initiative of AARP, the AARP Foundation, and the Robert Wood Johnson Foundation.