Will health care reform be healthy for nursing?

The Council of State Governments reports that although there are regional differences, health care has emerged as state government officials' most important concern, with education and energy following close behind. There is no question that health care reform is necessary, but how will these initiatives will be funded? As the competition for resources escalates, employers, legislators and regulators will be looking for ways to redistribute a limited number of dollars. Historically, that has translated into a reduction of RN staff and the increased use of unlicensed assistive personnel.

Since it is unlikely that a national solution to health care access will emerge in the near future, states are taking the lead. This is certainly evident from the latest round of attempts at state-level health care reform.

The initiatives represent a variety of approaches to covering the uninsured, including new mechanisms to subsidize coverage for low-income families, new variations on employer and personal responsibility for health insurance coverage, and new strategies to facilitate the purchase of insurance for small businesses and for individuals without access to employer-sponsored insurance. The boldest state-level efforts aim at comprehensive (near-universal) coverage, while others focus on incremental approaches such as providing coverage for children or public-private partnerships to insure low-income workers. The boldest reform proposals have come from the Northeast: Massachusetts, Vermont, and Maine. These initiatives go further toward helping low-income families purchase health insurance than in any other states. One of the key elements shared by all three reforms is that they subsidize coverage for families with annual incomes up to approximately $53,000 (300 percent of the federal poverty level [FPL] for a family of four). Each of these states uses Medicaid to partly fund its subsidized product, demonstrating the importance of Medicaid as a financing source.

A number of other states, like Illinois, Pennsylvania, and Tennessee are pursuing less comprehensive approaches, but still significant through coverage of all their children. Oregon, Wisconsin, Washington, and New Mexico are considering similar approaches. And all this is happening at a time when reauthorization for State Childrens' Health Insurance Program (SCHIP) is under consideration by Congress. Experts agree that, overall, SCHIP has been successful since its' inception in 1997. Cumbersome enrollment processes improved with numbers enrolled peaking in 2004-2005. It appears the numbers are now leveling off. Experts in the field believe the cessation in growth is less about enrollment processes, but rather related to limited resources to address new enrollees. Georgia's Peach Care for Kids program boasts an enrollment of 273,000 children, attained since 1999, but estimates 100,000 kids are still left uncovered. Even with the large number of uncovered kids, the state has been forced to freeze new enrollments due to a lack of funding to support the current enrollees. Georgia is experiencing a shortfall of federal funds of $131 million, in spite of the $ 4 million received from the stop gap measure passed by Congress in December. So, what does this mean for nursing?

There's no question that health care reform is needed, but at issue is how these initiatives will be funded. Many states face significant deficits. So, as the competition for resources escalates, employers, legislators and regulators will be looking for ways to redistribute a limited number of dollars. Historically, that has translated into a reduction of RN staff and increased use of unlicensed assistive personnel (UAPs). Legislative trends across states seem to support this pattern. So far in 2007, seven states have introduced legislation that would recognize medication technicians. We have witnessed efforts to increase responsibilities of UAPs for years, but have lacked evidence to restrict this practice. This is a call to action! We need to continue to contribute to the repository of research that demonstrates the unique contributions of registered professional nurses while finding our voice to communicate the distinctions.

Summary review by Janet Haebler, MSN RN