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Nurse policy experts on the candidates’ healthcare platforms

Friday, October 5, 2012  
By Cathryn Domrose

Barring unforeseen events or crises, the economy will probably trump healthcare as the deciding factor for many nurses — and everyone else — in the upcoming presidential election, say those involved in nursing and healthcare policy. "Everything else kind of pales in comparison," said Colleen Conway-Welch, RN, PhD, CNM, FAAN, FACNM, dean and professor of nursing at the Vanderbilt University School of Nursing in Nashville, Tenn. Spouses without work, delayed retirements, and fear of layoffs and facility closures forced by reforms reducing provider reimbursements are foremost in many nurses’ minds, she said.

But issues such as covering the uninsured and people with pre-existing conditions, prevention and wellness, nursing education and women’s health also will be important to nurse voters, said Diana J. Mason, RN, PhD, FAAN, nursing professor at the Hunter-Bellevue School of Nursing in New York City, editor-in-chief emeritus of the American Journal of Nursing, and lead co-editor of "Policy and Politics in Nursing and Health Care."

"Because nurses know healthcare so well and see the problems with the healthcare system, I think healthcare will mean a lot to them," she said.

To give nurses a clearer picture of where the candidates stand on healthcare and nursing issues, talked to nurses who study national health policy. Based on the candidates’ websites, interviews and speeches, the policy experts analyzed the healthcare positions of President Barack Obama and former Massachusetts Gov. Mitt Romney’s healthcare positions.

The experts agreed both candidates want to contain healthcare costs and provide patients with high-quality care. But the candidates have very different approaches to achieving those goals. Obama favors a more federal approach as outlined in his Affordable Care Act. Romney says reform should be implemented through the states, with costs controlled through free-market competition.

Though not perfect, Obama’s reforms provide Americans with a minimum level of healthcare, something the country has long needed, Mason said. "If the government doesn’t take charge of overseeing increasing access to healthcare, improving outcomes and reducing costs, I’m not sure who is going to have that responsibility," she said.

Conway-Welch said the federal government has generally done a poor job of running large national programs. "One size does not fit all, and that is the problem with a federal healthcare plan," she said. She said the marketplace would better control costs and improve quality by fostering competition among insurance companies and providers.

Romney’s plan would give states more freedom and flexibility to create their own healthcare programs, which nurse analysts said could work well, but could also create very unequal systems. "We have some states that will do a good job with this and some that won’t, and that would be very concerning to me," said Kathy Ferket, RN, MSN, APN, chair of the policy and advocacy committee for the Illinois Organization of Nurse Leaders. The state-by-state approach would not be able to offer national prevention programs, testing of new payment systems or incentives to improve quality and access to coverage, Mason said. "Before the ACA, [state-by-state reform] is what we had, and we couldn’t get there."

On the Affordable Care Act

If elected, Romney has pledged to work with Congress to repeal the ACA, though recently he has said he wants to keep parts of it. Romney also favors limiting federal standards and requirements on private and public insurance; using exchanges, subsidies and high-risk pools to help the uninsured; caps on malpractice settlements and innovation grants for ways to settle disputes out of court; and allowing people to purchase insurance across state lines.

Conway-Welch believes Romney’s plan to start over and craft a new national healthcare policy makes sense, given the political divisiveness created by the ACA. "The ACA was passed with not one Republican vote. To me that was crazy," she said. "You don’t have to throw everything out because there are some good things. But somehow we need to achieve a more bipartisan solution to healthcare." She believes a new plan could be more responsive to the needs of patients and families. "They’ve been left out of this debate."

But Linda McCauley, RN, PhD, FAAN, FAAOHN, dean and professor at Emory University’s Nell Hodgson Woodruff School of Nursing in Atlanta, said overturning the ACA would be a huge step backward after years of struggle to get a national healthcare plan. Many national nursing groups support the ACA and some had a hand in creating it, she said. Besides its insurance provisions, the law contains incentives for prevention and wellness, language including advance practice nurses as primary care providers, funding for nursing education programs and nurse-run clinics and opportunities for nurses as care coordinators, she said. "These things don’t get any attention, but they are all so great for nurses."

Even if Romney decides to keep some reforms, any new bill will have to get through Congress, which could take years, McCauley said. "The huge advantage of the Obama plan is that it’s a law. It’s already being implemented and people are beginning to see positive things. … What really scares me is that if Romney is elected and kills Obamacare, it could be years before a new law is passed," resulting in "unnecessary illness, unnecessary pain and unnecessary deaths."

Apart from promising to repeal the ACA, Romney has been vague about his ideas for comprehensive reform, said Nancy M. Short, RN, DrPH, MBA, associate professor at Duke University School of Nursing in Durham, N.C. For instance, his website states he would "prevent discrimination against individuals with pre-existing conditions who maintain continuous coverage," she said. "This is already available under current law as COBRA and it hasn’t worked well at all."

Some strengths in Romney’s plan include allowing insurance to be purchased across state lines and letting people use their health savings accounts to pay for health insurance premiums, Short said, though he does not offer many details on how these would be implemented or regulated.

On Medicare and Medicaid

The candidates’ approaches to Medicare and Medicaid also are divided sharply along ideological lines. Obama has pledged to keep the two large public health insurance programs intact, while containing costs by capping provider reimbursements, going after Medicare fraud and waste, and cutting administrative costs in the Medicare Advantage program. Romney has adopted a plan proposed by his vice-presidential nominee, Rep. Paul Ryan, R.-Wis., to give states a fixed amount of money to spend on Medicaid. People 65 and over would get a fixed amount of money to spend on health insurance, which could be private or a traditional government plan. The plan would not affect anyone currently older than 55.

Conway-Welch compared Romney’s Medicare plan to giving someone enough money to buy a Volkswagen. "If you want the Rolls-Royce, you pay extra, but the Volkswagen level is good enough." Having a defined contribution forces people to think about their healthcare spending and forgo things they may not really need, she said.

Other policy experts said the system could confuse seniors. Educated people with resources to buy the plan they want might benefit from choices, McCauley said, but those without education or resources might get stuck paying higher deductibles and co-payments, or skipping necessary care because they can’t afford it.

Some also expressed skepticism that Romney’s plan would control costs, noting that Medicare Advantage, which allows Medicare recipients to choose a private plan, was shown to cost more than traditional Medicare — although it also has high beneficiary satisfaction rates. "Historically, competition has not worked well in healthcare to secure the health of populations and keep costs at a sustainable level," Short said.

Obama’s plan to control costs, in part by limiting or cutting reimbursements to providers, concerns some clinicians and hospital administrators. Short said many of the nurse managers she teaches fear that if reimbursements do not cover the cost of care, hospitals might lay off staff or close units. Critics of Obama’s plan say value-based purchasing, which bases Medicare reimbursements on the quality of care and the providers’ ability to meet certain federal standards such as reduced readmission rates, has not been proven and could have unintended consequences, especially for those who care for medically high-risk patients, Short said.

If Medicaid were handed over to the states in fixed block grants, as Romney proposes, some states would create good programs to cover their neediest residents, including reimbursing nurse-run clinics, McCauley said. But without federal oversight, such programs might not be a priority for others, particularly when state budgets are tight. In states that limit scope of practice for nurse practitioners, nurse-run clinics probably would not get Medicaid money, she said.

No matter what the plan for Medicaid and Medicare, all policy nurses agreed it should include provisions for advance practice nurses. Conway-Welch, who said she usually favors letting states create their own programs, believes some federal guidance is necessary to ensure advance practice nurses in all states are allowed full scope of practice and are compensated as primary care providers. Private insurance companies have not always been open to reimbursing nurse practitioners and nurse-midwives for care, noted Bobbie Berkowitz, RN, PhD, CNAA, FAAN, dean and Mary O’Neil Mundinger Professor at Columbia University School of Nursing and senior vice president of the Columbia University Medical Center in New York. "Will that voucher [for private insurance in the Romney Medicare plan] pay for access to advance practice nurses?" she asked.

On nurses and nursing

Both candidates have shown respect for nurses, policy experts said, although they would like more recognition from both on how advance practice nurses help provide quality healthcare. The American Nurses Association received no response from Romney to questions about his positions on healthcare and other nursing topics, said Rose Gonzalez, RN, MPS, the ANA’s director of government affairs. ANA members voted to endorse Obama, who did respond. Obama appointed nurses to high-level positions in his administration, including Mary Wakefield, RN, PhD, as head of the Health Resources and Services Administration, and Marilyn Tavenner, RN, BSN, MHA, as acting head of the Centers for Medicare & Medicaid Services.

The Affordable Care Act authorizes money for Title VIII nursing education programs, and Obama included funds for nursing programs as part of his 2009 economic stimulus package.

Romney also supports nurses, said Conway-Welch. As governor, he appointed an advance practice nurse to an advisory board that oversees universal healthcare quality initiatives in Massachusetts. Ferket hopes if Romney is elected, he would keep Tavenner, who has a history of working well with both major political parties, in her position at CMS. Romney has not stated a position on funding nursing education programs, but some nurse policy analysts said he and a Republican-controlled Congress would cut or limit money for nursing programs to help reduce the federal deficit.

No matter which healthcare position or which candidate they support in this election, nurses need to make their voices heard and their votes count, nurse policy analysts agreed. "If we want to have a say in shaping the future," Berkowitz said, "we need to gear up our strategies for advocacy and our collective voices."

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Cathryn Domrose is a staff writer. Write to
Obama and Romney’s healthcare positions at a glance

Obama champions the Affordable Care Act passed by Congress in 2010. The ACA offers states some leeway in areas such as creating health insurance exchanges, but uses federal regulations, funds and standards to provide insurance coverage, improve quality and contain costs. Most Americans will be required to buy health insurance by 2014, with subsidies for those with lower incomes. The ACA will be paid for in part through a tax on couples who make more than $250,000 a year and cuts — or savings, depending on who you talk to — in Medicare. Details on Obama’s healthcare positions are at

Romney, who helped enact a comprehensive healthcare plan in Massachusetts, believes healthcare reform should be primarily up to the states. He favors controlling costs by encouraging competition among providers and insurance companies in the marketplace, as well as caps on medical malpractice lawsuits, encouraging purchasing pools among small businesses and promoting "alternatives to fee for service," according to his website,

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