Lessons from NIWI: Government 101

by Joana Duran, MSN, PNP, CNS
Legislative Chair
LA NAPNAP

Through the Nurse In Washington Internship (NIWI), we learned about the importance of policy and politics in creating evidence-based changes in practice. As nurses, we know that research can teach us about the best ways to do things, but without knowing how to navigate the legislative process successfully, we are not able to translate that knowledge into practical changes to the way things are done. Policies affect and govern how care is given on a federal, state, community, or institutional level. Nurses can play key roles in reforming policies to reflect research findings if they know how to navigate the system. You can start small, by learning the administrative network at your hospital and changing an institutional policy that affects how you deliver care at the bedside. Someday, you might feel ready to tackle public policies that govern the way healthcare is viewed and delivered to the entire nation. For that, you will need to know a little bit about how the legislative process works, so here is some basic information:

Branches of Government: The US Federal government is divided into three branches, the Legislative Branch (also known as Congress, which is comprised of the House of Representatives and the Senate), the Executive Branch (made up of the President and the Vice President), and the Judicial Branch (which is the Supreme Court). Bills that govern public policies are introduced and approved by Congress (the Legislative Branch), then signed off by the President (the Executive Branch) before they are made into law. Often, the interpretation of these laws is left up to each individual state, which is why the wording of each bill is so important. Questions or challenges to the interpretation or applications of these laws may be brought to the Supreme Court (Judicial Branch). If a change must be made to an existing policy, it must be introduced back into Congress as a new bill or amendment.

House of Representatives: There are 435 seats in the House. The number of representatives per state is determined by the size of that state's population, so more populous states have more representatives in the House. Each representative serves a two year term, and all 435 seats are up for re-election every two years at the same time. A member of the House represents a local district and the concerns of its constituents (residents). The House can be more rigid, and has several rules regarding the amount of time spent debating any particular bill. If there is a majority, a bill will move forward regardless of what the minority wants. For that reason, the House can be less compromising, and things move more quickly.

Senate: There are 100 seats in the Senate. Each state has two representatives. Each member holds office for 6 years, and one third of the Senate is up for re-election every two years. The Senate is set up to give the minority a voice, which is why filibusters can take place. A filibuster is a procedure by which a lone member of the Senate can delay or completely obstruct the passing of a bill by "talking it out", or debating it for an indefinite period of time. This can make things move more slowly. It takes a 60 member vote to stop a filibuster, which is the majority of the seats in the Senate.

Legislative Process: The legislative process begins when a new bill is introduced into either the House or Senate. This can be an amendment to an existing law, or a proposal for a new policy. The bill is referenced to the appropriate committee, and then subcommittee. Mark-ups are made in the subcommittee and full committee. If the bill is reported out favorably, it goes to the full House or Senate Chamber, where it is voted upon. This is then repeated in the other chamber. If the two chambers differ, the committees will negotiate the differences. Finally, the bill is sent to the President, who either approves, or vetoes (disapproves) it.

Key Committees and Caucuses:

In the House: The House committees and caucuses that are most relevant to healthcare policy and reform are Appropriations (Labor Health and Human Services Subcommittee), Energy and Commerce (Health Subcommittee), Ways and Means (Health Subcommittee), and House Nursing Caucus.

In the Senate: The Senate committees and caucuses that are most relevant to healthcare policy and reform are Appropriations (Labor Health and Human Services Subcommittee), Health Education Labor and Pensions, and Finance (Health Subcommittee).

The Funding Process: In legislation, there is the process of Authorization and Appropriations, and the two must not be confused. Authorization is the process by which a new program is approved. The program is then created and expanded, and must be reauthorized regularly. Appropriations happens each year, and is the process by which funds are delegated in order to fund a program. Once a program is chosen for funding and a certain amount of funds has been decided upon and disbursed, funding will be provided for one fiscal year, which lasts from September 30th to October 1st of the following year.

Federal Budgeting for Healthcare/Nursing: The President releases his budget in February. This is merely a proposal, with no force of law, but it articulates priorities to Congress and the nation. Congress reviews his budget and develops its own, which includes categorical allocations for funding (like defense, health, etc.). The House and Senate Appropriations Committees develop 12 different funding bills that provide line-item detail for all the programs and agencies of the federal government. The Labor Health and Human Services (LHHS) Appropriations bill contains funding for healthcare research and workforce programs. Advocates often make the difference between a program receiving funding or not.

The Role of Advocacy: Senate members and House representatives rely on grass roots advocacy efforts, coalition building, and community leadership by individuals and groups that can offer constructive solutions and proposals to creating better policies. Congress members care about what these individuals and groups have to say, because they must keep them happy in order to be reelected. However, if advocates are uneducated about the issues at hand, don't understand the legislative process and how to effect change, or have inappropriate requests and demands, Congress members will not support their efforts by bringing issues to the floor of the House or Senate in the form of a bill.

Nurse In Washington Internship (NIWI) 2010

by Joana Duran MSN, PNP, CNS
Legislative Chair
LA NAPNAP

In the month of March, 2010, I had the privilege to travel to the Nation's Capitol to represent NAPNAP and children's health policy issues during the time when the Healthcare Reform Bill was passed. Six of us were chosen from across the country to participate in the Nurse In Washington Internship (NIWI), an experience for which I will be forever grateful. I would like to share with you some of the things I learned during my time in Washington DC, in hopes that it will make you a more informed and prepared advocate for children's health.

First, it is important to consider the timing of advocating for children's health issues during a period of healthcare reform. With approximately 9 million uninsured children in the United States, access to healthcare for the pediatric population is a major concern. As legislators investigate solutions to this problem through reform, the input of healthcare providers, such as Nurse Practitioners (NPs), provides valuable insight into the best ways to ensure access for all.

Some of the issues addressed with legislators regarding healthcare reform included:

1. Ensuring access to care for all children through a care delivery system that makes full use of all its providers. For example, using Nurse Practitioners as full providers in the Medical Home Model. The Medical Home Model seeks to ensure access to primary care services for all, so that everyone will have a provider for basic healthcare services, screenings, etc. Nurse Practitioners are the perfect candidates to fill this role. NPs provide a holistic approach to the delivery of healthcare maintenance and specialty care services, routine developmental screenings, anticipatory guidance, treatment of common illnesses, childhood immunizations, school physicals, and referrals. By employing Nurse Practitioners to their full scope of practice, the number of primary care providers will increase, resulting in more accessibility to medical homes for everyone. This also means opposing arbitrary restrictions on the role of NPs within the medical home. Through education and training, NPs are prepared to lead medical homes, and legislation should enable all providers to practice to the full extent of their license and training.

2. Providing effective guidelines and models for primary care providers to tackle major pediatric health issues such as childhood obesity. NAPNAP has created the Health Eating and Activity Together (HEAT) Program, which includes a set of guidelines for primary care providers to use in treating childhood obesity and providing health education and anticipatory guidance to parents with a holistic approach. The HEAT model can be implemented in any primary care or specialty setting, and was developed in response to the growing need for providers to have training and confidence in tackling this issue in the clinic.

3. Supporting appropriations for the National Institute of Nursing Research (NINR) branch of the National Institutes of Health (NIH). The NINR supports basic and clinical research with the goal of discovering effective approaches to achieving and sustaining good health, and improving clinical settings and the quality of care delivered. Nursing research is essential in ensuring that clinicians are using research-based best clinical practices. The NINR is requesting funding of $160 million for the 2011 Fiscal Year (FY).

4. Supporting Title VIII funding and Nursing Workforce Development Programs at the Health Resources and Services Administration (HRSA) through a $267.3 million grant for the 2011 Fiscal Year (FY). These programs support the recruitment, education, and retention of nurses by providing nursing education loan repayment and scholarships. These efforts alleviate the nursing shortage by ensuring a higher number of active nurses in the workforce.

If you would like to learn more about how you can get involved, click here to view NAPNAP's Handbook on Federal Advocacy to learn about effective advocacy techniques, including understanding the legislative process, developing relationships with policy makers, coalition building, and appropriate lobbying.

LAUSD Changes Sports Physical Policy to Support PNPs

by Joana Duran MSN, PNP, CNS
Legislative Chair
LA NAPNAP

As the health needs of the population continue to grow, more and more nurse practitioners (NPs) find themselves assuming the role of Primary Care Provider (PCP), following patients regularly, making diagnoses, prescribing medications, and signing medical releases to authorize participation in a variety of activities. However, some community officials, legal institutions, school boards, and even the public are still unaware of the NP's scope of practice, and outdated policies and regulations may limit the NP from carrying out some of these responsibilities. One example of this is that many Pediatric NPs in the Los Angeles community were not able to perform Sports Physicals and authorize students to participate in sports within the Los Angeles Unified School District (LAUSD), due to outdated Sports Physical Release forms that required the signature of a Physician. This was quite inconvenient for many NPs, and did not take into consideration the full extent of NP scope of practice, and the role of NPs as practitioners trained to make assessments regarding issues of primary care practice such as these. The LA Chapter of NAPNAP, as well as other professional NP organizations in the Los Angeles area expressed their feelings to the Department of Student Medical Services (SMS) at the LAUSD, and they were extremely receptive and eager to cooperate. The SMS Director, Dr. Kimberly Uyeda released a statement to all the schools of the LAUSD, requesting that they accept medical release forms and authorizations signed by NPs from now on. A copy of her statement is included below.

Expanding Nurse Practitioner Scope of Practice to Make Room for Healthcare Reform

by Joana Duran MSN, PNP, CNS

Legislative Chair

LA NAPNAP

The role of the Nurse Practitioner (NP) was originated in the 1960s, in response to a nationwide physician shortage. Today, there are an estimated 145,000 NPs practicing throughout the United States, each providing a continuum of primary healthcare services in a variety of acute, outpatient, and specialty care settings, with varying degrees of autonomy. Current legislature gives each state control over the laws that govern NP scope of practice, resulting in wide discrepancies in the types of services an NP can deliver to patients from state-to-state. Never has the topic of NP scope of practice been of such concern to policymakers as during this time, when maximizing accessibility of primary healthcare services for the public, and controlling healthcare costs, are at the top of the agenda for healthcare reform.

It is believed that in order to meet the healthcare needs of our growing population, address physician shortages, and reduce the cost of healthcare, primary care providers of all training backgrounds will have to step forward to provide care to their fullest scope of practice. Differences in NP scope of practice legislation from state-to-state inhibit the use of NPs to their maximum capacity, prohibiting them from offering the full range of valuable, accessible, and affordable primary care services that they are trained to provide. Currently, only six states, including Alaska, Arizona, New Hampshire, New Mexico, Oregon, and Washington have NP scopes of practice that are among the most expansive, allowing NPs to practice independently with no physician oversight, prescribe medications, develop protocols, and legally direct a medical home on their own. California is a bit more conservative, allowing NPs to diagnose, order tests and medical equipment, refer patients, and furnish medications, but only according to protocols that are developed in collaboration with the physician with whom them practice.

A national effort has been initiated to uniformly expand NP scope of practice and increase NP autonomy across the board. Particularly, in the area of primary care, as President Obama’s plans for healthcare reform currently revolve around the medical home model, where everyone has access to a primary care provider that can provide basic healthcare services, as well as referrals to specialty services when complications arise. Expanding NP scope of practice would allow NPs to function autonomously throughout the country as primary care providers, directing their own practices, and meeting the growing need for more medical homes.

A Changing Healthcare System for a Changing World

by Joana Duran MSN, PNP, CNS

Legislative Chair

LA NAPNAP

The summer is winding down and fall is just around the corner. Pediatric Nurse Practitioners everywhere are bracing themselves for back to school physicals, and the tidal wave of URIs and reactive airways that will surely ensue with the changing season. But many of us will notice a few changes this year as we order those TB tests, inhalers, and doses of amoxicillin, as our healthcare system has undergone some major changes on both a local and national level over the last few months, impacting the way we deliver care to the children on Los Angeles County and nationwide.

As many of you know, the State of California is facing a deficit of $26.3 billion. Tax revenues have plummeted nearly 30 percent, and continue to fall, and the unemployment rate has risen to a historic 12%. The result has been a statewide budget crisis that is calling for significant cuts in the funds allocated to the departments of health and education in our state. A brief review of recent cuts reveals one thing for sure; it’s becoming harder than ever to be a kid in California. Among other things, the Governor cut $79.9 million from Child Welfare Services, which investigates instances of child abuse and neglect, $50 million from the Early Start Program, which provides disabled young children with early intervention services, $2 million from the Student Aid Commission, which provides financial assistance to students pursuing higher education, and $50 million from the Healthy Families program, which provides health insurance to uninsured children in California. The latter program barely survived a complete cut, thanks to the testimony of several community members and health professionals, including a letter from LA NAPNAP that was brought before the budget committee.

Other statewide health insurance programs such as CCS, Medi-Cal, and CHDP remain intact, but have undergone structural changes that you may have noticed. For instance, CCS now requires the completion of additional forms and records by healthcare providers in order to renew coverage. In addition, they will no longer be covering children who are unregistered immigrants, a decision that was very controversial, and took several years to reach. These patients will still be covered for emergency services, but will have to qualify for Medi-Cal in order to receive long-term care for chronic illnesses, or return to their native countries for treatment and follow-up.

On a national level, the healthcare crisis has reached overwhelming proportions. Over 45 million Americans are currently uninsured, including over 8 million children. 80 percent of these are in working families, and even those with healthcare coverage are struggling to cope with soaring medical costs. The economic recession, combined with the rising costs of health services and insurance, has left employers and small businesses admittedly unable to provide health insurance to all of their employees. Finally, a history of underinvestment in preventative services (only 4 cents of every health care dollar is spend on prevention and public health) has lead to an epidemic of chronic diseases such as obesity in our pediatric population.

Under the Obama Administration, the goal of healthcare reform is to lower the costs associated with the current healthcare system “for people and businesses, not just insurance companies”. The administration outlines their plan to accomplish this though a series of steps, which include:

-Investing in electronic health information technology systems.

-Improving access to support of prevention and proven disease management programs.

-Lowering costs by taking on anticompetitive actions in the drug and insurance companies.

-Reducing costs of catastrophic illnesses for employers and their employees.

The objective is to offer affordable and accessible coverage options for those who are not currently insured. Medicare will be left intact to provide coverage for elderly and disabled Americans, others will qualify for a new affordable National Health Insurance plan that can be purchased from the government and a competitive price, while those who are privately insured may remain with their current healthcare plans if they are satisfied, and many will see the quality of their care improve and costs go down. There is also talk of a new tax credit for families and businesses who can’t afford healthcare insurance, as well as a requirement of all large employers to contribute towards healthcare coverage for their employees or towards the cost of the public plan. Children will be required to have health insurance, and there are also plans to expand coverage provided by current programs such as Medicaid and SCHIP, allowing more flexibility for state health reform plans.

The Obama administration also promises guaranteed eligibility, new accessible insurance options, comprehensive benefits, affordable premiums, co-pays, and deductibles, simplified paperwork, easy enrollment, portability and choice, and quality and efficiency. All while maintaining a national focus on promoting prevention and strengthening public health through employers (offering worksite health promotion programs and preventative services), school systems (requiring schools to adhere to nutritional standards and healthful environments in order to combat the childhood obesity epidemic), workforce (offering incentives to join the workforce of public health practitioners and providers, as well as providing adequate funding for education and training to combat new health threats), and federal, state, and local governments (these must work together at all levels to develop national and regional strategies for health promotion, and collaborate on funding mechanisms to support its implementation). It remains to be said, however, exactly how all of this will be accomplished.

The government has set noble goals to encourage a healthier and more securely insured population, but recognizes that health promotion is a state of mind that begins with the individual taking responsibility for their own health and making the right decisions in their own lives. By ensuring that all Americans have access to the most basic and preventative healthcare services, the Obama administration hopes that citizens will take an interest in their own health. As healthcare providers, our hope is that our interactions with patients when providing care, and efforts at health education, will impact this change in our culture, which ultimately remains with the individual.