Obamacare is ramping up a health-care turf war

February 27, 2013

Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoons for the latest edition — and read all previous columns here.

The Affordable Care Act will extend health insurance to millions of Americans — a number that grows weekly with Republican governors signing onto the Medicaid expansion.

Health policy experts expect that increased insurance coverage will lead to increased demand for health care. Once a patient has access to health insurance coverage, the thinking goes, she or he will be more likely to turn up seeking care.

Nine months out from the insurance expansion, there's a fierce battle underway — largely in the states — over who gets to provide that care.

All states have something known as "scope of practice" laws, which delineate which health-care providers can provide which services. This sets the rules whether a nurse, for example, can make a diagnosis or prescribe medication on her own — or whether she needs a sign-off from a physician.

Federal laws also deal, in a way, with scope of practice. The Medicare program, for example, will only allow doctors to certify that a patient is eligible for hospice care, rather than a nurse of physician assistant. Those regulations play a big role in determining who can be hired for which health-care jobs.

With the Affordable Care Act's insurance expansion looming, there's at least one group making the case that it's time for these laws to change: The nurse practitioners. In Washington, D.C., and in state houses, the American Association of Nurse Practitioners is making the case that it's time to broaden the scope of practice laws — and that the Affordable Care Act significantly strengthens their case.

"We're about to add about 30 million people to our health insurance system and there needs to be someone available to see them," AANP President Angela Golden told me when we met Monday. "We're uniquely positioned to do that."

The case that Golden made to me was this: Nearly all nurse practitioners have graduate degrees. Sixty-eight percent practice in a primary-care setting — one of the areas that most badly needs physicians. She can point to multiple studies finding that nurse practitioners have just as good outcomes as physicians.

"There are so many people who are going to need this care," Golden says, "And we have a proven track record of providing this care, and doing it very well."

The nurse practitioners' argument does not, however, have a strong track record of winning over state legislators. In 2012, seven states weighed legislation that would increase their scope of practice. Even with the insurance expansion looming, none of those bills became law.

The biggest opponents of these scope of practice laws tend to be physician groups, who make the case that nurse practitioners have significantly fewer years of education than doctors. When the Institute of Medicine issued a report in 2010, recommending that Medicare reimburse nurses for some of the services currently limited to physicians, the American Medical Association quickly responded that "Nurses are critical to the healthcare team, but there is no substitute for education and training."

Tay Kopanos, who directs state government affairs for AANP, told me about the situation they've faced in Kentucky for two years now. Last year, the group supported a bill that would expand scope of practice for nurse practitioners.

"After it was introduced, the medical society introduced a counter-bill offering more restricted regulation of nurse practitioners," she says. "This year, the nurse practitioners introduced a bill that would give direct access. A couple of weeks later, the medical society introduced the same, more restrictive bill."

With opposition still strong, what makes nurse practitioners more confident of their changes this time around? Golden sites a few factors. For one, the Affordable Care Act is now here to stay: There's none of the uncertainty of a Supreme Court decision or an election hanging over the law.

Her association has also seen an uptick in legislative activity. Fourteen states are now considering legislation to expand nurse practitioner scope of practice, twice as many as did back in 2012.

Last, the group continues to accrue more endorsements for its policy position. Most recently, the National Governor's Association released a literature review that found nurse practitioners to be "well qualified to deliver certain elements of primary care."

"In light of the research evidence, states might consider changing scope of practice restrictions and assuring adequate reimbursement for their services as a way of encouraging and incentivizing greater NP involvement in the provision of primary health care," the paper continues.

The nurse practitioners are also looking for change on the federal level: They're pushing legislation that would give their members greater authority to authorize home health care and hospice for Medicare patients.

Again, it's not the first time that they have supported such legislation. But, this time around, they're counting on a new climate in health policy to make all the difference.

"I'm not Pollyanna about this," Golden says. "But I just can't imagine a better time for us to be working on this agenda."

KLIFF NOTES: Top health policy reads from around the Web.

Arkansas strikes a unique deal to expand Medicaid. "The feds have given Arkansas permission to pursue a plan that would provide private health insurance to anyone between 0-138 percent of the federal poverty level, giving coverage to more than 200,000 of the currently uninsured. The government would pay for the entirety of the premium, though consumers might be subject to some co-pays." David Ramsey in the Arkansas Times.

Long-term care premiums for women may be about to spike. "Starting next year, the Affordable Care Act will largely prohibit insurers who sell individual and small-group health policies from charging women higher premiums than men for the same coverage. Long-term-care insurance, however, isn't bound by that law, and the country's largest provider of such coverage has announced it will begin setting its prices based on sex this spring." Michelle Andrews in Kaiser Health News.

New Jersey Republicans tread carefully around the Medicaid expansion. "Scott Garrett (R-N.J.) withheld judgment Tuesday when informed by a reporter that Christie had signed on to the Medicaid expansion. Garrett said he 'did not anticipate' Christie accepting the expansion, but did not criticize the move. 'I'll have to see what his rationale is, and then we'll have to figure out the other half of that, (which) is how that's paid for,' Garrett said." Sam Baker in the Hill

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