White House Report Promotes Full Practice Authority for RNs and APRNs

  

The White House yesterday released a report entitled “Reforming America’s Healthcare System Through Choice and Competition” that describes the influence of state and federal laws, regulations, guidance, and policies on choice and competition in health care markets and identifies actions that states or the federal government could take to develop a better functioning health care market.

This report bears great news for RNs and APRNs. It recognizes and promotes the role that RNs and APRNs play in patient care and recommends that the federal government and state governments should allow RNs and APRNs (and other allied health professionals) to practice to the full extent of their education and training. The report makes the following recommendations regarding scope of practice:

  • States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their licenses, utilizing their full skill sets.
  • The federal government and states should consider accompanying legislative and administrative proposals to allow non-physician and non-dentist providers to be paid directly for their services where evidence supports that the provider can safely and effectively provide that care.
  • States should consider eliminating requirements for rigid collaborative practice and supervision agreements between physicians and dentists and their care extenders (e.g., APRNs, physician assistants, hygienists) that are not justified by legitimate health and safety concerns.

The report also promotes the use of telehealth services, noting that, “telehealth has great potential to improve access in underserved locations, reduce costs, and generate improved short- and long-term health outcomes.” The report makes several recommendations regarding telehealth:

  • States should consider adopting licensure compacts or model laws that improve license portability by allowing healthcare providers to more easily practice in multiple states, thereby creating additional opportunities for telehealth practice.
  • States and the federal government should explore legislative and administrative proposals modifying reimbursement policies that prohibit or impede alternatives to in-person services, including covering telehealth services when they are an appropriate form of care delivery.
  • States generally should consider allowing individual healthcare providers and payers to mutually determine whether and when it is safe and appropriate to provide telehealth services, including when there has not been a prior in-person visit.
  • Congress and other policymakers should increase opportunities for license portability through policies that maintain accountability and disciplinary mechanisms, including permitting licensed professionals to provide telehealth service to out-of-state patients.

ANA’s comments to the Medicare Payment Advisory Commission (MedPAC) expressed our support to expand telehealth services to Medicare beneficiaries, especially in areas in which RNs and APRNs provide care, and ANA encourages the administration to continue to consider the role that RNs and APRNs – able to practice to the full extent of their education and training – play in providing primary care, telehealth, and other health care services to increase access to beneficiaries, also recognizing that reimbursement is necessary to not only provide the services, but to also fill the void in certain specialties and geographies.

ANA applauds the White House for recognizing through this report the crucial role that RNs and APRNs play in the U.S. health care system and for promoting innovative telehealth strategies that will better allow them to practice to the full extent of their education and training. ANA also commends the administration’s recent expansion – through the CY 2019 Medicare Part B Physician Fee Schedule final rule – of telehealth services for prolonged preventive health services and for purposes of treatment of a substance use disorder or a co-occurring mental health disorder. These common-sense strategies will allow RNs and APRNs to maximize their significant contributions to quality patient care and outcomes.

Open Enrollment for 2019 Coverage Begins as Healthcare Looms Large Over Midterms

  

The open enrollment period to purchase individual health insurance coverage on the federal and state health insurance exchanges began on Wednesday, November 1st and runs through Saturday, December 15th. The open enrollment period is the only opportunity for individuals to enroll or re-enroll in an existing exchange plan for coverage for calendar year 2019. All consumers can access federal and state exchanges via www.Healthcare.gov; most consumers will purchase health insurance on the federal exchange, though consumers in these 12 states will purchase health insurance on their state of residence’s exchange. Consumers enrolled in a plan in 2018 who fail to update their information by December 15th will be automatically re-enrolled in the same or similar plan for 2019 (and must pay their premium for January to maintain coverage); consumers who were not enrolled in 2018 and do not sign up for a plan for 2019 will be locked out of exchange coverage until 2020.

Like last year, the administration has scaled back its efforts to encourage consumers to sign up for individual health insurance plans on the exchanges. The U.S. Department of Health and Human Services (HHS) plans to spend $10 million on marketing and outreach, including email, text messaging and auto-dial messages, as well as targeting individuals who are uninsured – particularly young and healthy individuals. The amount that HHS budgeted for marketing and outreach matches the amount that it budgeted in 2017; however, this is roughly 10 percent of what was budgeted for previous open enrollment periods.

The administration has also added additional confusion regarding what constitutes an individual health insurance plan by promoting subpar health insurance coverage, such as association health plans and short-term, limited duration insurance. While these plans may offer low premiums, they do not provide the comprehensive coverage of pre-existing conditions required for plans sold on the exchanges and often come with high deductibles and out-of-pocket spending. The administration also ended cost-sharing reduction subsidies, though insurance plans on the exchanges are still required to provide cost-sharing reductions for individuals with household income at or below 250 percent of the Federal Poverty Level and this policy change will not impact these consumers’ out-of-pocket spending. And in December 2017 Congress repealed the individual mandate penalty for individuals who failed to purchase individual health insurance coverage.

Despite these headwinds, 11.8 million Americans enrolled in coverage for 2018 on the federal and state exchanges, representing only a 3.7 percent decline from 2017. ANA has joined with other consumer- and provider-based groups to ensure consumers are aware of their options and are well-positioned to make the best choices for themselves and their families. It is essential that nurses ensure consumers are aware of the current insurance marketplace landscape, the need to select plans that offer meaningful coverage and that the open enrollment period is the only time they’ll be able to select plans from the marketplace exchanges.

ANA developed a toolkit of materials that can be customized and tailored to reach your nurses. ANA sent this toolkit to the presidents and executive directors of its Constituent and State Nursing Associations and to the presidents and executive staff leaders of its Organizational Affiliates; the toolkit includes the following:

  • Sample Social Media Messaging to encourage nurses and health care consumers to visit Healthcare.gov and either obtain coverage or re-enroll in a previously selected plan.
  • Frequently Asked Questions pertaining to open enrollment and the current political environment.
  • Talking Points to offer clear and concise explanations for why ANA is committed to promoting open enrollment and ensuring health care consumers are aware of all their health coverage options.

Health care stands to play a pivotal role in the midterm elections next Tuesday, November 6th. Public polling throughout 2018 has consistently shown health care to be the most important issue on voters’ minds, and the open enrollment period underscores how important health care is to individual consumers. ANA-PAC recently finalized its list of congressional endorsements for the 2018 election cycle, supporting candidates from both parties who are committed to advancing the nursing profession and ensuring that nurses have substantive input when lawmakers are crafting health policy. To find your polling place, please visit our #NursesVote Action Center and make certain that your voice is heard on this pivotal Election Day.

Opioid Bill Contains Victories for Medicaid – as the Administration Undermines Medicaid Access

  

This week the Senate passed a landmark piece of legislation, the SUPPORT for Patients and Communities Act, that aims to curb the nation’s ongoing opioid-use disorder crisis. The legislation includes a critical provision that enables nurse practitioners and physician assistants to prescribe buprenorphine permanently – once they obtain a waiver required by any provider to prescribe medication-assisted treatment (MAT) – and expands MAT prescribing authority for five years to other advanced practice registered nurse (APRN) specialties: certified nurse-midwives, clinical nurse specialists and certified registered nurse anesthetists.

Medicaid Provisions in the SUPPORT for Patients and Communities Act

The bill also includes several critical Medicaid provisions aimed at treating individuals who suffer from an opioid-use disorder and preventing others from developing an opioid-use disorder. Taken together, these provisions will significantly increase access to opioid-use disorder treatment and counseling services for some of the nation’s most vulnerable populations and will decrease the rate of new opioid-use disorders.

These provisions include:

  • A temporary suspension (from Fiscal Year 2020 through FY 2023) of the Medicaid institution for mental disease (IMD) exclusion for short-term stays (less than 30 days per year) and the codification of regulations that allow managed care organizations to receive federal funding for patients who are in an IMD for 15 days or less per month (current law does not allow federal payment for patient stays in IMD facilities with greater than 16 beds);
  • A requirement for states to cover MAT, including methadone and counseling services, for opioid-use disorders from FY 2021 through FY 2025;
  • A provision that allows states to cover care for infants with neonatal abstinence syndrome at a residential pediatric recovery center and an extension of enhanced federal match provided under Medicaid for health home services to treat individuals with substance use disorders;
  • A requirement for state Medicaid programs to not terminate coverage for juvenile inmates under the age of 21 while they are incarcerated and an extension of Medicaid coverage for former foster youths ages 18 to 26 who move states, and;
  • A requirement for states to comply with drug review and use requirements as a condition of receiving federal Medicaid funding and a provision that allows state Medicaid programs access to state prescription drug monitoring programs.

Trump Administration Approval of Medicaid Work Requirements

It is ironic, then, that as the SUPPORT for Patients and Communities Act heads to President Trump’s desk, his administration is actively taking steps that will create barriers for Medicaid beneficiaries to remain covered under the program. CMS Administrator Seema Verma recently defended the administration’s policy of approving Medicaid waivers for demonstration projects that impose work requirements on certain Medicaid populations (i.e., the Medicaid expansion population of low-income, childless adults).

CMS recently faced criticism after 4,300 Arkansans lost Medicaid coverage in September as a result of not meeting the state’s new work requirements; this is the first time in the Medicaid program’s 53-year history that beneficiaries have lost coverage for not meeting work requirements. The administration has approved work requirements for Indiana and New Hampshire, and waivers to impose work requirements are pending in South Dakota, Kansas, Mississippi, Ohio, Maine, Utah and Arizona. Kentucky’s work requirements waiver was struck down in federal court in July, though the administration is currently working with Kentucky to revise implement those requirements nonetheless.

Studies show that work requirements for Medicaid beneficiaries have little to no impact on employment and, as demonstrated in Arkansas, result in coverage losses. According to a December 2017 Kaiser Family Foundation issue brief, roughly 6 in 10 of the 22 million non-disabled adults receiving Medicaid benefits are employed either full- or part-time, while 8 in 10 of these adults live in a working family. Most of these individuals work either for small firms or in low-paying industries which do not offer healthcare coverage and thus rely on Medicaid for such. Further, among those adults who are not working, most report a major barrier to employment such as illness, disability, or care-giving duties. According to the same Kaiser issue brief, Medicaid expansion has not negatively impacted labor market participation; in fact, some research demonstrates that Medicaid coverage supports work.

ANA Commends Congress and Urges Its Members to Vote in the Midterms

ANA applauds Congress for its hard work and dedication in passing the SUPPORT for Patients and Communities Act and for recognizing the role that RNs and APRNs play in patient care for those with an opioid-use disorder.

However, ANA firmly believes in universal access to comprehensive and affordable healthcare services for all Americans. The recent moves by both the Trump administration and state governments fly directly in the face of that goal and represent major steps backward in the effort to ensure that all Americans – especially vulnerable populations such as low-income women and those with pre-existing conditions – have access to all necessary healthcare services. These moves also undermine the progress made in Congress with the SUPPORT for Patients and Communities Act.

Healthcare stands to be a major issue in the upcoming 2018 midterm elections – 22 percent of respondents to a June 2018 NBC News/Wall Street Journal poll named healthcare as the most important factor in deciding their vote. These elections are right around the corner and are an incredibly important opportunity for ANA’s members to make their voices heard when it comes to determining the future of healthcare in this country. When nurses vote, lawmakers in Washington, DC, and in statehouses across the country listen. Visit ANA’s #NursesVote Action Center today and help us make this the most meaningful election for nurses yet.