Trump Administration Moves Create Major Uncertainty In Healthcare System


The Trump administration has toyed for months with the idea of withholding cost-sharing reduction (CSR) payments to insurance companies participating in the individual insurance marketplace implemented by the Affordable Care Act (ACA). This has injected a great level of risk into the healthcare system which has in turn created a lot of uncertainty and confusion. These CSR payments are intended to help low-income individuals with income between 100% and 250% of the federal poverty level pay for co-pays, co-insurance, and deductibles. The ACA limits to a percentage of their income the amount of cost-sharing these individuals pay. For instance, an individual with an annual income of $17,000 might only have a $125 deductible compared with a $2,500 deductible for someone with a $25,000 annual income under the same insurance plan. (See a detailed description of CSR payments here). The federal government makes CSR payments to insurance companies to balance out the difference between what the individual pays and what the insurance company charges (fortunately, the Trump administration today stated that it will make CSR payments for August).

The Congressional Budget Office (CBO) on August 15th released an analysis on the impact that withholding the CSR payments would have on insurance premiums and insurance coverage. According to the CBO report, insurance premiums for individual insurance coverage would increase by 20 percent in 2018 and by 25 percent by 2020, while 5 percent of people would live in areas that would have no insurers in the non-group market in 2018.

Furthermore, withholding CSR payments would increase the federal deficit by $194 billion from 2017 through 2026, largely as a result of higher federal premium tax credit payments. Higher federal deficits would also put pressure on existing federal healthcare and social services programs, including Medicaid, and would further threaten the ability of the federal and state governments to provide health care services to the nation’s vulnerable populations.

In addition to the chaos and uncertainty the Trump administration is causing with respect to CSR payments, it is also making moves to undo some of the progress made under the ACA toward achieving quality outcomes and a higher degree of care coordination. A recent rule proposal published on the website of the Office of Management and Budget would eliminate the mandatory implementation of the bundled payment models for cardiac care coordination and cardiac rehabilitation, as well as implement changes to the comprehensive care joint replacement model. These advanced payment models promote care coordination and place an emphasis on patient outcomes and quality of care; elimination of these models would be a detriment to patients and nurses alike.

Stable payment systems and innovative payment models which emphasize care coordination and patient outcomes will better enable nurses to provide quality care and ensure that patients are able to receive the best quality of care in a timely fashion and with better outcomes. As such, the American Nurses Association strongly supports both the federal CSR payments and the implementation of the aforementioned advanced payment models.

State Nurses Associations ask Legislators to Consider the Facts on Nursing Practice



As nurses and consumer advocates in Texas fought for full Advanced Practice Registered Nurse (APRN) practice authority this past legislative session, those opposing the measure trotted out an unlikely source: a patient who had suffered harm at the hands of an APRN. Likewise, nurses and consumers in Oklahoma were stymied in their push for full practice authority when a legislator expressed concern with a growing rate of malpractice claims against APRNs. But when you step back from arguments that are based on emotion and anecdotes, all that’s left are facts—and facts are stubborn things.

In this instance, the facts show that the arguments against full APRN scope of practice in Oklahoma and Texas don’t hold water. Take the patient who was harmed, for example.  While it’s undoubtedly true that patients are sometimes harmed in the delivery of healthcare, what truly matters is whether APRNs are able to practice safely and effectively in comparison to what one might expect from other healthcare providers. And, as this space has covered, APRNs fare well in that analysis. Indeed, as the National Academy of Healthcare noted, “the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by the decades of research that has examined this question.”

This is further borne out by malpractice claims and payout data, contrary to the concerns of the legislator from Oklahoma. Some of the most recent data available from the National Practitioner Databank, a national repository of malpractice claims and payouts, shows that nurse practitioners did  experience an 18% increase in malpractice claims from 2007-2011. And yet, during that same time, the number of nurse practitioners increased by a whopping 28%. The fact is that although malpractice claims increased by 18%, they should have increased by 28%, in line with the increase in nurse practitioners. In other words, nurse practitioners actually improved their safety as determined by the rate of malpractice claims during the study timeframe.

What’s more, a 2013 American Association of Nurse Practitioners’ study of the National Practitioner Databank found that the malpractice payment rate for nurse practitioners was half that of Physician Assistants and ten times less than that of MDs and DOs. Put another way, while it’s true that one in a thousand APRNs made a malpractice payout during the study period, that was a much lower rate than the one in five hundred PAs, or the one in one hundred MDs/DOs.

Facts are stubborn things. And here are some for states without full APRN practice authority to consider: APRNs practice safely, effectively, and cost-efficiently, and are much less likely to harm patients or pay out malpractice claims than other healthcare providers.

Nurses Wonder: When is Enough, Enough?



Ad Nauseum is a Latin term describing something that has continued “to the point of nausea.” Merriam-Webster defines it as “to a sickening or excessive degree.” Ad Nauseum, then, holds the distinction of being the perfect word to describe the current status of research demonstrating the safety and efficacy of Advanced Practice Registered Nurses (APRNs).

As one nurse put it, “we may be the most studied profession out there. You certainly don’t see dentists being required to justify their practice through hundreds upon hundreds of studies over the course of decades before they are allowed to practice to fullest extent of their license.”

It’s been six years since the National Academy of Medicine concluded in its groundbreaking “Future of Nursing” report that “the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by the decades of research that has examined this question.” The Institute backed this up with mountains of peer-reviewed scientific evidence.

Since then, the evidence has continued to pour in. Kleiner, Park, and Wing found in 2014 that “more restrictive state licensing practices [for APRNs] increase the costs of medical care… and do not appear to influence health care quality….” Xue, Ye, Brewer, and Spetz found in a systematic literature review that “removing restrictions on NP scope of practice regulations could be a viable and effective strategy to increase primary care capacity.” Kurtzman et al concluded in 2017 that “[Nurse practitioner, ‘NP’] care is comparable to physician care in most ways and…the quality of NP-delivered care does not significantly vary by states’ NP independence status.”

These studies are just a smattering of scores of research published since the National Academy of Medicine, on the basis of decades of research, concluded without stipulation that APRNs practice just as safely, effectively, and efficiently as physicians.

And yet, 28 states still do not allow APRNs to practice to the full scope of their training and education. The VA recently allowed APRNs full practice authority, but excluded nurse anesthetists.

This is not for lack of effort. Nurses, consumers, patients, and advocacy groups have collaborated in various ways to ask legislators in the 28 states to allow full APRN practice in the interest of achieving the “triple aim” of improving patient outcomes, population health, and per capita cost. The Robert Wood Johnson Foundation, AARP, the FTC, the National Governors Association, and many other influential voices have also weighed in on the side of granting full practice authority to APRNs in all US states.

In many cases, these efforts have been thwarted by legislators and others who demand more evidence. But when decades of research ad nauseum clearly demonstrate the safety and efficacy of full APRN practice, many patients and nurses find themselves wondering: when is enough, enough?