Many adults in the United States are not getting the recommended screening tests for colorectal, breast, and cervical cancers, according to data published in the Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report. For 2013, screening for these types of cancers either fell behind previous rates or showed no improvement.
Among adults in the age groups recommended for screening, about 1 in 5 women reported not being up-to-date with cervical cancer screening, about 1 in 4 women reported not being up-to-date with breast cancer screening, and about 2 in 5 adults reported not being up-to-date with colorectal cancer screening.
The report found that colorectal cancer testing was essentially unchanged in 2013 compared with 2010. Pap test use among women aged 21 to 65 years was lower than in 2000, and the number of mammography screenings was stagnant, showing very little change from previous years.
“It is concerning to see a stall in colorectal cancer screening rates,” says Lisa C. Richardson, MD, MPH, director of CDC’s Division of Cancer Prevention and Control. “We must find new ways to make people and providers aware that getting tested for colorectal cancer could prevent cancer and save their lives.”
Researchers reviewed data from the National Health Interview Survey 2013, which is used to monitor progress toward Healthy People 2020 goals for cancer screening based on the most recent U.S. Preventive Services Task Force guidelines.
The screening data for 2013 show that 58.2% of adults aged 50 to 75 years reported being screened for colorectal cancer; 72.6% of women aged 50 to 74 had a mammogram; and 80.7% of women aged 21 to 65 had a Pap test. All of these percentages are below the Healthy People 2020 targets.
The report found that adults without insurance or a usual source of health care generally had the lowest screening test use. For example, less than one quarter of adults in these groups reported recent colorectal cancer screening, compared with more than 60% of adults with private insurance or a usual source of health care. More efforts are needed to achieve cancer screening goals and reduce screening disparities.
The authors did report some good news: the proportion of women in the highest education and income groups who were screened for breast cancer exceeded the Healthy People 2020 target, and the proportion of people aged 65 to 75 who were screened for colorectal cancer was also near the target.
Through the Affordable Care Act, more Americans will qualify to get health care coverage that fits their needs and budget, including important preventive services such as screening for some cancers that may be covered with no additional costs. Visit Healthcare.gov to learn more.
Nursing is entering an era of great transformation that is driven by three major changes: an aging baby boomer population; the ongoing impact of the Affordable Care Act (ACA); and rising educational goals for the profession, including greater emphasis on the bachelor’s of science in nursing (BSN) and advanced practice nursing (APN) degrees.
For minority nurses, these changes bring a variety of benefits, as well as some possible drawbacks.
The aging of the baby boomers is expected to produce a plethora of new nursing jobs, which could lead to higher wages, greater job security, and greater variety in types of work. By the same token, this deluge of new patients could put new strains on the nursing workforce, possibly leading to higher patient-to-nurse ratios.
The health care law is changing the way nurses deliver care—emphasizing more outreach into the community and closer collaboration with patients. These changes could boost the need for nurses from the same cultural background as patients, at a time when African Americans and Hispanics are underrepresented in nursing. But the changes also mean less work for nurses in the traditional hospital setting.
Finally, nurses will have greater opportunities to advance their careers by going back to school for more training; APNs, and especially nurse practitioners (NPs), are already in great demand to cope with a growing physician shortage. However, having to spend more time in school may be challenging for nurses with limited finances.
Nursing is embracing these fundamental changes to keep pace with a rapidly evolving health care system, says Jo Ann Webb, RN, MHA, senior director of federal relations and policy at the American Organization of Nurse Executives. “Health care is changing, and nursing has to change with it.”
Baby Boom Changes Postponed, But Not Cancelled
For several years now, the profession has been bracing for a massive shortage of nurses, but it’s been slow to materialize.
The massive baby boomer generation, making up almost one-third of the population, began to turn age 65 in 2011. As they continue to get older, both supply and demand of nurses will be affected in a big way. On the supply side, retiring baby boomer nurses will empty the ranks of the profession. On the demand side, aging baby boomer patients will need more nursing to manage their declining health.
Yet, these massive changes were postponed by the 2008-2009 recession and the weak economy that followed, argues Marcia Faller, RN, PhD, chief clinical officer for AMN Healthcare, a health care staffing company based in San Diego.
Aging nurses, short on household funds, held off retiring and even came out of retirement to work again. Meanwhile, the aging patients have put off care, flattening the demand for health services. “Everybody is trying to figure how these changes will play out,” says Faller, who led a major AMN Healthcare survey on registered nurses in 2013.
But as a result of this delay, new nurses who had expected a strong jobs market have struggled to find openings. For example, a Denver TV station reported in 2013 that, of 752 openings for RNs in Colorado at that time, only four were for new graduates.
Lack of jobs has been especially hard on minority nurses, many of whom lack savings to fall back on. With their careers sidetracked, they’ve had to take non-RN jobs in health care or in completely unrelated fields.
In a new graduate hiring survey, the California Institute for Nursing & Health Care reported that in 2012–2013, the latest year available, a little over 40% of new RN graduates in the state hadn’t found an RN job—only a slight improvement over the previous three years. Of those who didn’t find RN jobs, 20% were working in non-RN roles in health care and 23% took jobs outside health care. The rest went back to school or volunteered in health care at no pay.
Many new graduates are angry and mistrustful. In a 2013 survey by two nursing professors at Molloy College, which was published by the National Student Nurses’ Association, many new RN grads thought the nursing shortage was just a “myth,” created by nursing schools to attract more students.
The impending nurse shortage, however, is not going away, says Mary H. Hill, PhD, RN, nursing professor and assistant provost of Howard University in Washington, DC. Aging patients can’t continue to delay treatment and aging nurses can’t continue to put off retirement. Indeed, states like Texas and many rural areas are already encountering shortages. “Nursing has experienced some challenges, but even greater challenges lie ahead as the baby boomers retire and leave the nursing workforce,” says Hill.
The need for more nurses will be overwhelming, according to the US Bureau of Labor Statistics (BLS). In a recent occupational outlook report, the BLS said there will need to be about 500,000 more nursing positions by 2022. In addition, about 500,000 baby boomer nurses are expected to retire over that same time period, meaning that over 1 million new nurses will be needed over the next decade, according to the BLS.
That means that the hospitals and other employers who are now rejecting young applicants will end up begging for them to apply, which could push up nurses’ wages. Hospitals could also simply pile more work onto existing nurses, but doing so would be unworkable in the long run.
Nursing schools have been pushing hard to expand class size so there will be enough nurses for this tsunami of demand. But they’ve had to turn applicants away, due to a lack of nurse educators. Nursing schools in New York, for example, rejected 2,900 qualified applicants in 2012, more than in any year since 2005, according to the Healthcare Association of New York State (HANYS). Many of these spurned applicants have probably moved on to other careers, which is a great loss for nursing.
Repercussions of the Affordable Care Act
Like the baby boom, the health care law represents another great sea change for nursing and is also still in its early stages. The full impact of the ACA “hasn’t shaken out yet,” according to Webb.
Beginning in January 2014, millions of Americans gained coverage under Medicaid and in subsidized policies sold on the new health insurance exchanges. But it’s still unclear how much these people will boost demand for health care and thus nurse hiring. Exchange policies tend to have very high deductibles, discouraging people from getting care. Additionally, millions of Americans still haven’t signed up, despite a federal requirement to do so. The penalties in the first year were fairly minor but will rise in succeeding years, which may boost coverage.
The elephant in the room, of course, is Republican opposition to the law. Republicans continue to promise repeal, and it could happen since they’ve gained control of the Senate and the House. In the meantime, however, this sweeping law is fundamentally changing the face of health care in this country—not just in terms of sheer numbers of patients, but also in the way it is delivered. And in another few years, it would be very hard to turn these changes back.
“I’m not saying it’s a perfect law,” says Webb, “but it has, in my view, put nursing on the map. Nurses have a bigger role now.” Accountable care organizations and patient-centered medical homes are new models of care that are encouraged by the ACA. Both models reward hospitals and other providers that coordinate care and provide more patient education—two areas where nurses excel.
“The ACA emphasizes primary and secondary prevention and education of patients,” says Shawona Daniel, MSN, CRNP, assistant professor of nursing at Tuskegee University, a historically black institution in Alabama. “Education is one of the most important nursing roles. I’d say 90% of what nurses do involves teaching patients and working on preventive issues, which helps keep patients out of the hospital.”
Webb added that working in medical homes requires computer skills in order to deal with electronic health records and telehealth services, such as e-mailing and Skyping patients, as well as using remote monitoring devices. “These patients need monitoring, and this is where nursing is really critical,” she argues.
The Shift Away From Hospitals
Daniel reported that virtually all of her students still expect to work in a hospital—at least initially. But the ACA favors new models of care outside the hospital. For example, Medicare is reducing hospital reimbursements, and hospitals are being penalized for readmissions within 30 days.
“There is an ongoing shift from inpatient to more community-based outpatient care,” says Hill.
Faller agreed with this assessment. “Only the sickest of the sick will be in the hospital, and care will flow out into the community,” she explains. As health care moves out of the hospital, home health is already a growing field, and it has become a magnet for telehealth and other high-tech services, she adds.
In addition, Hill says nurses will be able to find ample jobs at dialysis centers, community health centers, physicians’ offices, outpatient surgery centers, and pain management clinics, to name a few settings. “There are just so many opportunities,” she argues.
As part of the de-emphasis on hospital care, many patients are being discharged earlier and placed in long-term acute care (LTAC) facilities, where they spend many weeks often still on ventilators and IVs. Care in the LTACs is “complex and challenging,” says Joseph Morris, CNS, GNP, PhD, director of nursing and allied health at Victor Valley College in Victorville, California. “Nurses who work in these facilities require advanced skills, such as advanced cardiac life support and telemetry training.”
Morris, who is trained in gerontology, welcomes the influx of aging baby boomers. Many nurses seem to feel that a geriatrics career—which can mean working in a nursing home—means “lowering your sights,” he says, but he disagrees. “It’s clinically challenging because you’re more likely to see multiple health problems.”
Dealing with older patients is also personally rewarding. Morris, who is African American, has fond memories of taking care of elderly black men in Detroit. In contrast to the stereotype of geriatric patients sitting in their wheelchairs muttering to themselves, “most geriatric patients are still active,” he says.
Nurses Get More Training
The job market is beginning to favor nurses who have a BSN degree, and advanced practice nurses such as NPs are in great demand.
Both trends earned key endorsements from the Institute of Medicine (IOM) in its 2010 report, The Future of Nursing. The report set a goal that 80% of nurses should have a BSN degree by 2020 and urged states to drop barriers against NPs working “to the full extent of their education and training.”
Hospitals are quickly shifting to BSNs. In New York, 70% of hospitals in 2013 preferred hiring BSNs, compared with 46% in 2011, according to HANYS. Many younger nurses are heeding the call. Faller pointed to the 2013 AMN Healthcare survey showing that almost one-quarter of nurses ages 19–39 said they would pursue a BSN, and more than one-third said they would pursue a master’s degree in nursing.
Hill says it’s fairly easy for someone with an associate degree in nursing to transition to a BSN degree. They can enroll in a “RN-to-BSN” transition program, which lasts 12–18 months and is available in many locations across the country.
Meanwhile, NPs have been proliferating. According to a 2013 report by the Health Resources and Services Administration (HRSA), the number of NP graduates grew by 69% from 2001 to 2011, fueled by the growing shortage of physicians in primary care and easing of state restrictions on NP practice.
“Nursing students are more ambitious than they used to be,” argues Daniel. “A lot of them want to go back to graduate school and become nurse practitioners.” She says she hopes some of them will choose a career in academia so that more nurses can be trained. This was another goal of the IOM report.
Morris says the new doctor of nursing practice credential, which will be required for all NP students starting in 2015, expands the amount of study, making NPs even more desirable as primary care providers as well as specialty caregivers.
Of course, the extra time and money needed for a BSN, and especially an NP, can be a barrier for minority students. Rather than pile up loans, Morris urged students to thoroughly research available scholarships. “Nursing students have not always been proactive in seeking out the opportunities.”
Push for Diversity
The new models of care fostered by the ACA require closer relationships between providers and patients, which means hiring nurses from the same ethnic background as their patients. Hospitals and other employers “want their nurses to be compatible with the culture or their patients,” says Faller. “But this will be a challenge, particularly for the Hispanic population.”
While Hispanics make up 17.1% of the population, they account for only 4.8% of RNs, according to the HRSA. There is also a gap for African Americans, who account for 13.2% of the population but just 9.9% of RNs.
As a black male nurse, Morris says it’s easier for him than for white caregivers to connect with black patients. He says many of them are still painfully aware of the infamous Tuskegee experiment. In a project that lasted until 1972, white doctors didn’t inform black male patients that they had syphilis, so that they could follow the natural progression of the disease. As a result, older black patients in particular are still wary of “being used as guinea pigs,” he says.
Morris has worked hard to boost African American representation in nursing, visiting schools to spread the word about a nursing career. He is also interested in boosting the number of black men in nursing. While men make up almost 10% of all nurses, very few black males enter the field, he says.
Nurses Have a Central Role to Play
There are many opportunities for minority nurses in this era of great change in the health care system. According to the IOM report, nurses will take center stage in this process.
“We believe nurses have key roles to play as team members and leaders for a reformed and better-integrated, patient-centered health care system,” the report maintained. “How well nurses are trained and do their jobs is inextricably tied to every health care quality measure that has been targeted for improvement over the past few years.”
Leigh Page is a Chicago-based freelance writer specializing in health care topics.
As millions of uninsured people get coverage under the Affordable Care Act (ACA), job opportunities for registered nurses could open up in the nation’s community health centers because many of the newly insured are expected to go there for care. These facilities, also known as federally qualified health centers (FQHCs), provide primary care in medically underserved areas, regardless of patients’ ability to pay. Teams of physicians, nurse practitioners, registered nurses, and other health care workers treat mostly Medicaid patients and the uninsured.
FQHCs, the mainstay of the nation’s health care safety net, have been growing by leaps and bounds in the past decade, posting an 80% increase in new jobs. Now a new wave of patients is expected, fueled by the Medicaid expansion and the new health insurance exchanges, where premiums for low-income people are subsidized.
Planners of the expansion predicted that since many physician practices have limited capacity for new patients, many of these patients would go to FQHCs. Therefore, the ACA set aside billions of dollars in construction funding to help FQHCs expand their facilities so they could handle an onrush of patients.
No one knows, however, how many new patients will come, and the centers, operating under tight budgets, have been holding off on hiring until they get a better idea.
Also, while FQHCs employ a significant number of RNs, these facilities may not appeal to everyone. Salary levels vary widely, with some facilities paying less than hospitals, and many FQHCs are more interested in health care workers with less training, like licensed practical nurses.
What FQHCs Want
Community health centers are looking for nurses who are committed to serving low-income people, usually minorities, says Gary Wiltz, MD, chair of the National Association of Community Health Centers.
“The work should be viewed as a calling,” he says. When Wiltz interviews job applicants for his own FQHC, the Teche Action Clinic in southern Louisiana, he says he wants to see compassion. “The patients are disenfranchised, but many of them have jobs and are working very hard,” he notes. “As a provider, you have to be aware of what they are going through.”
Jennifer Fabre, RN, a nurse practitioner at Teche Action, says nurses are paid less than those who work in hospitals or nursing homes. But Community Health Services, an FQHC in Hartford, Connecticut, pays them comparable rates, according to Valerie Tyson, RN, a nurse at the Connecticut facility.
Tyson says working in a FQHC is very different from the hospital med-surg unit where she used to work. “The hospital has people who are very sick, but here the patients have an acute illness or need follow-up care for a chronic illness,” she says. “This is their primary care stop.”
A big part of the job, she explains, is teaching patients to manage chronic conditions. The RNs also take patients’ calls, routing some of them to doctors or nurse practitioners but taking care of most of them, she adds.
The Connecticut FQHC serves inner-city patients who are mostly Hispanic and black, some sharing Tyson’s roots in Jamaica. Unlike in the hospital, “you get to know these patients over time,” she says. “You develop a relationship with them.”
Fabre added that nurses have to understand their patients’ needs. “You do whatever you need to do to help the patient,” she says. “It doesn’t do patients any good if you prescribe a medication for them and they can’t pay for it.”
Roots in the Civil Rights Era
FQHCs have a rich history of community service, going back to the Civil Rights era. The oldest rural FQHC, the Delta Health Center, was founded in 1967 in Mound Bayou, Mississippi—the oldest predominantly black settlement in America.
This little village is in the heart of the Mississippi Delta, a land of cotton fields that gave birth to the blues. The health center sits on land once owned by the brother of Confederate president Jefferson Davis, Joseph E. Davis, who encouraged “self-leadership” among his slaves, letting them build a “model community.”
After emancipation, Joseph E. Davis’ former slaves spent two decades earning enough money to purchase the land, founding the village in 1887. Today, Mound Bayou has 687 households and is still almost entirely black. The town came into prominence again in the Civil Rights era of the 1960s, when it caught the eye of H. Jack Geiger, MD, an idealistic Massachusetts physician who wanted to create a new type of health care facility for the poor.
In the 1964 Economic Opportunity Act, the cornerstone of President Lyndon Johnson’s “War on Poverty,” Geiger persuaded President Johnson to include $1.2 million for test sites at Mound Bayou and Boston. Envisioning a self-sustaining community, Geiger and his followers not only built a clinic in Mound Bayou but also dug wells and helped residents improve farming methods.
FQHCs have enjoyed a renaissance in the new century, starting with a wave of new federal funding under President George W. Bush. Patient volume grew by 50%, reaching the 15 million mark in 2006. Under President Obama, the Recovery Act set aside $2 billion in extra funding for FQHCs in 2009, and patient volume then reached 20 million.
The ACA set aside $11 billion for the centers, mostly for construction, to help them build capacity to meet the coverage expansion. The Delta Health Center received $5 million of this funding, allowing for its first significant expansion since it opened 47 years ago.
The new building will open in February. “We’re going to have brand-new rooms and new equipment,” says Neuaviska Stidhum, RN, the chief operating officer at Delta. “It means we’ll be able to see more patients.”
Centers Holding off on Hiring
But even as Delta and many other FQHCs expand, they are holding off on hiring more staff and even, in some cases, opening some of their new projects. Facilities have to be careful about hiring because the new federal funding does not cover operational expenses. Teche Action Clinic, Wiltz’s FQHC in Louisiana, renovated two new sites using federal money, but it doesn’t have the funds to open them.
Moreover, there are signs that the anticipated onrush of new patients may not be as large as expected. Half of the states, including Mississippi and Louisiana, aren’t participating in the Medicaid expansion. Technical problems with exchange websites are dissuading some people from signing up, and the fine for not obtaining coverage may initially be too low to force some people to buy insurance.
Stidhum adds that many doctors’ offices in the Delta region still have a lot of capacity, so there would be less reason for the newly insured patients to use her FQHC. “We don’t know what we’ll do yet, “said Stidhum when asked about hiring. “Maybe we’ll need more staff, or maybe we’ll just need to shift their duties around.”
The story is different in Connecticut, which has joined the Medicaid expansion and has a very active insurance exchange. Tyson says her Hartford FQHC has put off hiring, but she is optimistic about hiring in the future. “The center is really busy,” she says. “If there are more patients, we would have to hire more nurses.”
It’s just after lunchtime at Community Clinic Inc. (CCI), a federally qualified health center in Takoma Park, Maryland, a Washington, DC, suburb with a large immigrant and refugee population. Team Nurse Jose Aguiluz, RN, leads the afternoon huddle, a daily ritual where primary care providers—physicians and nurse practitioners—discuss their most complex cases with other members of the clinical team, including community health workers, medical assistants, and Aguiluz himself.
The huddle’s purpose is to spotlight patients with multiple conditions that need to be carefully monitored. The team identifies those who may benefit from “care management,” an approach that combines intensive patient education, follow-up calls and visits, and coordination with specialists. Most of CCI’s patients are low-income and face significant barriers to care, including a lack of transportation, lack of health insurance for those not covered by Medicaid or Medicare, lack of family support like child or elder care, poor nutrition, and mental health complications.
Today’s discussion, for example, includes a woman with bipolar disorder, schizophrenia, and breast cancer who is leery about undergoing a mastectomy and an encephalopathic patient who is convinced he has been followed for the past 20 years.
Care management at CCI has been in the works for two years, ever since the organization decided to become a “patient-centered medical home,” where patients follow a treatment plan and are cared for by a multidisciplinary team of professionals, led by a doctor or nurse practitioner.
Care management, or care coordination as it is also called, is intended to keep patients healthy and is one of the guiding principles of the Affordable Care Act (ACA), President Obama’s signature health care law passed in 2010. In addition to requiring everyone to carry health insurance starting this year, the ACA attempts to lower costs by discouraging episodic care and incentivizing care that anticipates acute illness before it occurs.
“The focus now is on preventative care,” says Aguiluz, who fields daily inquiries about the ACA from patients. “The questions we’re asking ourselves is: How are we treating chronic conditions? How do we prevent people from seeking care in the hospital?”
Nurses will play an instrumental role in an evolving health care system brought forth by the ACA. The law presents both opportunities and challenges to both registered nurses and advanced practice nurses since both groups will be called upon to meet the needs of newly insured patients seeking care on a more regular basis.
Nurses will be integral not only on care coordination teams as both managers and clinicians, but also in a more robust primary care sector the ACA mandates. Health policy experts question whether there will be an adequate supply of primary care providers with fewer medical students pursuing careers in primary care. Nurse practitioners are eager to fill the need—particularly in underserved communities—but face unique battles when it comes to being uniformly embraced in primary care roles.
The Role of RNs in Care Coordination
According to the Department of Health and Human Services, health centers like CCI are expected to be a testing ground for how well the ACA works since they serve as a magnet for uninsured patients. Some of CCI’s uninsured will now be eligible for Medicaid while others will qualify for subsidies to purchase individual policies. The ACA set aside $11 billion for health centers nationwide, although no funds are specifically designated for care management. Navigators have been hired or contracted by many health centers to assist patients shopping for insurance on the online health care exchanges.
“If you look at the law, it talks about shifting care into the community away from hospitals,” says Susan Hassmiller, PhD, RN, FAAN, senior advisor on nursing at the Robert Wood Johnson Foundation. “In my mind, nurses are the ideal people to deliver care in this changing model. We need people who can take care of patients holistically, over their lifetime. ”
Health centers have hired more nurses in recent years not in direct anticipation of the ACA, but as a result of structural changes to the way they serve clients. Since CCI began its transformation into a medical home nearly two years ago, its nursing staff has grown from two to 10, says Shobhna Shukla, RN, MSN, FNP, clinical programs director at CCI. The “linchpin” of each clinical team at each of CCI’s seven locations, nurses could be a determining factor when newly insured consumers select a primary care provider, explains Shukla.
“Health centers are often measured by the quality of their nursing staff,” she adds. “What we do with nurses here…is going to be very important in terms of when people make choices about where to go.”
For years, Andrew Swiderski, MD, MPH, a pediatrician at CCI, felt frustrated by his inability to keep up with the “big pile of chronic issues” presented by certain patients—asthma, obesity, allergies, and diabetes among them. Now that care management is part of CCI’s culture, a dedicated RN and community health worker help Swiderski’s patients navigate the maze of specialist referrals, prescriptions, and other preventative services they need. It frees Swiderski to focus on the patient’s immediate medical issue in the short window of time he has with them.
“I feel so much better about what I do,” says Swiderski. “I don’t have to feel guilty about patients who need constant follow-up.” After Swiderski’s visit with a patient, the team nurse spends time educating the patient and his or her family about the next steps in their treatment plan.
“It’s amazing the depth [the team nurse] covers,” he says.
Empowering the Uninsured
The medical home model being implemented at health centers around the country and guidelines set forth by the ACA are, in many ways, complementary, says Margarita Sol, RN, the nursing care coordinator who oversees care management efforts at each of CCI’s seven clinics. Both initiatives prioritize access to health care, care coordination, prevention, health outcomes, and choice. “Choice means it’s patient-centered,” she adds.
In Maryland, like other states who opted to expand Medicaid, patients who previously didn’t qualify for the program will be eligible now. Meanwhile patients who earn too much for Medicaid could receive subsidies to purchase insurance on the exchange.
While they can’t predict how many new patients they’ll see as a result of the law, CCI clinicians say current patients who are self-paying are likely to benefit from expanded insurance options. They won’t have to shoulder the cost of necessities like labs, visits to specialists, and medical supplies or equipment entirely on their own.
“There is a pool of patients who have been waiting for more care outside of our clinic [that] has been on hold or at a sluggish pace,” says Sol. Now, adds Shukla, “they won’t have to delay if they don’t have the cash.”
Ruth Jackson of Brandywine, Maryland, knows firsthand the anxiety that comes with delaying care. Jackson, 41, is an uninsured single adult and a full-time student who pays for her own medical expenses. Before she became uninsured, her primary care doctor noticed her thyroid was enlarged. By the time Jackson got around to scheduling an MRI, she had quit her job so she no longer had health insurance. She paid $200 for the MRI, which revealed nodules on her thyroid. Jackson has since postponed a biopsy of the nodules because she can’t afford one.
“It’s worrisome,” she says. “I don’t know if my condition has gotten worse.”
Before starting a master’s degree in public administration, Jackson’s goal was to keep working while pursuing her studies. Then her parents became bedridden and wheelchair-bound, and Jackson became their full-time caregiver. Faced with a choice of having employer-sponsored health insurance or caring for her parents, she chose the latter.
For her master’s thesis, Jackson is writing about the experience of uninsured consumers—herself included—using the online health exchange. Her research focuses on clients of Greater Baden Medical Services, a Brandywine-based community health center where 44% of patients are uninsured, according to Colenthia Malloy, chief executive officer. Jackson also serves as a client representative on Greater Baden’s Board of Directors.
To Jackson, the ACA’s long-term promise is that “every person including myself will have access to care,” which means she’ll have better control over her asthma and will be able to visit a dentist, whom she hasn’t seen in two years. In the short term, she says, having insurance means “being able to determine whether I have cancer.”
Nurses, Jackson says, can play an influential role in educating consumers about how the ACA benefits them. One nurse-managed health center in Baltimore is doing just that. The East Baltimore Community Nursing Centers are in the process of becoming training sites for navigators who will assist clients sign up for health insurance, says Patty Wilson, RN, MSN, director of the centers.
Some of the centers’ clients are having difficulty enrolling, particularly with technical glitches in the Maryland health exchange website. Also, clients don’t prioritize purchasing insurance as work and family obligations take up most of their time. While they “have other things on their plate,” says Wilson, each center’s goal is to assist clients “become advocates for their own health care.”
Nurse Practitioners and the Primary Care Workforce
At Unity Health Care, a federally qualified health center in Washington, DC, the number of nurse practitioners occupying slots as primary care providers has grown from a “handful” to about 50 across Unity’s clinics in DC, says Sarah Price, RN, MSN, director of nursing development. While MDs make up the majority of providers at Unity, nurse practitioners have their own patient panels and are “very independent and focused on primary care,” she says.
“We weren’t able to be where we are in terms of thinking outside the box without hiring nurse practitioners,” says Malloy of Greater Baden Health Services, which will extend hours at all their clinics this year to keep up with demand. Nurse practitioners make up 30% of Greater Baden’s providers.
According to the American Association of Nurse Practitioners (AANP), 89% of nurse practitioners receive training in a primary care specialty, including family medicine, pediatrics, and women’s health. And while the AANP reports growth in enrollment and graduation rates for nurse practitioners, other experts say the shortage of faculty and the lack of clinical training opportunities and dedicated mentorship cripple the ability of nursing schools to contribute meaningfully to the primary care workforce.
Unlike family physicians, nurse practitioners in primary care don’t undergo a residency program before taking on their own patients. Nurse practitioners from earlier generations usually earned their advanced degrees after years working in a clinic or hospital as a registered nurse. Newer graduates, however, are heading straight to graduate programs with fewer clinical experiences under their belt. Swiderski, the CCI pediatrician, says he has seen inexperienced nurse practitioners “get thrown into the fire” only to deliver “suboptimal care.”
“There has not been equivalent support for undergraduate or graduate nursing education until now,” writes Jackie Tillett, ND, CNM, FACNM, in a 2011 paper published in the Journal of Perinatal and Neonatal Nursing.
The ACA somewhat rectifies this situation by setting aside money to bolster the clinical experiences of registered nurses and nurse practitioners. The law lifts the cap on grants given to nurses to repay loans if they pursue doctoral degrees, and it also gives financial support to nurses who want to teach at the university level. The National Health Service Corps has also expanded under the ACA, with nurses receiving $50,000 for every two years of service with an at-risk population.
Additionally, the ACA funds demonstration projects at five hospitals throughout the country to train advanced practice nurses. The Centers for Medicare & Medicaid Services (CMS) will reimburse the hospitals to place advanced practice nurses with clinical preceptors in their communities, says Matthew McHugh, PhD, JD, MPH, RN, FAAN, associate director for health outcomes and policy research at the University of Pennsylvania, one of the five sites chosen by CMS.
“It’s important to focus on the substance and quality of the training so that nurses can work in a new and more complex health care system,” says McHugh.
Legislative and political barriers preventing nurse practitioners from fully occupying primary care roles need to be removed, say McHugh and other experts. Only 17 states and the District of Columbia allow nurse practitioners to practice independently without a doctor’s supervision. Reimbursement rates of private insurance and government programs to nurse practitioners and physicians performing the same services also vary greatly, with nurse practitioners usually receiving less money. In 2010, the Institute of Medicine with the Robert Wood Johnson Foundation issued a policy statement urging states to allow nurse practitioners to practice to the full extent of their training, regardless of where they work.
Yet until laws are liberalized across all 50 states, nurse practitioners will have to continue to advocate for their rightful place as primary care providers, even with the ACA as the law of the land.
“There is lot of care that needs to be provided,” says McHugh. “And we need everyone practicing to the top of their abilities to make the most of the workforce that we can.”
Archana Pyati lives in Silver Spring, Maryland, and writes frequently on health and science topics.
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