In 1993, then President William Clinton introduced a plan for healthcare reform. This was known as the Health Security Plan. At that time, in the United States, nearly 37.1 million people were without healthcare insurance (Kaiser Foundation, 1994). One year later, healthcare reform was pronounced dead. Even though public opinion polls showed strong support for healthcare reform that year, reform legislation did not pass muster with Congress. Sound familiar?

Fast forward to 2007. The Senate and the House of Representatives of the United States each introduced bills on healthcare reform. Over the next 2 years there were lively debates. Then, in 2008, Barack Obama was elected the president. He took the oath of office in January 2009, vowing to make healthcare reform a national priority. By the end of 2009, the Affordable Healthcare for America Act (H.R. 3962) passed in the House in November and the Patient Protection and Affordable Care Act (H.R. 3590) passed in the Senate in December (Library of Congress, 2010). But now, only a few months later, those in the know in Washington, DC, say healthcare reform is on a shaky ground.

These two bills, H.R. 3962 and 3590, were originally to be reconciled by a conference committee. The next step was for the House and the Senate to vote on the reconciled bill. However, the death of Senator Edward Kennedy, a longtime proponent of healthcare reform, and the election of Republication Scott Brown to replace him brought about a significant turn of events. The election of a Republican in a previously held Democratic seat now means that the Democratic filibuster-proof majority is gone because Senate rules require 60 votes to move a bill in regular order and end unlimited debate. That said, the White House presses on, arguing that healthcare reform still is alive and still a legislative priority in 2010. And today, 46 million Americans are without healthcare insurance (U.S. Census Bureau, 2009).

AS WE SPEAK

At the time of this writing, there are several healthcare options being bantered about in Washington. The options are to

* eliminate any plans to pass healthcare reform legislation;

* present a bill that includes only the most popular provisions, (e.g., requiring that insurance companies be barred from refusing to cover individuals with preexisting health conditions or charging those patients higher premiums, the repeal of the antitrust exemption for insurance companies, and other smaller steps to improve the affordability of coverage);

* move H.R. 3590 (the Senate bill) through the House of Representatives without any other changes; or

* move forward on a "fixes package" through both groups. This would mean that the Senate bill plus the additional reconciliation bill would move through both Houses. The outcome would hopefully bridge the differences that currently exist regarding affordability and funding with both groups in Congress.

The two-step Senate bill plus reconciliation is rumored to be the most popular at this time. First, the House of Representatives would adopt the Senate bill (H.R. 3590), but that bill would be modified as per a prenegotiated agreement on the fixes. Then, the House would vote to adopt an additional bill, modifying the enacted Senate-based bill consistent with the negotiated agreement. The "reconciliation bill" would then go to the Senate for adoption in the reconciliation process. Rumors are that the Senate bill plus reconciliation is gaining the most momentum at this time (Emergency Nurses Association [ENA], 2010).

NO QUICK FIXES

Advanced practice nurses (APNs) know that healthcare is (or at least should be) an integrated system. For affordable, universal coverage to work, the financial risk must be spread to decrease costs for individuals requiring Americans to buy at least a basic insurance package. Then, there must be government-supervised exchanges to ensure that there is enough competition among insurers to keep premiums down.

There are still escalating healthcare costs, increased health insurance premiums, and the lack of healthcare coverage for individuals with preexisting healthcare conditions, to name only a few of this nation's ills. There are no quick fixes. But, APNs are on the move to create opportunities to continue to inform legislators and strategizing their "call to action."

NURSE PRACTITIONERS CALL TO ACTION

In 2009, nurse practitioners (NPs) were invited to congressional briefings, regarding the role of APNs in today's healthcare system. The American Academy of Nurse Practitioners (AANP), in collaboration with the American College of Nurse Practitioners, the National Association of Pediatric Nurse Practitioners, the National Organization of Nurse Practitioner Faculties, and the American Nurses Association, sponsored a congressional briefing that promoted the role of the NP in healthcare reform. At this briefing, time was spent educating key leaders about the NP as a licensed independent care provider. Some of the other topics of exchange and dialogue included the (1) need for more primary care NP providers, (2) the role of NPs as leaders in the medical/healthcare home initiative, and (3) the importance for increased disease prevention and health promotion, especially in patients with chronic illness. Healthcare information technology was also discussed at this briefing (AANP, 2009).

Nurse practitioners summarized their visit by stating to congressional leaders that

* healthcare reform in United States needs to include the recognition and utilization of NPs as primary care providers,

* the Institute of Medicine's definition of primary care be used in all proposed legislations and regulations pertaining to the provision of primary care,

* special attention be given to safety net providers who provide care for who would not otherwise have access to care,

* emphasis be placed on the prevention and management of chronic diseases, and

* nurse practitioners be included in the design and development of all healthcare reform models (AANP, 2009).

CLINICAL NURSE SPECIALISTS CALL TO ACTION

Other congressional briefings focused on the role of other APNs, including the nurse-midwife, the anesthetist, and the clinical nurse specialist (CNS). For example, the National Association of Clinical Nurse Specialists highlighted their public policy agenda, which was increase access to affordable, safe, quality healthcare for all, enhance and promote the unique, high-value contribution of CNSs to the health and well-being of individuals, families, groups, and communities, promote the advancement of the practice of nursing; and enhance the nursing practice work environment to increase the culture of safety and quality (National Association of Clinical Nurse Specialists, 2009, p. 1).

EMERGENCY APNs CALL TO ACTION-NOW

In July 2009, the ENA adopted 10 statements called "platform planks." These statements relate to the following issues.

1. Emergency and trauma care systems by supporting regionalized, coordinated, and accountable emergency care, mandating and funding integrated trauma system development throughout the nation, addressing on-call specialist problems resulting from changes in the EMTALA regulations, reducing and eliminating factors contributing to crowding/boarding by addressing both operational and policy issues as systemic problems, and protecting ED health care workers from requirements to report citizenship status of patients presenting to the ED.

2. Health care workforce by increasing funding for the Nursing Workforce Development Programs under Title VIII of the Public Health Services Act at a level to meet current and future health care needs, increasing nurse faculty scholarship funding to develop the next generation of educators and mid-level practitioners and increasing scholarship funding for entry into practice, maximizing education funding for health care professionals who commit to practice in underserved areas, and providing funding for health care worker education to deliver "culturally proficient" care, e.g., ethnic, religion, gender.

3. Information technology by supporting efforts to standardize the electronic interchange of personal health information while protecting the privacy rights of individuals.

4. Insurance coverage by providing a plan for affordable health insurance for the uninsured and underinsured, broadening State Children's Health Insurance Program (SCHIP) to cover all uninsured and underinsured children, requiring a minimum level of insurance to be maintained by all, and providing a tax credit for employers and individuals on their purchase of insurance.

5. Insurance reform by urging state and federal governments to lead the coalition building required for health care insurance reform and promoting insurer and hospital efficiency to create equitable care, i.e., a higher percentage of every dollar is spent on patient care.

6. Preventive health-care health promotion and injury prevention by promoting and increasing funding for the continuum of preventive health care education-"womb to tomb," providing incentives and/or tax credit for focusing on wellness and healthy lifestyles, advocating strategies targeting education/behavioral changes, legislation/enforcement, and engineering/technology approaches to prevent the incidents and severity of injuries.

7. Primary care by supporting funding of incentives to develop a primary care workforce sufficient to meet the nation's health care needs, promoting national access to primary care through the enhancement of services by local community health centers and neighborhood clinics, supporting and increasing the use of advanced practice nurses in appropriate settings, eliminating barriers that prevent (a) the triaging of patients from the ED to primary care health facilities and (b) expediting care within the ED, advancing a continuum of quality care for patients with mental illnesses and substance use disorders, including collaboration among EDs and community-based programs engaged in building and maintaining a coordinated system of services, and advocating for access to chronic disease specialty clinics.

8. Reimbursement by establishing a dedicated funding to reimburse hospitals for the financial losses incurred by providing uncompensated emergency and trauma care and stabilizing and increasing reimbursement to providers and hospitals sufficient to meet costs.

9. Tort reform and medical errors, and the containment of alternative dispute resolution programs-involving nurses and physicians-to resolve malpractice claims outside of the court system, or sort out the merits of a case before it enters the system and supporting systems-based improvements to reduce errors, the development of standards of safe staffing practices to maintain quality patient care, and the active participation between the government and health care providers to make the U.S. health system safer with improved outcomes for patients.

10. Utilization of the health care system by providing funding for public education on the appropriate utilization of the health care system from cradle to grave, mandating health care plans to address patient accountability for appropriate use of health care resources, for example, proper use of the ED, fostering continued transparency of health care performance measures and corresponding reimbursements, advocating for standard definitions of health care performance measurements; and providing for case management system with sufficient resources to manage patients' crises without the intervention of a separately organized emergency service. (ENA, 2009, pp. 1-3)

In a February 2010 article, "Can Nurses Drive Health Reform?" the president and CEO of the Robert Wood Johnson Foundation reported that their organization commissioned a nursing survey because of the importance related to "expanding the leadership of nurses and tapping into all the wisdom and expertise that nurses have [which] is critical to healthcare reform and the healthcare system" (Simmons, 2010, p. 1). In this Gallup Survey of 1,500 opinion leaders, nurses were viewed as one of the most trusted sources of health information, but they were not always perceived as being the most influential with regard to healthcare reform. This was from the perspective of government, insurance, and pharmaceutical companies (Simmons, 2010). However, many nursing leaders believe that the sentiment is changing now, about how nursing leaders are influencing healthcare reform, policy, and research today. In addition, there is new evidence that has identified that nurses now have more influence regarding access to care, healthcare costs, and system efficiency.

Furthermore, patients have embraced the roles of APNs. In a recent New York Times article, Linda Aiken, Professor of Nursing and Sociology, who directs the Center of Health Outcomes and Policy Research at the University of Pennsylvania, noted that patients were extremely pleased with the care provided by APNs. Dr. Aiken reported,

There's never been a problem with consumers thinking they're getting second-rate care with nurse practitioners. Quite the opposite. Patients who were cared for by nurse practitioners were more satisfied, some studies have found, and they believed nurse practitioners did a better job at patient education and communication. (Andrews, 2010)

Emergency APNs stand ready, willing, and able to be part of the solution in the care of emergency patients. As the topic of reform continues to unfolds, emergency APNs need to be recognized as part of the healthcare reform process in the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community (Institute of Medicine, 2001).

Emergency APNs must be included in legislative initiatives that involve the definition of the care provider with regard to not only reimbursement but also programs that may emerge from the congressional efforts to reform the healthcare system currently being discussed. Emergency APNs must continue to keep healthcare reform issues alive for the sake of the 119.2 million patients who visit our EDs annually (National Health Statistics Report, 2008). As advocates, our patients are counting on us-to be their voice; so, nursing must speak with one voice.

Our representatives need to hear from us now. We are the providers of healthcare. It is our responsibility and our duty to ourselves and to our patients to make our concerns known-today!! It is imperative that emergency APNs included "at the table" as part of this reform movement. One easy way for ENA members to stay abreast of the issues and know whom to contact is to visit the ENA Legislative Action Center at http://www.ena.org.

As we move toward this next phase of healthcare discussions, let us emerge as the visionaries for healthcare's future and for next generation of care in the United States. Emergency APNs intersect every aspect of healthcare from prehospital and emergency care to preventative care (e.g., injury prevention). Emergency APNs provide consistency and continuity. But, the bottom line is that patients trust nurses. This is an area we need to capitalize on when we speak to our healthcare constituents. If we fail to do all this, our resuscitation efforts-to restore life to an ailing healthcare system in the United States-will have failed again, just as they did in 1993.

Note

H.R. 3590-The Patient Protection And Affordable Care Act was signed into law March 21, 2010

K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP

Jean A. Proehl, RN, MN, CEN, CPEN, FAEN

Emergency Nurse Practitioner, St. Mary Medical Center, Long Beach, CA

Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, Lebanon, NH

REFERENCES