A little while back some of you may remember a little things called the Health care reform discussions, and if you don’t it might be time that you moved out of that cave you’ve been living in.  Anyway after a hiatus of many years from my ever now and then legislative visits to our Nation’s Capitol I was well enough to endure a flight out to DC, and thanks to my electric scooter (for which my daughter had to personally shell out nearly $2,000 to buy so I might have a modicum of freedom – thank you Adventist Health) I was able to scurry around the halls of our Nation’s Capitol and meet with various legislators and their aides and provide them with this nurse’s point of view on the health care discussions that were ongoing at that time.

Since I’m a California resident I always make a point to visit my representative who translates into Senators Boxer and Feinstein and Congressman Schiff, but since health care reform isn’t an issue limited to California, or just to Democrats or Republicans I also made a point to visit other Senators and Congressmen/women.   Over the years I found that even though Senator Feinstein is a Democrat, she and by extension her staff make a concerted effort to at least provide the appearance of listening to the opinions of the non-Democrats that comprise our fine State, the same unfortunately cannot be said for Senator Boxer or her staff.  There has been an ugly trend in her office for her staff to present an attitude of condescension to those who are of a different political persuasion then their boss.  This was never more apparent than my visit to her Hart Office.

I arrived on my scooter to follow-up on the appointment request that I had faxed several weeks early to her DC office.  The receptionist declared that no such request had been received, but when I presented her a copy of the request (received receipt an all) she amended her statement of denial to include that it had been received by the wrong fax machine in their office to which I responded and no one had the ability to put it in the correct person’s inbox?  Shamed by my assertion and at her obvious dereliction of duty she finally acquiesced to my request that I speak with someone from the Senator’s health care team, she hastily picked up the phone, called someone and shortly afterwards a young woman came out to meet with me in the reception area.  I introduced myself and asked the young woman to take a seat on the couch so I wouldn’t have to crane my neck upward to speak with her, but lacking all understanding of socially appropriate behavior she insisted on standing, thus towering above me and forcing me to look up for the duration of our conversation.  She paid little attention to what I had to say and after she interrupted for a second time to demand that I simply give her a one-line statement on my position since of course she was a very busy person.  I took a breath, gathered my thoughts and politely told her that as a RN and a healthcare expert I would not boil it down to “one-liner” for her, but since it was apparent that she didn’t give a damn I would end the conversation.  She tried to collect herself and continue the discussion, but for me there was no reason to continue why should I waste my time and energy on a person who had such obvious disdain for a constituent who held a differing opinion from her “illustrious” leader, Boxer.

So off we went to meet with other Congresspeople, including Senator Feinstein, whose office at least attempted to present to their constituents that they cared about their opinions even if those opinions diverged from their own.

Thus after spending several days wandering the halls, thanks to my electric scooter, and meeting with numerous elected representatives I concluded that Boxer’s office staff by far was the rudest and least hospitable to people and they win the award for “the worse office on the HILL”

On Tuesday, March 23, 2010 President Obama signed H.R. 3590, the Patient Protection and Affordable Care Act (PPACA) into law, and a collective sigh of relief could be heard, or was that a cry of despair that swept across the land?  Well it really does depend on which side you were championing, but it’s this columnist humble opinion that the real impact, value, benefits and whatnot of H.R. 3590 is far in the future and many of us may not be around to see how this scheme plays out; but let’s try to do a little crystal ball gazing.

Many of my readers may recall my two-part article “The Grass is Always Greener” that ran in the January 2008 and February 2008 issues of Working Nurse.  I believe that I made it quite clear in this two-part series that I wasn’t in favor of the so-called healthcare overhaul, and after watching and participating in last year’s discussions, town halls, real or manufactured, and debates too numerous to name I can firmly state that I’m still not in support of the overhaul especially not the one that has been saddled upon our citizenry and several future generations of citizens of our nation.  Gasp!  How can I a 30+year veteran of the nursing profession not be in support of this gracious gift bestowed upon us by our much wiser and worldly elected members of Congress?  You may think that I was oblivious to the pronunciations of such illustrious membership organizations such as the American Medical Association (AMA) and the American Nurses Association (ANA) which threw their full weight behind the President’s plan, but the reality is that neither organization represents a majority of their respective professions; and I was well aware of the Democratic-controlled Congress’ monumental plan to create out of whole cloth a Health Care bill that would become the law of the land.  Well, I know I’m not the only nurse that doesn’t see the ANA as a significant other in my career as a nurse and strongly oppose their choice to advertise that they “represent the interests of nearly 3 million nurses”, when the fact cannot be further from the truth with their actual membership being around 11% of America’s 3 million nurses; the AMA is not much better with a membership around 17% and yet choosing to present a “face” to the American people that they “speak for” the majority of physicians when they too fall far short of this grandiose promise.

Such examples “hyperbole” weren’t the sole domain of the proponents, but the opponents of what would later become known as the Patient Protection and Affordable Care Act (PPACA) as well.  Newspapers, Radio talk shows, daily newscasts and bloggers weighed in and their reports were replete with news stories and opinion of all types about the good, the bad and the ugly that was being discussed as the bill was being drafted and debated.  Many held out great hopes that the bill, when it finally reached the President’s desk for his signature would usher in Health Care nirvana for all (well at least all legal US residents, that is).  As I watched and listened to the various pundits – those from the left, the right, the far left and far right – I quickly concluded that this bill would be the proverbial elephant as described by a trio of blind men and H.R. 3590 did not disappoint.

I think that pretty much everyone I know and even strangers that I spoke with seemed to unanimously agree in the need for some kind of health care/health care insurance reform, but these same individuals were rarely of the same voice as to “the what” that change should be and I think the theatre that was health care reform discussion put on by Congress this past year was a mirror of that very same elusive “what”.  Ironically, the most ardent supporters of health care reform, such as President Obama, Speaker Pelosi, Majority Leader Reid, and others quickly dubbed the Republicans as the Party of NO when it came to the health care reform-taking place in Congress.  One only had to do the math, so to speak, to realize that Pelosi and Reid didn’t need a single Republican vote (up until Massachusetts sent their first Republican to the Senate in who knows how many decades) to pass their respective bills.  In the House the holdouts that were putting a crimp in Pelosi’s scheme were the “Blue Dog” Democrats who were the real members of the Party of NO, which is one of the reasons the Public were treated to such a circus throughout the health care reform discussions.  Most Americans were unaccustomed to the deal making, arm twisting, and at times heated language that our “Honorable” legislators can and do engage in when dealing with legislation making, and this time was no exception; except that the American people had been promised transparency, being able to view the debates and discussion on CSPAN, five days to review any bill on line before it was signed into law and so forth by the President and Party they swept into power in the last Presidential election.  I also think the American people were not prepared to be pilloried, insulted, and demonized by their very own members of Congress when they confronted these members at the August Town Hall meetings, in their Congress people’s offices or during protests, at one point a clear majority of American’s opposed the proposed legislation and yet many of our elected officials pontificated that “those folks just don’t what’s good for them, and that it rested on Congress to make things right”.  French history has a similar episode – It is said that Marie-Antoinette upon learning that her subjects had no bread to eat is said to have responded with the now notorious quote “Qu’ils mangent de la brioche” (better known as “let them eat cake”).

Indeed the summer of 2009 could be characterized as the summer of discontent, with many Congressman and women shying away from holding any formal meetings to help educate, answer questions and provide an open and free dialogue.  Senator Specter at one such town hall, which was televised, made a comment that shocked me when I heard it, what was his comment, you may wonder?  In response to an audience member about another meeting the Senator was to attend, the Specter responded in the vein of “he didn’t have to be there or go there” to which the audience erupted with comments of “that’s what he was elected to do, it was his job, etc.”  My own Congressman held, to my knowledge, only one town hall in Alhambra in an outdoor venue, that was originally suppose to be indoors, and hundreds of people stood in the sweltering August heat, under the blistering sun for hours before the meeting began in hopes of a town hall meeting.  In the end it was revealed that Schiff had organized a panel of proponents of healthcare reform, and the almost one hundred seats that were available had been reserved for the handicapped.  The very same seats which would later be filled by mostly bussed in supporters of the bill under discussion.  Such machinations marked many a town hall meeting, which only inflamed the public even more, convincing many that there was “evil” afoot, and the sociologist in me would have to agree.  Town Halls historically are small gatherings of citizens to discuss issues concerning the citizenry; these meetings are not usually orchestrated with individuals being required to show proof that they are constituents (we were told to be prepared to show proof that we were indeed constituents at my town hall), nor is there usually panel convened to “educate” the citizenry, or limits to the number of questions asked, holding telephone town halls instead of “live” meetings and so forth.  However there were Congress people that did brave both the ire and support of their constituents, and where this respect was shown these meetings seemed to have a more positive outcome with people agreeing that it was okay to disagree without having to be disagreeable.  One could almost judge the position of the Congressperson on the Health care reform bill by simply observing the attitude that Congressperson had towards the participants in the meeting.  Thus it was no surprise to me when the lines were drawn that those who supported Health Care reform were the enlightened and those opposed were described as “Brown Shirts” or “Astro-turf”.  These pejoratives did little to foster an open dialogue, and soon it appeared as though Health Care Reform was D.O.A.

Flash forward to March of this year and voila health care reform is the law of the land, and though HR 3590 and the companion reconciliation bill were signed into law there are still many unanswered questions and of course legal challenges.  Now that the bill has been signed into law, nurses, physicians and other frontline healthcare providers are going to bare the brunt of these changes, both good and bad.  This nation has had a chronic nursing shortage, and the last decade has seen a growing physician shortage (specifically General Practitioner/Primary Care physicians) these shortages will only be exacerbated by the passage of the PPACA.  There is talk that the roles of nurse practitioners (NP), physician’s assistant (PA) and even Naturopathic Doctors (ND) will need to be expanded in order to meet the needs of a nearly estimated 34 million people that will be added to the rolls of the insured, and many state legislatures are taking the expansion of the role of NP and PA’s under consideration.  This expansion of the roles of the above care providers will no doubt be met with resistance from the medical and nursing communities; one only needs to attend a local chapter meeting of the California Association Nurse Practitioners (CANP) to become educated on the frustrations and roadblocks that CANP has often faced when trying to make “simple” changes, including trying to codify a nurse practitioners scope of practice separate from our state’s current nurse practice act which has faced defeat at every turn to date.  At present Congress seems to think they can wave a magic wand and legislate wholesale changes to state’s regulation of both medical and nursing practice, which may prove more difficult then the passage of the PPACA, since we have no national physician or nurse practice acts, as these have been the purview of the states.  Additionally, though one can offer huge sums of federally funded grants and dollars to increase the physician and nursing educational pipeline, it still takes time to “backfill” and then reach the saturation point where we are educating and graduating enough nurses and physicians to meet growing demand as well as keeping pace with those leaving the field.  Add to the mix that at least twenty states (California is not one of them) have signaled that they may opt out of the high-risk pools that were meant to allow individuals with pre-existing medical conditions and chronic disease to buy health insurance, as well as the fourteen states (again California is not one of these states) that have filed suit claiming that the law is unconstitutional which may make the implementation of the PPACA long and laborious.  During the numerous legal battles that will doubtless continue to arise in response to the passage of PPACA nurses can and must continue to act as advocates for not only the patient but for the profession.

As a French native I’m not eager to see us adopt a French-style system, nor am I blind to the weaknesses of our health care delivery model.  In this debate, I’m what would’ve been described as an incrementalist, thus I didn’t support the sweeping changes pushed by one side nor doing nothing as others argued.  In many of my early writings I often used the following example, when a gardener finds himself or herself confronted by an ailing rose bush does he: a.) Pull out the entire bush and replace it with a new rose bush; or b.) Prune back the bad branches thus allowing the stronger, healthy branches to grow.  If instead of all the partisan bickering, ones-up-manship and spinmeistering that seemed to consume Congress this past year, the American people would have been better served if Congress had spent their energies on incremental change that would’ve delivered more bang for their bucks.  Just think what impact Congress could’ve made if they’d simply chosen to legislate that all insurance forms be delivered in a standardized format, imagine the trees we could save if they made electronic medical records the law of the land (France is one nation that’s been way ahead of this curve with all its citizen having the medical information available on a secure electronic card for longer than I can remember), or that all hospitals, clinics, labs etc., use a cost system similar to the DRG where doctors and patients alike would actually have a real grasp of the cost of treatment, or even allowing health insurance to be truly portable and purchased across state lines.  These four changes appear small, but have a much larger impact, unfortunately Congress was looking for the “grand gesture” and thus PPACA was born, a bill that far too many of our Congressmen and women have yet to read in full and who can blame them the bill is well over two-thousand pages.  Perhaps if they had read their bill they might have discovered for example that neurologists had been left out of the key categories that would qualify for reimbursement.  Opps!   No worries we’ll go back later and fix that little glitch, sounds just like what every homeowner faces when they remodel their home it never seems to come in on time or on budget, which is one of the primary concerns of so many Americans – cost and deliverables.

So lets take a quick and “dirty” look at some of the deliverables of PPACA:

Changes to take place this year – 2010

Perhaps the most notable change is that children and adults previously denied coverage due to pre-existing conditions would be able to access healthcare insurance, this would be accomplished by the establishment of high-risk pools.  These high-risk pools are to be Federally subsidized, but the “how” and “when” is yet to be established,

Lifetime maximums are now a thing of the past,

Insurance can no longer drop an individual if they become ill,

No more annual limits, which benefits those with catastrophic illness,

Children up to the age of 26 can stay on their parent’s plan,

Small business offering insurance can apply for a 35% tax credit from the premiums paid,

New plans written during this time period would have to offer preventive care with no co-pays or deductibles,

Medicare D participants will receive a $250 credit to help with the “donut hole”, and

Retirees aged 55-64will be offered access to a re-insurance program.

Next year (2011)

Medicare must provide plans with preventive care with no co-pays or deductibles

Medicare Part D participants will receive 50% off drugs falling in the “donut hole”, and

Health insurance companies will have to justify any premium increase or risk the possibility of being taken out of the state’s insurance exchange pool.

What happens in 2014

AN IRS penalty of $750 per individual or 2% of income (whichever is greater) will occur for those who choose not to purchase health insurance,

No one can be denied access to insurance for pre-existing conditions,

The temporary/state high-risk pools are gone as states will be required to have their insurance exchanges in place, and

Annual caps on benefits are now banned completely.

What happens in 2018

All plans must offer preventive care with no co-pays or deductibles,

Expect ongoing and possibly very contentious discussions regarding what PPACA does and does not “do”, as so often happens with legislation much of the legislative language can be “spun” to bolster or weaken one side or the other’s argument.  As nurses we can’t and shouldn’t dismiss the impact that this bill will have on our profession, the patients we care for or the institutions we work in because it’s far from a panacea for what ails our nation’s health system.  We have a crippling nursing shortage, a growing physician shortage, many hospitals and clinic are closed or closing and I see few provisions in the PPACA that are meant to address these issues.  Don’t expect to see our Emergency Departments (ED) “decompress”, because I doubt the average patient is willing to wait days or weeks to see their Primary Care Physician.  Remember when HMO’s were billed as being the great salvation to ending the crush of patients that used the ED as their source of primary care and this hypothesis was been proven flawed.  Recently, the New York Times reported the following with this ominous headline – “Health Care Cost Increase Is Projected for New Law”.  The chief Medicare actuary, Richard S. Foster, was quoted in the NY Times article to have said “Overall national health expenditures under the health reform act would increase by a total of $311 billion,” compared with the amounts that would have otherwise been spent from 2010 to 2019, which contradicts President Obama’s statement that it would “bring down health care costs for families and business and governments” which was made at the bill signing last month.  Foster went on to state that though 34 million uninsured people will gain coverage under the law 23 million (including 5 million illegal immigrants) will still remain uninsured in 2019.   Most telling was the following statement from Foster, “these savings assume that the law will be carried out as written, and that may be an unrealistic assumption.  The cuts could become unsustainable because they may drive some hospitals and nursing homes into the red, possibly jeopardizing access to care for beneficiaries”.  The full New York Times article can be accessed here.

As of this moment everyone, including nurses, will have to play a strange game of hurry up and wait, though the law has passed it’s becoming apparent that many of the promises and threats of our elected officials are both real and not to be believed all at the same time.  Recently, when several large companies such as AT&T reported, as required by law, that they would see a loss of profits due to the changes in the law, Congressman Waxman and others held numerous press conferences denouncing these “scare tactics” by several of these large companies, demanding and even scheduling hearings for the representatives to come before Congress and explain themselves only to cancel said meetings later when it was learned that the companies were not engaging in fear-mongering as some in Congress had accused them of but simply complying with the law.  Thus it is apparent that much in this new law still needs to be fully vetted, there is a report available from the Congressional Budget Office (CBO), that can be accessed as a PDF  here.  This report  provides the CBO’s opinion in a letter to Speaker Pelosi dated March 18, 2010 on both the PPACA and the companion reconciliation bill and yet concludes “Although the CBO completed a preliminary review of legislative language prior to its release, the agency has not thoroughly examined the reconciliation proposal to verify its consistency with the previous draft. This estimate is therefore preliminary, pending a review of the language of the reconciliation proposal, as well as further review and refinement of the budgetary projections.”

So whether PPACA remains whole or suffers from changes and amendments due to successful legal challenges or is found to be unconstitutional on its face by the Supreme Court the actions that brought PPACA may have changed our political and healthcare landscape for generations to come.  As nurses we will find ourselves, as so many others who deliver healthcare, in the heart of the mix, and thus can best serve our patients and ourselves by educating ourselves on what PPACA entails.  There is a real need to look beyond the rhetoric and opinion and learn to separate the “hard” facts from the “soft” facts, and the fact from the fiction our patients deserves this and we need this in order to be the best possible healthcare advocates that we can.  As nurses we should continue to monitor all media venues to gather and sift through all the data so we can comprehend the impact of PPACA, attend meetings that will surely sprout up to help “explain” PPACA, and think about setting aside some time during the next few weeks, draw yourself a bubble bath or brew a big pot of coffee and read the 2,000+page law that is the PPACA and educate yourself on this law that has already sent ripples through our healthcare system – our patients and our profession deserves

After reading this post, one might think that I have a bone to pick with the editors, and some reporters of the Los Times – and you’d be right!

For years, it has been my opinion that when it comes to nurses, nursing unions and the nursing profession the LA Times has been inconsistent and at times down right off in left field when it comes to nurses.  My disagreement with the LA Times on this topic goes back many years, and started with an article they ran on nursing which reported, incorrectly, that the American Nurses Association (ANA), was some how representative of all California.  When I read this article I quickly responded with a letter to the editor and provided them with data from the ANA itself showing that less then 11% of all active RNs were members of the organization nation wide . Did they run this letter, of course not, but they did run a very small correction in the Home section of the paper much later.  The correction was so small it barely served as a correction at all since it was so small it was all but insignificant and surely hardly worth the ink that was used to print it.  This episode would mark my first, but far from my last, run in with the LA Times Reader Advocate, Ms. Gold.

Over the years, I’ve been vigilant and responsive to articles that have run in the newspaper especially when those articles shed a bad light on nursing that was not deserved, or glossed over what were gross nursing mistakes because those nurses worked in some venerated institution.  For far too long all forms of media have relied upon groups such as the ANA, California Nurses Association (C.N.A.) and other such ilk to provide them with data and information on all things nursing.  I’ve nothing against the media citing these and other organizations as sources of information, they are after all groups that represent nurses and thus have some expertise in the nursing arena.  What’s wrong is when the media blindly cite suspect facts from these organizations with little effort to fact check the organization’s statements.  Such as when the ANA purports to represent the interests of the almost 3 million RNs; or when the C.N.A. labels itself the voice of the California RN – when neither of these facts are accurate, let alone true.  When individuals such as myself take the time to educate the media and provide them with the correct statistics and facts the response is often the proverbial paternalistic pat on the head, as if we’re somehow ignorant but well-intentioned children.

Equally frustrating is when the media soft peddles the mistakes or bad deeds of an organization or institution they consider venerable.  Not that long ago the LA Times and various other media outlets barraged us with the numerous medical and nursing misdeeds of the now defunct King-Drew Medical Center (KDMC).  Now granted there were many serious medical/nursing and even management errors occurring in this institution, and the press would have been remiss if they failed to report the story aggressively.  However, when two nurses at Cedars-Sinai nearly offed a handful of infants, including the Quaid twins, little was really covered.  Oh yes, there was front-page article about the initial incident, then there was at least one or two “follow-up” articles.  What I found striking about the handling of the nursing errors at both hospital was the way the articles were spun.  Granted KDMC’s problem were nearly endemic, but the heparin incident at Cedars was also on a grand scale, but the article spun this serious nursing error and breech of nursing protocol as well there have been other heparin incidents and these are primarily due to the labels not being different enough between the adult and children dosages and the fault was much more a “labeling” issue and not really the fault of Cedars-employed nurses.  As a RN I took issue with this redirection of blame, because as someone who had administered more than once dose of Heparin to infants during my career I knew precisely where the blame for this error lay, and it wasn’t with the labeling – it was squarely on the shoulder of the two nurses who failed to not only read the label, but to also implement the time honored and basic nurse practice of double checking of certain drugs (heparin being one of them).  What is this double-checking I speak of, simple the first nurse checks the order, checks the medication, draws the ordered amount, then another nurse checks the order, inspects the bottle the medication was drawn from and then verifies that the appropriate amount has been drawn, as well as verifying that the correct patient is receiving the medication at the correct time and by the appropriate route all the while placing their initials at the appropriate stages and places (this describes a general overview of the procedure, some hospitals have even more detailed safety protocols in place).  But why come down so hard, nurses are only human, and this was just a mistake.  Perhaps, but Cedars is also a so-called Magnet hospital which is supposed to designate that they have a higher standard for nurses, and such a failure of basic nursing safety protocols is indicative of a hospital that is not worthy of claiming that its nurses are a “cut above”, since the heparin incident is not a “ordinary” nursing error, because as it turned out apparently the mistake happened not once but twice.

Which brings me to the ongoing LA Times investigative report about the California BRN and the handling of nurse licensure.  In its December 27, 2009 – Inept nurses free to work in new locales (http://www.latimes.com/news/local/la-me-nurses27-2009dec27,0,2090185.story) the article took a detailed look at the licensing failures that occur because there’s no real national clearing house, i.e. national nurse license agency which can lead to nurses gaming the system and securing licenses in additional states when they have a suspended or revoked license in another state.  This is a very real problem, since every state is solely responsible for the verification of a nurse who is applying for or renewing their license in that state.  Some states have a better verification system then others, catching a nurse with an out-of-state suspended or revoked license then others (California falls into the not so successful verification system).  As part of their research the LA Times reported interviewed the National Council of State Boards of Nursing (NCBSN), regarding this issue.  The quote from NCSBN that really caught my attention was this one “Officials at the National Council of State Boards of Nursing said they don’t tell nursing boards how often to consult their database.”  But wait a minute the NCBSN is comprised of representatives (most of the Executive Director) from each of our Nation’s state board of nursing!  So what does this quasi-governmental agency really do; I call it quasi-governmental and not non-profit since it appears that its board is comprised entirely of representatives of governmental agencies.  In my opinion very little is done to truly protect the nursing profession and the patients we care for, since when the Philippine test stealing scandal broke in 2006 the NCBSN stayed relatively silent on the matter (I wonder if this had anything to do with the fact that the NCBSN was in the process of opening an NCLEX testing center in that country?), if not for the local Philippine Nursing Association, the Association of Nurse Executives and a handful of nurse activist such as myself very little would have been done to force a retest of the suspect exam period.  The NCBSN finally took a stand after the fact, so much for serving as a watchdog.

Though I think that its important that the LA Times reveals failures of our system of checks and balances, I think it’s equally important that they aggressively investigate agencies such as the NCBSN, that our BRN pays fees to and on which the BRN executive director (in this case the interim executive director) is a member of – if it cannot aid its board members to be better advocates for the profession then does it serve a purpose.  Or perhaps the purpose it serves is to continue to charge fees for tests once administered and collected by the individual states thus consolidating power and wealth in the quasi-governmental agency that presents itself as a non-profit?