David M. Keepnews

Policy Perspectives of Major Nursing Organizations

Understanding the roles of interest groups is an important element of examining policy change. There are a number of interest groups that affect the policy environment for nursing and that shape the profession’s impact on health policy. This article is the first of a series featuring interviews with executive directors/chief executive officers of three major nursing organizations, focusing on their policy priorities and how these priorities are determined. The three organizations featured in this article are the American Nurses Association (ANA), the American Association of Colleges of Nursing (AACN) and the National Council of State Boards of Nursing (NCSBN).

Occupational mix adjustment: a risky plan. Some hospitals may hire fewer RNs as a result of recent legislation.

Some hospitals may hire fewer RNs as a result of recent legislation.

A fresh approach to an old issue.

N ew York nursing organizations are actively supporting a proposal that merits close attention. The proposal takes a fresh approach to an old issue— advancing educational requirements for professional nursing practice—by moving to require registered nurses (RNs) to earn a bachelor’s degree in nursing within 10 years of initial licensure. This proposal, first advanced through the state’s Board for Nursing, is currently being considered in both houses of the state legislature. More than 40 years since the American Nurses Association (ANA) first proposed the bachelor’s degree as the minimum educational requirement for professional nursing practice, debate over entry into practice has long been at a standstill. To be sure, much has changed in nursing education since 1965—most dramatically, the virtual disappearance of the hospital-based diploma programs which were then predominant, and the rapid growth of associate degree-granting community college programs, which today produce a majority of new nursing graduates. However, at the level of public policy, there has been little perceptible change in licensure requirements for basic nursing practice (with the exception of North Dakota, the first state to adopt a requirement for new RNs to hold a bachelor’s degree in nursing— a requirement that was recently rescinded). Nursing’s lack of progress in advancing its educational requirements stands in contrast to other health professions, including pharmacy and physical therapy, which have moved to require doctoral-level education for their new practitioners. And outside of the United States, a growing list of countries, states, and provinces (including the Philippines, Australia, Ontario, and other Canadian provinces, among others) now require baccalaureate education. The topic of entry into practice has been an uncomfortable one for many, not just because of the profession’s inability to make substantial progress on this issue but also because of the depth of emotion that the subject brings out. The issue devolved some time ago from being about the advancement of the nursing profession to being perceived as demeaning and downgrading nurses with associate degrees or diplomas. That perception—accurate or not—has long stymied productive discussion of entry into practice. The proposal currently being advanced in New York State would not change requirements for entry into practice. It involves a significantly different approach, one that maintains current educational routes into nursing practice while setting a uniform standard for experienced nurses. Its application would be entirely prospective—it would apply only to individuals who enter nursing school after the proposal has been enacted. This approach finds precedent in current New York requirements for public school teachers, who must hold a bachelor’s degree to be initially certified to teach but must earn a master’s degree within 5 years to obtain a more permanent credential. Policy, Politics, & Nursing Practice Vol. 7 No. 1, February 2006, 4-6 DOI: 10.1177/1527154406286891

Developing a Policy Brief

A policy brief is a document that provides a succinct explanation and analysis of a policy issue or problem, together with policy options and recommendations for addressing that issue or problem. This article provides an explanation of what a policy brief is, how it is used, and how it is developed.

Canada’s Insite Decision A Victory for Public Health

Recently, the Supreme Court of Canada delivered an important victory for the public’s health when it ruled that Insite, a harm reduction program in Vancouver, British Columbia, should be allowed to remain open (Austen, 2011). Insite serves as a safe injection site for injection drug users (IDUs). Among its services, it provides clean supplies, including clean syringes, with which users can inject their own “preobtained” drugs in a supervised setting. Nurses and other staff are available to intervene in case of overdose or other health problems. The program also serves to connect IDUs with primary care services, mental health treatment, and addictions counseling. An affiliated program provides detoxification services for IDUs who want to stop using drugs. Canada’s Controlled Drugs and Substances Act (CDSA) includes criminal penalties for possession of or trafficking in illegal drugs. It also allows the Minister of Health to grant an exemption for medical and scientific purposes. Insite opened its doors in 2003 under an exemption granted by Canada’s Liberal government. Insite is located in Vancouver’s downtown eastside, an area known for widespread drug use. Opening a safe injection site there was a measured response to address some of the myriad health and social problems facing the community. The program reflects principles of harm reduction for IDUs: instead of limiting services to drug users who are ready to stop using, Insite provides a means to reduce some of their major health risks, not the least of which is the risk of acquiring and transmitting HIV and Hepatitis C through shared injection equipment. It is the same approach that has driven syringe exchange programs in the United States and elsewhere. U.S. readers may recall that Congress had banned federal funding of such programs starting in 1998 but lifted this ban in 2009, amid mounting evidence that syringe exchange programs reduce transmission of HIV and Hepatitis C with no apparent increase in drug use or crime. Vancouver’s Insite had also amassed significant research in support of the efficacy of safe injection sites—including research on Insite as well as sites in Australia and other countries (Health Canada, 2008). Insite’s initial exemption under the CDSA expired in 2006. It received two extensions, but its 2008 exemption application was denied by the Minister of Health in Canada’s Conservative government. Insite had won a favorable ruling in court, including a further exemption. After the federal government’s appeal of that ruling was dismissed by an appellate court, the government appealed that dismissal to the federal Supreme Court. Section 7 of the Canadian Charter of Rights and Freedoms declares that “Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.” In its decision, rendered on September 30, the Supreme Court of Canada ruled that denying Insite an exemption from federal drug possession and trafficking laws was indeed “not in accordance with the principles of fundamental justice.” The Court’s decision focused on a single program in one Canadian city, and it necessarily rested on interpretation and application of Canadian law—its federal Constitution and its federal drug laws. But the decision holds important implications for harm reduction efforts beyond Vancouver and beyond Canada. Insite is the first safe injection site in North America. The Court’s decision is likely to encourage programs in other parts of Canada to seek exemptions that will allow them to open safe injection sites. But the ruling is also an important vindication of the public health principles underlying harm reduction efforts. On behalf of a unanimous Court, Chief Justice Beverley McLachlin wrote that the effect of denying Insite an exemption “would have been to prevent injection drug users from accessing the health services offered by Insite, threatening the health and indeed the lives of potential clients.” She further wrote that

Evaluating Nurse Staffing Regulation

Ongoing research on the impact of nurse staffing regulation can yield important information that can guide continued staffing policy efforts. Understanding the impact of such efforts should include evaluating the outcomes of recent legislation in Oregon and Illinois as well as continued examination of staffing ratios in California. Successful efforts will need to transcend traditional boundaries between researchers, policy analysts, advocates, and organizations.

Bringing Nursing Leadership to Shaping State Policy: An Interview With Virginia Trotter Betts

In this interview, Virginia Trotter Betts, JD, MSN, RN, FAAN, a former American Nurses Association (ANA) president who has served in leading national health policy roles, discusses her current role and experiences as Commissioner of the Tennessee Department of Mental Health and Developmental Disabilities.

Policy Perspectives of Major Nursing Organizations, Part II

Understanding the roles of interest groups is an important element of examining policy change. There are a number of interest groups that affect the policy environment for nursing and that shape the profession’s impact on health policy. This article, the second of a two-part series, presents interviews with executive directors and chief executive officers of major nursing organizations about their organizations’ policy priorities and policy-related activities. Included in this article are the American Organization of Nurse Executives, the National League for Nursing, Sigma Theta Tau International, and the National Black Nurses Association.

Medicaid Expansion and the Victims of Partisanship

As implementation of the U.S. health reform law—the Affordable Care Act (ACA)—continues to move forward, partisan cries to repeal the law appear to have died down considerably. This is not surprising; for the most part, repeal efforts were never serious. The House of Representatives, with a solid Republican majority, easily passed more than 40 proposals to repeal or defund the law, but no one expected the Senate, with its Democratic majority, to follow suit. And even if the Senate had somehow joined the House in voting for repeal, no rational scenario would have included President Obama signing a bill to erase his major domestic policy achievement. Rather, repeal efforts have been symbolic—a way for some members of Congress to demonstrate their continued opposition to “ObamaCare.” That may have made sense earlier. But while many Americans still have some concerns about the law, most support the idea of making changes to improve it rather than repealing it. Thus, calls for repeal have lost their political value and have been largely abandoned in favor of other opportunities to oppose Administration policies. In June 2012, the U.S. Supreme Court cleared the way for implementation of a central aspect of the ACA when it refused to invalidate the “individual mandate”—the law’s requirement that most people who are not otherwise insured through their employer or a government program must purchase insurance coverage. By a 5–4 majority, the Court rejected arguments that Congress exceeded its authority under the U.S. Constitution by enacting this individual mandate (National Federation of Independent Business v. Sebelius, 2012). At the same time, the Court invalidated another important part of the ACA: the requirement that states must adopt an expanded standard for Medicaid eligibility. Medicaid, a program of medical assistance for many of the poor, is administered by each state with both federal and state funding. While states have considerable latitude in operating their Medicaid programs, they do so while meeting some federal requirements for eligibility for the program, the range of services offered, and other standards. The ACA created a new, clear, minimum standard for eligibility—requiring states to cover anyone whose income fell below 138% of the Federal Poverty Level. Once fully implemented, this change was expected to cover as many as 17 million uninsured poor people. And the terms for doing so were generous to the states—100% of the additional cost to the states is covered by the federal government until 2014, when it goes down to 90%. The law provided that the consequences for any state that refused to participate in this expansion—that is, for declining to cover large numbers of uninsured poor people, under extremely favorable financial terms—could be exclusion from the Medicaid program.

Protecting and Expanding Medicaid

In June of this year, the U.S. Supreme Court issued its muchawaited ruling on major legal challenges to the Affordable Care Act (ACA), the health reform law passed by Congress and signed into law by President Obama in 2010 (National Federation of Independent Business v. Sebelius, 2012). The Court ruled that Congress acted within its constitutional authority in enacting a key component of the ACA—the requirement that individuals not covered by private or government-sponsored insurance be required to purchase health insurance. Had the Court ruled otherwise, progress on health reform in the United States would have been turned back overnight. Understandably, the Court’s ruling to uphold the ACA and its individual mandate has garnered considerable attention. But the Court also ruled on another important provision of the ACA. The health reform law included a major expansion of Medicaid. A joint state–federal program administered by the states, Medicaid provides health care coverage to millions of America’s poor. The federal government provides over half of the funding for this program; states provide coverage within a framework of minimum federal requirements, with the ability to provide more generous benefits and eligibility if they choose. State participation in Medicaid is voluntary— states are not required to participate, although all currently do. The ACA requires states to expand Medicaid eligibility to individuals with incomes below 133% of Federal Poverty Level beginning in 2014. This Medicaid expansion was projected to provide coverage to 17 million uninsured Americans. States will receive substantial funding for this expansion—100% of the cost of this expansion for the first 2 years, going down to 90% in 6 years. The ACA included a powerful mechanism for enforcing this requirement: any state that failed to comply could face the prospect of losing all its federal Medicaid funding. The Supreme Court, by a 7-2 majority, found this penalty “coercive” and outside of Congress’s authority. Justices Ruth Bader Ginsburg and Sonia Sotomayor were the sole dissenters from this ruling. The Medicaid expansion remains part of the ACA, effective in 2014. But as a result of the Supreme Court ruling, the powerful enforcement mechanism it authorized—loss of Medicaid funding for noncompliant states—will not be available. The generous federal reimbursement levels to fund this expansion make it too good a deal for most states to pass up. Yet some states have declared that they will refuse to expand their Medicaid programs. How many states will actually punish their own residents (and their state budgets) and how many will instead forego this political grandstanding before 2014 remains to be seen. At the same time, proposals supported by some political leaders would, if enacted, fundamentally change the character of the Medicaid program by transforming it into a block grant program. Earlier this year, the federal budget proposed by House Budget Committee chairman Paul Ryan (R-WI)— who is now the Republican candidate for vice-president— would have reduced federal funding by US