Nurse Practitioners Make the ACA Work

July 18, 2016

By Arnold Birenbaum
Associate Director Emeritus, Rose F. Kennedy University
Center for Excellence in Developmental Disabilities Education, Research and Services, and
Professor Emeritus
Albert Einstein College of Medicine

The Affordable Care Act (also known as Obamacare and the ACA) has received a great deal of criticism from conservative politicians, and members of the public as well, because it created a new entitlement through the state and federal- based health exchanges and expanded an old one (Medicaid). In addition, some seniors felt that they were going to be competing with newly insured younger folks to get to see the doctor. There is no question there are legitimate professional concerns related to how the health care system will be able to perform with a heavier work load. Health professionals chimed in as well, noting that the fee structure was unfair to them, with some Medicaid services they delivered were at cost or below. Yet to date, doctors are not complaining about being overworked. Health services planning and the increased use of nurse practitioners and other health providers have reduced the likelihood of crowd out.

We must keep aware of challenges of adequate capacity in a health care system where two thirds of Medicare fee-for-service beneficiaries have multiple chronic conditions and make frequent visits to their physicians. While I am a firm believer in the idea that a good doctor is worth waiting for, there are now alternatives to long waits that will satisfy most patient needs. To improve the delivery of services to this population, and to the one quarter of all adults with multiple chronic conditions, the health care system is responding to incentives to restructure services.

The introduction of large numbers of newly insured people, about eighteen million as of January 2016, has not led to complaints of longer wait times between visits or reduced time when seen by a practitioner. This is a particularly important finding when starting up any publicly financed insurance program since individuals who anticipate being insured may delay visits to health care providers until their visits are covered. This was the case when Canada introduced a single-payer system for financing health care and was also observed when Medicare was initiated in 1965.

The ACA promotes increase reliance on mid-level health care providers such as nurse practitioners, a trend established in the 1970s. At the time of the Nixon Administration, the medical profession trained physician assistants to help with the new flow of patients created by Medicare and Medicaid, and unintendedly, stimulated nursing to seek more responsibility as well.

March, 2015 marked the date when Nebraska, soon to be followed by Maryland, expanded the scope of practice of advanced practice nurses. This means that nurse practitioners, and other nurses with doctorates and masters' degrees, can practice primary care without being supervised by a physician. An additional eight states are anticipating changes in their nurse practices act in the near future. These opportunities to expand their practices, that is, ". . . to order and interpret diagnostic tests, prescribe medications and administer treatments," according to a detailed article in the New York Times Science Section, in May, 2015, is very timely since the American health care delivery system has to meet new demands for services, especially primary care.

In managing acute and chronic physical and mental conditions by performing history taking and the physical examination, nurse practitioners, within their scope of practice, diagnose medical disorders, order treatments, perform advanced procedures, prescribe medications, and make referrals. While initially proud of their independence from nursing, nurse practitioners sought to be qualified to engage in their scope of practice by working within the profession of nursing to establish an advanced degree to go with their more complex and responsible practices-The Doctor of Nursing Practice (DNP). In addition, the state nursing associations often lead the charge for advanced-practice nurses so they could get legal approval from state legislatures and governors to write prescriptions without countersigning by physicians. By 2015, twenty states changed their nursing practice law and regulations so that it is possible now for nurse practitioners to work without a doctor's oversight. The adversity created by the short supply of physicians willing and able to do primary care, promoted an opportunity for advanced practice nurses, with at least a Master's degree in Nursing, to step into the breach. The communication skills that they demonstrated went beyond those associated with the more data-oriented physician assistants. Nurse practitioners were absorbed within the profession and an increasingly diversified nursing field was one of the outcomes.

The writers of the Affordable Care Act recognized that capacity building would be important, given the primary care needs of patients, both those with minor health issues and those with multiple chronic conditions. In addition to allocating funds to train primary care providers and to increase Medicare payments for primary care, the ACA made funds available to train what became known as advance practice nurses. Their training would allow them to become care coordinators in what has been called "medical homes," "or health homes," programs which focus on care coordination for patients with serious chronic illnesses.

The ACA's provisions to expand primary care was also necessary because the concept of a medical home, a weapon in the fight against fragmented care, was built on the availability of nurse practitioners to deliver primary care and furnish coordinative services, such as tests and specialist visits, for people with chronic illnesses in the "medical home" model of services. While routine care is part of the mix, providers in the medical home model are trained to act proactively, with a patient-centered team being able to prevent further deterioration rather than effect a cure. Moreover, the patient-centered medical home is designed to meet the needs and choices of patients who want to contribute to their own care plan and who aspire to avoid or reduce their inpatient hospital care.

The ACA made an effort to expand capacity, but it was built on earlier legislation that sanctioned the expansion of primary care using nurse practitioners. The Medicare Modernization Act and Extension Act of 2006, which originally allowed only physicians to be considered primary care providers, was modified in 2008, during the second Bush administration but with the Democrats in control of the House and the Senate, to permit NPs to become care coordinators, especially for people with chronic conditions in the Medical Home Demonstration Expansion. This newly empowered source of primary care, NPs' participation in patient-centered medical homes was endorsed by the American College of Physicians in 2009 so long as these providers were held to the same eligibility and evaluative standards as medical general practitioners. 

Comparative studies of the care delivered by nurse practitioners vs. primary-care physicians have found that NPs can furnish high-quality care and are well-regarded by patients. The AARP, as well as other advocates for consumers support efforts to train more NP going forward.
We can anticipate the increased use of NPs as the idea of medical homes, with the emphasis on intensive care coordination, receives greater consumer acceptance. Finally as more preventive medical services are handed off by doctors so they can concentrate on more complex forms of care, the demand for nurse practitioners should increase. And we can anticipate that the schools of nursing will refocus on education and training of advanced practice nurses.