For the first time in eight years, a new year brings a new administration to the United States. Most Americans, regardless of their political persuasion, seem ready to embrace what they hope will be a complete change from the status quo.
Patients and health care providers alike will be watching to see whether President-Elect Barack Obama, his Cabinet, and the 111th Congress can initiate the wholesale health care reform the nation needs. Clinician Reviews asked American Academy of Nurse Practitioners President Diana “Dee” Swanson, MSN, NP-C, FAANP, and American Academy of Physician Assistants President Cynthia B. Lord, MHS, PA-C, for their perspectives on what’s ahead—and how NPs and PAs fit in.
What are some of the challenges of working with a new administration and new members of Congress, and how do you work around those obstacles?
Swanson: I would say, probably, having the kind of recognition that we need. There are a lot of loud, moneyed voices out there that dominate the conversation—primarily physician groups and insurance groups. Hopefully with the new administration, they will listen to new, fresh voices—because clearly, the voices that have been heard to date have not offered any solutions to the problems that we face. All they’ve offered is more of the same, with their hand out, asking for more money.
My personal high priority is that we get a seat at the table with the Obama transition team. We have got to get in on the ground floor with a new administration, and it is imperative that we be able to meet with [Secretary of Health and Human Services nominee] Tom Daschle and discuss what we can bring to primary care.
Our health care system is floundering; we all know that. Primary care is floundering. Only 2% of medical school graduates are choosing primary care. There are 125,000-plus NPs out there prepared to provide primary care. We’ve got barriers all over the place to being able to efficiently do that. So my personal priority is to be at the table with the transition team.
Lord: Two things that we’re going to focus on are time and education. We’ve worked with Senator Daschle’s office before, so there are legislative aides and people that we know. But certainly with the new administration and members of Congress to contact, that’s going to take some time. So we’re already well into making those initial contacts, and certainly we’ll call in PAs from various states to help out in key areas.
The other thing that’s going to be required is education, because it is our job to explain why the issues that affect PAs actually affect the ability to provide quality, cost-effective care to patients, and how that impacts patient care. Although we have a number of friends who are still in Congress and in those positions of authority—so we won’t have to start from square one—there’s going to be that whole new regime that comes in.
So I think time and education are going to be our biggest challenges but also opportunities—because we’re not the same profession we were even 10 years ago. We’re not what we were 40 years ago. And we can certainly cite more areas where PAs have made an impact.
Based on what you know about the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
Swanson: From my perspective, it’s a good start. Nobody in the last eight years has seriously addressed health issues at all. I don’t know how it will play out. Clearly, there are a lot of pressing issues—the economy notwithstanding—that will affect the ability of the new administration to implement changes.
I suspect that what we will see will be a collage, I suppose, of existing systems and structures. I think the idea to use the federal employee health model is admirable. Whether President-Elect Obama’s actually going to be able to get that implemented.… Certainly, he has a majority in the House and Senate, [but] not enough to prevent a filibuster, which I’m sure is going to be a challenge when you’re threatening large groups like health insurance companies.
I think his heart is in the right place; I just think there are a lot of factors that won’t come into play until he actually is in office and starts dealing with people. And I think it’s easy to envision what you’d like to see, and it’s another thing to get down to the nuts and bolts of how to make it happen. But I hope they listen to new voices. I hope that they are as open as they seem to be.
Lord: A lot of this is so theoretical when you get down to how it is going to happen. But overall, the concept seems like a reasonable one. It builds on what currently does work, including the employer-sponsored plans, Medicare, Medicaid. I mean, they have to be improved, but there are components that do work. The SCHIP [State Children’s Health Insurance Program]—I talk to PAs across the country, and if it weren’t for SCHIP, some kids would have nothing. So, we do have plans and programs that work. They can work better. We also need to look at insurance reform to make the private market more consumer-friendly.
Another aspect is an improved focus on wellness and health disparities. I’ve always said we chase disease. Health promotion, or disease prevention, means “Let’s truly work on obesity, let’s get you so you don’t have diabetes.” But what do we do? We take care of very sick patients who already have those diseases. At least theoretically, the Obama-Biden model looks at that and says, “This is where we’re going to focus,” on prevention and health care disparities….
Now, of course, when people actually get into office, they always find out what their hurdles are. We seem excited because this group is trying to be more bipartisan and not look at party but rather “Let’s look at the problem and bring in a broad group of players.” So we’re hopeful.
One of the keys is—I hope—that they reach out. Obama has been very smart in using the Internet and mobilizing people, whether it was building his campaign or collecting money, but also now giving people an opportunity to voice their opinions. So I’m hoping they use that information—that they don’t just say, “We want to hear from you,” and then don’t do anything with that.
Allowing for the fact that the level of reform our health care system needs will take time, what do you think should be the priorities? What must be addressed first?
Swanson: What has to be addressed first? The uninsured. From my perspective, I’m a full-time NP in a rural health practice in Indiana, and I see a lot of people who have no health insurance. That has a profound effect on their ability to be healthy, productive, contributing members of their local communities, their state, and the United States. I have people who are insulin-requiring diabetics who can’t afford to test their glucose, who can’t afford testing supplies or insulin—just the basics of managing their care—much less worry about optimal glycemic control. I have people who are young, who have diseases that can cause early demise—hyperlipidemia, hypertension, obesity.
Health care shouldn’t be a privilege. It should be a right. The Declaration of Independence says that we have the right to pursue happiness, and health has to be part of that.
There are innovative plans that are out there. Indiana has the Healthy Indiana Plan, which has been in place for about a year. It’s funded in part by tobacco money. This is for people who are uninsured and can’t afford to purchase employer-offered insurance plans. It covers preventive care, hospital care, acute care. And people are required to get their preventive health care or they lose this health savings account that they accrue over a period of time. They get, I believe, $1,000 in a health savings account, and if they don’t do their preventive care during the year, they lose that. That is a powerful incentive.
You know, it’s just so interconnected. If your children are unhealthy, they’re not going to do well in school. If you have unhealthy workers, they’re going to cost the system money. A lot of these people wait until they’re in crisis and present to the emergency room, and that’s expensive, as is the hospital. I feel that addressing the needs of the uninsured is critical, and that involves primary care.
Lord: We have to look at universal coverage. But I think philosophically, before you get there, there has to be an understanding amongst all of us in health care—including physicians—that no man is an island. We have to work in coalitions; we have to work together. I can give you a million reasons why PAs are part of the solution, but we’ve always qualified that: We’re part of the solution; we’re not the solution.... Everyone’s role is important. This is about patient care; this isn’t about PAs, or NPs, or physicians. It’s about patients….
And then from there, we need to look at universal coverage: How do we get that access? How do we get people covered? It may very well be addressed by phasing in coverage. It may not just all happen; they may have to do some kind of phase-in.
And on the other end, where’s your workforce? Who’s going to see all these people? You’re between a rock and a hard place. [At the American Medical Association meeting last month] Massachusetts was at the microphone a lot talking about their universal coverage plan, the theory of it and what has developed. Everybody hasn’t even tried to get care yet, but [with] just the increase from everyone knowing that they have access, people are still waiting in line. There just aren’t enough providers. So, my theory is, there are enough sick people to go around. We all have to work together on that and see what the strengths of each group are.
In an ideal world, what would you like to see achieved in terms of health care reform—in general and with regard to NPs/PAs—by the end of 2009?
Swanson: I would like to see that health care is valued and is a right and not a privilege. In an ideal world, everyone would be able to receive health care services. The system would not be physician-centric or system-centric; it would be patient-centric.
We would have electronic health records so that we could communicate among systems. There would be a central repository for an individual’s health records that they themselves could have access to, so that you would never show up in a venue and not have a history for a patient.
There would be no barriers. All qualified providers would be able to provide the services that are needed, without turf issues and false claims of quality—we all know the quality issue is a trumped-up issue. There’s plenty of data out there that people other than physicians probably are better qualified to provide primary care services. So I would like to see no barriers to information, to access, to quality.
Lord: I would certainly like to see a cultural shift—which, in medicine, will certainly be a shift—where we acknowledge that we all are part of this team and that patients come first. There are so many different groups and types of providers, at all different levels; if we could all acknowledge that everyone plays a role, I think we’d get the most out of it. We truly would improve patient care. So there’s my “save the world and create world peace” answer: that we all truly function to the max and don’t worry about who’s stepping on whose toes.
And from a PA’s standpoint, I hope that we see full engagement of the Academy and the PA community in health care reform. I certainly would like to see, instead of us knocking at the door, saying “Please make sure we’re included,” that groups come to us, to the Academy, and say, “We want you at the table. What is your plan? What do you have to offer?”
It can’t just be done legislatively; it can’t just be done by the payers. Everyone has to work together to develop that plan. It’s an exciting time, because everyone wants change. The country wants it; it’s not just one political group. Patients want it, and they’re speaking out. We’re advocating for our patients. I think those things continue to be really important.