PART IV
Critical Elements in Managing Advanced Practice Nursing Environments
OUTLINE
Chapter 19 Maximizing APRN Power and Influencing Policy
Chapter 20 Marketing and Negotiation
Chapter 21 Reimbursement and Payment for APRN Services
Chapter 22 Understanding Regulatory, Legal, and Credentialing Requirements
Chapter 23 Integrative Review of APRN Outcomes and Performance Improvement Research
Chapter 24 Using Health Care Information Technology to Evaluate and Improve Performance and Patient
Outcomes
CHAPTER 19
Maximizing APRN Power and Influencing Policy
The purpose of this chapter is to build advanced practice registered nurse (APRN) policy competency.
Readers will be reminded of nursing's core historical function in policymaking and given three different
frameworks to explore the policymaking process. Current and emerging APRN policy issues will be
emphasized, and the chapter ends with a discussion on APRN policy leadership skills and defines the
specific attitudes and behaviors necessary to be influential in the policy realm. These skills are
highlighted in the exemplars. It is the authors' great hope that students reading this chapter will be
moved to expand their roles beyond the clinical and broaden their circle of influence on how health care
gets paid for, measured, and delivered.
Policy: Historic Core Function in Nursing
Florence Nightingale spent much of her career walking the halls of Parliament promoting policy change
to improve quality, dignity, and equity, first for the Crimean war soldiers and later for the poor of
London. Her 3 years of clinical practice gave her clinical expertise and credibility to assume the role of
policymaker. She embraced that role because of her high degree of moral distress and concern about
the needless suffering and premature death of her patients (Jameton, 1993; Whitehead, Herbertson,
Hamric, Epstein, & Fisher, 2015). She believed she knew the right thing to do for the soldiers, and the
constraints she faced were significant. Empowered by her clinical practice during the Crimean war, she
used data that she had collected systematically to persuade Parliament to make needed military and
civic law reforms that promoted health. In 1858, Nightingale became the first woman elected as a
member of the Royal Statistical Society, and she later became an honorary member of the American
Statistical Association (Gill & Gill, 2005). Her work and prestige were Victorian era validations of the
importance of using evidence to inform policy. Nightingale's activism presaged the APRN as patient
advocate and policy shaper. She leveraged statistics and clinical expertise to become an effective
advocate for influencing policy. She expected nurses to have a high degree of social interest in the
human condition and to be involved in the policymaking process. As Nightingale's work demonstrated,
health policy challenges and opportunities can be found in both “big P” policies such as formal laws,
rules, and regulations at the local, state, national, and/or international level and in the “small p” policy
arena such as nongovernmental organizational guidelines, decisions, and social norms guiding behavior
(Brownson, Chriqui, & Stamatakis, 2009).
This historic covenant with the public must be strengthened. APRNs must deepen their commitment to
and become masterful at critiquing, formulating, and influencing policies that interfere with human
wholeness and health. Most APRNs in practice today have experienced the effects of polices that lead
directly to poor health care. We must substantively weave policy into the core APRN roles so that those
experiences move APRNs into leadership roles and they become advocates for change.
Policy: APRNs and Modern Roles
Powerful APRN clinical experiences, when effectively communicated, serve to deepen policymakers'
understanding of health-related issues. APRN practice experiences are poignant stories that enlighten
policy issues by providing a human context while bringing nursing's value to the health policy arena.
Most APRNs in practice today have experienced the effects of ill-conceived policies that lead to needless
suffering, poor resource use, and poorly coordinated, highly specialized, fragmented health care. This
practice experience, coupled with the ability to analyze the policy process, provides a strong foundation
to propel APRNs into politically competent action and advocacy.
Engaging in policymaking is a core element of leadership to be cultivated by all APRNs (see Chapter 11).
The Institute of Medicine (IOM) report The Future of Nursing (2010) has determined that “nurses have a
key role to play as team members and leaders for a reformed and better integrated patient-centered
health care system” (p. xii). Major health reform legislation in 2010—the Patient Protection and
Affordable Care Act (ACA)—mandated health insurance coverage, which has swept nearly 20 million
additional people into the US health care delivery system and lowered the US uninsured rate to less
than 10%, the lowest in 50 years (Obama Care Facts, 2016). The system had to accommodate the surge
in demand, but the ACA also required a change in the way care was delivered, focusing on value-based
care that improves the health of the population and de-emphasizing fee for service, while lowering
costs. The election of Donald Trump to the Presidency in 2016 was in part based on a platform that
promised repeal and replacement of the ACA; this has created uncertainty in the future direction of
health care reform. However, the movement toward value-based care preceded the ACA and has
bipartisan support (Muhlestein, Burton, & Winfield, 2017). The approach under the Trump
administration may be different, but the goals of achieving better care, a healthier population, and
lower costs will likely remain the same. Meeting these goals poses significant challenges to APRNs.
Addressing this challenge, Altman, Butler, and Shern (2016) identified three specific recommendations
that are highly pertinent to APRNs engaging in policymaking:
• Recommendation 1: Build Common Ground Around Scope of Practice and Other Issues in Policy and
Practice (Altman et al., 2016, pp. 51-52). Removal of scope-of-practice barriers will require a broader
and more diverse stakeholder base. Interprofessional practice requires all members of the team to
function at the top of their license and is becoming the new standard of care, so more common ground
must be sought. In order for APRNs to function at the highest level of their education and training,
garnering common ground will require persistence and a strong degree of political competency because
more than 50% of the states have outdated nurse practice acts that do not reflect national APRN
education standards and current APRN practice that focus on full practice authority. It will take a
significant degree of political organizational networking, coalition building, campaigning, and educating
the public to remove the barriers to practice that are embedded in many states' nurse practice acts.
There has been a growing chorus of agencies working to lift these and other barriers to APRN practice.
At the federal level, the Centers for Medicare & Medicaid Services (2012) issued a final rule broadening
the concept of medical staff, permitting hospitals to allow other practitioners (e.g., APRNs, physician
assistants, and pharmacists) to perform all functions within their scope of practice. Despite this rule,
medical staff membership and hospital privileges remain subject to existing state laws and business
preferences. One major concern is that APRN regulatory practice constraints are restraint of trade.
Importantly, the Federal Trade Commission (2014) has engaged in advocacy for APRNs' scope of practice
expansion in order to promote healthy competition in many states, providing letters, comments, and/or
testimony to this end.
• Recommendation 7: Expand Efforts and Opportunities for Interprofessional Collaboration and
Leadership Development for Nurses (Altman et al., 2016, p. 155). APRNs should enact, support, and
promote interprofessional collaboration and programs that focus on leadership. Health care
professionals from all disciplines should work together in building improved health care systems,
particularly in an interprofessional and collaborative environment. Preparing and enabling nurses to lead
change to advance health will require APRNs to develop leadership skills, which include having a high
degree of respect for other professions and shaping and influencing policymaking at all levels. This
recommendation will require APRNs to become insightful and politically savvy, know how to find
common ground, and translate research/best practices into practice. This recommendation emphasizes
that nurses must hold key leadership positions across decision-making bodies in the government and
private sector.
• Recommendation 8: Promote the Involvement of Nurses in the Redesign of Care Delivery and Payment
Systems (Altman et al., 2016, p. 156). APRNs must work with payors, health care organizations,
providers, employers, and regulators in the redesign of care delivery and payment systems. To this end,
APRNs are encouraged to serve in executive and leadership positions in government, for-profit, and
nonprofit organizations; health care delivery systems (e.g., as hospital chief executive officers or chief
operations officers); and advisory committees.
Among the recommendations in The Future of Nursing (IOM, 2010) is Recommendation 8: Build an
infrastructure for the collection and analysis of interprofessional health care workforce data. This
requires APRNs to be involved in improving the research enterprise around quality and safety metrics,
payment models, and the health care workforce to better inform policymaking. To that end, Altman
et al. offered three themes for nursing that will drive the IOM's recommendation further (2016, p. 4):
1. The need to build a broader coalition to increase awareness of nurses' ability to play a full role in
health professions practice, education, collaboration, and leadership;
2. The need to continue to make promoting diversity in the nursing workforce a priority; and
3. The need for better data with which to assess and drive progress.
Politics Versus Policy
Health Policy
All policy involves decisions that influence the daily life of citizens. Longest (2016) has defined health
policy as the authoritative decisions pertaining to health or health care, made in the legislative,
executive, or judicial branches of government, that are intended to direct or influence the actions,
behaviors, or decisions of citizens.
Although there are many definitions of policy and politics, policy generally refers to decisions resulting in
a law or regulation. Politics refers to power relationships. It is the responsibility of a multitude of
policymakers, whether mayors, county supervisors, government employees, legislators, governors, or
presidents, to make health policy. Overall responsibility generally places authority with the legislative
branch to craft laws (Box 19.1); the executive branch crafts rules to implement the laws, and the judicial
branch interprets conflicts among the spheres of government, citizens, and a public or private entity.
Box 19.1
How to Find a Legislative Bill and Determine Bipartisan Support
To find a federal bill, go to the Library of Congress website (https://www.congress.gov/) and find the
current legislative session. Search keywords or enter the bill number. Once you get to the bill summary,
do an analysis to determine whether the bill has any chance of passing by going to the list of cosponsors.
The Library of Congress does not list political affiliation next to the cosponsor's name, which requires
looking up each member to find out to which party he or she belongs. Be sure that members of Congress
from each party are cosponsoring the bill in equivalent numbers. If it is only one party sponsoring the
bill, you may conclude that the bill is largely partisan, with small chance of passage. A politically
competent APRN will always look for bipartisan cosponsorship of bills, which have the highest chance of
actually becoming law. The same method will work for a bill in any state legislature (found on each
state's government website).
Politics
Politics is the process used to influence those who are making health policy. Politics introduces
nonrational, divisive, and self-interested approaches to policymaking, often along ideologic lines. In the
United States, the core disagreement between the two political parties comes down to what the role of
the government should be (if any) in resolving the conflicting viewpoints. Any political maneuvering to
enhance one's power or status within a group may be described as politics. Politics in a democracy is the
nonviolent way of reaching agreement between differing points of view and requires compromise in
which neither party gets precisely what it wants. Compromise and deal-making are the only alternatives
to coercion or authoritarianism (Crick, 1962). Politics is largely associated with a struggle for ascendancy
among groups having different priorities and power relationships. Preferences and interests of
stakeholders and political bargaining (favor swapping) are important and extremely influential political
factors that overlie the policymaking process. The self-interest paradigm suggests that human motives
are not any different in political arenas than they are in the private marketplace. This behavioral
assumption implies that it is rational for people and organizations to use the power of government to
achieve what they cannot accomplish on their own. Ideally, elected officials seek office to serve the
public interest, not their own. However, to be successful in the electoral process, they need electoral
support through financial contributions, rendering them beholden to fundraising and funders (Feldstein,
2006). Highly politicized decisions often create outcomes that have little to do with efficient use of
scarce resources and what is best for the general public. These forces, which may or may not be based
on evidence, contribute to the lack of coordination among health policies in the United States, making
policy formulation highly complex and exceedingly interesting.
APRNs must engage in the political process to influence public policy and resource allocation decisions
within political, economic, and social systems and institutions. APRN political advocacy facilitates civic
engagement and collective action, which may be motivated by patient-centered moral or ethical
principles or simply to protect what has already been allocated. Advocacy can include many activities
undertaken by a person or organization, such as media campaigns, public speaking, commissioning and
publishing policy-relevant research or polls, and filing an amicus curiae (friend of the court) brief.
Lobbying as a political advocacy tool is only effective if a relationship between the lobbyist and legislator
influences or shapes a policy issue. Social media for political advocacy is playing an increasingly
significant role in modern politics (Rim & Song, 2016).
United States Differs From the International Community
The US health system and political process for creating health care policy is unique in that the system is
decentralized, fragmented, and complicated. In the United States, there is no single entity responsible
for health care delivery, payment, or policymaking. There are many spheres of policymaking with
overlapping authority involving a wide diversity of people, cultures, traditions, and illness patterns.
Although the federal government may create broad guidelines, the 50 states, for the most part, have the
autonomy to create policies that best serve their citizenry—hence the large patchwork of public,
private, local, state, and federal entities. These can be operating as governmental, nonprofit, or forprofit entities, all of which are creating policies and/or delivering care. Moreover, unlike other
developed nations, US health care policy is highly political and can shift dramatically from one
administration to another, creating further instability.
The US federal government is a provider of health services via the prison system and the Department of
Veterans Affairs. In the United States, the creation of the ACA was a contentious effort to solve deep,
underlying problems in the nation's health care system. Many of the ACA provisions encouraged
innovating and testing new models and payment mechanisms for care delivery, creating new challenges
for APRN influence. As was heard by a policymaker, “if you've seen one accountable care organization,
you've seen one accountable care organization.” However, for the most part, health care delivery is still
largely under private sector control, making US health policy development incremental, fragmented,
highly politicized, and far more decentralized than in the rest of the world.
For most of the rest of the world, and in countries such as China, Canada, Great Britain, Switzerland, and
the Netherlands, there is a highly centralized health authority for policymaking and a more integrated
care delivery system. These nations, with centralized systems of care, are able to track the impact of
their policy decisions more closely and build more tightly controlled surveillance systems to follow
epidemics, immunization rates, spending, workforce, and other important markers of a strong health
care system. Moreover, centralized health care systems limit the number of policymakers that need to
be influenced, which can be a great advantage. Although there are a smaller number of people to
influence, if those policymakers are strongly opposed to issues such as expanded APRN practice,
centralization becomes disadvantageous. The unique US public-private, federal-state, nonprofit, and forprofit arrangements in which the majority of people get their insurance through their employer make it
difficult to enact programs that are highly effective in other nations in the United States. Exemplar 19.1
depicts the experience of nurse practitioners (NPs) who practice across the boundaries of the health
care systems of two countries, Canada and the United States.
Exemplar 19.1
A Tale of Two Countries, Two Nurse Practitioners, and Two Health Care Systems
Nancy Brew, Mark Schultz
A husband-and-wife nurse practitioner (NP) team, Nancy (Brew) and Mark (Schultz), had been living and
practicing in Alaska for over 20 years when they emigrated to British Columbia (BC), Canada, in 2006.
Nancy had worked as a family nurse practitioner (FNP) in Alaska for many years and experienced
increasing moral distressa (see Chapter 13) from trying to provide equitable and quality care to
uninsured and underinsured patients in the expensive, private-payor US health care system. Mark was
working in an Anchorage intensive care unit and wanted to pursue his graduate degree to become an
FNP. They were both drawn to the concept of health care for all, so the idea of working in a country in
which everyone had access to health care and no one had to fear bankruptcy or losing their home if
medical disaster struck was compelling. Together, they decided to stretch their professional wings and
embark on an international practice adventure.
Universal health care access to physician and hospital services was established in Canada in the 1960s.
The Canadian health care system is chiefly administered via provincial and territorial governments. NPauthorizing legislation is now present in all 13 Canadian provinces and territories, and in 2016, 4500 NPs
were licensed and practicing in Canada. Similar to NPs in the United States, Canadian NPs are regulated
on a province-by-province basis, so there are some variations in scope across the country. The majority
of jurisdictions do not require NPs to establish collaborative agreements with a physician or a group of
physicians. Many provinces have also given NPs the authority to admit, treat, and discharge patients in a
hospital. As of 2016, NPs in all but one province could prescribe controlled substances.
Funding in a socialized health care system presents unique challenges to moving advanced nursing
practice forward. Each regional government determines how to fund advanced practice nurse (APN)
practice. In British Columbia (BC), almost all primary care is still provided by small physician group
practices in a fee-for-service model in which each patient visit is individually billed to BC's Medical
Services Plan. To date, BC NPs have not gained authorization to bill; thus, APNs in BC are fiscally unable
to open their own practices or freely join existing physician practices, even in the most underserved
rural areas. A limited number of salaried positions have been created for BC NPs, but many of these are
in specialty areas because the primary care physicians resist APN practice. Hence Mark has worked
predominantly in cardiology and orthopedic surgery since becoming an NP, although he was trained in
family practice. This is ironic because the NP role in BC was initially legislated to improve access to
primary care. There is a great need for primary care providers in BC, with a significant number of
patients unable to find one. NPs could be doing more to address the Canadian primary care shortage,
but Canadian health care, as a single-payor, government-run system, lacks a market-based approach to
workforce shortages.
Nancy and Mark found it interesting to have worked in health care on both sides of the border during
the 2010 American health care reform debate. The Canadian health care system was held up as a
cautionary tale, that the Canadian system was an egregious example of poor care, long waits, and
unaccountable all-empowering bureaucracy that ran health care into the Canadian ground. Although it
is true there can be months' long wait times to see specialists for nonurgent conditions, Nancy and Mark
have found that appropriate specialty referrals are given rather freely. Nonurgent computed
tomography scans can occur in a week, nonurgent magnetic resonance imaging may take a few months,
and the wait times for hip and knee replacements can approach 6 months. The couple found that in
Canada, visits are shorter and charting is more concise, but Canadian health care is similarly evidence
based and equal in quality. In contrast to in the United States, all Canadian residents and citizens have
full access to inpatient and outpatient health care but are likely to pay a monthly premium depending
on personal income level. For example, in BC in 2016, the monthly premium for a single individual was
$0 to $75.00 and that for a family of three or more was $0 to $150.00. Canadians are responsible for the
cost of outpatient prescriptions, which are subsidized to varying degrees by provincial governments.
As they reflect on 10 years of Canadian practice, while still “locuming” during the summers in the Alaska
bush, they have seen firsthand the strengths in each system and how the different health care policies
play out. In the United States, they see poor care as a result of an individual's inability to pay and cite
the example of an uninsured man from a rural fishing village with advanced heart failure. He cannot
afford the ferry ride to the clinic and cuts his pills in half or often runs out of them altogether. When he
succumbs to cardiac decompensation, he is flown to a regional hospital where he spends several days in
the intensive care unit ($40,000) only to return to his village without medication, to repeat the cycle.
These costs are ultimately absorbed by the government and health care system. Were he in the
Canadian system, he would be followed more closely, possibly by a cardiac outreach team, provided
with filled prescriptions, and offered a transportation subsidy. However, Canadian NPs have witnessed
the moral hazardb of unlimited access to health care, in the form of occasionally frivolous visits, such as
seeking a bandage for a minor cut or scrape rather than going to the store, or long waits to see a
dermatologist for acne that could have been treated in primary care. Both private pay cost barriers and
system overuse issues are policy driven and have enormous impact on the larger economy and lives of
individuals.
Although they recognize the grass is not greener in Canada for APN practice, these two NPs are grateful
to live and work in Canada for its all-inclusive health care system, provided at a per capita cost that is
considerably less than in the United States. There are times when they wish they could take the best
parts of both systems and combine them to decrease the moral distress in the United States and the
moral hazard in Canada.
aMoral distress—when one knows the right thing to do, but institutional constraints make it almost
impossible to pursue the right course of action (Hamric, 2009; Jameton, 1984).
bMoral hazard—when a party insulated from risk behaves differently than he or she would behave if he
or she were fully exposed to the risk (Jameton, 1984).
Sadly, but consistently, the US health care outcomes are not what would be expected given that the
United States spends at least 50% more per capita on health care. Compared with other developed
nations, life expectancy in almost all age groups—up to age 75 years—is shorter than their counterparts
in 16 other wealthy, developed nations. The scope of the US health disadvantage is pervasive and
involves more than life expectancy: the United States ranks at or near the bottom in both prevalence
and mortality for multiple diseases, risk factors, and injuries. The US health disadvantage spans many
illness and injuries. When compared to peer countries, Americans fare worse in at least nine areas:
1. Infant mortality and low birth weight
2. Injuries and homicides
3. Adolescent pregnancies and sexually transmitted infections
4. HIV/AIDS
5. Drug-related deaths
6. Obesity
7. Heart disease
8. Lung disease
9. Disability
These findings suggest no support for the oft-repeated claim that US health care is the best in the world.
The reason for the US disadvantage has been attributed to four factors: a fragmented health system,
poor health behaviors, poor social and economic conditions, and automobile domination of the built
environment, minimizing walking as an important physical activity. These challenging problems require a
robust public health system (Woolf & Aron, 2013). The APRN is well qualified to lead change in this area.
Key Policy Concepts
Federalism
It is essential to understand the different responsibilities and authorities of the state and federal
governments because these are highly relevant to most health care programs, such as Medicare,
Medicaid, and the State Children's Health Insurance Program, as well as to the creation of an
interoperable health information system. Federalism refers to the allocation of governing responsibility
between the states and federal government. The states and the federal government have a complex
relationship governing health policy, which explains a large part of our chaotic and fragmented approach
to health care in place today. Passage of the ACA in 2010 required states to expand access, enhance
quality, and lower costs, albeit with a great degree of flexibility. The ACA has greatly amplified the
tensions between federal mandates and states' rights, to the degree that the US Supreme Court had to
clarify the constitutionality of the federal government's powers in requiring individuals to purchase
health insurance. With the decision handed down in the Supreme Court case National Federation of
Independent Business v. Sebelius (2012), the Court upheld most provisions of the ACA, declaring the
individual mandate and the expansion of Medicaid constitutional; however, it was ruled that Congress
may not link all Medicaid funds based on participation in the expansion. In May of 2017, the US House of
Representatives voted in the American Health Care Act (AHCA), the first step toward dismantling the
ACA federalist approach. This included, but was not limited to, eliminating taxes imposed by the ACA,
removing individual and employer mandates, allowing states to waive the ACA's essential health benefit
requirement, and allowing insurers to deny coverage to those with preexisting health conditions if they
do not maintain continuous coverage (Jost, 2017a).
The US Constitution unambiguously gives the federal government absolute power to preempt state laws
when it chooses to do so. However, the 50 states are also granted unfettered authority, such as
regulation of health care professionals and health insurance plans (Bodenheimer & Grumbach, 2012).
Ambiguity between state and federal authority allows states to experiment with policy solutions. The
“states as learning laboratory” concept has grown out of local health policy problems and enables states
to experiment with innovative policy solutions that could not be done on a national level. Moreover,
states have local health care problems, requiring local, flexible, and humane solutions. Many federal
health policy decisions are devolving decision making to the states. Because health care is experienced
at the local level, APRNs must be aware of the overlapping state and federal spheres of government and
the tension between their authorities.
Incrementalism
Although the policymaking process is a continuous interrelated cycle, most efforts to change policy stem
from the negative effects of an existing policy. In the United States, we rarely reform, but we frequently
modify. This concept of continuous, often modest modification of existing polices is termed
incrementalism. Major reforms of health policy are seen rarely, usually once in a generation, such as
Medicare and Medicaid in 1965 and the ACA in 2010. Minor changes of existing policies play out slowly
over time and are therefore more predictable. Incrementalism promotes stability and stakeholder
compromise. A good example of incrementalism is the gradual increase in federal spending for
biomedical research from $300 in 1887 to more than $33 billion in 2017, going to the 27 institutes and
centers within the National Institutes of Health. Within that structure, the National Center for Nursing
Research was created in 1985 by a congressional override of a presidential veto as a result of the
influence of strong nurse leaders. In 1993, the Center was elevated to the National Institute for Nursing
Research and funded with $50 million; funding levels in 2017 will exceed $146 million.
Presidential Politics
US presidential politics is playing a larger role in health care in the United States. The presidential
candidates frame health issues that greatly influence the public perception regarding the severity of the
problem and responsibility for the problem. These candidates are trying to win support for their health
care priorities and are often unaware of the evidence regarding what is driving cost or disease burden.
Even though the United States faces serious health concerns, largely driven by poor health behaviors
and a chronic disease epidemic, there is very little political will to address the root cause of these
drivers. For example, many of the US agriculture policies subsidize corn, which is used in many
processed foods (high-fructose corn syrup). Those processed foods are a large part of the poor American
diet, leading to obesity and the long list of health issues that cascade from obesity (Stanhope et al.,
2015). The very first presidential primary is held in Iowa, a large agriculture state that produces more
corn (2.5 billion bushels) than any other state (IowaCorn.org, 2016). This essentially shuts down any
conversation on aligning US farming policy with health policy. Of the 12 presidential candidates
caucusing in Iowa in 2016, not a single candidate addressed America's eating and food problems and
their link to chronic disease.
Moreover, the Republican-controlled House of Representatives had voted on defunding, crippling, or
repealing the ACA 55 times between 2010 and 2015 (Haberkorn, 2015). In May 2017, with the
Republicans controlling the Congress and the pre-sidency, the House was finally able to pass the AHCA
(an ACA “repeal and replace” bill) by a 217 to 213 vote (Jost, 2017a). However, further efforts to repeal
and replace the ACA came to a halt in July 2017 with a 49 to 51 Senate vote (Jost, 2017b). At that time,
the Republicans left the door open for another attempt to “repeal and replace” but, as demonstrated by
this failed effort to bring about this major Republican legislative initiative, American congressional and
presidential politics have become a continuous cycle, making it difficult for candidates to address
complex problems that are too big or too unpopular. This exemplifies the difficult and complex nature of
health policy, which requires considerable political capital to address.
APRNs, Civic Engagement, and Money
Without question, and regardless of one's political affiliation, there is widespread agreement that
money has enormous influence on elections, the wealthy have more influence on elections, and
candidates who win office promote policies that help their donors. Some of the more effective interest
groups do not align with one political party but give equally to both parties so that they can gain access
to important decision makers. It is estimated that members of Congress spend anywhere from 25% to
50% (and sometimes more) of their time fundraising, especially as an election approaches (Sherb, 2012).
APRNs have come a long way in supporting candidates. In 2016, there were 5 nurses and 17 physicians
elected to Congress. The easiest form of civic engagement is to vote for or donate to a candidate or
political action committee (PAC); next is to work on a campaign, followed by running for office. Table
19.1 outlines health professions lobbying spending, donations to PACs, and how they distributed those
funds across political parties.
TABLE 19.1
Selected APRN and Other Health Professions Organizations Political Action Committee (PAC) and
Lobbying Donations, 2016a
Health Professions Organization
PACs
(Partial Cycle as of February 28, 2016)
Lobbying
American Association of Nurse Anesthetists
American College of Nurse-Midwives
$1,241,000 [55% Republican]
$468,000 [21% Republican]
American Association of Nurse Practitioners
$90,000
$108,000 [50% Republican]
National Association of Clinical Nurse Specialists No PAC Reported
$401,000
0
American Medical Association $2,000,000 [64% Republican]
$15,290,000
American Nurses Association
$855,000
$262,649 [15% Republican]
$830,000
aTotal lobbying spending for health professionals, 2016: $65,000,00; total number of health professional
clients reported, 2016: 208; total number of health professions lobbyists reported, 2016: 726.
Adapted from Center for Responsive Politics. (2016, December 2). Retrieved from
http://www.opensecrets.org/.
Policy Models and Frameworks
Longest Model
Longest (2016) has conceptualized policymaking as an interdependent process. The Longest model
defines a policy formulation phase, an implementation phase, and a modification phase (Fig. 19.1).
Importantly, this model illustrates the incremental and cyclical nature of policymaking, two of the most
important features of the US health care policymaking process with which APRNs must be familiar.
Essentially, all health care policy decisions are subject to modification because policymaking in the
United States involves making decisions that are revisited when circumstances shift. The US system is
not designed for big bold reform. Rather, it considers intended or unintended consequences of existing
policy and tweaks changes (Longest, 2016).
FIG 19.1 The Longest model. (From Longest, B. B., Jr. [2010]. Health policymaking in the United States
[5th ed.]. Chicago, IL: Health Administration Press.)
Policy Modification
The US system is based on continuous policy modification. Almost every policy results in some form of
unintended consequence, which is only learned through implementation of a prior policy. Policies that
are appropriate and relevant at one point in time become highly inappropriate as time passes and
economic, social, demographic, and commercial circumstances shift. Policy consequences are the reason
that stakeholders and policymakers seek to modify policy continually. These policy changes can be
driven by stakeholders when a policy negatively affects a group or by members of Congress or
rulemakers when policy does not meet their objective. Understanding the process of policy modification
and amendment of earlier polices is a key to mastering political competency (Box 19.2).
Box 19.2
Role of Public Comment
Public laws do not contain specific language about how the policy or program is to be carried out. For
health-related issues, the executive branch agency, usually the Department of Health and Human
Services, must publish its proposed rules in the daily Federal Register, seeking public comment. The
public comment opportunity is usually limited to 60 days; however, stakeholder groups can exert an
enormous degree of influence in the rulemaking process during this limited period. This public comment
stems from two important American principles: (1) that democracy can only work if its citizenry is
informed and participates, and (2) the federal government does not hold all the expertise but must
solicit comment from experts involved in the issue to alert the agency to unforeseen options or
consequences (Regulations.gov, 2016). Advanced practice registered nurse (APRN) organizations can
powerfully influence rulemaking by submitting evidence-based public comment and by activating the
APRN grass roots to launch a public comment campaign. The Federal Register will tally the number of
responses received and report how many were in favor of or opposed to the proposed rule. Thoughtful,
well-crafted public comments submitted by an APRN organization have been directly incorporated into
final rules, rendering submission of public comments and the rulemaking process crucially important
activities for APRNs. For example, when the Federal Register published rules removing Medicare
payment restrictions for APRNs, excerpts of a letter submitted by the American College of Nurse
Practitioners were quoted and used as an evidence source to support the payment expansions.
The Kingdon or Garbage Can Model
Agenda setting is a major component of the Longest policy formulation phase. With so many health
policy problems in the United States, why do some problems get attention and others languish at the
bottom of the policy agenda for decades? Kingdon (1995) conceptualized an open policy window, with
three conditions streaming through the open window at once. First, the problem must come to the
attention of the policymaker; second, it must have a menu of possible policy solutions that have tae very
real potential to solve the problem; and third, it must have the right political circumstances. If all three
of these conditions occur simultaneously, the policy window opens and progress can be made on the
issue (Fig. 19.2). Conversely, once shut, this policy window (opportunity) may never open again.
FIG 19.2 Kingdon's policy streams model. (From Kingdon, J. [1995]. Agendas, alternatives, and public
policies [2nd ed.]. New York, NY: Harper Collins College.)
Policy Activators
Policy problems come to the attention of policymakers in a number of ways, including through
constituents, litigation, research findings, market forces, fiscal environment, crisis, special interest
groups, and the media, singly or collectively. Wakefield (2008) has identified policy dynamics particular
to agenda setting (Table 19.2). Additional dynamics have been added, and each dynamic has one or
more so-called accelerator, which drives the agenda setting or triggers policymakers to take action on an
issue. The political circumstances that push problems onto the agenda must have a high degree of public
importance and low degree of stakeholder conflict surrounding the policy solution. If there is a great
deal of stakeholder disagreement, competing proposals may be put forth, weakening the likelihood that
the problem will be addressed. Strong health services research can provide the evidence base to help
policymakers specify and therefore accelerate agenda setting (Longest, 2016).
TABLE 19.2
Influence of Policy Dynamics on Agenda Setting
Dynamic
Activator
Examples
Constituents The constituent can have enormous impact on agenda setting. When members of
Congress learn from their constituents about deeply moving tragedies that could have been prevented
or lessened, the member is moved to introduce legislation.
An automobile accident in a remote
area killed three members of a family and seriously injured two. A senator knew the family, which
prompted introduction of the Wakefield Act, designed to improve pediatric emergency response in rural
areas and honor the family. It became public law, the Wakefield Emergency Medical Services for
Children.
Litigation
Court decisions play an increasingly prominent role in setting health policy.
The
Supreme Court upholds the constitutionality of the Patient Protection and Affordable Care Act (ACA) but
removes the mandate for states to expand Medicaid, thus allowing states to “opt out” of expanding
coverage to the poor.
Research findings
A pediatrician in Flint, Michigan, investigated and published her findings on the
toxic drinking water and its impact on the developmental growth of children. Scores of bills are
introduced at the federal level to ensure safe drinking water.
Market forces The pharmaceutical industry greatly expands commercial advertising/marketing of
prescribed drugs to consumers. This direct advertising creates higher demands on pharmaceuticals,
driving up health care costs.
Legislation is introduced to authorize the Food and Drug Administration
to restrict direct-to-consumer advertising for prescribed drugs.
Fiscal environment
Very different budget decisions are made when the government is addressing
deficit rather than surplus spending. Deficit spending restricts budgets to a pay-as-you-go policy. Deficit
financing forces budgetary restrictions. Many discretionary health programs, including nursing
workforce development, get budget cuts or receive level funding.
Special interest groups Well-organized special interest groups with a clear message can have an
enormous impact on government action or inaction.
The autism advocacy community frames the
increase in autism spectrum disorders as a public health emergency, motivating Congress to pass
legislation spanning a wide range of provisions for those with autism, including research, treatment, and
services (https://www.autismvotes.org/advocacy).
Crises Crises can promote rapid response policy changes, usually centered on quality and access.
Startling opioid and heroin addiction rates across the United States led to scores of bills on
tightening opioid prescribing, making naloxone available to first responders, and funding treatment
centers.
Political ideology
The majority party (Democrats versus Republicans) has a large impact on
agenda setting. The divide centers on what role the government should play in US society.
The
newly installed 112th Republican-controlled US House of Representatives introduced the second bill of
the session in January 2011, the Repealing the Job-Killing Health Care Law Act, a failed attempt to repeal
the ACA.
Media The lay press, reporting on policy issues or crises, often compel policymakers to take action.
Major news outlet report that millions of unencrypted personal health care records were stolen
or mistakenly made public. Tensions rise between added reporting requirements and privacy. Legislation
is introduced on strategies to enforce the Health Insurance Portability and Accountability Act (HIPAA)
and mandate encryption.
U.S. president with a high degree of commitment
When the occupant of the White House sets
health reform as a major domestic policy agenda by linking unsustainable health care costs to the health
of the macroeconomy, the power of that office becomes evident.
In March 2010, President
Obama signs the historic ACA, despite a 2-year debate, town hall meetings across the nation, and
multiple national speeches explaining to the public why reform is necessary. It becomes the major
initiative of his presidency.
Adapted from Wakefield, M. K. (2008). Government response: Legislation. In Milstead, J. (Ed.), Health
policy and politics: A nurse's guide (3rd ed., pp. 65-88). Sudbury, MA: Jones & Bartlett.
Knowledge Transfer Framework
APRN research must be robust enough and highly relevant to be useful for policymakers. Not all
research can or should have an impact. The nature of the political process compels researchers to link
their work to policy formation. APRNs could more forcefully link their research to policymaking by
framing it in a policy context. Gold (2009) has created a framework for researchers to increase the
likelihood that their findings will reach some “take-up” of new ideas to be useful and implementable in
the policy sphere. It opens up a pathway through the unexplored “black box” between health research
and its use by policymakers. Such pathways can help stakeholders bridge between the research and the
end user by asking five questions. An example of high-quality, nurse practitioner–led research is the
well-designed study by Chao, Grilo, White, and Sinha (2015) in which they found that chronic stress had
a significant direct effect on food cravings and food cravings had a significant direct effect on body mass
index. The highly relevant policy link is that interventions aimed at lowering obesity rates must address
the underlying emotional and stress landscapes that cause food cravings and not merely focus on food
habits. This may well explain why the obesity epidemic is exploding, because current interventions are
primarily dietary. Addressing the questions in Fig. 19.3 makes it more likely the research will be
transferred into policy.
FIG 19.3 Pathway to move and accelerate effective research into policy.
Current Advanced Practice Nursing Policy Issues
Framing Current Issues: Cost, Quality, and Access
The cost-quality-access triad (Fig. 19.4) focuses on the drivers of health policy, across all levels of health
care, whether it is at the international, national, state, local, community, institutional, or corporate level.
Cost, quality, and access, as health policy drivers, are inherently interdependent; a shift in one inevitably
affects the others. Cost, quality, and access issues are not tangential problems to the US health care
challenges—they are the challenge.
FIG 19.4 Cost-quality-access schema.
Cost
The ACA enactment in 2010 stands alongside the passage of Medicaid and Medicare in 1965 as a grand
and challenging change in US health care policy. This massive bill aimed to improve access, improve
quality, and, most importantly, control the rate of cost increase in health care. At the time the ACA was
signed in 2010, the total amount spent on health care in the United States was $2.6 trillion, up from $2
trillion in 2005 (Centers for Medicare & Medicaid Services [CMS], 2011). By 2013, the amount had
increased by another $300 billion to $2.9 trillion or $9255 per capita (Hartman, Martin, Lassman, &
Catlin, 2015). For 2015, the national health expenditures were estimated at $3.2 trillion, another $300
billion increase in 3 years (Keehan et al., 2015). To put this in perspective, if you take the $600 billion
anticipated increase in health care cost from 2010 to 2015, you could provide a family income of about
$52,000 for about 11.5 million families (McCormally, 2011).
Although the expanded coverage anticipated by the ACA has been put in jeopardy by the goals of the
Trump administration, improved economic growth and the increasing need for health care services by
the baby boomer population will likely cause health care spending to outpace the annual growth of the
US gross domestic product (GDP) in the next decade and beyond. Even with focused efforts to bend the
cost curve of health care, increases in health spending are expected to be 5.8% per year until 2024, with
the GDP growing only 4.7% per year during the same period (Keehan et al., 2015). By 2024, the health
share of the GDP may reach 19.6%. The proportion of the country's GDP expended on health care is of
importance to the future of the United States because every dollar spent on health care is a dollar less
spent on education, transportation, housing, food, and other essentials. In comparison with the current
percent of GDP, the cost of health care in 1960 was about 6% of the GDP and in 1980 it was about 9% of
GDP (Kaiser Family Foundation, 2011).
Policymakers have a large stake in continuing policies to control the cost of health care. By 2024,
federal, state, and local government programs will account for 47% of all health care spending, reaching
an estimated $2.5 trillion. This rise from 43% in 2013 can in part be attributed to expanded Medicaid
eligibility, increased enrollment in Medicare, and subsidies provided for the health insurance exchanges
(Keehan et al., 2015). Past efforts to control costs included the implementation of health plans in the
1970s, introduction of diagnosis-related groups in the 1980s, and instituting competition in the health
care market in the 1990s. Efforts in the 2000s were marked by cost control through price regulation and
in the 2010s by linking payment to quality (using clinical metrics) and continuing price controls. Even
these varied attempts to control costs have had limited impact. Building on these past efforts, the ACA
created accountable care organizations (ACOs), integrated systems that bring together hospitals,
outpatient clinics, and specialty services to deliver better care coordination and quality of service. ACOs
are a vehicle to implement the intent of the ACA by creating more integrated systems that can
coordinate care better, thus improving quality and managing costs more effectively.
It remains to be seen how the ACA will be modified and which mechanisms will be deployed to control
costs under the Trump administration, but as stated earlier, the movement toward value-based care
preceded the ACA and has bipartisan support (Muhlestein et al., 2017). Many health care delivery
organizations have made great strides in improving the value of care and will likely continue to improve
care delivery and coordination based on ACA principles.
Quality
Attention to quality became a national issue following the IOM's series of reports, To Err is Human
(Kohn, Corrigan, & Donaldson, 2000) and Crossing the Quality Chasm (IOM, 2001), focusing on the
problems in the health care system leading to poor care. Linking quality to payment is how government
and private companies try to ensure that quality of care is not compromised because of cost-saving
measures. Linking quality to cost control is referred to as value-based purchasing. As part of value-based
purchasing, the CMS (2006) identified 27 so-called never events and established a policy that hospitals
would not get paid for taking care of patients experiencing an event that should never happen, such as
wrong-site surgery and any stage 3 or 4 or pressure ulcers acquired after admission or presentation to a
health care setting. “Never events” are now referred to as Serious Reportable Events (SREs); the
National Quality Forum recognizes 29 SREs. Most SREs occur not only in hospitals but also in officebased surgery centers, ambulatory practice settings, and long-term care or skilled nursing facilities
(National Quality Forum, 2011). APRNs are expected to know these SREs and work to ensure that they
do not occur. A current compilation of SREs can be found at
http://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx
As part of nursing's effort to improve quality of care, the Nursing Alliance for Quality of Care (NAQC) was
initiated in 2009 and funded through the Robert Wood Johnson Foundation and is now managed by the
American Nurses Association (http://www.naqc.org/). Nursing had no alliance to bring together
stakeholders, and there was concern that nursing would not address the critical issues surrounding care
(NAQC, 2010). The NAQC is composed of nursing organizations and consumer groups. Policymakers
recognize the contributions of nurses in advancing consumer-centered, high-quality health care. The
NAQC was modeled after other alliances that primarily focused on improving the quality of care. The
Hospital Quality Alliance, founded in 2002, was the first quality alliance formed, bringing together
numerous stakeholders supported by the CMS and the American Hospital Association, primarily to get
hospitals on board to report quality measures. In the past decade, several more alliances have emerged
that focus on the review and/or development of quality measures. APRNs can obtain information about
advancing nursing quality through the American Nurses Association and the work of the NAQC, their
professional organizations, and, in general, being aware of the work in quality improvement through
organizations such as the Institute for Healthcare Improvement.
The Relationship Between Access and Health Insurance
Access to health care has been linked to health insurance, and the ACA has made important strides to
make insurance accessible to individuals and families. Although average annual premium increases for
family coverage are well below the rate of increases from 1999 to 2005, the 2016 increases in premiums
and deductibles have risen much faster than inflation and worker's earnings (Fig. 19.5). However, for
those purchasing insurance on the ACA's Health Insurance Marketplaces, the benchmark plans'
premiums stayed relatively flat in 2014-2015 (Kaiser Family Foundation, 2016b).
FIG 19.5 Trends in employer-sponsored health insurance. (From Long, M., Rae, M., Claxton, G.,
Jankiewicz, A., & Rousseau, D.; Kaiser Family Foundation. [2016]. Eligibility and coverage trends in
employer-sponsored insurance. JAMA, 315, 1824.)
As a direct result of the ACA provisions that expand access to care, in 2016 there were only 11 million
Americans without health insurance, a dramatic drop from a high of 45 million before the
implementation of the ACA (Kaiser Family Foundation, 2016b; Marken, 2016). This dramatic drop has
been attributed largely to Medicaid expansion, health insurance marketplace coverage, and changes in
private insurance that allow young adults to stay on their parent's health insurance plans and require
plans to cover people with preexisting health conditions. Although the number of uninsured has
dropped, a new issue has emerged from a 2014 survey finding that 31 million people had such high outof-pocket costs or deductibles relative to their incomes that they were underinsured (Collins,
Rasmussen, Beutel, & Doty, 2015). Over 10% of adults enrolled in a private health insurance plan had a
deductible of $3000 and 41% of those had debt loads of $4000 or more. Over 50% of underinsured
individuals reported problems paying medical bills or had medical debt (Collins et al., 2015).
A hazard for the uninsured is that they are often charged the full price for health services (Kaiser Family
Foundation, 2016a). In a study of Medicare cost reports, the top 50 US hospitals with the highest ratios
of charges over Medicare-allowable costs (markups) had markups about 10 times higher than allowable
costs. Uninsured patients may be asked to pay the full charges, and out-of-network patients and
casualty and workers' compensation insurers are often expected to pay a large portion of the full
charges (Bai & Anderson, 2015). Insurance companies negotiate payment levels—often 40% to 60%
discounted from established prices—but uninsured individuals do not have the same benefit. Several
states have passed laws requiring hospitals to charge the same price to all patients and have established
limits on what collection agencies can do. However, this remains a persistent, morally disturbing
problem in many states, with those least able to pay being charged the most for health care.
Policy Initiatives in Health Reform
The ACA and the Health Care and Education Reconciliation Act of 2010, which amended some provisions
in the ACA, represent the most far-reaching legislation enacted since the passage of Medicare and
Medicaid in 1965. Major elements of the ACA included the creation of a high-value health care system
through payment reform mechanisms such as bundled payment (e.g., Medicare pays $30,000 for
coronary artery bypass graft surgery, including all care/complications for 120 days postprocedure);
requiring reporting on quality measures to inform the public and provide a basis for payment;
strengthening the primary care system; controlling costs through better coordination of services,
especially for individuals with multiple chronic illnesses; and increasing access to health care. Many
requirements in the ACA overlap the cost, quality, and access policy issues. Now over 5 years into the
rollout of the legislation, substantial gains in coverage have been met and new models of care delivery
and payment are in place. Over 20 million previously uninsured individuals are now covered, the CMS
Innovation Center continues to test new payment models focused on improving value, and more people
are cared for in systems that emphasize value over volume (Bauchner & Fontanarosa, 2016). Even with
these efforts, according to Lavizzo-Mourey (2016), the promise of affordable, comprehensive, personcentered care is still a point on the horizon. The AHCA, at the time of this writing, has only been passed
by the House of Representatives; it keeps 90% of the original ACA in place but it is believed to
substantially threaten the gains in insured lives achieved under the ACA (Jost, 2017). The Congressional
Budget Office projected that the AHCA would result in 14 million people dropping or losing coverage by
2018, rising to 24 million by 2026. The losses would come primarily from repeal of the individual
mandate and Medicaid cuts (Jost, 2017).
Cost and Quality
ACOs, newer systems of care, are being developed that link patient care outcomes to costs of treatment
to create a high-value health care system (Fig. 19.6). An ACO is a system that horizontally integrates care
across a continuum and includes at a minimum a primary care provider, specialists, and a hospital.
Examples of ACOs include the Geisinger Health System, Kaiser Permanente, and the Mayo Clinic. ACOs
are responsible for providing high-quality care to a minimum of 5000 Medicare enrollees while
controlling costs. Instead of insurers being responsible for controlling cost, providers will be responsible.
Based on reduced costs of care, savings are then shared with the providers. Although there have been
previous attempts to create coordinated care systems, a new requirement—that ACOs must report
quality measures—is transformational.
FIG 19.6 Value-based health care delivery system. (Adapted from Nursing Alliance for Quality Care.
[2010]. Strategic policy and advocacy roadmap. Retrieved from
http://www.naqc.org/Docs/NewsletterDocs/2010-SPAR.pdf.)
According to the American Association of Nurse Practitioners (AANP, 2012), ACOs create incentives for
health care providers to work together to treat an individual patient across care settings. ACOs agree to
lower the cost of health care while meeting identified performance standards by sharing resources and
coordinating care. NPs are authorized to be ACO professionals. However, a last-minute change in the
Shared Savings section of the ACA for Medicare patients limits the assignment of patients for this
program to those who are being cared for by primary care physicians. Therefore, patients who choose
an NP for their primary care provider cannot be counted as beneficiaries and any shared savings are not
assigned. Thus although this does not prevent NPs from joining an ACO, it does prevent their patients
from being assigned to a Medicare ACO and then gaining any subsequent benefits that result from
participation. Essentially, APRNs are locked out of the governance structures, leadership, and cost
savings (profit) from these structures that are set up to greatly benefit from APRN service. Each ACO is
governed differently, and it will be important for APRNs to be involved in leading, governing, and sharing
the ACO savings and not become employees of these emerging structures. At this time, the AANP and
other nursing advocacy groups continue to push for a statutory fix to reinstate assignment of patients of
all ACO professionals, including NPs, by adding provider-neutral language.
Medicare bundled payments, in which payment for care is based on a lump sum payment for an episode
of care rather than on an individual visit, procedure, or service, began in April 2016 for hip and knee
replacements, to include all surgery costs through full recovery for hospitals in 67 geographic areas. In
2014, more than 400,000 Medicare recipients had hip or knee replacements costing more than $7 billion
for just the hospitalization (Delbanco & de Brantes, 2015). Through this new payment model, hospitals
will benefit financially from high-quality, lower cost service but may have to repay Medicare if quality
and cost targets are not achieved. In addition to efforts to provide better coordination through bundled
payments, the ACA also specifies a program to reduce readmission. Hospitals are required to report on
all readmissions over a specific time period, and the readmission rates are made public and posted on
the Hospital Compare website (https://www.medicare.gov/hospitalcompare/search.html?). Both the
bundled payment model and the requirement to reduce admissions are areas in which APRN practice
can contribute significant savings and improved outcomes (Newhouse et al., 2011).
The Patient-Centered Outcomes Research Institute (PCORI) was established to conduct research related
to testing health care interventions, with the goal of identifying those interventions that truly make a
difference. PCORI is an independent research institute authorized by Congress in 2010. The Board of
Governors is constituted to represent the broader health care community. However, in 2016, the board
composition was dominated by 12 physicians and the remaining 9 members represented a variety of
health care constituencies, including one APRN. The focus in PCORI is to fund comparative effectiveness
research to answer real-world questions about what works best for patients, considering their individual
circumstances and concerns. To do this, PCORI requires the engagement of patients and other
stakeholders throughout the research process, and they require a partnership with the target
community. PCORI funds studies on diverse topics such as comparing self-management and peer
support communication programs among patients with chronic obstructive pulmonary disease and their
family caregivers, testing telehealth for those with Down syndrome, and translating and incorporating
older adult opinions into meaningful research. By 2019, PCORI will have spent $6 billion on comparative
effectiveness research (Reichard, 2013).
Access
Access to health care is emphasized in the ACA through many policy mechanisms. A controversial
section of the ACA is the requirement for individuals to purchase health insurance, known as the
individual mandate. Anyone not covered by an employer or government program must purchase health
insurance or pay a penalty. Twenty-six states challenged this requirement in court and on June 28, 2012,
the Supreme Court issued a historic decision that upheld the individual mandate by considering it a tax
that was within the power of the federal government to levy. The ruling was masterful in bridging
different philosophic views among the justices and many different political agendas. To make the
required insurance affordable to those who are not covered through employment or a government
program, health insurance exchanges have been established by states. These provide marketplace
information about costs and benefits so that individuals can transparently choose the best plan. In
addition, the ACA required an expansion of the Medicaid program to all individuals younger than 65
years with incomes up to 133% of the poverty level ($32,319 for a family of four). The Medicaid
expansion of the ACA significantly increased coverage that had previously been limited primarily to
pregnant women, children, and other select groups. The AHCA, with support from the Trump
administration, aims to eliminate the enhanced funding levels that made states' expansion of Medicaid
possible. With this loss of funding, coverage for over 11 million people who have gained eligibility
through ACA Medicaid expansion is at stake (Rosenbaum, 2017).
The Supreme Court decision allowed states to opt out of the expansion and not lose federal funding for
programs already in existence, thus finding a middle ground. As of January 2016, 19 states were not
expanding their programs. According to Garfield and Damico (2016), Medicaid eligibility for adults in
states not expanding is severely limited. In 2016, the median income limit for parents is about 44% of
poverty, or an annual income of $8840 a year for a family of three, and in nearly all states not
expanding, childless adults are ineligible. These individuals and families are caught in a coverage gap
because they have incomes above Medicaid eligibility limits but below the lower limit for marketplace
premium tax credits. The ACA expected that low-income people would receive coverage through
Medicaid, so there is no financial assistance to people in poverty for other coverage options. A
promising and expanding opportunity for APRNs to increase access to care is working for or developing
nurse-managed clinics (NMCs). The ACA provides funds to help support expansion of NMCs. There are
currently over 250 NMCs, with most clinics being part of an academic nursing program. Most NMCs are
recognized as patient-centered medical homes approved through the National Committee for Quality
Assurance (Kennedy, Caselli, & Berry, 2011). To be recognized, a clinic must comply with all the quality
reporting requirements and have electronic health records (see Chapter 24).
Emerging Advanced Practice Nursing Policy Issues
APRN Payment Issues
There are continued challenges for APRNs related to payment rates. Medicare continues with their longstanding policy of paying APRNs 85% of the Physician Fee Schedule (PFS). However, when services are
billed as “incident-to” physician care, billing can be at the 100% rate (see Chapter 21). As of 2011,
certified nurse-midwives (CNMs) are the only APRN group to receive 100% of the PFS. This increase from
65% was initiated in 2011; however, CNMs are not yet eligible to participate in some Medicare services
such as conducting/billing a Medicare initial or annual wellness visit. Certified registered nurse
anesthetists (CRNAs) have a specific fee schedule established by Medicare that defines payment that is
modified by the level of independence of practice, ranging from supervision by a physician to no
supervision by a physician.
Over the years, there has been considerable discussion about the 85% rate, with many APRNs
advocating for same pay for the same service (comparable worth). Others have argued that having
reduced payment makes APRNs a cost-effective solution to high health care costs. A study of Medicare
Part A (inpatient) and Part B (office visit) compared claims for 2009-2010 submitted by NPs with national
provider identifier (NPI) numbers and primary care physicians. After adjusting for demographic
characteristics, claims for beneficiaries assigned to an NP were $207, or 29%, less than for the primary
care physicians. This held for inpatient and total office visit paid amounts as well, with 11% and 18% less
for NP patients, respectively. This suggests that increasing access to NP primary care had not increased
costs for the Medicare program and may be cost saving (Perloff, DesRoches, & Buerhaus, 2016). The
findings from an older study of CRNA cost-effectiveness found that when simulated under high-use,
ideal conditions with 12 stations and 4 cases per station, an anesthesiologist would generate yearly
revenue minus costs of $1,285,945, whereas the independent CRNA generated $3,277,945. When lower
demand was simulated with 12 stations and 2 cases per station, only the independent CRNA had a
positive net revenue of $702,690, whereas the anesthesiologist model lost $1,289,310 (Hogan, Seifert,
Moore, & Simonson, 2010). Clearly, independent CRNAs provide the best economic benefit.
Overall, Medicare is a huge program and only growing bigger because of the large US aging demographic
shift. From a policy perspective, the cost increases from ACA-mandated changes to the Medicare
program, coupled with pressures to control the health care cost curve, have created a difficult policy
situation. Legislators view the Medicare program as untouchable, believing that limiting benefits
significantly would likely end political careers. For many years, Medicare had in place a sustainable
growth rate formula that required “mandatory” fee cuts that were always averted by last minute
congressional action. No savings were attained but no other solution was offered to replace the
imaginary cuts until 2015, when the formula was finally repealed and replaced by the Medicare Access
and CHIP Reauthorization Act of 2015 (MACRA).
MACRA established a new schedule of Medicare fee updates for APRNs, physicians, and other eligible
health care providers. Payment rates are increased by 0.5% a year now, but there will be no rate
changes between 2020 and 2025. In 2019, APRNs, physicians, and other eligible providers will need to
choose to be paid under the new Merit-based Incentive Payment System or to join the Alternative
Payment Model (APM) program. APRNs and other providers who receive a substantial portion of their
payments from an ACO, medical home, or another APM will receive 5% annual increases in Medicare
payments through 2024. Payments to medical professionals who instead participate in the Merit-based
Incentive Payment System will be adjusted upward or downward according to measures of their
performance quality using a variety of indicators. Clinicians rated as exceptional on these indicators are
eligible for additional payments through 2024. Then from 2026 on, Medicare will have two separate feeupdate systems: APRNs and others participating in the APM program will receive annual increases of
0.75%, while nonparticipants will receive increases of 0.25% (Oberlander & Laugesen, 2015).
Payment to APRNs by private insurers continues to be challenging in many states. Because insurers are
regulated at the state level, approval of APRNs as part of a network has to be done state by state. There
are many examples of private insurers cutting payment rates to APRNs. In 2009, a large insurer in
Oregon cut payment rates to APRNs for mental health care and other insurers followed. Soon after this,
notices were sent to APRNs that primary care rates would also be cut. To address this arbitrary policy,
Oregon became the first state to require insurance companies follow “equal pay for equal work” rules
on insurance reimbursements for NP, physician assistant, and physician services in primary care and
mental health care (Oregon Nurses Association, n.d.).
The economic benefits of APRNs are clear. The Perryman Group issued a report in 2012 that found
substantial economic benefits for Texas when APRNs provide health care. Assuming a modest net
savings of about 6.2% when health care is provided by APRNs, the money not spent on health care
would create 97,205 permanent jobs and each year generate $8.0 billion in gross product. Tax receipts
to the state from those newly created jobs would increase by almost $700 million (The Perryman Group,
2012).
More recent work by Perloff et al. (2016) found that Medicare evaluation and management payments
for those patients receiving NP services were 29% less than for services provided by primary care
physicians. According to these authors, this is the first national-level data set to examine the cost of
primary care services provided by NPs and primary care physicians over a 12-month time frame (20092010). However, challenges remain in using the Medicare data for analyzing APRN practice. To capture
the practice of APRNs accurately, all APRNs need to be billing under their own NPI number. Use of
“incident-to” billing, although it generates 100% of the PFS, hides the work of APRNs and attributes the
service to another's NPI number. In some situations, supervision requirements set by organizations,
employment arrangements, or scope of practice requirements may limit APRNs' ability to bill under their
own NPI number. The importance of APRNs using their NPI for all services cannot be overstated.
APRN Full Practice Authority
The National Council of State Boards of Nursing (NCSBN, 2014) has proposed a model nurse practice act
that would achieve full practice authority for all APRN roles. This model practice act explicitly describes
APRNs as licensed independent practitioners within standards established or recognized by the NCSBN.
The challenge is that achieving this or similar legislation requires that many state licensing laws be relegislated. State licensing laws define the permissible scope of practice for the health care professions.
The purpose of state health professions laws are to protect the public and to assure consumers that
health care workers conduct their practices in areas for which they are properly trained. However,
according to LeBuhn and Swankin (2010), scope of practice laws too often are unnecessarily restrictive
and serve to protect the economic interests of another group. These authors reiterated the 1995 Pew
Health Professions Commission's Task Force on Health Care Workforce Regulation report, which
recognized the blurred boundaries between professional scopes of practice as technology has advanced
and workforce innovations have been embraced and called for increased regulatory flexibility. The Pew
Commission noted that varying objectives and levels of specificity are found in different professions'
scopes of practice without rationale and that the system “treats practice acts as rewards for the
professions” rather than as rational mechanisms for safe and effective care by competent practitioners.
Importantly, the Pew report stressed that practice acts should be based on demonstrated initial and
continuing competence and that it should be expected that different professions share overlapping
scopes of practice.
With the publication of The Future of Nursing: Leading Change, Advancing Health (IOM, 2011), the
support for full practice authority has accelerated with support from the National Governors
Association, the National Conference of State Legislatures, the American Association of Retired Persons,
and the Federal Trade Commission, among others. In contrast to this support, the American Medical
Association and other state and national medical organizations continue to be formidable opponents. In
The Future of Nursing report (2011), Safriet addressed the historical and political context for much of
organized medicine's opposition. Physicians were the first to gain legislative recognition of their practice
and essentially claimed the entire health-illness continuum as their exclusive purview, and it was
interpreted as solely under their control. It is within this context that other health professions have had
to carve out their practice acts, as illustrated by the efforts by APRNs to expand their scope of practice in
Florida (see Exemplar 19.2).
Exemplar 19.2
An APRN Cliffhanger in Florida: Political Competence in Action
Janet DuBois
Advanced practice registered nurses (APRNs) in Florida have been waging a political battle for over 20
years to gain the authority to prescribe controlled substances, and Florida is the only state in the United
States to prohibit APRNs from prescribing them. This not only contributes to decreased access to care
but also adds to the financial burden of both the patient and the health care system. According to the
US Census Bureau (2010), 86% of the state falls within the definition of a rural area, affecting over 1.6
million residents, many of whom have limited access to primary care services. This is due to the
common barriers that rural-dwelling Americans experience, including lack of access/primary care
provider services, transportation, lack of insurance, and language and culture barriers (US Census
Bureau, 2010). Limiting APRNs' ability to prescribe controlled substances adds to these barriers and
makes it difficult to provide comprehensive care for all citizens. Many APRNs report having to schedule
another visit for their patients to coincide with a physician presence or having to refer their patients to a
primary care physician just to prescribe a much needed medication that is a controlled substance. This
includes those used to treat common conditions such as coughs, diarrhea, anxiety, sleep disorders,
weight loss, and psychiatric illnesses.
Coalition Building
Many of the APRN organizations in Florida have come together to form the Florida Coalition of
Advanced Practice Nurses, to address advanced practice nursing scope of practice issues within the
state. Members include the Florida Nurse Practitioner Network, the Florida Association of Nurse
Anesthetists, the Certified Nurse Midwives, the Florida Association of Nurse Practitioners, and the
Florida Nurses Association, to name a few. The Coalition meets quarterly as a group and many members
participate in weekly meetings during the active legislative session, called the “huddle,” to discuss
ongoing legislation and issues and to strategize to achieve the mutually agreed upon goals, the primary
one being full scope of practice. A critical early step was to get all APRN groups to have a unified voice so
they could strengthen and better serve more than 14,000 advanced practice nurses in Florida.
During the 2016 Florida legislative session, coalition members agreed to promote the Florida House bill
to eliminate practice barriers around prescribing controlled substances. Throughout the session, each
organization's key leaders worked closely with their lobbyist and both the Florida Senate and House bill
sponsors to promote this legislative goal, craft appropriate language, and offer their clinical knowledge
and expertise to ensure the best outcomes. Much of the dialogue surrounded negotiating with the
opposition and what compromises we were willing to make in order to pass favorable legislation. In the
past, the Florida Medical Association had agreed to support similar legislation if we were willing to have
joint board oversight (Board of Nursing and Board of Medicine), or the anesthesiologist group pressured
our bill sponsor into adding limitations on what certified registered nurse anesthetists could do, taking
away privileges they already had. We were not willing to compromise on either of these points, which
resulted in the bill not passing in previous years. On the other hand, we did compromise by agreeing to
limitations on the amount of Schedule II opioids and psychotropics we would be authorized to prescribe.
Effective use of APRN Power
Persistence and Activating the Grass Roots
The initial version of the House bill (HB 423) was filed in October of 2015 (presession) and passed
through multiple committees prior to coming before the full House for a final vote. The bill went
through the various required House committees with little opposition and was presented for a full
House vote on March 2, 2016, passing with 117 Yeas and 2 Nays. We considered this a victory but knew
we still had to get the Senate companion bill (SB 1250) passed before our long-awaited controlled
substances prescribing authority could become a reality. We anticipated that this would be an uphill
battle with the Senate because there was more fierce opposition there to the bill. The Senate delayed
scheduling, and the Senate president was opposed to scheduling the bill for a final Senate vote should it
pass through all committees. Two weeks before the end of the session (February 26th), the Senate
Appropriations Committee received the bill but delayed voting on it. Naturally we were getting
extremely nervous and decided it was time to put some pressure on the committee members. We sent
out email blasts through the Coalition instructing them to call or email all 19 members of the
Appropriations Committee to support our bill and schedule it for a vote. Finally, on March 1st, the
Appropriations Committee passed the bill with a very positive 17/0 vote. While the session was winding
down, SB 1250 was still in committee and the Senate President was stalling and refused to allow the bill
to be put on the calendar for a final reading and vote. That's when the bill really stalled. Three days
before the end of the 2016 legislative session, we began to really panic; we were so close to this
landmark legislation and yet it looked like we may not get the bill passed! We started calling in favors we
had among legislators and sending urgent emails to all the APRNs in Florida, our colleagues in practice
(including our physician supporters), academia, and friends and family to call and email the Senate
President to implore him to place the bill for a final Senate vote. The Senate President received
hundreds of emails and calls from APRNs, physicians, patients, and friends and family urging him to
place the bill on the calendar. Still, he didn't budge.
Engaging a Champion
In a last ditch effort, a few of the larger organization's lobbyists called on another, more seasoned
lobbyist who in the past had always supported or represented APRNs. He made a call to a powerful
former governor of Florida, who intervened on our behalf, instructing the Senate to place the bill for a
vote. At last, 2 days before the end of the session, the bill was voted on in the Senate and passed
unanimously. However, it still needed to be reconciled with the House version before becoming law. In
the last 2 days of the session, the bill went back and forth between the House and the Senate four times
before the final vote in the House at approximately 5:33 p.m. on the very last day of the session.
Needless to say, the victory was sweet but the process was long and tedious. The bill was signed into law
by the Governor of Florida on April 14, 2016.
While the final bill authorized APRNs with national certification and a master's degree in their specialty
field to prescribe controlled substances, there are some caveats. The bill only allows for a 7-day supply
of any Schedule II drugs and only allows psychiatric nurse practitioners to prescribe Schedule II
psychotropic drugs for children under 18 years of age, aimed at limiting the prescribing of attentiondeficit/hyperactivity disorder medications to children. In addition, the law stipulated that a formulary
committee, consisting of three APRNs, three physicians, and one pharmacist, was to meet and establish
any further limitations on the prescribing of controlled substances. The law became effective January 1,
2017, and all APRNs who meet the standards are able to register with the DEA and are prescribing
controlled substances II-V. We still consider this a landmark victory, and we will continue to work with
policymakers, stakeholders, and legislators to reach our goal of full practice authority in Florida.
To change this paradigm, in 2006 Safriet worked with six professional licensing boards, including the
Federation of State Medical Boards and the NCSBN, to achieve consensus on a position paper addressing
scope of practice legislation. Notably, the six organizations agreed that the criteria related to who is
qualified to perform functions safely without risk of harm to the public are the only justifiable conditions
for defining scopes of practice (NCSBN, 2009). In spite of these efforts, full practice authority remains a
goal for many states. The NCSBN compiles a state-by-state report tracking status of practice and
prescribing across all APRN roles (NCSBN, 2016a). Provider-neutral language in all rules and regulations
would go far in removing artificial barriers to practice that lack an evidence base.
In 2013, the Veterans Health Administration (VHA) drafted a new nursing handbook that would grant its
3600 APRNs with full practice authority, even in states that require physician oversight. The proposal
was designed to “reduce variability in practice across the entire VA health care system,” among other
issues, according to the VHA. Organized medicine responded with 104,256 comments against the
proposed rule, including 43 state medical organizations and others strongly denouncing the proposed
change and urging that “VHA policies support physician-led health care teams and state-based licensure
and regulation remain unchanged” (Basu, 2014). However, the VHA received a total of 223,296
comments on the proposed rule, mostly in favor of expanding APRN practice. It is clear to see that an
engaged citizenry had an impact on this ruling. It is a disappointment that the final ruling did not include
CRNAs, and the exclusion of this APRN category is counter to the evidence on CRNA safety and
effectiveness. The APRN Full Practice Authority was granted in 2016 for NPs, CNMs, and CNSs, and more
work will need to be done to get CRNAs included in a future ruling.
APRN Workforce Development
Data about the US nursing workforce has been critical to formulating rational policies related to APRNs.
Lack of data has been a major issue in defining the benefits of APRNs. The primary source of valid and
reliable data has been the Health Resources and Services Administration, which in 2012 began a national
survey of NPs, the National Sample Survey of Nurse Practitioners. However, this survey does not sample
other APRNs beyond NPs. Another data source about the NP practice environment is the National Nurse
Practitioner Practice Site Census, which has been conducted by the AANP every 2 to 3 years to
characterize and review trends in the NP workforce (AANP, 2015). CRNA and CNM data are of higher
quality because each of these advanced nursing practice specialties has a single organization and
national certifying body tracking its workforce over time, essentially a census. They are able to analyze
their data to answer policy-relevant questions quickly, with a few keystrokes. CNS data have been more
difficult to accurately obtain and track. In states where CNSs do not have title protection, they may selfidentify as CNSs but do not meet the criteria of an APRN as defined by the Consensus statement or the
American Association of Colleges of Nursing. The National Association of Clinical Nurse Specialists did its
first CNS census survey in 2014, and CNS surveys are done jointly every 2 years by the NCSBN and the
National Forum of State Nursing Workforce Centers (NCSBN, 2016b).
The Bureau of Labor Statistics also reports occupational employment statistics for NPs, CRNAs, and
CNMs; however, CNSs are not separated from the registered nurse category (Bureau of Labor Statistics,
Department of Labor, 2012). Some data may be available through nursing organizations, current NCSBN
national data, and some state nursing workforce centers. The quality of data from these sources is
variable.
A policy issue to which APRNs need to continually attend is ensuring that APRN data are identifiable for
quality evaluation and outcome assessment. When APRN services are billed “incident-to” the physician
services, the value of the APRN work is attributed to the physician. A model for data collection for
APRNs is NMCs, which have effective data collecting and reporting systems and are recognized by the
National Committee for Quality Assurance as patient-centered medical homes. Having strong, current,
reliable APRN workforce data is essential for overcoming invisibility and building political power.
APRN Political Competence in the Policy Arena
The move to doctoral education for APRNs elevates the need for APRN involvement in policy
development because effective leadership demands it. Policy competence is clearly emphasized in the
Doctor of Nursing Practice (DNP) competencies as Essential V: Health care policy for advocacy in health
care and is embedded in all of the other DNP Essentials (American Association of Colleges of Nursing,
2006). Policy competency requires APRNs to incorporate policy strategies continuously among the
practice, research, and policy nexus in all practice settings (Table 19.3). As DNP programs explode in
both numbers of programs and graduates, policy analysis and political competence must be integrated
into every course, content area, and project so that the DNP graduate has the ability to assume a broad
leadership role on behalf of the public and nursing profession. The solutions to today's social injustices,
politicized delivery systems, perverse financing, and uneven quality in the health care system are
difficult. APRNs are well positioned with clinical credibility to inform, design, and influence policy
solutions, but this will happen only if they expand their arena of influence beyond the clinical setting
(see Exemplar 19.3 on the nation's largest nursing PAC).
TABLE 19.3
Doctor of Nursing Practice (DNP) Competenciesa for Health Policy and Politics
DNP Essentialb Policy Skill
I. Scientific underpinnings for practice
• Analyze policy and the practice of politics, political systems, and political behavior with nursing science
to effect policy-level change.
II. Organizational and systems leadership for quality improvement and systems thinking
• Create and sustain coalitions (policy communities) on health care quality and access via policy
development at institutional, community, corporate, regional, national, or international levels.
III. Clinical scholarship and analytic methods for evidence-based practice
• Participate in design, translation, or dissemination of APRN practice inquiry within the context of
health services research.
• Use evidence/best practices to inform policymakers about APRN practice and quality.
IV. Information systems/technology and patient care technology for the improvement and
transformation of health care
• Influence sensible metric development.
• Ensure that nursing's values are captured.
• Overcome APRN invisibility by ensuring the inclusion of nursing and APRNs in all administrative and
clinical databases.
• Provide policy leadership to link meaningful data on nursing activity electronically to cost, quality, and
health outcomes.
V. Health care policy for advocacy in health care
• Engage in political activism and policy development, mentor activism, and participate on boards that
affect health policies.
VI. Interprofessional collaboration for improving patient and population health outcomes
• Promote interprofessional practice.
• Build interprofessional coalitions as a powerful advocacy tool to promote positive change in the health
care delivery system.
• Communicate across disciplines to build common ground.
VII. Clinical prevention and population health for improving the nation's health
• Promote the financing and delivery of evidence-based clinical preventive and population health
services in all health policy arenas.
VIII. Advanced nursing practice
• Function as a content expert and a policy change leader and serve as steward for advanced practice
nursing.
aRelevant to all advanced practice registered nurses (APRNs).
bAdapted from American Association of Colleges of Nursing. (2006). The essentials of doctoral education
for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/publications/position/
DNPEssentials.pdf.
Exemplar 19.3
The Anatomy of a Successful Political Action Committee, From One of the Nation's Strongesta
The American Association of Nurse Anesthetists (AANA) has the largest federal nursing political action
committee (PAC) in the nation by far. With donations of over $1.3 million per 2-year election cycle, it is
also one of the top federal health care PACs in the country. They are very proud of their thoughtful
process for governing their PAC and making distributions. The certified registered nurse anesthetist
(CRNA)-PAC Mission is to Advance the Profession of Nurse Anesthesia through Federal Political
Advocacy, and they place a strong emphasis on being highly strategic, inclusive, and thoughtful. All
operations related to the PAC, including fundraising, research, marketing, communication, and
disbursements, stem from strategy and input from the mission, member leadership, and advocacy
agenda of the AANA. The PAC is governed by eight CRNAs and one CRNA student. They are assisted by
one full-time AANA staff member who regularly works with the PAC committee to serve as liaison and
share compliance and political knowledge to make the most informed decisions. There are five key
reasons why their PAC is so highly successful.
Grassroots Driven
First, they deploy a highly inclusive process asking grassroots CRNAs for local information about
congressional campaigns. Making highly strategic disbursement decisions, they begin with the CRNA
community and involve them in identifying key campaigns. Their sole criteria are directed at making
disbursements to candidates who will move the CRNA agenda forward. Because the CRNA community is
politically diverse, they do not formally endorse candidates. The PAC bases its financial support on the
candidate's familiarity with and support of the CRNA profession and ability to influence the overall
health care agenda in Congress. The PAC remains in close contact with individual CRNAs through the
process.
Educating Policymakers
What the PAC disbursements gain for the AANA is access to federal elected officials and other leading
policymakers. Policymakers are dealing with a wide breadth of issues and may not know how a policy is
being played out in their community. Making PAC donations provides access to policymakers and
opportunities for CRNAs to educate them about the benefits of CRNA care and how restricting CRNA
practice impacts patients and increases health care costs. With the demanding schedule placed on
lawmakers, the PAC affords one-on-one opportunities to discuss issues important to CRNAs that are
otherwise unattainable.
Inspire and Acculturate CRNA Students Early Into Policy Engagement
A strong value and part of the culture of the AANA is to involve its student members, which reflects the
fact that the AANA has over 90% of all CRNAs as paid members. Nurse anesthesia students learn that
their jobs providing anesthesia can be legislated away in an instant, making CRNA students aware of and
engaged in policy from the start. The AANA presents policy engagement as having a visible and practical
relationship to the students' practice and livelihood and encourages early donating to the PAC so that it
becomes a pattern as they mature in their careers.
Common Single Threat
Another key aspect of the success of the AANA's CRNA-PAC is that the American Society of
Anesthesiologists (ASA) is a very real and outspoken opponent to CRNA practice and has unfortunately
tried to block CRNA practice and reimbursement at every turn. While there are decades of peerreviewed research documenting the safety and efficacy of CRNA practice, the ASA clings to its ideologic
agenda that CRNA practice is “unsafe.” Moreover, as a physician organization, the ASA has a $3.8 million
PAC, nearly double the size of the AANA's CRNA-PAC. A large number of AANA members agree that the
ASA opposition is a very real threat to their livelihood. AANA members see PAC contributions as a way to
gain access to lawmakers so that they may educate them to more sound, patient-centered, and
evidence-based policymaking.
Bipartisan Giving
Policymakers are carefully vetted, and disbursements target legislators who will carry the CRNA agenda
forward. The CRNA-PAC typically gives equally to the Republicans and Democrats with a slight skew
toward the party that is in power in the US House of Representatives and the US Senate. This way the
CRNA-PAC is not viewed as being aligned with a single political party, giving members and AANA
leadership access to and an information channel with bipartisan legislators and candidates.
aDr. Eileen O'Grady would like to thank Kate Fry of the AANA Staff and PAC Liaison, who was generous
with her time in being interviewed for this exemplar.
Political Competence
Politically competent APRNs serve as content experts with policymakers and their staff. Often,
policymakers in the legislative branch are generalists who have a working knowledge on a broad range
of topics such as immigration, transportation, energy, agriculture, and tax policy. However, in the
regulatory branch, the policymaker will be far more knowledgeable on a narrower range of topics. At
the institutional level, the corporate, or “C suite,” executive is also broad based, focusing on the
institution's profit margin, reputation in the community, and public reporting profile. These wideranging knowledge bases make it imperative for the APRN to use core nursing skills to determine the
policymaker's baseline level of knowledge before launching into information sharing or making
suggestions. Serving as a resource to policymakers with evidence-based information and helpful
suggestions that are in the public interest is crucial and requires a thoughtful, skillful approach. When
serving in this capacity, it is important to avoid a self-serving posture. To influence or participate
meaningfully and effectively in policy development, APRNs must be aware of the policymaking process
from idea conception to implementation as well as the open windows of political opportunity. Being
effective in policy influence requires having deep knowledge about the problem the policy is intending
to solve. Furthermore, intentionally developing and maintaining strong relationships with policymakers
and other health care interest groups are important APRN activities. This requires asking many
questions, building rapport, and seeking to understand where the policymaker is coming from before
pushing an APRN or a patient-centered agenda forward. Heeding the US policy process, policymakers
seek advisement on highly specific policy modifications rather than major reform recommendations.
Elected officials turn over at a far higher rate than civil servants or health care executives, who make
careers out of formulating and implementing health policy. Because of the longevity of their careers, the
strong trustworthy relationships APRNs make with the policymaker's staff as well as regulatory
professionals can yield great results over time.
Individual Skills
Deep Knowledge
Self-Awareness
The value of APRNs is an important idea but, to be heard effectively, a great degree of maturity,
discipline, humility, restraint, and respect for self and others must be practiced. Most political careers
are created with small steps; when the person is effective, she or he is elevated into larger and larger
spheres of influence. The politic...
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