January 2013

Volume 10, Issue 1

HEADLINES

Sequestration Update
FROM THE STATES . . .

LINKS

NLN Government Affairs Action Center
NLN Public Policy

Sequestration Update

The 112th Congress completed its two-year session, first by going over the self-made "fiscal cliff" at midnight on January 1, 2013, and then, almost 23 hours later, passing a tax and spending package in time before further damage was done to the nation's economic confidence. The fiscal cliff deal, the American Taxpayer Relief Act of 2012, passed as a substitute to H.R. 8.

H.R. 8 delays for 60 days, to March 1, 2013, the automatic spending cuts (sequestration) scheduled to occur pursuant to the 2011 Budget Control Act (BCA). While the experts were wrong about the fiscal cliff "Mayan apocalypse," the mindless, across-the-board sequestration presents economy-wounding cuts in government spending.

As reported in the July 2012 Nursing Education Policy newsletter, the BCA provided for $2.1 trillion in deficit reduction by setting 10-year caps on discretionary spending. In the event that Congress was unable to enact an additional $1.2 trillion in savings (via a balance of increased taxes plus spending cuts), the backup sequester mechanism would automatically shear discretionary spending for nine years, beginning in January 2013, with half to come from defense and the other half from nondefense discretionary (NDD) programs.

Last July the NLN endorsed, with 3,000 other organizations, a letter to Congress opposing sequestration of NDD programs. Signatories to the letter argued that NDD cuts already had been accomplished when Congress adhered to the BCA caps in 2012 in writing its appropriations bills for that year. NDD programs have been cut considerably already — they are one part of the budget that is shrinking, not growing — and the families that depend on these programs already have sacrificed. NDD spending as a share of gross domestic product already is at its lowest level since the Eisenhower administration — and that is before the additional $1.2 trillion in sequestration cuts that will come over the next decade if no debt deal is reached by March 1. By delaying the sequester, this spending fight over funding government safety-net programs may be exacerbated when the FY 2013 continuing resolution runs out in March.

The real threat to creating financial chaos (as in doing real damage by going over a cliff) will be the refusal to raise the debt ceiling to finance the spending already enacted by Congress. Unlike other industrial nations, through the decades the US Congress has voted to increase the debt limit to allow federal borrowing in the absence of sufficient revenue. A failure to raise the debt ceiling would result in the administration being unable to fund all the spending that it is required to do by the prior spending acts of Congress. Without an increase in the debt ceiling, the United States could default on its promise to pay interest on US treasury securities, which might create an international crisis in the financial markets. The debt ceiling already has been hit and the Treasury Department can only run the clock out until around February. Get ready for another showdown being called a budget debate, but is really a debate about our values and priorities as a nation.

FROM THE STATES . . .

New Report Calls for Larger Role for Nurse Practitioners

A new report from the National Governors Association (NGA) states that nurse practitioners could play a more prominent role in health care delivery and recommends that states consider easing laws under which they practice. The extended coverage of uninsured people in 2014, as well as the aging of the population, will mean an increased need for primary care providers. According to the NGA report, one way to accomplish that is by fully using the services of nurse practitioners.

The obstacle to accomplish this is the scope of practice laws in the states. The NGA research found wide variation in state laws regarding nurse practitioners, including the extent to which they are allowed to prescribe drugs, operate independently of physicians, and bill insurers and Medicaid. Sixteen states and the District of Columbia allow nurse practitioners to practice independently of a physician and to diagnose, treat and refer patients, as well as prescribe medication. The remaining states require some form of physician involvement, but how much varies from state to state.

The NGA report notes that in 2010 the Institute of Medicine criticized states in its Future of Nursing report for preventing nurse practitioners from practicing to the full extent of their training. Partly as a result, in 2011 Kaiser Permanente began to discuss advancing nurse practitioners from team members to clinic leaders in certain geographic areas. A Colorado prenatal clinic was selected to pilot that model. While the report notes that it is too early to compare costs with clinics led by physicians, in other measures the two are indistinguishable. Kaiser Permanente is planning to expand the nurse-led model.

The IOM report also said that some physician groups were concerned about extending state laws to allow nurse practitioners to practice more broadly, citing worries about patient safety and quality of care. However, a review by NGA found no studies that raised concerns about the quality of care and most showed care was comparable to physician-provided care. Physician groups also may have financial concerns but, according to the NGA report, a recent analysis found no differences in physician earnings between states that have expanded scope of practice laws and those that do not.