Nurses may be the
for a stressed-out
health care system
By Barbara K. Redman
he Affordable Care Act will usher in the
most far-reaching changes to America's
health care system since Medicare. But
among its many benefits and reforms there
looms a serious crisis of accessibility. The
nation's present system for delivery of primary
health care simply is not capable of meeting the
demands soon to be placed upon it.
By 2016 the Act will provide coverage to
millions of previously uninsured Americans
through a private insurer or state agency.
Michigan alone has an estimated 1.2 million
uninsured residents. Many of these individuals
already have been regular visitors to emergency
rooms and urgent care facilities, too often
for conditions that are not emergencies.
Others typically have received care only when
experiencing a severe health problem.
With insurance, more people than ever
before are likely to seek preventive and routine
health services, also known as primary care.
This is a good thing, as early detection of health
issues can lower costs of treatment and means
financial savings for consumers. But when
you combine these millions with an aging
population, typified by huge numbers of Baby
Boomers entering their Medicare years, the
stress on the nation's health care delivery system
promises to increase significantly.
So who will provide health care for all these
Unfortunately, while the need for primary
care unquestionably will grow significantly,
many parts of the United States -including
Michigan—don't have enough health care
providers. Increasingly, medical students prefer
specialties or sub-specialties over primary
care, apparently because specialty fields are
more lucrative and enable quicker repayment
of student loans. The Association of American
Medical Colleges estimates that by 2015, the
nation will have 63,000 fewer physicians than
it needs. Michigan alone will have a shortage
of 4,400 primary care physicians and 4,000
specialty physicians by 2020. It is estimated that
only one-third of active physicians in our state
now practice primary care.
40 February 28 • 2013
Fortunately, a large group of health
professionals already is available to help fill
this gap. Advanced practice registered nurses
(APRNs), who have graduate degrees and
national certification, possess the sophisticated
clinical knowledge and skills to provide
excellent patient care; studies over several
decades have shown that APRNs provide high-
quality, enviably cost-effective primary care
with positive clinical outcomes and high levels
of patient satisfaction.
In a landmark 2010 report, the Institute of
Medicine recommended programs to increase
the number of persons with degrees in nursing.
However, the critical need for growth in
nursing's workforce is hampered by two major
obstacles -- insufficient funding for nursing
education and often outdated or unclear state
regulations. For example, the Health Resources
and Services Administration reports that more
than 50,000 qualified applicants are turned
away from nursing schools nationwide each
year because of a shortage of doctoral-level
faculty. The Affordable Care Act includes
funding to increase nursing faculty and
scholarships for nursing students, and these
programs may begin to resolve this issue, but
only that, if fully implemented.
The Institute of Medicine report also
recommended that state and federal
governments should remove regulatory barriers
that prevent APRNs from practicing to the
full extent of their education and training.
Regardless of specialty, the major regulatory
issue surrounding APRNs is their ability to
provide direct patient care autonomously,
within the scope of their practice as defined by
their state's statutes. As one national nursing
organization explains, "All APRNs collaborate,
consult with, or refer to physicians. Many
APRNs practice in health care teams with
physicians and other types of health care
providers. The issue is whether specific legal
requirements for physician involvement limit
the services APRNs can provide and areas
where they can practice:'
At present, the scope of practice allowed
for APRNs varies by both state and specialty.
Many states do allow APRNs to diagnose, treat
and prescribe autonomously. In Michigan,
the Public Health Code does not yet define
the scope of practice for APRNs, and vague
and ambiguous regulations do not encourage
graduating APRNs to remain in Michigan to
The Affordable Care Act's potential for
real reform will not be realized unless health
services are indeed immediately available to
those who need them, when they need them.
Increasing the number of health care providers
is an obvious and fundamental way to help
resolve the coming crisis in access. The most
efficient, cost-effective and patient-centered
way to accomplish this both now and over the
long term is by state and federal legislation
that enables the nation's highly skilled corps of
advanced practice registered nurses to do what
they have been educated, trained and nationally
certified to do.
Barbara K. Redman, PhD, RN, FAAN,
is dean of the Wayne State University College