Nurses may be the best prescription 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 people? 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. T 40 February 28 • 2013 JN 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 practice. 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 of Nursing.