Letter from the nursing community to the Senate Health Education, Labor and Pensions (HELP) Committee commending them on crafting the Affordable Health Choices Act of 2009

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Chairman Edward Kennedy Ranking
Senate Health Education Labor and Pensions Committee 
428 Senate Dirksen Office Building
Washington, DC 20510 

Member Michael Enzi
Senate Health Education Labor and Pensions Committee
835 Senate Hart Office Building
Washington, DC 20510

Dear Chairman Kennedy and Senator Enzi:

The 36 undersigned nursing organizations would like to commend the work of the Senate Health Education, Labor and Pensions (HELP) Committee in crafting the Affordable Health Choices Act of 2009. This legislation represents a movement towards comprehensive and meaningful reform for our nation’s healthcare system.

We appreciate your recognition of the need to expand the nursing workforce, and thank you for your commitment to reauthorize the Title VIII Nursing Workforce Development Programs under the Public Health Service Act. We are pleased to see so many important provisions included in the bill that will help address the growing nursing shortage. Expansion of the Nursing Workforce Diversity Program will allow the profession to educate and provide growth opportunities for racial and ethnic minorities underrepresented among registered nurses. Additionally, the inclusion of extended provisions to increase the nurse faculty population will provide great benefit to our schools as they work to overcome student capacity barriers. These and the other sections that amend the Title VIII programs will help to ensure they meet their mission of increasing the nursing workforce and providing quality care to our nation’s underserved communities. Therefore, we are most grateful that Section 442 (Authorization of Appropriations for Parts B through D of Title VIII) of the bill seeks to increase funding for the Title VIII programs so that more nurses are educated to address the demand for emerging nursing positions, particularly as they relate to public health, prevention, and primary care needs.

To enhance these changes, we feel that the inclusion of the Capitation Grant program outlined in the Nurse Education, Expansion, and Development Act of 2009 (S. 497), which was introduced by Senator Richard Durbin (D-IL), would further augment the legislation’s ability to fully address the needs of our nursing schools, enabling them to expand student capacity. From 1971 to 1978, Congress provided Capitation Grants (formula grants based on the number of students enrolled) to schools of nursing in support of nursing education. These grants had a stabilizing effect on past nursing shortages by addressing the financial obstacles of nursing programs.

Each year, schools of nursing turn away tens of thousands of students due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. Compared to other academic disciplines, the cost of nursing education is relatively high, like medicine, which further increases the financial burden on nursing schools. Schools require specialized laboratory equipment, computer software, and simulated hospital units to prepare students to provide lifesaving nursing services in a complex healthcare system. Moreover,nursing education is faculty-intensive with a high ratio of faculty to students, on average 1:10, as mandated by state registered nurse practice acts. Therefore, we feel the Capitation Grant program offered in S. 497 would augment the existing authorities and the revisions made in your bill.

We support the development of a National Health Care Workforce Commission under section 411. Quality data on the national healthcare workforce is critical to ensure that care is comprehensive and coordinated and all providers are used to their full scope of practice. This can only occur with the collaboration from all healthcare providers in the planning and development of national standards for data collection and analysis. Therefore, we recommend that the membership of this commission has an equal representation among health professionals.

The Nursing Community commends the use of “community-based multidisciplinary teams” to support primary care through the Medical Home Model. This model demonstrates a commitment to quality, coordinated care by all health providers, and represents a focus not just on treating illness, but on emphasizing wellness and prevention — for this reason we believe this approach to care would be more appropriately named “Health Home” or “Patient Home.” We also firmly believe that Advanced Practice Registered Nurses (APRNs) should be clearly identified as primary care providers and authorized to lead Medical Homes. However, we are concerned that the current language under Section 212 suggests that only physicians would be authorized to lead a Medical Home.

APRN’s skill and education, which emphasizes patient and family-centered, whole-person care, makes them particularly well suited providers to head the Medical Home Model. According to the American Academy of Nurse Practitioners, there are over 125,000 Nurse Practitioners (NPs) practicing in the United States today. Of those NPs, 66% serve in at least one primary care setting. Therefore, approximately 82,500 NPs are practicing in primary care. Nurse Practitioners widely practice, as primary care providers, particularly in underserved and rural areas, with outcomes equivalent to their physician and physician assistant colleagues. We encourage the Committee to use the language defining Medical Homes from the Schwartz-Cantwell bill, Preserving Patient Access to Primary Care Act of 2009 (S. 1174, H.R. 2350).

As highlighted above, NPs are excellent primary care providers. Therefore, we believe that the “Primary Care Training and Enhancement” program, under Section 432 of this bill should be expanded to explicitly state and include APRNs such as Nurse Practitioners, and Certified Nurse Midwives.

The Nursing Community is pleased to see the inclusion of the Institute of Medicine’s definition of primary care and commend the Committee for the emphasis the legislation places on delivering primary care and preventive services under a reformed healthcare system. However, we feel that the definition of primary care providers, as noted on page 573 of the legislation, could be unintentionally limiting as it describes the clinician as providing preventative and health promotion services for “…men, women, and children of all ages…”. This suggests that a single primary care provider must offer care to all three populations and would indicate that providers who offer population-specific primary care, such as certified nurse-midwives, pediatric nurse practitioners, pediatricians, and others who serve a subset of the population would not meet the primary care provider definition. If this is not the intent of this language, we suggest its removal or clarification. A viable option would be to incorporate the definition of primary care providers from the Schwartz-Cantwell bill, Preserving Patient Access to Primary Care Act of 2009, with the inclusion of certified nurse-midwives.

We would like to thank you for your support of additional funding for the National Health Service Corps (p. 125). The National Health Service Corps (NHSC) plays an essential role in bringing primary care services to underserved areas. Many nurse practitioners have benefited from this program, and, with enhanced funding, many more will be able to pay for their educations and move on to provide needed health care services. We would ask that, in report language accompanying this legislation, Congress instruct the Health Resources and Services Administration to return to its original policy to ensure that pediatric nurse practitioners are eligible for NHSC scholarships as well as the loan repayment program.

Nurses are a central element in healthcare quality and safety. It is clear that the Committee recognizes the fundamental need for accessible quality care and understands the contribution nurses will make to ensure the provisions of the bill are implemented. The Affordable Health Choices Act of 2009 details new and expansive quality programs in Titles II (Improving the Quality and Efficiency of Health Care) and III (Improving the Health of the American People). These programs, particularly Section 931 Quality Measure Development, will expand the role of and need for nurses as they will be critical to collecting and implementing established quality indicators. We encourage the use of a standardized data framework for electronic collection of data by nurses in hospitals, ambulatory surgical centers, as well as community and public health settings that utilize standardized terminology and believe that nursing sensitive measures should be collected as a part of the national quality measures. We also concur that the data should be available to the public as outlined in your bill.

We would like to suggest that as an adjunct to the important work the Senate HELP Committee is doing regarding expanding nursing education, parallel efforts be undertaken with the Senate Finance Committee to expand clinical education for APRNs. In hospitals, the vast majority of care is provided by nurses, yet nurses receive little federal funding for clinical training. Unlike the Graduate Medical Education program that has been the primary vehicle for physician training in hospitals over the last 40 years, nursing education programs have not had the support or the funding to sufficiently provide nurses with the training needed for the complex healthcare environment. Because of the critical role nurses play in quality care and patient safety, nursing clinical education should be viewed with the same importance as medicine when reshaping healthcare and moving toward system-wide reform. We suggest a modification of the Medicare funding for nursing to include funds for training APRNs.

Finally, the Nursing Community is pleased to see that the Committee thought broadly about healthcare providers when drafting this legislation. Use of the terms “provider” and “practitioner” demonstrates a commitment to a new model where quality care is delivered by a team rather than any one provider. We encourage consistent terminology, where applicable, throughout the legislation.

The Affordable Health Choices Act of 2009 offers numerous programs that would augment the nursing workforce for the benefit of the nation’s health. For example Section 412, State Health Care Workforce Development Grants; Section 428, Nurse-managed Health Clinics; Section 429, Elimination of Cap on Commissioned Corp; Section 430, Establishing a Ready Reserve Corps all have the potential to improve the health professions workforce and directly impact the quality of patient care and improve the health of all Americans. We would like to reiterate our appreciation to the Senate HELP Committee for the significant efforts to draft this important legislation that will seek to address healthcare disparities as well as the primary care, prevention, and nursing needs of not only our underserved populations, but the entire nation. Lastly, improving the health of the nation requires the collaboration of the entire community and health professionals. We commend the excellent work of the Committee to highlight the need for prevention and a strong public health system. The Nursing Community looks forward to working further with the Committee to address the concerns raised above, and to support your efforts to achieve meaningful, comprehensive reform of our nation’s health care system.


Academy of Medical-Surgical Nurses
American Academy of Nurse Practitioners
American Academy of Nursing
American Association of Colleges of Nursing
American Association of Legal Nurse Consultants
American Association of Nurse Anesthetists
American Association of Occupational Health Nurses
American College of Nurse Practitioners
American College of Nurse-Midwives
American Holistic Nurses Association
American Nephrology Nurses' Association
American Nurses Association
American Organization of Nurse Executives
American Public Health Association, Public Health Nursing Section
American Society of PeriAnesthesia Nurses
Association of Community Health Nursing Educators
Association of Nurses in AIDS Care
Association of periOperative Registered Nurses
Association of State and Territorial Directors of Nursing
Dermatology Nurses' Association
Gerontological Advanced Practice Nurses Association
Hospice & Palliative Nurses Association
Infusion Nurses Society
National American Arab Nurses Association
National Association of Clinical Nurse Specialists
National Association of Neonatal Nurse Practitioners
National Association of Nurse Practitioners in Women's Health
National Association of Pediatric Nurse Practitioners
National Association of School Nurses
National Organization of Nurse Practitioner Faculties
Nurses Organization of Veterans Affairs
Philippine Nurses Association of America, Inc
Preventive Cardiovascular Nurses Association
Quad Council of Public Health Nursing Organizations
Society of Urologic Nurses and Associates
Wound Ostomy & Continence Nurses Society

cc: Senator Christopher Dodd (D-CT)
Senator Tom Harkin (D-IA)
Senator Barbara A. Mikulski (D-MD) 
Senator Jeff Bingaman (D-NM) 
Senator Patty Murray (D-WA) 
Senator Jack Reed (D-RI) 
Senator Bernard Sanders (I) (VT) 
Senator Sherrod Brown (D-OH) 
Senator Robert P. Casey, Jr. (D-PA) 
Senator Kay Hagan (D-NC) 
Senator Jeff Merkley (D-OR) 
Senator Judd Gregg (R-NH) 
Senator Lamar Alexander (R-TN) 
Senator Richard Burr (R-NC) 
Senator Johnny Isakson (R-GA) 
Senator John McCain (R-AZ) 
Senator Orrin G. Hatch (R-UT) 
Senator Lisa Murkowski (R-AK) 
Senator Tom Coburn, M.D. (R-OK) 
Senator Pat Roberts (R-KS)