One Good Expansion Deserves Another

September is here again marking the start of another academic year—when educators, students and people who remember youthful years celebrate a new season of possibilities. It’s exciting to see students return to our hallways at the University of Michigan School of Nursing, ready for engaged learning in health promotion, evidence-based practice, and leadership. Providing it is our honor and our responsibility, especially in this fast-paced and complex era of health care reform.

 

On September 3, the first day of the new school year for the University of Michigan “bicentennial class” of 2017, the Michigan House of Representatives approved the long-awaited Senate version of the Medicaid expansion to 133 percent of the federal poverty level. Thus Michigan becomes the 20th state to pass Medicaid expansion today, with Governor Snyder officially signing it into law (pending federal approval), and to receive full federal funding for it through 2017. Like the insurance exchanges that open on October 1, Medicaid expansion is a key part of the federal Affordable Care Act that will extend health care coverage and access to millions of Americans.

 

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane,” said Martin Luther King, Jr. We experienced feelings of anticipation and then tempered relief on August 27—the eve of 50th anniversary of the MLK “dream speech” and the March on Washington—when Michigan state senators politicked late into the night on their Medicaid expansion vote and finally delivered. While I am proud of their decision to expand Medicaid, what they delivered lacks “immediate effect.”

 

Talk about bittersweet: By expanding public funding for health care through Medicaid, they furthered MLK’s dream for a society that supports access to care for its rich and poor, young and old. But because of the lack of immediate effect, we likely have to wait until spring 2014 (instead of January) to see the benefits in Michigan. Officials are discussing ramifications of this procedural delay. Jim Haveman, director of the state Department of Community Health, has estimated that Michigan will lose about $7 million per day while delaying implementation of Medicaid expansion.

 

As complex as that battle has been, I recognize it’s still the low-hanging fruit of implementing true reform. There’s much more to do to tackle disparities in health outcomes, and to really move our country from sick care to health care. Challenges remain as to how to make prevention a major emphasis without the confines of the 10 minute clinic visit; to engage communities in population health choices; and to put as much research emphasis on prevention, health promotion, and models of care that improve outcomes as on research of new drugs and acute-care procedures.

 

The solutions all rely to a major degree on nursing. The increasingly popular “nurse navigator” term implies that nurses are the logical people in the system to show the way with tools to stay healthy. Top schools of nursing are working hard to remain “cutting edge” in making progress in health care quality and efficiency. Our students need to know more than ever before to educate others on wellness and holistic prevention.

Nurses will need to continue championing early risk assessment, self-care management, care coordination, and community-based approaches. For older adulthood, a time of increasing chronic conditions, we need to emphasize active social engagement, physical activity and cognitive stimulation, because exercise and cognitive abilities are top predictors of frailty.

 

Nurses—particularly advanced practice nurse practitioners (NPs)—are increasingly key to primary care workforce shortages as well. As explained recently at Health Affairs, “Primary care NP graduates accounted for 84 percent of all NP graduates in 2012, whereas U.S. medical school primary care matches accounted for about 11.6 percent….”

 

I am confident nurses can step up to challenges of a new era in health care. We train them to do so, every year.

 

I will reinvigorate my advocacy to expand scope of practice for advanced practice nurses, to help in treating hundreds of thousands of new health care consumers in Michigan. Now it is more important than ever before to untether primary care nurses from unnecessary physician oversight. By the time Medicaid expansion begins to cover eager new health care consumers at Michigan clinics next spring, I hope the state’s legislature will have done the right thing again, making us one more state that empowers nurses to work as efficiently as possible.