There are signs that the public is also beginning to raise serious questions about managed care practices. According to the Princeton Survey Research Associates, a Princeton-based polling organization that conducted a recent national survey (See http://www.nursingworld.org/pressrel/1996/survey.htm) for the American Nurses Association (ANA), of 1,001 American adults polled, as many as 75% indicate serious concern that the quality of patient care is being diminished by cost-cutting practices -- a concern that has increased significantly since 1994. 75% of the survey respondents believe that reducing the number of registered nurses who provide bedside patient care in hospitals lowers the quality of care, and 67% said that increasing the use of unlicensed health care workers for care traditionally performed by registered nurses has the same quality-diminishing effect. Americans want information about the level of nursing care in hospitals, but many feel that it would be difficult to obtain. Eighty-two percent of those polled want to know the average number of patients assigned to each nurse, and 80% want to know the hospital's policy on types of care Unlicensed health care assistants are allowed to perform.

Public education campaigns at the state and local level, similar to ANA's national "Every Patient Deserves A Nurse" campaign, and news reports of significant problems with patient safety and quality of care in hospitals are on the increase. More than 500,000 "Every Patient Deserves A Nurse" brochures have been distributed across the country resulting in countless stories in local and national print and broadcast media, including the Pittsburgh Post-Gazette, the Los Angeles Times, the Washington Post, Newsweek, Time, CNN, CBS Evening News and the New York Times. As a result, complaints from consumers are beginning to have an effect on public policy. The New York Times has reported that over the last 18 months, at least 34 states have outlawed or curtailed methods that many HMOs have used to shorten some types of stays, discipline physicians or keep patients in the dark about incentives and ground rules of managed care. According to the National Conference of State Legislators, more than 400 bills affecting managed-care practices were introduced in state legislatures in 1996.

It is essential for organized nursing to work effectively to build broad coalitions rather than work from a singular or exclusive point of view and, at times, to be willing to move ahead in steps rather than in leaps. In California, two very similar statewide initiatives aimed at strictly controlling the managed care industry were narrowly defeated -- primarily because the two major proponents (the California Nurses Association and SEIU) couldn't agree on a single initiative and, as a result, split their votes and were out spent in the public campaign by their managed care industry opponents.

However even with the progress at the state level, action on the federal level will be required to affect the large ERISA self-insured employer plans which are exempt from state insurance laws. ANA initiated federal legislation in the 104th Congress and will have it reintroduced when the 105th Congress convenes in January. The Patient Safety Act of 1996" (HR 3355) (See http://www.nursingworld.org/pressrel/1996/patsafe.htm) introduced by Representative Maurice Hinchley (D-NY) calls for public access to information about nurse staffing and care givers' qualifications, "whistle blower" protections for nurses who speak out on behalf of patient care issues, and review of the impact of proposed mergers and acquisitions of health care institutions on patient health and safety.