The rapid and continued growth of managed care has produced a wide range of important public policy issues and choices. Decisions made in the public policy arena will have either positive or negative mplications for nursing. If nurses are to control their own destiny, it is essential that they fully understand and appreciate the linkages between public policy, nursing practice, and their own workplace employment conditions. Managed care prompts public policy debate and decisions on issues of critical importance to nurses, including: 1) Access, cost and quality of care; 2) Licensure and regulation; 3) Employment opportunities and conditions; 4) Educational preparation; and 5) Ethical issues.

1) Access, Cost and Quality of Care

Nurses have historically been advocates for access to quality, cost-effective health care services for all people. Lack of insurance coverage causes people not only to avoid preventive care, but to delay seeking illness care until later into the episode of illness. Frequently this avoidance or delay increases the costs of care for an illness that could have been treated earlier, often in a less expensive setting, or the need for care avoided altogether.

Additionally, the increase in the number of uninsured not only represents a barrier to appropriate, timely care, but it also creates pressure on the system to absorb the costs for this uncompensated care. Historically, hospitals and other providers have provided uncompensated care by "cost-shifting" the charges for this care onto paying patients -- in other words, charging privately insured and self-paying patients more to offset the hospital's loses for uncompensated care and the underpayment by Medicaid and Medicare. Under capitated arrangements or deeply discounted fees-for-services, this option is not as readily available. Providers, especially hospitals, then look for ways in which to reduce their operating costs, through such strategies as downsizing, work redesign and substitution of less expensive personnel. Nurses must continue to be actively involved in advocating for insurance coverage for all people.

A. Increase in the Number of Uninsured

Despite the rapidly growing managed care sector, the percentage of US workers covered under employer-sponsored health plans dropped from a high of 77.7% in 1990 to 73.9% in 1995. It is expected to drop even lower -- to 70.4% by 2002 according to a study recently released by the Lewin Group, a Washington-based health care consulting firm. The study estimates that the number of uninsured Americans will increase to 45.6 million by 2002, an increase of more than 5 million since 1994 (Auerbach, 1996). Additionally, many companies that provide employer-sponsored plans have increased premiums for family coverage which may help explain the decline in dependent coverage (from 83% in 1989, to 78.9% in 1995). ANA has strongly supported legislation at the state and national levels to prevent further erosion of these benefits.

The 1995 proposal of the Republicans in Congress to reduce the Medicare and Medicaid programs by $450 billion over seven years would have devastated the quality of patient care, both because of the proposed structural changes in the programs themselves, and because there no longer would be adequate funding to pay for acceptable care. In the wake of the 1996 elections, issues of cost will receive as much, if not more, limelight than issues of quality, especially as revised predictions of Medicare insolvency are revealed. ANA and organized nursing must remain among the leaders in defending quality of care in both Medicare and Medicaid.

B. Mental Health Parity

Advocates for mental health care have raised widespread concern about the practice of many managed care companies that provide more limited coverage for treatment of mental illness than for physical illness. In 1996, Congress approved language that to provide minimal parity in coverage of mental illness, scaling back the more comprehensive language that had been approved in the Senate (the Senate bill was strongly supported by ANA). Clearly, increases in crime, homelessness, suicide and other social problems are not due solely to lack of access to mental health services; but without ready access to mental health treatment options, those afflicted by such problems face a bleak future.

C. Emergency Treatment

Many managed care plans have required some form of preauthorization for emergency room visits and have disallowed payment for non-emergency conditions. Of course, many patients seek emergency treatment for what they believe to be life-threatening conditions that turn out to be more benign--as in the patient who is experiencing chest pain that turns out to be indigestion. Several states have seen efforts to enact legislation to require coverage of services under a "prudent layperson" standard -- in other words, services will be covered if an average person, having an average knowledge of health care, would have sought emergency treatment under the same circumstances. This issue is likely to be introduced early in the 105th Congress; in fact, the American College of Emergency Physicians (ACEP) and Kaiser-Permanente have already agreed upon principles for legislation on this issue. ANA has supported this type of legislation in the past and will continue to do so.

D. Medicare Managed Care and Cost-Savings

The fastest growing segment of managed care is the Medicare Managed Care program. HMOs have been contracting with the Medicare program for two decades to provide services to Medicare beneficiaries under what is commonly referred to as Medicare risk-contracting. HMOs receive payment equal to 95% of Medicare's average cost of treating a Medicare beneficiary under a traditional fee-for-service arrangement. Some critics have suggested that this practice has actually increased, not decreased, costs to the Medicare program, as Medicare risk-contract programs typically attract younger, healthier Medicare beneficiaries -- who cost the contractor much less -- leaving older and sicker patients in fee-for-service Medicare, thus driving up the average cost of treating beneficiaries under fee-for-service and, in turn, driving up payments to Medicare risk contractors. This debate is likely to grow more heated, particularly as Congress and the Administration examine what steps to take to ensure the viability of the Medicare program as a whole.

E. The Imposition of "Gag" Rules

Consumer concern has also been sparked by the discovery of "gag" rules that prevent physicians or other providers from revealing a full range of treatment options to patients or, in some instances, from revealing their own financial self-interest in keeping treatment costs down. Nursing has long advocated for patients' rights to have access to full information about their condition and their treatment options. Several states were successful in their efforts to outlaw "gag" rules. (See information in State Government Affairs area in NursingWorld.) However, in some instances, legislation has been limited in scope to physician communications. Nursing has made it a priority to ensure that other providers, including nurses, and their patients are also protected from the imposition of "gag" rules.

F. Efforts to Prevent Arbitrarily Short Stays

One managed care practice that effectively galvanized consumer interest has been some managed care organizations' imposition of arbitrary "caps" on the length of hospital stays for specific conditions. The most prominent example is that of allowing only a 24-hour stay for normal childbirth, but there are many examples of limits placed by managed care organizations on treatment options or duration. Some managed care organizations have recently begun requiring that mastectomies be done on an outpatient basis.

Health professionals and consumers alike have expressed concern over the potential impact of placing rigid limits on hospital stays. Increasing consumer concern led to successful efforts in several states to require payment for a minimum of 48 hours for normal childbirth, and a longer stay for Caesarean sections. (See information on 1996 legislation in the State Government Affairs section of Nursing World). The 104th Congress eventually passed legislation to prevent premature discharge policies. ANA and other nursing organizations supported such legislation, along with proposals to ensure access to nursing care in the home and other appropriate follow-up.

Efforts to guarantee minimum hospital stays require careful consideration by nursing. Nurses have long advocated for the availability of treatment in non-hospital settings -- in communities, in the home, in schools and workplaces. The assumption that all safety concerns are allayed by a longer hospital stay is not always valid. In the case of normal childbirth, many mothers prefer not to have any hospital stay at all -- they opt to give birth at home, often with the assistance of a certified nurse-midwife -- and nursing has supported their right to make that choice. Patients should be offered appropriate, safe, and cost-effective options for care, not confronted solely by arbitrary caps on hospital treatment without alternatives or appropriate follow-up care and education. ANA and state nurses associations sought to shape legislation on short maternity stays to ensure that appropriate follow-up care in the home was also made available upon discharge.