The AMA's rejection of the public plan puts this powerful doctors' lobby in direct opposition with the President. The AMA, insurance companies and Republicans oppose a public plan. Republicans have waved the red flag of "socialism" in their rhetoric denouncing a public plan. Insurance companies are clearly concerned about having a deep pocket competitor that could reduce costs to plan participants and drive down their own profits. Doctors are also concerned about the bottom line. They believe that a public plan would draw people away from private insurance, and that the plan would offer them lower rates of reimbursement relative to private health insurance.
What About Nurses?
Media outlets have paid very little attention to another important group in the delivery of health care: Nurses. Indeed, nurses probably have more "contact hours" with patients than doctors, and they serve a vital role in the delivery of health care.
Historically, however, nurses have suffered from pernicious societal stereotypes and unequal power, relative to doctors and other professionals. The nursing profession is predominately female. On average, nurses have less educational training and wealth than doctors. These factors undoubtedly cause policy makers and the media to ignore the thoughts of nurses regarding important health care issues.
Although the media have largely overlooked the opinions of nurses regarding health care reform, nursing organizations have proffered reasoned and legitimate positions on the subject that warrant intense consideration. Because nurses have a much smaller pecuniary stake in the outcome of many reform proposals, their positions might reflect patients' and the public's interests more accurately than the views of doctors and insurance companies, which are undoubtedly influenced by personal financial considerations.
Public Plan
There are several unions that cater exclusively to nurses. Nurses are also members of general labor unions. Using the position of these unions as an indication of what nurses favor, it appears that nurses disagree with doctors on the issue of a publicly sponsored health plan.
The California Nurses Association and its national arm, the National Nurses Organizing Committee, represent 80,000 nursing professionals in 50 states. CNA/NNOC will become the nation's largest nurses union, after it merges with with the Massachusetts Nurses Association and United American Nurses. Following the merger, CNA/NNOC will represent 150,000 nurses. The CNA/NNOC supports "universal health care" in the form of a "single-payer style system." CNA/NNOC has been a strong advocate of a single-payer system and recently testified before Congress in support of this policy reform.
The Service Employees International Union is a general labor union that represents 80,000 nurses. Although SEIU and CNA/NNOC have experienced bitter clashes in the past regarding policy, the two organizations have "buried the hatchet" and have agreed to help unionize workers in the nation's largest hospital systems. Under this joint effort, nurses will join CNA/NNOC, while other hospital personnel will join SEIU. The organizations, however, plan to create a "joint union of registered nurses" in Florida.
SEIU, like CNA/NNOC favors a single-payer public plan option. Indeed, SEIU, along with the American Federation of State, County and Municipal Employees, dropped out of government-sponsored health care negotiations because it feared that other members of the consensus group would reject a public plan option.
The American Nurses Association (a professional association -- rather than a union) represents the interests of the nation's 2.9 million registered nurses (RNs). Last week, the ANA responded to the AMA's rejection of a public plan option with a critical press release that includes the following language:
The American Nurses Association . . . believes the best way to achieve its overall health system goal – guaranteed, affordable, high-quality health care for all – is through the inclusion of a public health insurance plan option in any health care reform legislation. ANA is deeply disappointed to learn of the American Medical Association’s position that private health insurance alone should dictate coverage options for all who don’t qualify for existing public plans, such as Medicare . . . .Although the media rushed to cover the AMA's dissent from President Obama's plan, it failed to give equal time to the ANA and to other nurses associations that offer a contrary view among health professionals. The uneven coverage deprives the public of access to diverse viewpoints and important information regarding this critical subject.
A public health insurance plan would expand choices and help protect against potential economic calamity for individuals or families who are not satisfied with their current health coverage, have difficulty paying for their health care, or cannot find
affordable coverage. ANA supports President Obama's call for a public plan option, and applauds its inclusion in Senator Kennedy’s comprehensive health reform legislation introduced June 9.
Nurse-Patient Ratios
CNA/NNOC has also been instrumental in pressing states to lower the ratio of patients to nurses. CNA fought a tough 12-year battle to legislate reform in this area in the State of California, even suing Governor Schwarzenegger who tried to kill the statutory requirements once he became governor. The California courts, however, ruled that Schwarzenegger exceeded the scope of his authority as governor.
Presently, bills are pending in both the House and the Senate which would enact new staffing ratios throughout the nation's hospitals. Representative Jan Schakowsky introduced the House measure (as she did in previous years), while Senator Barbara Boxer sponsored the Senate bill. In addition to mandating a reduction in staffing ratios, the proposed legislation contains "whistleblower" provisions that would protect nurses who report noncomplying facilities.
Nurses stand to gain more from the reduction of staffing ratios than from other issues related to health care reform. Thus, they are not exactly "unbiased" parties to this subject. Nevertheless, the staffing ratio issue raises interesting questions that should inform the broader topic of health care reform.
Much of the debate over health care reform has centered around the need for cost reductions. Hospitals, understandably, oppose reducing staffing ratios on the grounds that this will increase their costs. CNA/NNOC, however, cites to several studies (in a neatly prepared brochure), which indicate that reforming staffing ratios by reducing the number of patients per nurse will ultimately decrease costs.
The research concludes that the present ratios overburden nurses and lead to costly medical mistakes. If nurses could spend more time in direct contact with individual patients, they could diagnose and treat (or seek treatment for) conditions in their patients, which would reduce preventable deaths, the need for return visits, and the expense of subsequent treatment. The research also links high turnover rates among nurses to high patient loads. Reforming staffing ratios could reduce the costs that hospitals spend to replace nurses, pay existing staff overtime, or to hire temporary nurses to cover shortages. Nursing professionals, however, do not hold uniform positions on the benefits of mandatory national staffing ratios (See: American Nurses Association - Mandatory Hospital Nurse to Patient Staffing Ratios: Time to Take a Different Approach).
Closing Thoughts
Although this essay finds substantial disagreement among leading nurses unions and doctors' representatives, exceptions to this general pattern exist. Physicians for a National Plan and Doctors for America, for example, support universal health care and a public plan, but these groups are much smaller and probably less powerful than the AMA. Some opinion polls, however, indicate that the majority of doctors and the American public favor a government-sponsored insurance plan.
The public plan opposition legitimately questions the impact of such a plan on the quality of care. This question seems relevant to and appropriate for every health care reform issue. But arguments related to the loss of profits for insurance companies ring hollow. Health care costs represent an enormous drain on individuals, business and society. If competition generated by a public plan could reduce these costs, then, as a matter of a longterm investment in society, a public plan seems like a valid and sensible policy.
If Congress creates a new public plan, insurers will have to lower their own costs, face reduced profits and adjust like every other sector in this changing economy. The nation should not compromise its economic and medical health in order to fatten the coffers of insurance companies and doctors. The country can and should ask the same of insurance companies that it has demanded of General Motors, Chrysler, and American consumers.
Update: This article was edited to include the views of the American Nurses Association regarding the "public plan" debate.
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