Nurse Anesthetists and Veterans

H.R.1247 -- Improving Veterans Access to Quality Care Act of 2015

The Improving Veterans Access to Care Act (H.R.1247) sponsored by Representatives Sam Graves (R-MO) and Jan Schakowsky (D-IL) (hereinafter alternatively "the Act"), is intended to reduce existing delays in healthcare delivery being experienced by the Veterans Health Administration (VHA) (Smith, 2015). The provisions of the Act would extend full practice authority to certain advanced practice registered nurses (APRNs), including nurse midwives, clinical nurse specialists, nurse practitioners, and certified registered nurse anesthetists in Department of Veterans Affairs (VA) health care facilities regardless of the state in which they are located. To date, the American Association of Nurse Anesthetists (AANA), the Association of Veterans Affairs Nurse Anesthetists (AVANA), more than 50 nursing organizations, as well as veterans service organizations, the Military Officers Association of America, the Air Force Sergeants Association, the American Association of Retired Persons (AARP) together with more than 75 members of Congress have all supported this legislative initiative (VHA APRN full practice authority, 2016). Notwithstanding this widespread support, however, some critics maintain that extending full practice authority to APRNs will diminished the quality of services provided veteran patients at VA health care facilities while others argue that that decision to extend full practice authority should reside at the state level. To determine the facts, this policy brief analysis provides a summary of the arguments in support of and against the Act, relevant background information, an evaluation of alternatives and a recommendation for action. In addition, a one-page policy brief is also provided that summarizes the foregoing information for ease of reference.

A summary of the issue

At present, advanced practice registered nurses (APRNs) practicing in VH A facilities across the country remain subject to the respective laws of the state in which the health care facility is located (ANA urges support for bill to increase veterans' access to APRNs' services, 2015). Although some states have already extended full practice authority to APRNs, other states continue to restrict their scope of practice in ways that detract from the ability of the VHA to delivery timely and efficacious health care services (ANA urges support, 2015). In response to this problem, the Act extends full practice authority to (APRNs) working in all VHA facilities regardless of the state laws that are in place. In this context, "full practice authority" means "allowing APRNs to practice to the full extent of their education and training and provides a common-sense solution to the challenges associated with ensuring America's veterans have access to high quality' health care services" (ANA urges support, 2015, p. 16).

Background information

Advanced practice registered nurses are registered nurses who possess a master's or doctorate degree together with relevant clinical experience and who typically specialize in one of the four main categories of APRNs: (a) clinical care; (b) midwifery, (c) primary care (nurse practitioner) and (d) anesthesia (Hinkley, 2013). In general, APRNs are empowered with many of the same practice authorities as physicians, including the ability to diagnose and treat illnesses and, depending on the jurisdiction involved, to prescribe medications in some jurisdictions (Hinkley, 2013). Although some states currently permit APRNs to practice independently within certain parameters or with complete autonomy, others still require APRNs to practice under the supervision of in collaboration with physicians (Hinkley, 2013). These three varying levels of practice authority are summarized in Table 1 below.

Table 1

Three levels of APRN practice authority

Practice Level

Description

Independent

No requirement for a written collaborative agreement, no supervision, no conditions for practice.

Not Independent

A written agreement exists that specifies scope of practice and medical acts allowed with or without a general supervision requirement by a MD, DO, DDS or podiatrist; or direct supervision required in the presence of a licensed, MD, DO, DDS or podiatrist with or without a written practice agreement.

Prescriptive Authority

An APRN is authorized to prescribe pharmacologic and non-pharmacologic therapies beyond the perioperative and periprocedural periods.

Source: APRN roles recognized, 2016

Supporters of the Act maintain that the authorization of full practice authority to the four categories of APRNs (i.e., nurse practitioners, certified nurse-midwives, clinical nurse specialists and certified registered nurse anesthetists) can help the VHA maximize the utility of these valuable health care professionals to reduce wait times for treatment (ANA urges support, 2015). Moreover, the Act is also congruent with recommendations provided by the Institute of Medicine'sreport, "The Future of Nursing: Leading Change, Advancing Health," as well as other initiatives being contemplated by the VHA to improve the timeliness and quality of health care services delivered to veteran patients (ANA urges support, 2016). In addition, the extension of full practice authority to the four categories of APRNs would make the VHA care model consistent with the existing models being used by the U.S. Armed Forces, Indian Health Service and Public Health Service systems where veteran patients can receive health care services pursuant to the Veterans Access Choice and Accountability Act of 2014 (P.L. 113-146) (ANA urges support, 2015).

Besides support from national nursing organizations representing nearly a quarter-million members, other national organizations support the Act as well including (a) the American Association of Nurse Anesthetists, (b) American Association of Colleges of Nursing, (c) American Association of Nurse Practitioners, and (d) the American College of Nurse Midwives (ANA urges support, 2015). Most recently referred by the Committee on Veterans' Affairs and the Committee on Armed Services, the Act is now being considered by the Subcommittee on Military Personnel where supporters fear it will languish and ultimately be defeated as shown in Table 1 below.

Table 1

Legislative history of H.R. 1247

All Actions

03/04/2015

Referred to House Armed Services

Type of Action: Introduction and Referral

Action By: House of Representatives

03/04/2015

Referred to House Veterans' Affairs

Type of Action: Introduction and Referral

Action By: House of Representatives

03/04/2015

Referred to the Committee on Veterans' Affairs, and in addition to the Committee on Armed Services, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.

Type of Action: Introduction and Referral

Action By: House of Representatives

03/04/2015

Introduced in House

Type of Action: Introduction and Referral

Action By: House of Representatives

03/19/2015

Referred to the Subcommittee on Health.

Type of Action: Committee Consideration

Action By: House Veterans' Affairs

08/13/2015

Referred to the Subcommittee on Military Personnel.

Type of Action: Committee Consideration

Action By: House Armed Services

Source: https://www.congress.gov/bill/114th-congress/house-bill/1247

Despite its exhaustive vetting and nationwide support from a wide range of stakeholders, the Act is estimated to have just a 6% chance of getting past the Subcommittee on Military Personnel and just a 2% chance of being ultimately enacted by the U.S. Congress (Govtrack H.R. 1247, 2016). Some of the factors that were taken into account in these estimates included the following:

• The sponsor is on a committee to which the bill has been referred, and the sponsor is a member of the majority party.

• The sponsor is in the majority party and at least one third of the bill's cosponsors are from the minority party.

• A cosponsor in the majority party has a high leadership score.

• At least two cosponsors serve on a committee to which the bill has been referred.

• The bill was referred to House Armed Services; and, • The bill was referred to House Veterans' Affairs (Govtrack H.R. 1247, 2016).

Analysis of alternatives

There are several alternatives available that would achieve the same desirable outcome that would otherwise be achieved by the Act in reducing waiting times for veterans at VHA health care facilities, each with its respective strengths and weaknesses, including those set forth in Table 2 below: