Nurses will get financial breaks if they become professors, and medical residents will find it more affordable to become family doctors under the landmark health-care legislation signed into law last week. The measure also means that teaching hospitals will treat fewer uninsured patients but be compensated with fewer federal dollars.
The House of Representatives voted 219 to 212 to pass the sweeping health bill that the Senate had approved on Christmas Eve. The major significance of the measure, HR 3590, is to extend insurance coverage to an additional 32 million people.
It will leave about 23 million people, including the nation’s undocumented immigrants, still uninsured, however, and it retains a controversial cap on the number of residency positions that Medicare finances at teaching hospitals. That limits the number of medical-school graduates who can enter the work force.
After approving the health-care act, the House passed a separate “reconciliation” bill, HR 4872, that was crafted by Democratic leaders in Congress as a vehicle for winning Congressional approval of both health-care and student-loan legislation. The reconciliation bill contains a number of revisions in the health-care legislation, including more perks for higher education, and must now be approved by the Senate. While such passage is expected, Republicans have vowed to put up a fight.
With or without the reconciliation changes, the new health-care law will have a far-reaching impact on institutions that train health-care workers, on the hospitals and community health centers where they are trained, and on the research being conducted there. Here are a few of the changes they will be seeing, and hoping to see, as the new law goes into effect and the amendments in the reconciliation bill are considered on the Senate floor.
Nursing Education
The legislation includes several provisions aimed at graduating more nurses.
Loan-forgiveness programs will be expanded for nurses who agree to teach in accredited nursing schools, which now face widespread faculty shortages. Those shortages have forced schools to turn away tens of thousands of qualified applicants each year, despite projections of severe nursing shortages.
The legislation also gives nursing schools and academic health centers more flexibility in how they spend certain federal nursing-education grants. The legislation lifted a cap that limited spending on doctoral nursing programs to 10 percent of the total grant amount. In addition, it reauthorizes financing for the Nursing Workforce Development programs, which have been the main source of federal support for nursing education. It also authorizes a Medicare-financed demonstration project at five hospitals to support the clinical education of registered nurses who hold advanced degrees, such as nurse practitioners. The American Association of Colleges of Nursing says those nurses will play a key role in meeting the primary-care needs of the growing number of insured patients.
Medical Training
A number of provisions encourage doctors in training to pursue primary-care careers, particularly in rural and other underserved areas. Those provisions include expanded loan and debt-forgiveness options and more money for community health centers, where many primary-care residents train.
The reconciliation bill would add even more money for community health centers. Farheen A. Qurashi, legislative director at the American Medical Student Association, says those centers will play increasingly important roles in patient care and medical training.
Many private doctors refuse to take Medicaid patients because the reimbursement rates are lower than those for Medicare. The reconciliation bill would increase Medicaid payment rates to primary-care doctors to match Medicare rates. However, the changes would be for only two years, 2013 and 2014. The health-care act approved last week did not adjust the rates at all.
Among the groups that had lobbied for higher reimbursement rates was the Committee of Interns and Residents/SEIU Healthcare, a national union representing doctor trainees. Although millions more people will be eligible for Medicaid, “those gains will be undermined if there aren’t enough primary-care physicians willing or able to take on this wave of new Medicaid patients,” the group said in a written statement.
While the new health-care law provides incentives for physicians to pursue primary care, it does not deal with concerns about a potential shortage of doctors over all. In response to those concerns, new and expanding medical schools have been increasing the number of physicians they are graduating. However, the size of the work force will continue to be constrained as long as the number of Medicare-paid residency slots is capped at 1997 levels, educators argue. An earlier health-reform bill would have allowed Medicare to pay for more training slots, but that measure died in Congress. Teaching hospitals can still create more positions, but they won’t be reimbursed for them.
The president of the Association of American Medical Colleges, Darrell G. Kirch, says lifting the cap is essential “so that future physicians can finish their training” and meet the needs of millions of newly covered Americans.
Teaching Hospitals
Lots of fingers are crossed at these safety-net hospitals, which stand to lose billions of dollars in federal “disproportionate share” payments under the new law. Those are the supplemental Medicaid and Medicare payments that teaching hospitals receive to compensate them for caring for so many uninsured and indigent people.
The Senate bill cut supplemental Medicaid payments by about $18-billion and Medicare payments by $25-billion over 10 years. The reconciliation bill, if it makes it through the Senate, would soften the blow by restoring a total of $7-billion of those cuts.
Officials of the Association of American Medical Colleges are still concerned.
“We want to make sure that people are being adequately insured before we eliminate support for the safety net,” says Atul Grover, chief advocacy officer at the association.
