Help health care: Let nurses in Texas do more

Austin American-Statesman, August 29, 2011

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It's as if [organized medicine is] saying, "If you give them an inch, they'll take a mile." Legislators swallow their arguments hook, line and sinker, and with the governor's approval, the phony hierarchy is kept alive.

Campaigning for the presidency, Gov. Rick Perry touts his record of job creation. What he’s not talking about is his record on health care, which represents a wholesale failure of leadership.

On his watch, Texas has held the disgraceful rank of last in access to health care, as well as last in percentage of residents without health insurance. Of Texas’ 254 counties, 194 (wholly or partially) are designated by the federal government as having acute shortages of primary care physicians. Of that number, 21 counties have one; 27 have zero.

There’s an elephant-in-the-room solution for the problem. It wouldn’t cost a dime but would save millions of dollars every year. Answer: Remove unwarranted constraints that limit advanced nurse professionals from practicing to the full level of their education.

In all 50 states, advanced practice registered nurses are credentialed and licensed by their boards of nursing to diagnose, treat and prescribe. About 80 percent provide primary care; the rest, specialty care. All provide preventive care and health teaching, and they’re great at what they do.

Texas is fortunate to have a large cadre of these qualified nurses, licensed by the Texas Board of Nursing, who are eager to practice to the full extent of their preparation. Their education involves extensive study of pharmaceutics, as the ability to prescribe medications is essential to providing primary care. As part of credentialing, nurses have this authority, but state laws vary on how they are allowed to prescribe.

Texas has the poorest access to care in part because it has the most restrictive laws in the nation on nurses’ ability to prescribe. Eighteen states grant independent prescriptive authority; 17 require a collaborative agreement with physicians; and 15, including Texas, require physician delegation to prescribe. Five states in the past three years switched from collaborative to independent authority.

Given the federal government’s designation of a widespread, acute physician shortage in areas of Texas, you can imagine how collaboration and delegation agreements would be tricky, if not impossible.

Why hasn’t Texas removed barriers to advanced nurses practicing to their full potential? Under the iron grip of deep-pocketed organized medicine, legislators have held back advanced practice nurses for 40 years.

Each legislative session, doctors dress up in white lab coats and explain to the health committees why they should remain the quarterback, the gatekeeper to health care. They say nurse practitioners are dangerous, but that they hire them and keep a close eye on them to ensure safety. They talk about how much longer their education took.

What they’re not talking about are the hundreds of studies showing safety and outcome levels equivalent to physicians and a higher rating for communication.

It’s as if they’re saying, “If you give them an inch, they’ll take a mile.” Legislators swallow their arguments hook, line and sinker, and with the governor’s approval, the phony hierarchy is kept alive. Perry and other governors fail to lead by not challenging the status quo nor placing the issue on their agendas.

Doctors’ arguments are curious, given they can’t come anywhere near producing enough providers. Family doctors are retiring. Medical students graduate with enormous debt and opt for the specialties over less lucrative primary care. If every nurse practitioner and family doctor were deployed, Texas still could not meet its need for accessible primary care.

Last session, Perry could have called for emergency legislation to alleviate the dire need for health care access, which disgraces his state. Instead he chose abortion legislation, despite 2011 data showing a significant and steady decline since 2000 — bucking the national trend. The nefarious law that he signed has landed in federal district court.

People suffer when they don’t have access to primary care; they stay sick longer. When the problem gets unbearable, they face long-distance drives for care and long waits in crowded emergency rooms — the wrong setting. At least in an ER they’re assured of eventually seeing a medical professional. This common and unnecessary Texas scenario is dangerous, causes needless human suffering and burdens health care systems.

By putting these nurses to work to their full potential, a visionary leader would create jobs while increasing access. It’s a shovel-ready project, and with the absence of Perry’s attention for 11 years, legislators continue to miss the boat.

A friend of mine was born, raised and educated in Texas and is heartbroken that she can’t practice as an advanced nurse in her native state. She could if she lived in three bordering states: New Mexico, Louisiana and Arkansas. She chose New Mexico.

Perry, you could be touting your health care record on the campaign trail. Be a real leader. Let the public interest be your guide and free up nurses to elevate us from last in the nation in access to care.

Toni Inglis, MSN, RN CNS (retired), FAAN, a lifelong Austin resident, is a retired neonatal intensive care nurse and editor of NursingNews. She also wrote a monthly opinion column for the Austin American-Statesman editorial pages for 10 years.