He also refused to create a health care exchange, an online market allowing the uninsured to shop for coverage.

You can just see him pounding his chest as he composed the letter to U.S. Health and Human Services Secretary Kathleen Sebelius: “Both represent brazen intrusions into the sovereignty of our state.”

He included the requisite talk of guns and the obligatory thrashing of the Medicaid program. He thanked God and the founders for his right to reject the federal “power grab.”

It takes some kind of chutzpah for a governor of the state with the highest percentage of uninsured — 1 in 4, or about 6 million Texans — to draw a line in the sand and announce that nothing’s going to change.

This cowboy swagger is amusing in an Austin City Limits ad, but in a letter from the head of a sovereign state to a member of the Cabinet?

Perry seems to be in a time warp, stuck somewhere between the American Revolution and the Wild West.

It would be humorous if it were not so disastrous.

In the 11-county Central Texas region, 360,000 people are uninsured.

Central Health, the Travis County hospital district, could have saved $7 million to $8 million a year, which could have been used to more effectively provide primary care.

People’s Community Clinic could have earned $1 million for primary care (more than 10 percent of its budget).

Some of the most frequent emergency room users will continue to be the mentally ill.

Costs will continue to be shifted to taxpayers and consumers through higher insurance premiums.

Expanding Medicaid would give us $76 billion between 2014 and 2019, with Texas putting up about $6 billion from the state budget for its share. That $6 billion is far less than Texas hospitals now spend in a single year for uncompensated care.

In the last paragraph of Perry’s letter to Sebelius, he wrote, “I look forward to implementing health care solutions that are right for the people of Texas. I urge you to support me in that effort.”

Really? For 12 years, public health care providers have waited for Perry to do something about health care.

All we’ve seen is a failed executive order to inject all sixth grade girls with a vaccine to protect against a sexually transmitted virus, an immunization made by the drug company for which Mike Toomey, his former chief of staff, lobbies.

Toomey also ran the pro-Perry super PAC during his failed presidential campaign.

In an interview Monday on Fox News, Perry said that the federal government doesn’t like us anyway and their data is just “fake and false on its face. The real issue here is freedom.” Really?

As a neonatal nurse, I’ve taken care of lots of sick and premature babies and their families, and I talk to plenty of Texans outside of work.

I have never once heard anyone express concern about Texas’ sovereignty.

I have, however, heard from a whole heckuvalot of Texans worried — make that panicked — that they might not be able to get insured, they lost their insurance with their job, they can’t find a primary care provider, they might go bankrupt with medical bills, or they will have an accident or illness in which they would have to come with the $10,000 they would owe before their deductible were to kick in.

There are babies at Dell Children’s Medical Center whose care may cost $4 million to $5 million in a year, yet their insurance coverage has a $1 million annual limit.

The hospital is out that money, and their parents are hopelessly in debt. Fortunately, by 2014, annual limits will be completely prohibited thanks to the law.

On any given day, the emergency room at University Medical Center Brackenridge — and every other public hospital in Texas — is full of people waiting to see a doctor for primary care. Without insurance, they can’t just pick up the phone and make an appointment.

I invite you to try doing that. It’s a real eye-opener.

Nurses see the tragedies every day of uninsured people who have put off seeking care until it’s too late.

Lives are shortened, quality of life is destroyed and hearts are broken.

Texas legislators must see this, too, because of the 254 counties they represent, 185 are considered medically underserved and parts of 46 others fall under the designation.

Maybe when the Legislature convenes in January, its members can turn this around and take the federal government up on its offer.

Without executive leadership, it will take real guts, but lawmakers could drag Texas off the bottom of the statistics heap and get their neighbors the medical care they need.

The words “missed opportunity” understate.

The visionary Berwick, champion for patients, was picked for the job because his “triple aim” (his words) at health care was the same as President Barack Obama’s reform goals: improving the patient experience, improving population health and reducing costs — and because Berwick had decades of experience successfully achieving those goals in this country and worldwide.

Through the organization he founded in the early 1990s, the Institute for Healthcare Improvement, care has been redesigned and hospitals trained to prevent thousands of injuries and deaths.

How has Berwick achieved these changes? Intractable problems in health care are identified, and IHI, often in partnership with the Robert Wood Johnson Foundation, take aim at them.

In the hospital system where I work, we know about Berwick, and we’ve worked with people from the IHI and the RWJ foundation. In 2003, we were chosen as one of 13 pilot sites to transform care at the bedside in medical-surgical units.

Direct-care, front-line nurses were challenged and given full license and encouragement to develop and test methods to improve care. And that we did. Many of the innovations Seton nurses designed are practiced in thousands of hospitals worldwide.

In the eight years since the project began, physicians, patients and families have become engaged in care; bedsores, patient falls, infection and birth trauma have been drastically reduced; communication during shift report has improved; multidisciplinary rounds are made to enhance discharge planning, teamwork and safety; patients are checked on hourly; response teams rush to a patient in crisis before it’s too late; and patient and nurse/doctor satisfaction and retention have dramatically improved. Hospital readmissions have fallen.

Through the transforming care project, in the perinatal area, birth trauma has effectively been eliminated. Clinicians developed a bundle of best practices for obstetricians.

This safety initiative has saved the government a bundle of money. In 2003, Seton billed Medicaid $500,000 for birth trauma; in 2009, zero.

Berwick has promoted understanding of this concept as a way to curb government spending on health care. As part of the Affordable Care Act, Berwick implemented financial incentives for doctors and hospitals to coordinate care and improve patient outcomes.

Stunningly, Congress refused to confirm the nomination of this proven, accomplished and promising leader. Eager to demonstrate contempt for the Affordable Care Act, Republican demagogues seized on Berwick as an irresistible target.

They dubbed him Dr. Death Panel. Why? Because he — and the Affordable Care Act — encourage end-of-life discussions between doctor and patient/family when medicine can do no more.

In addition, they exploited his remarks as an academic praising Britain’s health care system for covering all its people and reining in costs while improving outcomes.

Taking his remarks out of context, Republicans portrayed him as an advocate of rationed care and socialized medicine. This, despite Berwick’s insistence all along that the British system cannot be copied here and that America’s system, having evolved around insurance, needs its own solution.

If you repeat “Dr. Death Panel” and “rationing care” enough times, you begin to brand and unfairly define Berwick and the health care reform law.

Marilyn Tavenner, a nurse and his top deputy, will succeed him. Let’s hope that she will be able to execute his goals. Congress will be more comfortable with her, as she is more manager than visionary.

Back to his triple aim. Has his work improved the patient experience? Yes. Has it improved population health? Yes. Has it reduced costs? Yes.

Have we missed an opportunity? Oh, and how.

Anne Mitchell (left) and Vickilyn Galle after their indictment in 2009

Facing a $27 billion budget shortfall, Gov. Rick Perry has revived a failed and tired idea from past legislative sessions. To save a paltry $7 million, he proposes to combine under one umbrella some of the most essential agencies in state government — the boards regulating doctors, nurses, dentists, chiropractors, podiatrists, optometrists, pharmacists, psychologists and physical and occupational therapists.

The health professions boards were created to protect the public from harm. Although sluggish from recent years’ budget cuts, they are effective in protecting us because they are separate agencies with investigators trained specifically for each respective health discipline. They make you, me and every Texan a lot safer when we seek health care.

From the economic and public safety standpoints, the governor’s one-size-fits-all gesture makes no sense at all.

It costs the state $29 million to run these boards, but through licensing fees and disciplinary fines they collectively bring in $79 million for the state’s general fund (numbers courtesy of the Legislative Budget Board and the Texas comptroller’s office).

For example, the Texas Medical Board, which oversees doctors, had a budget of $9.4 million for fiscal year 2010 but brought in $35.7 million to state coffers.

The separate regulatory boards are cash cows for the state. It makes me wonder if the governor can count.

The professions are exceedingly different, with vocation-specific investigators. Nursing experts know nothing about regulating dentistry and vice versa.

The complex Winkler County case demonstrates the importance of a separate health board to protect the public.

The medical board first investigated Dr. Rolando G. Arafiles Jr. in 2007. It found that among other unprofessional and unethical offenses, he failed to keep adequate medical records in supervising a physician assistant who was prescribing nontherapeutic drugs at a weight loss clinic. His penalty was a $1,000 fine and a three-year stipulation on his license.

The doctor relocated, and in 2009, nurses Anne Mitchell and Vickilyn Galle of Winkler County reported the doctor to the board citing numerous cases of improper care, one of which was examining the genitalia of patients in the rural emergency room whose symptoms included stomach distress, headache and sinus pain, and blood pressure and jaw problems.

When the board notified Arafiles of the complaint, he enlisted his golfing buddy, the county sheriff, to find out who reported him. After identifying the nurses through spurious means, the hospital administrator immediately fired them, and the county and district attorneys charged the nurses with misuse of official information — a third-degree felony punishable by 10 years in prison and/or a $10,000 fine.

The medical board sent a letter to the prosecuting attorneys stating that it is improper to criminally prosecute people for raising complaints with the board — that the board depends on the eyes and ears of health care professionals to carry out its duty to protect the public from improper practitioners.

After the nurses’ report, the board investigated Arafiles and charged him with poor medical judgment, nontherapeutic prescribing, failure to maintain adequate records, overbilling, witness intimidation and other violations.

Mitchell and her family endured a torturous eight months waiting for the criminal trial to determine if she would go to prison or be fined an amount she could not pay. In 2010, Mitchell was acquitted in less than an hour, making national headlines and prompting a Texas attorney general investigation into the doctor and Winkler County officials.

The medical board subsequently issued a public reprimand of Arafiles, ordering physician monitoring of his practice and a $5,000 fine. He also was ordered to complete a rigorous course followed by assessments of his competence and medical jurisprudence.

Soon thereafter, the doctor, sheriff, county attorney and hospital administrator were indicted on charges of retaliation against the nurses. They await trial.

The Winkler County case demonstrates the crucial role of a board in protecting the public. The complexity of this case likely would not have been handled effectively by an umbrella agency. Functioning as a single agency would only dilute and weaken the power to protect the public’s safety.

If Lyndon Johnson had been alive on March 24 when President Barack Obama signed the Patient Protection and Affordable Care Act into law, he would have remarked from experience that the battle for health care reform had only begun.

We remember the July 30, 1965, signing of Medicare into law as the smooth establishment of a popular program. But that’s not at all how it went down. The program was nearly destroyed by doctors and hospitals threatening to boycott it.

Calling it “socialized medicine,” the American Medical Association waged war against the program before and after it became law, with doctors warning their patients against it, thus threatening the public support that Johnson needed.

Johnson outmaneuvered them by giving the AMA a seat on an advisory council that oversaw rules and regulations, one of which was setting physician fees, and the doctors acceded. Thus began wealth among physicians.

Many hospitals, especially in the South, were segregated and threatened to boycott because of the provision that hospitals be integrated. Johnson allowed no compromise and set up a battle council.

He had Vice President Hubert Humphrey telephone mayors to pressure resistant hospitals. In the final weeks before Medicare’s beginning, the hospitals integrated rather than lose federal dollars. LBJ sent hundreds of inspectors to ensure hospitals receiving Medicare funds were indeed integrated.

Thus began Medicare.

Fast forward to 2010. On the campaign trail for president, Obama got his strongest applause when he spoke of insuring all Americans and keeping insurers from denying coverage based on pre-existing conditions. The brightest minds in health care drafted a plan that would achieve those results.

The bill enjoyed the support of organized doctors and hospitals. Insurance companies were the holdout. When the public option was ultimately dropped in favor of insurance exchanges, the companies jumped on board, and the bill was passed.

Unlike the interest-group battle over Medicare, this law is threatened by party politics. The ads from this election cycle show how prominent the issue weighs and how ugly the rhetoric can get. The fact that the provisions in this law kick in more slowly than Medicare leaves it even more vulnerable to attack.

If the conservatives regain power, they’re not likely to repeal the law. But if they strip away critical, easy-target elements — such as the requirement that uncovered individuals be required to buy at least a basic policy and the subsidies to make sure they can afford them and/or the requirement that large employers provide health benefits — then coverage for the uninsured will be effectively gutted. With 21 states, including Texas, suing to stop parts of the reform, a showdown looms.

The major objection is the insistence that it is unaffordable. When Medicare became law, health care represented 6 percent of U.S. economic output. Today, the figure is an unsustainable 18 percent. Our health care system pays for the quantity rather than the value of care, and it should be clear to everyone that without fundamental change, the same trend will continue.

Included in the overhaul is a Center for Medicare and Medicaid Innovation where local hospitals can do what the hospital where I work did. Within six years, we reduced our term infant birth trauma from 0.3 percent (half the national average) to 0.01 percent. We did this by bundling best practices and improving interdisciplinary communication in the delivery room.

In 2003, we billed $1.5 million for birth trauma. Last year, we billed $25,000. While representing a loss for our hospital, it’s a huge savings for Texas, which foots much of the Medicaid bill.

Rather than a government takeover of health care, the law frees communities and local health systems from existing payment rules and allows them to experiment, as my hospital did, for ways to deliver better care and ultimately lower health care costs.

The midterm elections seem to be all about exploiting the down economy and taking aim at those who courageously cast a vote to overhaul an unsustainable system. They should not be targeted and punished. People would do well to remember the fury and acrimony that surrounded the passage of Medicare.

This law is designed to insure nearly all Americans while increasing the value of care. If allowed to stay intact, it may well be as momentous as Medicare.

Conspicuously absent from the health care overhaul were meaningful measures to control costs. There’s a reason for that: Government cannot legislate that issue, as health care is inherently too complex. An example of a clumsy congressional attempt was the enactment into law in the late 1990s to cut Medicare physician payments. The draconian law has resulted in politically messy fights, with Congress blocking the cuts 10 times in the last eight years, including four times since January.

If there’s one man in the country who knows how to proceed with controlling health care costs, it’s Berwick, a Harvard clinical professor of pediatrics and health care policy.

Republicans should be the ones most interested in his nomination succeeding. Stunningly, they are the ones opposing it. Why? They cite remarks he has made — all taken out of context — about rationed care, the British National Health Service and primary care “medical home” models of care.

Professors by nature think outside of the box, and they are rewarded for it. Any beginning student of U.S. health care policy learns that in a country with a fifth to a quarter of its population uninsured, it’s a matter of public policy by omission that health care is rationed. I suspect most health care policy professors will rightly instruct that if rationing is a given, then as a society, it’s in the public interest to do so with eyes open rather than closed, something Berwick referred to in an interview last year in the journal Biotechnology Healthcare.

In this interview, Berwick referred to an initiative funded in the American Recovery and Reinvestment Act of 2009 to evaluate the comparative effectiveness of targeted therapies and recommend reducing those that are ineffective and costly. The program is named Comparative Effectiveness Research; he calls it what it is, evidence-based medicine. He cautioned against mandating compliance with CER directives, preferring instead making information and research available to clinicians in the form of advisories.

Berwick knows what he’s talking about. He founded the Institute for Healthcare Improvement in the early 1990s, which has worked with thousands of hospitals worldwide to develop evidence-based best practices. As part of Ascension Health, the hospital where I’ve worked as a neonatal intensive care nurse for 30 years is one of those hospitals working with IHI. Berwick certainly has made a transformational change in my area and in most areas of my hospital.

During this past decade, Berwick’s organization successfully has tackled some of the most deadly, costly, tragic — and avoidable — events in health care: hospital-acquired pneumonia from ventilator usage, central venous line infections, adverse drug reactions and many more. Real cost controls in health care will take place from within the industry, and using evidence-based practice is the best hope.

In my own area, we have effectively eliminated birth trauma injury to term infants. Our hospital also worked with Berwick’s organization to develop another IHI life-saving innovation — rapid-response teams. These teams, which have spread all over the United States, consist of a critical care nurse and respiratory therapist available 24/7 to seek out patients and answer calls from nurses on the floor, usually outside of the intensive care unit, who see patients going downhill. The teams provide oxygen, IVs, drugs or other therapies to stabilize patients.

Hospitals have seen a 50 percent reduction in “code blue” calls — patients who need to be resuscitated because they’ve stopped breathing and their hearts have stopped beating. Every time I hear the hospital operator call overhead, “Rapid response team, report to room X,” I smile and think of Berwick. I think of how grateful that patient and his or her family will be that the patient was caught in time before it was too late.

The smile vanishes quickly, though, when I think of the impending disaster of taking professorial remarks out of context and destroying what may well be this country’s only real hope of improving health care while reining in costs. Despite Republican rhetoric, Berwick, more than anyone, recognizes that local communities and clinicians, not a national system, will be the ones to rein in costs.

Inglis is an editor and neonatal intensive care staff nurse with the Seton Family of Hospitals in Austin and a former student of health care policy.

Undoubtedly overlooked by most, that statement struck me as profound and rocketed me back to 1992. The gods had smiled upon me, and I found myself at the LBJ School of Public Affairs, out of place among 10 promising graduate students chosen to take the last policy seminar taught by the late Barbara Jordan. The first African American elected to the Texas Senate since Reconstruction, Jordan went on to a distinguished career in Congress, ended her public service teaching at the LBJ School of Public Affairs.

U.S. Representative Barbara Jordan opens the impeachment hearings on July 25, 1974. Her brow remained unfurrowed during the electrifying eight-minute and 45-second speech.

I was old enough to be my classmates’ mom, but I was as bendable as a wire hanger. We studied policy from every conceivable angle, dissecting it into many parts — politics (not a dirty word), democratic pluralism, congressional prerogative, the U.S. Constitution, the presidency, leadership, vision, interest-group impact, agency roles in the policy process, the judiciary and more. To this day, Jordan’s reverence for our democracy is as ingrained within me as her conviction that public service is a high and honorable calling.

One important lesson we learned is that Americans are not comfortable with fundamental policy change, and that’s clearly been in evidence during the past year’s health care reform brawl. The nation has not legislated fundamental change since the 1960s, and, unaccustomed, emotions have run high.

Members of congress yelled “you lie” and “baby killer” from the chambers of the people’s House. Congressmen were spat upon and were the target of racial and homophobic epithets by angry protestors as they walked the steps to the Congress to cast their difficult votes.

After the bill was signed into law, all hell broke loose. Several representatives who voted for the bill have received death threats, profane voicemails, white powder mailed in envelopes and bricks hurled through their home and office windows with hateful notes attached. Three days after the vote, attorneys general from more than a dozen states, including Texas, filed suit asserting as unconstitutional the mandate for individuals to buy insurance.

The late Jake Pickle, who represented the 10th Congressional District from 1963 to 1995, knew firsthand about difficult votes. As a new congressman, he was confronted with the 1964 Civil Rights legislation. His constituency was bitterly divided on the issue. He knew in his heart that forbidding discrimination based on race and sex was the right thing to do. He also knew as a new congressman, a “yes” vote could well cost him his seat. He voted his conscience: “Aye.” He remembered that vote in his 1997 memoir, “Jake,” as his gutsiest, proudest moment in the U.S. Congress.

The health care legislation was never about socialism, red versus blue, a public option, abortion, government takeover, poll numbers or midterm election fallout. Those are all abstractions or side issues. All along, this legislation has been about uniting around the principle of equality, so that, like all other industrialized nations, in America health care will be available for everyone, not just the privileged.

In her keynote address to the National Democratic Convention in 1976, Jordan said with her voice and wisdom ringing from the mountain top, “First, we believe in equality for all and privileges for none … But this is the great danger America faces: that we will cease to be one nation and become instead a collection of interest groups — city against suburb, region against region, individual against individual. … But a spirit of harmony will survive in America … if each of us remembers, when self-interest and bitterness seem to prevail, that we share a common destiny.”

We also learned in Jordan’s class that true leadership is rare, that it requires a vision for the people along with the trust, skills, faith and perseverance to carry it out. How I wish she had lived to see a young visionary black senator swept into presidential office with the promise of “real” (meaning fundamental) change.

How proud the congresswoman would be that within 14 months of inauguration, Obama accomplished what three presidents had failed to do. Franklin Roosevelt, Harry Truman and Richard Nixon each placed universal coverage high on their agendas and fought valiantly for it. The late Sen. Edward Kennedy called it the last great unfinished business of our society.

The president rightly could have added to his remarks, “This is what leadership looks like.”

On January 18, 2001, as one of the numerous “midnight” regulations of the Clinton administration, the federal requirement for hospital physician supervision of nurse anesthetists was dropped. But on November 13, 2001, just before the January ruling was to go into effect, it was reversed by the Bush administration.

The November ruling requires physician supervision of CRNAs in hospitals receiving Medicare reimbursement. The ruling compromises by permitting state governors to request a waiver to opt out of the requirement, if deemed in the best interest of the state’s residents. The governor may do so only after consulting the state’s boards of nursing and medicine, and after determining if opting out is consistent with state law. To date, six states have opted out of the requirement — in order, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, and New Mexico.

Although nurse anesthetists are legally allowed to provide anesthesia in all 50 states, some states require that they do so with supervision. However, 31 states don’t require physician supervision of CRNAs. This is specified though the states’ nursing and medical practice acts, the rules of their nursing and medical boards, and their hospital licensing laws: all three must be in accordance in order to secure exemption from the new ruling.

How the Rulings Effect Practice

“In my judgment, the supervision rulings do not affect practice or the quality of anesthesia care,” said Sandi Peters, CRNA, former president of the Texas Association of Nurse Anesthetists. “I practice in three rural hospitals. In one practice site Im employed as a staff anesthetist; in the other two I independently contract. The physician who supervises me is usually a surgeon who likely has hd no advanced anesthesia training. Physician supervised or not, my practice is the same at all three hospitals.”

“Physician supervision of nurse anesthetists has absolutely nothing to do with practice or patient safety,” says Ira Gunn, MLN, CRNA, FAAN, who for nearly 50 years has practiced anesthesia and worked extensively with state legislatures, the Congress and administrative bodies regulating the nurse anesthesia profession. The 30,000-member American Association of Nurse Anesthetists (AANA) established a professional advocacy award in her name. “It has to do with politics, turf, control and income. It’s a holdover from the days of the ‘captain-of-the-ship’ legal doctrine, which became obsolete long ago in most jurisdictions.”

Gunn clarified a common misperception about who exactly “supervises” CRNAs. “People assume that physician supervision rulings are about anesthesiologists supervising nurse anesthetists. That isn’t true. Physician supervision rulings refer to any physician, including those without advanced anesthesia training. In practice it’s likely a surgeon,” said Gunn. “The American Society of Anesthesiologists (ASA) successfully campaigned to convince surgeons that they were liable for CRNAs. Nothing could be further from the truth. CRNAs carry their own medical malpractice insurance. Nurse anesthetists are trained by nurses, credentialed by nurses, and regulated by nurses. The profession is independent of medicine.”

Peters agrees. “ASA’s misleading information made surgeons feel that they would be liable for any mishap if they didn’t supervise CRNAs. The surgeons I work with haven’t had advanced anesthesia training, and many tell me they don’t feel qualified or comfortable supervising my anesthesia care.”

“In another twist on the subject, HCFA (the federal Health Care Financing Administration) never defined ‘supervision,’” Peters continues. “In practice, it could mean anything from a physician being somewhere in the building to one looking over the old ether screen and asking the CRNA if everything’s okay. So, there’s no consistency. Supervision is meaningless in real-life practice.”

“The Bush administration reversal was deeply disappointing to practicing CRNAs,” Peters says, “because it meant an opportunity was lost to lose unnecessary encumbrances to practice. It also places a procedural burden on state governors to opt out.”

Deborah Chambers, CRNA, MHSA, past president of AANA, says, “The AANA believes that CMS (Centers for Medicare & Medicaid Services) got it right the first time with the January 2001 rule on supervision. But since the November 13 ruling is in place, the AANA will work with that rule to ensure safe, high-quality anesthesia care for all Americans. We are confident that governors will make the right decisions for the citizens of their states by choosing to opt out of the requirement.”

Witkowski, too, is disappointed in the latest ruling. “It promotes a phony hierarchy of providers, granting physicians greater status and economic reward. It’s demoralizing to the ‘underlings,’ the dedicated people who do the work. It makes them feel beaten down and leave the profession, contributing to the shortage of anesthesia providers. What’s worse, rulings like these drive up prices and limit access,” she says.

A question of Geography

Access to health care is a challenge in U.S. rural areas, as most healthcare providers prefer to practice in urban areas. Thus, the Clinton administration’s January 2001 ruling was strongly supported by the both the American Hospital Association and the National Rural Health Association. Small wonder, as CRNAs are the sole providers of anesthesia in many inner-city hospitals and in more than 65% of rural hospitals, according to the AANA. [http://www.aana.com/crna/ataglance.asp]

Rodney Lester, PhD, CRNA, president of the AANA, understands the critical role CRNAs play in meeting the healthcare needs of rural communities. “If it weren’t for CRNAs, people living in rural and medically underserved areas simply wouldn’t be able to maintain access to the services they need requiring anesthesia—for example, trauma stabilization, diagnostic procedures, and emergency surgeries related to obstetrics, orthopedics, and a myriad of acute conditions,” Lester says.

Hospital medical bylaws reflect this geographic difference in access to services. In the 29 states where physician supervision of CRNAs is not required by law, the medical bylaws of rural hospitals typically don’t require supervision.  However, urban hospital bylaws, which are far more restrictive, tend to require physician supervision. As Witkowski explains, “Some bylaws in urban hospitals with plenty of physician coverage can be so limiting that [CRNAs] wouldn’t be able to make any independent judgments at all. CRNAs would do well to read their hospital’s bylaws and address those that are too restrictive.”

The Future of Physician Supervision

The future of the physician supervision requirement is anyone’s guess. Publicly, the ASA frames physician supervision of CRNAs in terms of patient safety rather than interprofessional turf, and it hailed the Bush ruling as a major victory. But from Gunn’s perspective, “CRNAs have always worked collaboratively with physicians, so supervision is neither necessary nor appropriate.”

Some believe the new ruling may be a violation of the original Medicare Act. Glen Maxey (D-Austin), a healthcare consultant who represented Travis County in the Texas legislature from 1991 to 2002, believes the January ruling shouldn’t have been rescinded. “When Medicare was passed in 1965,” Maxey says, “a fundamental principle of the program was that it wouldn’t interfere with state law regarding the regulation of healthcare professionals. Since the January 2001 ruling would have deferred to the states on supervision, it should have been allowed to stand.”

Thirty years ago, the Catholic order of the Franciscan Sisters of Mary decided to send Sister Angela to the Texas Rio Grande Valley, one of the poorest, hottest regions in the United States. Sister Angela was finishing her master’s degree in maternal nursing and nurse midwifery at Columbia University and passed the board exam to become credentialed as a certified nurse midwife (CNM). By 1972 when she reached Raymondville, a small town near the southern tip of Texas, she nwas ready to take on her new responsibilities as a nurse at Su Clínica, a federal migrant health center.

She quickly discovered the difficulties local women faced in obtaining health care. “Most of the women labor as seasonal farm-workers, making between $1 and $3 per gunnysack filled with picked onions, cucumbers, turnips—whatever is in season,” she explains. “They have no health insurance or car, and there is no public transportation. Consequently they become isolated, staying in their colonias.” At the time the local women—who typically marry young and have numerous children—had another reason to worry. “The local clinics did not offer maternity care. If a woman wanted a hospital delivery, she had to find a ride, travel 25 miles on rough, rural two-lane highways stopping through small towns to get to the Harlingen hospital [the only hospital with an obstetrician in the region].” This was unacceptable to 32-year-old Sister Angela. “These women desperately needed a birthing center,” she said, “and I promised myself that it would happen.”

Gaining Ground for CNMs

In the meantime, Sister Angela faced some formidable obstacles to establishing the first nurse midwifery clinic in the state. “From the moment I set foot in Texas, I knew I was going to have a horrific fight on my hands,” she recalls today. The Texas Board of Medical Examiners had declared that when CNMs were delivering babies, they were practicing medicine. Sr. Angela was heavily involved in the fight against this assertion, and an opinion was requested from the Texas Attorney General’s office, which issued an opinion (H1293) in 1978 that clearly stated that CNMs were not practicing medicine by delivering babies, thus clearly defining the legal base for nurse midwives to practice in Texas.

The next obstacle was the issue of direct reimbursement. “As luck would have it, the sole physician on the Texas Medicaid Advisory Committee was an obstetrician who frequently declared, ‘over my dead body will nurse midwives ever receive Medicaid reimbursement for delivering babies in Texas,’” she said. Six years into her fight, Sister Angela was approached by an attorney who offered to represent the clients of her birth center in a class-action lawsuit that would require Medicaid to pay for nurse midwifery. “After just one letter from [the attorney], the doctor lost his steam,” said Sister Angela. “The taste of victory was sweet in 1989 when I received the first Medicaid provider number issued for a CNM in the State of Texas.” Today, all 50 states allow direct Medicaid reimbursement to CNMs.

In 1986, Sister Angela served on the Texas Department of Health advisory committee that wrote the original Texas Birth Center Rules and Regulations, and assisted with their revision 10 years later. She is currently helping to update them. She helped write the National Association of Childbearing Center’s “Standards for Birth Centers” and serves as site visitor to birth centers seeking accreditation based on those standards. Her efforts have not gone unnoticed. A frequent television and radio guest as well as a keynote and commencement speaker, in 1990 she was awarded the most prestigious honor that a CMA can receive, the Hattie Hemschemeyer Award for outstanding contributions to midwifery and maternal and child health. On September 10, 2002, she was inducted into the Texas Women’s Hall of Fame, sharing the honor with former recipients the late former Congresswoman Barbara Jordan, former Governor Ann Richards, former First Lady Barbara Bush and astronaut Sally Ride.

Breaking Ground for the Women of Texas

In 1980, Sister Angela began looking for medical and financial support. Funding came through private grants, contributions from the local diocese, and the sponsorship of three Catholic orders. Help often came from unexpected directions. “An electrical contractor passionately wanted this birth center to open,” she recalls, “He’d call his friends to help, so that construction was free or at a huge discount.”

In 1983, on four acres of former cucumber fields, Sr. Angela opened the Holy Family Birth Center, with one sister to manage the office, two CNM sisters, and two RN sisters. News of the clinic spread by word of mouth and since then, the complex has expanded significantly. Today its bright yellow buildings are home to a clinic, a classroom, a chapel, six birthing suites, and a residence for staff, fellows, students, and visitor. Seven RNs, four CNMs, two fellows, and two volunteers deliver services. Over 20 years, more than 5,000 babies have been delivered at the center, which is accredited by the Commission for the Accreditation of Birth Centers. With the U.S. infant mortality rate at 7.0 deaths per 1,000 births (1999 data),1 the birth center rate is only 1.3 per 1000; 0.7 per 1000 if lethal anomalies are excluded. Her victory for nurse midwifery in Texas has had a ripple effect nationwide. Today there are over 160 freestanding childbearing centers located throughout the United States.

“At our center, if the patients don’t have Medicaid, they are happy to work off their bill with in-kind services such as doing laundry, mowing, trimming bushes, cleaning, or driving,” said Sister Angela. “We’re a family-friendly place. If the volunteers have babies they are breast-feeding or young children, they’re welcomed at the center with open arms.”

Birth center volunteers and clinical fellows routinely describe their work as a life-changing experience. “I like the fact that I’m crossing all the lines—doing public health, childbirth education, health teaching, clinic work, labor and delivery, antepartum, well-baby clinics, home visits,” explains Shaanti Abbruzzese, a University of California at San Francisco nurse midwifery graduate who recently completed a fellowship. “I’ll never look at maternal care the same again.”

To learn more, visit www.holyfamilybirthcenter.com.

REFERENCE

1. National Center for Health Statistics. New CDC Report Shows Decline in Infant Mortality Rate in 1999 Analyzes Patterns of Infant Mortality. Centers for Disease Control and Prevention. 2002. http://www.cdc.gov/nchs/releases/02facts/99infant.htm.

A few years ago a hospital might experience a shortage of one or two critical drugs per year. This past year the number has been closer to dozens of drugs. And the shortages can last from a few weeks to months at a time. The highest-profile drug shortage since Sept. 11 is Cipro, the antibiotic treatment for anthrax, with demand exceeding supply.

Cipro notwithstanding, the drugs typically in short supply are the injectable forms used in hospitals and outpatient surgery. In the past few years, we’ve seen shortages of Wydase, adult tetanus, Isoproterenol, Penicillin G, Fentanyl, Succinylcholine, Compazine, Narcan, Romazican, and IV Benadryl, to name a few.

There are reasons for this shortage. The hospital injectable drugs cost more to manufacture because they must be made in a sterile and bacteria-free environment, which few generic drug manufacturers have. Moreover, the pharmaceutical companies view this market as limited, with relatively few hospitalized patients compared to the millions who take pills as outpatients. And the outpatient market is far more responsive to advertising and promotions.

In my area, neonatal intensive care, since 1999 we have experienced shortages of Wydase, Fentanyl, and Penicillin G — drugs for which there is no substitute. Wydase injected into the site of serious IV infiltrates can save the infant from losing a limb. Fentanyl is preferred for pain management because of fewer respiratory and intestinal side effects. And there is no alternative for Penicillin G to treat infants with congenital syphilis.

U.S. health care is structured so that the profit-maximizing sector makes our drugs, and government protects and encourages this industry. This tight arrangement is ideal for our pharmaceutical industry to succeed in answering clinicians’ calls to find drugs to treat illness, something they’ve done very well.

In the last decade alone dramatic discoveries have led to drug therapies for horrific illnesses previously thought hopeless, for example, drug cocktails with protease inhibitors to manage AIDS, and the new generation psychotropic medications to treat severe mental illness such as schizophrenia. These drugs work and have so few side effects that patients are sticking with their drug regimens. These discoveries have saved and extended lives, improved health and restored hope.

Government protections and encouragement for this industry’s “free” market are dramatic, and arguably exceed those for any other industry. Many new drugs stem from basic research supported by the National Institutes of Health. Drug companies have low tax rates and can deduct marketing as well as research and development expenses. Most important, government provides patent protections for new drugs that are 17 years and longer, during which time the companies are free to charge whatever the market will bear.

The mergers and acquisitions of pharmaceutical companies in the 1990s profoundly shifted traditional pharmaceutical economics. With a limited number of production lines, continuing to produce the older, less profitable drugs takes up factory space that could be used for newer, more profitable drugs. Often when there’s only one maker left for a generic drug, the company grossly inflates its cost — a practice some call “price gouging.” And hospitals, under severe financial pressures, cope by keeping inventories small and bargaining aggressively for lowest drug prices.

The problem of nationwide drug shortages is serious enough that the federal government must now tighten its control over the industry. The very least that can be done is to enact the recommendation of the American Society of Health-System Pharmacists — requiring companies to notify the Food and Drug Administration (F.D.A.) and healthcare providers of anticipated shortages of any drug. After all, the notoriously tightlipped pharmaceutical companies — both the innovators and generics alike — are aware of manufacturing problems in advance of anyone else.

The inherent flaw all along in our setup of a government-protected pharmaceutical industry has been that thorny clinical problem of getting the drugs to all people who need them. The product here is not big-screen TVs. It’s drug therapy that people depend on for quality of life and even survival.

What can nurses do? The relatively new phenomenon of drug shortages can create havoc, perplexity and anger in the clinical setting. Nurses who understand (not necessarily accept) the reasons for the shortage are in a position to serve as a calming influence by offering intellectual insight to their colleagues, other clinicians and patients struggling to comprehend and deal with the shortages.

Part of our professional code of ethics tells us that we’ll strive to “improve standards of nursing practice and promote … efforts to meet health needs of the public.” I’ve always taken that aspect of the code very seriously.

During the 12 years that I was a hospital staff and head nurse, I was also involved in local politics. During that time, an influx of foreign nurses pointed to the need for a clearer definition of nursing responsibilities in the Nursing Practice Act. After joining the Governmental Affairs Committee of the Texas Nurses Association, we set to work to rewrite parts of the act and then to lobby the Legislature for its passage.

It became clear to me during that time that policy work in state government was the most efficient way to improve nursing and health care for people. I could see that as a nurse I was in a unique position to make that happen, so I decided to run for state office. Having worked in local politics, I was able to garner a lot of support and campaign help.

Survey after national survey has shown that the public at large trusts nurses and holds them in high esteem. I certainly found that to be true both within my hometown of El Paso and within the Legislature. People in my district trusted me and re-elected me every term for 13 years until I retired in 1997. My fellow legislators relied heavily on me for expertise in health care. When I spoke on health care, it got their attention.

Was it difficult for you to juggle work and family?

That’s difficult for any woman. I had a husband and 10 children, so I needed to work. When the children were young, hospital work with its 24/7 coverage requirements offered me the opportunity to work a flexible schedule to accommodate child care and events.

I didn’t run for state office until the youngest child graduated from high school. Serving in the Legislature is a full-time job, whether in session or not.

What are you proudest of in your legislative work?

I feel good about the work I did for AIDS. When I was first elected in 1984, the AIDS epidemic was becoming public. Legislation was needed to cover many of the problems-like confidentiality, directives for health care workers (precautions), regulations, funding for education. My health care background was important in overcoming the hysteria. Every subsequent session, there was a lot of work to be done to refine legislation and to make sure that what was gained was not torn apart.

One of the first bills I worked on was assuring that licensed respiratory therapist regulations did not conflict with nursing practice. I worked with the Texas Nurses Association every term to update the Nursing Practice Act. I helped get funding for a huge study about the nursing shortage in Texas.

The Board of Nurse Examiners Sunset review would come up, and every session I worked to get the [board] the money it needed for testing and checking out complaints against people. I worked with [the Texas Department of] Mental Health and Mental Retardation for smaller group homes for the developmentally disabled and to review lawsuits for better care for custodial or institutionalized patients. I made sure state-funded institutions kept up with best-practice standards.

I am glad I was there to give my input from the nursing perspective to health care legislation and the budget wars. I know it helped. Serving on the Public Health and Appropriations Committees allowed me to balance finances with political considerations. That’s important work.

What reaction have your children had to your political activity?

I think it has affected them pretty profoundly. All of them really enjoyed helping me with my campaigns. They all tell me they’re proud of me for the work I’ve done.

My son, Chuck McDonald, was assistant press secretary to former Texas Gov. Ann Richards. He is now a busy political consultant with a public relations firm.

My youngest daughter, Elizabeth, is a neonatal intensive care nurse in Austin. She tells me that since becoming a nurse, she’s often amazed at seeing the tangible results of my labor in the Legislature.

For example, in El Paso, she made the connection with my work and how AIDS patients and those with mental illness were treated more humanely. She tells me she knows how my work has made life better for a lot of Texans, and that makes me happy.