On the Brink of Change: NP, PA Leaders' Hopes for 2009

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Lord: A lot of this is so theoretical when you get down to how it is going to happen. But overall, the concept seems like a reasonable one. It builds on what currently does work, including the employer-sponsored plans, Medicare, Medicaid. I mean, they have to be improved, but there are components that do work. The SCHIP [State Children’s Health Insurance Program]—I talk to PAs across the country, and if it weren’t for SCHIP, some kids would have nothing. So, we do have plans and programs that work. They can work better. We also need to look at insurance reform to make the private market more consumer-friendly.

Another aspect is an improved focus on wellness and health disparities. I’ve always said we chase disease. Health promotion, or disease prevention, means “Let’s truly work on obesity, let’s get you so you don’t have diabetes.” But what do we do? We take care of very sick patients who already have those diseases. At least theoretically, the Obama-Biden model looks at that and says, “This is where we’re going to focus,” on prevention and health care disparities….

Now, of course, when people actually get into office, they always find out what their hurdles are. We seem excited because this group is trying to be more bipartisan and not look at party but rather “Let’s look at the problem and bring in a broad group of players.” So we’re hopeful.

One of the keys is—I hope—that they reach out. Obama has been very smart in using the Internet and mobilizing people, whether it was building his campaign or collecting money, but also now giving people an opportunity to voice their opinions. So I’m hoping they use that information—that they don’t just say, “We want to hear from you,” and then don’t do anything with that.

Allowing for the fact that the level of reform our health care system needs will take time, what do you think should be the priorities? What must be addressed first?
Swanson: What has to be addressed first? The uninsured. From my perspective, I’m a full-time NP in a rural health practice in Indiana, and I see a lot of people who have no health insurance. That has a profound effect on their ability to be healthy, productive, contributing members of their local communities, their state, and the United States. I have people who are insulin-requiring diabetics who can’t afford to test their glucose, who can’t afford testing supplies or insulin—just the basics of managing their care—much less worry about optimal glycemic control. I have people who are young, who have diseases that can cause early demise—hyperlipidemia, hypertension, obesity.

Health care shouldn’t be a privilege. It should be a right. The Declaration of Independence says that we have the right to pursue happiness, and health has to be part of that.

There are innovative plans that are out there. Indiana has the Healthy Indiana Plan, which has been in place for about a year. It’s funded in part by tobacco money. This is for people who are uninsured and can’t afford to purchase employer-offered insurance plans. It covers preventive care, hospital care, acute care. And people are required to get their preventive health care or they lose this health savings account that they accrue over a period of time. They get, I believe, $1,000 in a health savings account, and if they don’t do their preventive care during the year, they lose that. That is a powerful incentive.

You know, it’s just so interconnected. If your children are unhealthy, they’re not going to do well in school. If you have unhealthy workers, they’re going to cost the system money. A lot of these people wait until they’re in crisis and present to the emergency room, and that’s expensive, as is the hospital. I feel that addressing the needs of the uninsured is critical, and that involves primary care.

Lord: We have to look at universal coverage. But I think philosophically, before you get there, there has to be an understanding amongst all of us in health care—including physicians—that no man is an island. We have to work in coalitions; we have to work together. I can give you a million reasons why PAs are part of the solution, but we’ve always qualified that: We’re part of the solution; we’re not the solution.... Everyone’s role is important. This is about patient care; this isn’t about PAs, or NPs, or physicians. It’s about patients….

And then from there, we need to look at universal coverage: How do we get that access? How do we get people covered? It may very well be addressed by phasing in coverage. It may not just all happen; they may have to do some kind of phase-in.

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