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Medicare & Medicaid

NP Delivery of Primary Care for Homebound Elderly Threatened by Proposed Medicaid Cuts

By Liz Seegert

July 18, 2017

As our population lives longer with more chronic conditions, an an estimated two to three million end up homebound, unable to leave their homes to receive primary care in a physician’s office.  It means they often go without care or end up in crisis in the emergency department, driving up costs and further affecting their quality of life.


There are programs and services that deliver quality home-based care, but they face looming cuts in reimbursement, or even outright elimination, thanks to the Senate’s health care bill. It would slash Medicaid by $700 to 800 million. A shortage of primary care physicians further strains efforts to deliver high-quality home-based care.


Nurse practitioners can help meet these challenges, said Denis Tarrant, NP, who runs a primary care house calls practice in New York City. He thinks the proposed health legislation will only make it harder and harder to serve his patients, and others like them around the U.S.


“We don’t have the ability to meet the primary care demand without nurse practitioners,” Tarrant said in a phone interview. He’s right — nurse practitioners are becoming an increasingly a more viable option around the country to make up for the shortfall of primary care MDs. Research from Kaiser Family Foundation, the Robert Wood Johnson Foundation, and elsewhere confirm that independently practicing NPs play a key role in solving the primary care shortage.


The Senate’s proposed cuts to Medicaid threaten not just primary care delivery but also home and community based care for our nation’s most vulnerable, and medically-needy older adults. The only place left to pick up the slack is the emergency department, Tarrant said.


The Senate is still scrambling for the necessary votes to pass legislation that will adversely affect tens of millions of people. Meanwhile, patients and families, along with those who care for them, remain in limbo.


You can listen to the full interview with Denis Tarrant below or subscribe to the podcast on iTunes.


Liz Seegert
Liz Seegert is a health care journalist and directs the media fellows program at the Center. She serves as topic editor on aging for the Association of Healthcare Journalists, writes for a variety of print and online publications and coproduces HealthCetera Radio on WBAI-FM. She tweets @lseegert. 

Nurses raise their voices: “Do No Harm”

By Editorial Staff

June 28, 2017



This post is written by George Washington University faculty member Joyce Pulcini, PhD, RN, PNP-BC, FAAN, with contributions by Kari Deakins and Jennifer Kanelos, George Washington University School of Nursing students who attended the action. Dr. Joyce is a member of the National Advisory Council at the Center for Health Policy and Media Engagement.



On a hot Washington Thursday, June 22, a group of health care professionals and students in white coats descended on Capitol Hill to protest the proposed American Health Care Act (AHCA)


This new Act would replace the current Affordable Care Act. President Trump was quoted as saying that the House-passed health care reform bill as being a “mean” health insurance bill. The AHCA would leave almost 24 million uninsured. Nurses, physicians and other [health] professionals stood tall at this press conference.  House Minority leader Nancy Pelosi, Congressman Raul Ruiz, a physician from California and Congressman Steny Hoyer from Maryland [were] in attendance.


The vehemence with which this group expressed their displeasure with the bill was refreshing.  We heard physician after physician speak of the horrors and dangers of having no insurance, the consequences of which we all have seen in many patients who deserve better.  Possible victims include: elderly patients in nursing homes, whose costs represent 42% of the Medicaid dollar (nursing home residents account for about 6% of Medicaid enrollees); women seeking gynecological care; pregnant women whose pregnancy may now be defined as a preexisting condition; children on Medicaid, which covers 40% of all children; and disabled individuals living in facilities covered by Medicaid.  All will be vulnerable. 


The [health care] group continued to voice the mantra, “Do no harm” and speakers addressed the harms of this proposed bill would have if passed. Passage of this bill would devastate a population that finally received health insurance through the ACA, after many years of poor or delayed care. Today’s American population is aging.  The proposed legislation would turn the clock back for the elderly, women and children toward failed “uncompensated care” pools.  We spoke of people with conditions that are preventable or curable if picked up under current routine preventive care (“essential health benefits”), which could disappear under the new law by 2019. 


GWSON students who attended the briefing share their reactions about attending:


Kari Deakins:

As a student it was very inspiring to be able to stand shoulder to shoulder with providers of the interdisciplinary team to share our disagreement with the new AHCA. Our patients will be from many socioeconomic backgrounds in the future, and we must ensure that vulnerable populations are protected. The newly proposed AHCA risks the loss of health care benefits to millions of Americans, the possible denial of future benefits to millions more. It was motivating to listen to our future colleagues and physicians tell countless stories about their patients who would be affected by this damaging legislation. We must be vigilant and active as students to protect our patients and those that who need our help, and as we move into our practice and nursing careers, we must remain proactive in the advocacy of our patients.”  


Jennifer Kanelos:

“Participating in the white coat press conference was one of the most inspiring and memorable days I’ve had at GW to date. Gathering on Capitol Hill with nurses, physicians and med students united in the belief that all Americans deserve access to affordable health coverage, left an impact on me that will last a lifetime. From day one, we learn at GW SON to provide patient centered care focused on evidence based research. The facts are unequivocal, denying millions of people health coverage like the AHCA would do, will have devastating results on our ability to provide care for those that need it most.

I am halfway into my nursing education, and something in me has changed for the better. My experience at GW and with patients in the clinical rotations, have given me a new outlook on the world. I see people and our country differently now, and standing among so many providers with the Capitol and Washington Monument behind us, I truly felt like I belonged to something bigger than myself. Energized by the passion and commitment of the speakers and elected officials, I became a healthcare advocate that day. I look forward to a lifetime of speaking out on behalf of my patients, working towards a more perfect union, and maybe even one day asking for your vote”.

We were all there to prevent the devastating effects of the AHCA. We cannot afford to harm the American people with this bill, which would dismantle care that had finally become a reality for so many. As health care professionals we must DO NO HARM!



Update: On Tuesday, June 27, Senate Republican leaders bowed to pressure from within their own ranks and postponed a vote to overhaul the Affordable Care Act until after the Fourth of July recess. 


This post is written by Joyce Pulcini, PhD, RN, PNP-BC, FAAN, with contributions by George Washington University School of Nursing students Kari Deakins and Jennifer Kanelos who attended the action with her.

Editorial Staff

Euphemisms: The Better Care Reconciliation Act of 2017

By Diana J. Mason

June 27, 2017


Language and framing are critically important to public debates about policy. The Better Care Reconciliation Act of 2017 is an example of framing that tries to obscure what is really going on.

The BCRA is the Senate’s version of a bill to repeal and replace the Affordable Care Act, also known as Obamacare. Let’s start with the language of “Obamacare”. The language used to name the Affordable Care Act (ACA) was a deliberate attempt to garner support for a law that would increase health coverage but also make other changes in the health care system to “bend the cost curve” of health care spending. “Obamacare” was the term used by those who opposed it and who opposed the presidency of Barack Obama. They thought that linking the law with Obama would cause some people to oppose it on principle. In fact, a number of people who had benefited from the ACA but said they opposed “Obamacare” didn’t know that the two were the same thing. This may account for the increasing popularity of the ACA as Congress and President Trump now try to repeal it.

Now consider the BCRA. What would get better with this bill? What gets worse? Who benefits, who loses?

  • Perhaps, some like that it would eliminate the individual mandate to have health insurance. But that will lead to higher premiums for everyone once they need health coverage and try to buy it. The Senate has just modified the bill to reduce the likelihood that younger, healthy people will eschew paying for insurance until they are sick. The modification is that individuals who have a break in their insurance coverage will have to wait six months before signing up for coverage.
  • Some may like that it will end Medicaid, as we know it. But this will have such detrimental effects on all of us that the opposition is growing. The bill goes farther than the House version of the repeal effort (called the American Health Care Act) by more drastically cutting Medicaid funding and allowing states to opt for block grants with spending caps. It is estimated that 40% of our nation’s children are on Medicaid. And their parents are likely the working poor, unable to afford other coverage.
  • While rural areas largely voted for Trump and a Republican Congress with their promise to repeal Obamacare, few realize that many rural hospitals depend upon the increase in people with health coverage under the ACA, including the Medicaid expansion. Under both the House and Senate version of the repeal bills, the number of uninsured people will rise to more than 20 million. When this coverage is drastically reduced through cuts in Medicaid and other changes that the BCRA will bring about, we’ll once again see an uptick in the closure of rural hospitals. Their financial margins are so thin that even small increases in the uninsured will strain emergency rooms, increase the rate of uncompensated care, and accelerate the economic decline of many rural communities when they lose this important community service.
  • The BCRA would get rid of the requirement for a minimum essential benefits package that must be covered by any insurance plan. Some folks like this, saying that they shouldn’t have to pay for someone’s maternity care or substance abuse treatment. But how do we know ahead of time what benefits we might need?
  • Others want to see a lowering of taxes for Americans. The bill reduces government spending on health care and will enable the Republican Congress and the president to lower taxes, particularly for the wealthy. So those who are well off will benefit. Those who are poor and middle class will not.

What is “better” in this bill? It is being framed as a better way to reduce government spending and increase tax breaks for Americans. What may not be fully realized by those who support the bill is that it does so directly on the backs of the poor and middle class but will affect our entire nation. It will not produce better care.

Diana J. Mason
Diana is a founder of the Center for Health, Media & Policy, and HealthCetera Radio. She is the President of the American Academy of Nursing, the Rudin Professor of Nursing at Hunter-Bellevue School of Nursing, and a health policy expert and leader. Diana tweets @djmasonrn.