How Many Nurses? ACA Intensifies Hospital Debate

Credit: Nena Terrell/USAID Ethiopia, USAID_IMAGES on Flickr, under Creative Commons (CC BY-NC 2.0).

(WOMENSENEWS)–The Affordable Care Act, which is expected to boost hospital admissions, has intensified a decades-old battle over the number of nurses who should be available to patients at all times.

Championed by National Nurses United, a 185,000-member national nurses union based in Silver Spring, Md., bills vehemently opposed by hospital administrators are working their way through seven state legislatures–Florida, Iowa, Michigan, Minnesota, New Jersey, New York and Texas–the District of Columbia city council and the U.S. Senate.

At the federal level, a bill authored by Sen. Barbara Boxer, the California Democrat, requires minimum staffing levels in hospitals that receive Medicare and Medicaid funds (the insurance programs for the elderly and low-income Americans) and fines up to $250,000 per violation of those staffing minimums.

The U.S. Census Bureau reports that 91 percent of the nation’s 3.8 million employed nurses are women. Among those employed nurses, 78 percent are registered nurses, 19 percent are licensed practical and licensed vocational nurses, 2 percent are nurse practitioners and 1 percent nurse anesthetists.

Ashley Forsberg, chair of the congress of public policy of the Michigan Nurses Association, a union that supports a bill in Michigan, predicts that minimum staffing laws will become increasingly important when many of the 32 million Americans who will obtain health insurance under the Affordable Care Act on Jan. 1, 2014, begin streaming into hospitals.

“Research has shown that minimum staffing ratios ensure patient safety and prevent burnout, a significant factor in shortages of nurses,” said Forsberg, a certified medical-surgical nurse, in a phone interview.

In addition to more patients, she said, nurses will have more seriously ill patients who require complex treatments and extensive patient education. The risk of falls and infections will increase, leading to longer hospitals stays and complications when patients go home.

The bills call for specific ratios in different parts of a hospital, such as one nurse for every patient in an operating room and one nurse for every four patients in a rehabilitation unit.

Medicaid Payment Cuts

As part of the bargaining over health reform, Congress voted in January to reduce by $4.2 billion payments to Medicaid, the insurance program for low-income Americans, to hospitals that treat an unusually high share of the poor. Lawmakers did so to help pay for part of the $30 billion needed in 2013 to keep Medicare payments to physicians constant.

As an alternative to mandatory nurse-to-patient ratios, hospitals support voluntary efforts, such as nurse training, to improve quality of care.

To improve transparency, five states require hospitals to disclose statistics about staffing levels to state regulatory agencies or the public.

Seven states require hospitals to establish committees of administrators and nurses to create staff plans that reflect the needs of patients, nurses and managers. The American Nurses Association, which includes both unionized and nonunionized nurses, prefers this approach. The group, based in Silver Spring, Md., says that minimum staffing laws don’t take into account factors such as the severity of illnesses of patients on a particular unit, or nurses’ depth of training and experience.

“If hospitals were actually doing these things, we wouldn’t be advocating for minimum staffing ratios,” said Jeff Breslin, president of the Michigan Nurses Association, in a phone interview. “Unfortunately, hospitals are run like corporations these days and are only focused on the short-term bottom line rather than the long-term impact of inadequate staffing on nurses as well as patients.”

Breslin added that minimum staffing laws ensure that patients in safety-net hospitals that serve the poor have an adequate number of nurses as well as hospitals in affluent areas.

To muster support for minimum staffing ratios, members of National Nurses United stress that minimum staffing laws can help hospitals meet provisions of the Affordable Care Act that will reward hospitals for positive patient outcomes.

Understaffing of nurses was a key factor in the spread of the most dangerous type of hospital acquired infection, methicillin-resistant Staphylococcus aureus (MRSA), found a July 2008 study published by Lancet Infectious Disease.

The Affordable Care Act has made reducing such infections a major priority.

Invisible Costs

Hospitals are reluctant to add extra nurses because insurance companies often pay a fixed rate for each case, which could force them to absorb the costs. The Bureau of Labor Statistics reported that the median annual wage of registered nurses was $64,690 in 2011.

Unfortunately, the cost of nursing care is invisible in hospital finance, said John Welton, dean of the School of Nursing and Health Sciences at Florida Southern College in Lakeland.

“When they get their bills, patients can see that their X-rays cost X dollars and the surgeon’s fee was Y,” he said in a phone interview. But nursing care is lumped under room and board. “If the cost of nursing care was listed separately, hospitals would have a measure of how much quality nursing care contributes to better outcomes, such as shorter hospital stays and fewer complications, and nurses would be compensated accordingly.”

The Chicago-based American Hospital Association, a national organization that represents nearly 5,000 hospitals, health care systems and networks, estimated in a March 2011 report that hospitals account for the biggest share–33 percent–of the nation’s health care dollars.

Only one state currently has a minimum nurse staffing law — California. Since the California legislature passed fixed ratios in 1999, hospitals have defeated dozens of bills across the nation by claiming that mandatory ratios deprive hospital administrators of the ability to make day-to-day staffing decisions to keep labor costs down, so that hospitals will remain solvent and health care costs will be contained.

Despite the obstacles, Michigan State Sen. Rebekah Warren, D-Lansing, predicts her staffing bill will pass this year.

“Patients and their families have always taken an interest in staffing legislation because of their experience,” said Warren, a daughter of a nurse, in a phone interview. “But thanks to the Affordable Care Act, the general public is paying attention too. Republican as well as Democratic voters and legislators are interested in the issue, which also bodes well.”