[Congressional Record Volume 143, Number 147 (Tuesday, October 28, 1997)]
[Senate]
[Page S11294]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DASCHLE:
  S. 1326. A bill to amend title XIX of the Social Security Act to 
provide for Medicaid coverage of all certified nurse practitioners and 
clinical nurse specialists services; to the Committee on Finance.


                   THE MEDICAID NURSING INCENTIVE ACT

  Mr. DASCHLE. Mr. President, today I am reintroducing the Medicaid 
Nursing Incentive Act, a bill to provide direct Medicaid reimbursement 
for nurse practitioners and clinical nurse specialists.
  This legislation eliminates a groundless and counterproductive 
anomaly in Medicaid payment policy. Under current law, State Medicaid 
programs can exclude certified nurse practitioners and clinical nurse 
specialists from Medicaid reimbursement, even though these 
practitioners are fully trained to provide many of the same services as 
those provided by primary care physicians. This loophole is both 
discriminatory and shortsighted; it severs a critical access link for 
Medicaid beneficiaries.
  The ultimate goal of this proposal is to enhance the availability of 
cost-effective primary care to our Nation's most needy citizens.
  Studies have documented the fact that millions of Americans each year 
go without the health care services they need, because physicians 
simply are not available to care for them. This problem plagues rural 
and urban areas alike, in parts of the country as diverse as south 
central Los Angeles and Lemmon, SD.
  Medicaid beneficiaries are particularly vulnerable, since in recent 
years an increasing number of health professionals have chosen not to 
care for them or have been unwilling to locate in the inner-city and 
rural communities where many of the beneficiaries live. Fortunately, 
there is an exception to this trend: nurse practitioners and clinical 
nurse specialists frequently accept patients whom others will not treat 
and serve in areas where others refuse to work.
  Studies have shown that nurse practitioners and clinical nurse 
specialists provide care that both patients and cost cutters can 
praise. Their advanced clinical training enables them to assume 
responsibility for up to 80 percent of the primary care services 
usually performed by physicians, many times at a lower cost and with a 
high level of patient satisfaction.
  Congress has already recognized the expanding contributions of nurse 
practitioners and clinical nurse specialists. For more than a decade, 
CHAMPUS has provided direct payment to nurse practitioners. In 1990, 
Congress mandated direct payment for nurse practitioner services under 
the Federal employee health benefits plan. The Medicare Program, which 
already covers nurse practitioners and clinical nurse specialist 
services in rural areas, was modified under this year's Balance Budget 
Act to provide coverage for these services in all geographic areas. The 
bill I am introducing today establishes the same payment policy under 
Medicaid.
  Mr. President, the ramifications of this issue extend beyond the 
Medicaid Program and its beneficiaries: there is a broader lesson here 
that applies to our search to make cost-effective, high-quality health 
care services available and accessible to all Americans.
  One of the cornerstones of this kind of care is the expansion of 
primary and preventative care, delivered to individuals in convenient, 
familiar places where they live, work, and go to school. More than 2 
million of our Nation's nurses currently provide care in these sites--
in home health agencies, nursing homes, ambulatory care clinics, and 
schools.
  In places like South Dakota, nurses are often the only health care 
professionals available in the small towns and rural counties across 
the State.
  These nurses and other nonphysician health professionals play an 
important role in the delivery of care. And, this role will increase as 
we move from a system that focuses on the costly treatment of illness 
to one that emphasizes primary and preventive care and health 
promotion.
  But, first, we must reevaluate outdated attitudes and break down 
barriers that prevent nurses from using the full range of their 
training and skills in caring for patients. In 1994, the Pew Health 
Professions Commission concluded that nurse practitioners are not being 
fully utilized to deliver primary care services. The commission 
recommended eliminating fiscal discrimination by paying nurse 
practitioners directly for the services they provide. This step will 
help nurse practitioners and clinical nurse specialists expand access 
to the primary care that so many communities currently lack.
  Mr. President, I hope my colleagues will support the measure I am 
introducing today, recognizing the critical role that nurse 
practitioners and other nonphysician health professionals play in our 
health care delivery system, and the increasingly significant 
contribution they can make in the future. I ask unanimous consent that 
the full text of the bill be printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1326

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. MEDICAID COVERAGE OF ALL CERTIFIED NURSE 
                   PRACTITIONER AND CLINICAL NURSE SPECIALIST 
                   SERVICES.

       (a) In General.--Section 1905(a)(21) of the Social Security 
     Act (42 U.S.C. 1396d(a)(21)) is amended to read as follows:
       ``(21) services furnished by a certified nurse practitioner 
     (as defined by the Secretary) or clinical nurse specialist 
     (as defined in subsection (v)) which the certified nurse 
     practitioner or clinical nurse specialist is legally 
     authorized to perform under State law (or the State 
     regulatory mechanism provided by State law), whether or not 
     the certified nurse practitioner or clinical nurse specialist 
     is under the supervision of, or associated with, a physician 
     or other health care provider;''.
       (b) Clinical Nurse Specialist Defined.--Section 1905 of 
     such Act (42 U.S.C. 1396d) is amended by adding at the end 
     the following new subsection:
       ``(v) The term `clinical nurse specialist' means an 
     individual who--
       ``(1) is a registered nurse and is licensed to practice 
     nursing in the State in which the clinical nurse specialist 
     services are performed; and
       ``(2) holds a master's degree in a defined area of clinical 
     nursing from an accredited educational institution.''.
       (c) Effective Date.--The amendments made by this section 
     shall become effective with respect to payments for calendar 
     quarters beginning on or after January 1, 1998.
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