[Congressional Record Volume 145, Number 56 (Thursday, April 22, 1999)]
[Senate]
[Pages S4114-S4115]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DASCHLE (for himself, Mrs. Boxer, and Mr. Dorgan):
  S. 863. 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; to the Committee on Finance.


                     medicaid nursing incentive act

  Mr. DASCHLE. Mr. President, today I am introducing the Medicaid 
Nursing Incentive Act, a bill to provide direct Medicaid reimbursement 
for nurse practitioners and clinical nurse specialists.
  This legislation eliminates a counterproductive Medicaid payment 
policy. Under current law, State Medicaid programs may 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 policy 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 vulnerable 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, South Dakota.
  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 beneficiaries live. Fortunately, there is 
an exception to the 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 quality, cost-effective care. Their advanced 
clinical training enables them to assume responsibility for up to 80 
percent of the primary care services usually performed by physicians, 
often 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 covered nurse practitioners and clinical nurse specialist 
services in rural areas, was modified under the Balanced Budget Act of 
1997 to provide coverage for these services in all geographic areas. 
The bill I am introducing today establishes the same payment policy 
under Medicaid.

[[Page S4115]]

  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 effort 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 preventive 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 only 
increase as we move from a system that focuses on the costly treatment 
of illness to one that emphasizes primary 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.
  As I have worked on access and reimbursement issues related to nurse 
practitioners and clinical nurse specialists, I have encountered two 
related issues I would also like to highlight.
  Later this month, I plan to introduce legislation to increase the 
reimbursement rate for nurse practitioners and clinical nurse 
specialists who practice in rural and underserved areas. Currently, 
physicians who serve in a health professional shortage area receive a 
10 percent boost in their Medicare payment as an incentive to provide 
services in the regions that need them the most. As we know, nurses are 
already providing critical primary and preventive care in these areas 
and deserve the bonus payments that physicians are already receiving.
  I would also encourage my colleagues to closely monitor the impact of 
Medicaid managed care on access to care provided by nurse practitioners 
and clinical nurse specialists. In some areas of the country, 
implementation of managed care has prevented patients from continuing 
to receive health care services from nurse practitioners and clinical 
nurse specialists because they are not listed as primary care providers 
or preferred providers. Advanced practice nurses provide cost-
effective, local, quality care, and I am concerned about early reports 
that access to these professionals is being limited by new health 
delivery arrangements. We should certainly keep an eye on this issue as 
Medicaid managed care systems develop.
  Mr. President, I hope my colleagues will carefully consider the 
issues I have raised and support the measure I am introducing today, 
recognizing the critical role nurse practitioners and other 
nonphysician health professionals play in our health care delivery 
system, as well as 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. 863

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Medicaid Nursing Incentive 
     Act of 1999''.

     SEC. 2. 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:
       ``(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, 2000.
                                 ______