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The 2001 nursing and health care legislative year started with a new, untested president and a power shift in Congress, buoyed by bipartisan momentum on the Patients' Bill of Rights and prescription benefits for seniors.

This arduous year now ends with any health care legislative agenda permanently transformed. "For better or worse, terrorism and bioterrorism have become the health issues for 2001," said Mary Wakefield, Ph.D., RN, FAAN, the new director for the Center for Rural Health at the University of North Dakota.

"All other issues pale in comparison to bioterrorism," Wakefield said, "but hopefully there is an upside, although it is devastating that such changes are attached to this catastrophe.

"In the next five years, we [may] see a stronger, tighter public health system because of this year's tragedies. The legacy of this year, we hope, will be positive changes to public health's infrastructure. Those changes can build a stronger link among health care workers, the government and the public by better using information linked by state-of-the-art technologies."

In November, Wakefield left her post as professor and director of the Center for Health Policy, Research and Ethics at George Mason University in Fairfax, Va.

With increasing focus on bioterrorism, much of the year's previous health agenda has been lost. "One major concern for the next legislative session is that health and nursing will be shifted to the background as the response to terrorism escalates," said E. Carol Polifroni, Ed.D., RN, associate professor at the University of Connecticut School of Nursing. "While these responses are necessary, we still need to focus on long-term health care issues."

The concern not only is conceptual, but fiscal. Medicare Part A and Social Security trust funds now serve as the immediate checkbook for many of the new expenses brought on by terrorism. Moreover, to stimulate a bludgeoned economy, lawmakers are pursuing various economic stimulus packages, which inevitably will wipe out what was once known as the 2001 budget surplus (projected in August at $170 billion to $180 billion).

"You can hear that giant sucking sound of dollars going out of the federal Treasury," Wakefield said.

The shift in the national agenda to fighting or coping with terrorism has broad repercussions. First, previous health care legislation-to expand coverage to the uninsured, the Patients' Bill of Rights, prescription drug benefits-has moved to the back burner. (See "Legislative activity: Before, after Sept. 11.")

"As the year ends, Congress will shy away from any highly partisan pieces of legislation, such at the Patients' Bill of Rights," Wakefield said. "Especially now, Congress wants to show a united front. They don't want to get caught up in in-fighting. As much as possible, they will put any controversial issues aside," she said.

Bioterrorism legislation
Bioterrorism-related legislation that will affect nurses includes:

2001 nursing highlights
Despite the spotlight now aimed at bioterrorism, the nursing shortage has received some legislative attention this year. The shortage, of course, has been a major focus of the American Nurses Association and other nursing supporters on Capitol Hill.

This year, said Erin McKeon, associate director of government affairs at the ANA, nursing issues received some long overdue notice. "The ANA testified at seven congressional hearings so far," she said. "Five hearings were focused on the nursing shortage. We are especially hearing about the nurse education bills," she said.

As of press time, the major nursing bills in play during the latter part of 2001 were:

Despite a heightened focus on nursing shortage legislation, longtime observers of the legislative process expressed concerns.

"Given that there is such a major nursing shortage, one would reasonably believe that the year 2001 was the year of the nurse," Polifroni said. "Sadly, however, that was not true. While most every legislative body discussed the shortage, there is little tangible evidence of specific outcomes."

Susan Tullai-McGuinness, MSN, MPA, RN, project director for a National Institute of Nursing Research workforce project, cautions that health care organizations need to assess the nurse work environment and implement strategies that will not only improve working conditions but patient outcomes as well. "This needs to occur in all settings," she said. "Not just hospitals."

Marge Hegge, Ed.D., RN, director of the South Dakota Colleagues in Caring Project, still hopes that a package made up of many of these nursing bills will pass this year. "We hear that Senator Daschle's office is working with a bipartisan group of legislators to pass them as early as December," she said.

"The fate of this legislation still remains to be seen," Wakefield said. "Although we're still moving forward, we need to beat the clock on this session. We're crossing our fingers and hope the legislation will be enacted this year. Although we have members of committees concerned about nursing workforce issues, we still need enough core committee members to see the issues through. If this legislation is not passed before Congress recesses, it will still be considered next year. But it will compete with new set of issues in 2002," Wakefield said.

Congress usually doesn't move quickly in the first three months of the year, said Wakefield, so she doubts anything will get done early next year.

Health care funding
As anyone in health care delivery knows, funding drives good care. Therefore, legislation affecting Medicare and Medicaid is always pertinent to nurses. President Bush's tax cut, enacted earlier this year, was said to greatly diminish any budgetary reforms that would have boosted Medicare and managed care coverage.

That tenuous discussion about Medicare changed dramatically and permanently with the events of Sept. 11. Debate earlier in the year was inching toward some mild reforms for Medicare proposed by President Bush. One of the most visible reform issues was prescription benefits for seniors. Although some see a resurrection of the issue, most believe that it cannot survive the competition from bioterrorism appropriations bills.

The battered economic climate helped contribute to Medicare spending increases of 10 percent for fiscal year 2001-the largest increase since 1995. Even without the damage of terrorist attacks, the increases have been attributed to health care inflation and the growing number of beneficiaries. Medicare beneficiaries will likely bear a portion of increased costs with increases in premiums, deductibles and co-payments. (Medicare is expected to spend $41.7 billion on physician services in 2002, a $500 million increase.)

Another legislative casualty of Sept. 11 is broader coverage for the uninsured. Wakefield believes any progress in securing coverage for the uninsured will be stalled for a while, which will exacerbate the problem.

"Much of health care funding for the uninsured is supported by state government or state-federal partnerships. For a lot of states, we now have a markedly weakened financial situation with revenues rising, unemployment rising and the economy slowing. [But] by law, states are required to operate with a balanced budget. Thus, they will need to find cuts," Wakefield said.

"There is a big outflow of money when people are out of work and not paying taxes. This, in turn, increases the state's welfare rolls. States are feeling a tremendous pinch all over," she said.

"Consequently, they will be belt-tightening, which will include health programs."

Wakefield points to a rough economy as increasing the burden on state budgets as well as reducing the number of employers who offer health insurance. "Employers are getting double-digit increases to cover their employees. They will want to shift those costs to their employees," Wakefield said.

Small businesses, especially, cannot afford 10 percent increases, she added, so employers will drop coverage. Increased costs and a weakened economy are likely through the end of 2002.

As 2001 winds down, Wakefield offers a summary of where the next legislative calendar is headed:

"It's important for nurses to stay engaged in the discussion and debates," she said. "When the cost of care goes up, access goes down and quality of care suffers. Nurses need to offer their perspective on what can be done and how to address those issues. Nurses, after all, are there to protect the public's access to care. This is the time to provide accurate information to policy-makers and the public when these hard choices [about care and delivery] are made," she said.

"It's important for nurses to contribute to the national and state dialogue. How [else are] they going to make sure the voice of nurses is heard for the benefit of the public's health?"