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Many student nurses in California do not have health insurance, said Patricia McFarland, RN, MSN, executive director for the Association of California Nurse Leaders. “We’re very concerned,” she said. “We really have to see what we can do to get more health care insurance for nursing students.”

Advanced practice nurses are experiencing the effects of insurance programs — private and public — that do not reimburse them for the actual cost of care or put limits on the kind of care that will be reimbursed, Jarrett said.

Mouthpiece for the masses

Felder Gillis said her clinic treats some uninsured patients without payment because clinic workers see it as their mission to give the best care they can. But free care takes its toll on the clinic’s operating budget, she said. The clinic is part of the San Francisco Community Clinic Consortium, a group of private, nonprofit clinics that treat many uninsured people in San Francisco, said Mark Fantone, director of communications for the consortium.

Sue Omel, RN, MPH, MS, BSN, a public health nurse in Oregon, said she and her staff spend more and more hours each week helping parents fill out forms to obtain some sort of health coverage for their children and sometimes for other family members. Her caseload hasn’t increased, she said, but she and her staff of nurses have less and less time to spend on actual patient care.

“We spend a huge amount of time trying to advocate for families because they don’t have insurance,” said Omel, field team supervisor at the Washington County Department of Health & Human Services in northern Oregon. “The advocacy piece is becoming overwhelming.”

Nurses in emergency departments, where an estimated one in three patients are uninsured, find themselves in a similar situation. They must triage patients who come in for basic primary care and spend time away from real emergency cases, Dodd said.

Nurses in clinics, hospitals, and home health also must deal with patients who have advanced cases of illness that could have been prevented or easily taken care of had they sought care earlier. Reports by the Institute of Medicine found that uninsured Americans received about half the care of those with health insurance. As a result, they tend to be sicker and die sooner. About half of uninsured children visited a physician in 2001, compared with three-quarters of insured children, the reports stated.

Felder Gillis said she has seen patients with diabetes who might have been able to prevent some complications had they been diagnosed and treated earlier. Omel has seen uninsured parents who become ill with a condition such as diabetes or a mental health problem and don’t seek treatment because they can’t pay for it. “Our job is not diabetes care,” she said. Nurses in her department make home visits to care for infants and pregnant mothers with health problems. “But you can’t ignore that.” So she ends up looking for ways to get health care for parents as well as their children.

“People need to have health insurance because they can’t afford the catastrophic things that happen,” Myrna Allen, RN, MSN, CHE, chief operating officer of the American Nurses Association\ California. “The problem is, we don’t know how to pay for it.”

Some states are trying new ideas. Last year, the California Legislature enacted an employer mandate law, which comes before voters in a referendum this year. If voters do not repeal the law, starting in 2006, employers with more than 50 employees will have to either provide some sort of coverage to their workers and dependents or pay into a state purchasing pool to cover them. Employers with more than 200 employees must extend coverage to dependents.

Employee contributions will be limited to 20% of premiums or 5% of wages for low- and middle-income workers, and limited deductibles. The state-provided coverage probably will be some sort of expansion of California’s Medicaid program, Allen said.