Until the advent of the original social insurance and old-age assistance enacted in 1935, the United States was notorious for its avoidance of social welfare policies. Assistance policies for the elderly have generally been much more widely accepted than other types of social welfare. The elderly are viewed as being pushed out of income producing roles by mandatory retirement or incapacities of aging, and thus, as especially deserving of aid. Medicare, Medicaid, and the Older Americans Act have made huge sums of money available for medical and health-related needs of the elderly. Medicare, Title 18 of the Social Security Act, covers medical care to the elderly while Medicaid, Title 19, covers medical care for low income, medically indigent persons of all ages. The Older Americans Act involves "middleman" policies and programs which fund and empower public and private agencies to develop and operate properties and carry out a variety of services for meeting the needs of the elderly.1 For fiscal year 1978, more than $500 million was appropriated for the Older Americans Act.
With so much money at issue, there are many groups which engage in the politics of aging and vie to serve as middlemen agencies. In addition to the more recognized "aging" organizations which represent senior citizens, there are also the professional and service interest groups such as the Gerontology Society, the Nursing Home Association, the American Association of Homes for the Aging, etc., each seeking to serve their organization's political interest. The organization which has exerted major influence in shaping and controlling the policy and implementation of Medicare and Medicaid has been the American Medical Association (AMA). A less influential but more numerous group of professionals are registered nurses. The American Nurses' Association, the professional organization of nursing, is showing indications of becoming more active in issues of health care for the elderly and the politics of aging.
In the last decade, the American Nurses' Association (ANA) has turned increasing attention to gerontological /geriatric nursing and to efforts to improve not only nursing care of the elderly, but also to create changes in the overall health care delivery system of the elderly. The ANA has a Division on Geriatric Practice, a certification procedure for nurses with expertise in this specialty, and it has developed standards for geriatric nursing practice. The American Nurse, the official newspaper of the ANA, has included increasing numbers of articles on health care issues for the elderly. Nurses representing local and state units of ANA have testified at Congressional hearings on long-term care of the elderly and on needed changes in Medicare. Thus, ANA might be viewed as an interest group which seeks to change health care delivery not only through direct influence on nursing, but also, through an effort to shape government policy on health care delivery to older citizens. This paper will focus on ANA as a nursing interest group in analyzing what has been and might be nursing's role in health care of the elderly.
Nurses encounter older patients/clients in acute care settings (hospitals), in long-term care institutions (nursing homes) and in their private homes and apartments. There is little question that decisions in the acute care settings are primarily predicated by the treatment regimen prescribed by the physicians. Nursing homes are considered to be the proper placement for persons whose major need is for skilled nursing care, and visiting nurses and public health nurses have long been the principal source of any home health care. Thus, it would appear that if ANA is to exercise measurable impact on health care of older persons, it should concentrate its efforts toward long-term nursing home care and home health care.
Long-term nursing home care might be influenced in a number of ways, but two possible ways will be mentioned. The first is through backing policies for getting more and better qualified personnel in nursing homes, and the second is through vigorous and rigid enforcement of regulatory standards which have been adopted as policy for nursing home care and safety. There are major difficulties to be overcome with each of these. As Binstock and Levin2 have pointed out, "politicians prefer to espouse and support policies that are immodest - dramatic and ambitious - in promise." Getting more and better qualified personnel is not dramatic and it could be fought by the nursing home industry because of concern about costs of better qualified personnel and profit margins.3
In terms of vigorous and rigid enforcement of regulatory standards, Mendelson and Hapgood3 indicate that "lack of effective public pressure is . . . the most basic reason for the failure of nursing home regulation." They also indicate that one of the most helpful measures for allowing the public to exercise j udgment in relation to nursing homes would be for HEW to take die simple, effective step of ordering operators of all nursing homes receiving federal money to post the latest inspection report prominently in the home with copies available to potential applicants. ANA could exert pressure on HEW to take this action, but nursing receives considerable funding for research and training through HEW, consequently, ANA might well hesitate, to do anything that might be disturbing in any way to HEW.
Nursing could possibly influence both the quantity and quality of personnel and the enforcement of regulations in nursing homes if it could get representation on the Council for Long-Term Care Facilities of the Joint Commission on Accreditation of Hospitals. This would seem to be a noncontested expectation since who better than professional nurses could evaluate the quality of nursing care, which is supposed to be the "reason for being" of long-term care facilities. Despite strong pressure, however, from both ANA and the National Association of Social Workers, for representation on the accrediting board, this board has resisted and maintained its make-up of representatives from the American Medical Association, the American Hospital Association, the American Health Care Association - formerly the American Nursing Home Association, and the American Association of Homes for the Aging, a representation that seems a natural conflict of interest for any serious accreditation.4 It would appear that only heavy public pressures or a legislative mandate will change this makeup.
The other tactic on which ANA could concentrate its efforts would be through attempting to modify Medicare and Medicaid policies and interpretations to allow for a health and social services model rather than a medical model in implementing these policies. Since political influence, like money, is limited in supply,5 it is likely that ANA will consider this expenditure of its influence to be the "best buy."
In the remainder of this paper, I shall discuss why I believe ANA is likely to participate primarily in attempts to modify Medicare and Medicaid policy and implementation radier than in direct efforts to modify nursing home conditions. I shall also consider what ANA's resources to facilitate or impede this participation are compared to the resources of the AMA which is almost certain to oppose many of the changes advocated by nursing.
If ANA were to choose to attempt to influence nursing homes, there are potential expressive benefits. Nursing homes are supposed to provide skilled nursing care. Their very name tends to lead the public to identify nursing homes with nursing, even though nursing homes may be staffed with a minimum number of registered nurses. These few registered nurses may have the minimal education for licensure and may have been inactive or minimally active in nursing prior to accepting the nursing home position. To the general public, however, published information about poor care and mistreatment in the nursing home leads to the assumption that the nursing profession generally and particular nurses are responsible for poor care or are shirking their responsibilities to provide good care. Also, older persons make up a high percentage of persons receiving nursing home care. Nursing promulgates the image of nurses as patient advocates, so nursing should be serving as advocates for the elderly.
If one turns from the previously mentioned potential expressive benefits to the material benefits to be gained by attempting to exert direct influence on nursing homes, it can be seen that the material are relatively minor. A few more, better qualified nurses might be hired at better salaries, which could be considered a benefit for ANA's constituency, but most of these better qualified nurses could probably find positions elsewhere at salaries which are just as high. On the other hand, if ANA's efforts to exert pressures on nursing jtiomes were unsuccessful, registered nurses who had participated in any of the pressure activities might lose jobs.
If ANA pursues the attempt to influence Medicare and Medicaid policy interpretations and implementation, there are some very real material benefits. Medicaid and Medicare constitute the largest share of the federal health budget.6 Currently the care provided under them is based on the medical model which is primarily an acute care model usually requiring institutionalization for treatment of disease or injury. The bulk of the monies goes to provide this institutional care and to cover the cost of the physician providers. Much of the care needed by elderly persons, however, is preventive care, health supervision, and maintenance care of chronic illness. It has been conceded that much of this care does not require the physician's diagnostic expertise and it could best be provided in the home or in an ambulatory, neighborhood clinic. This outpatient treatment reduces the risks incurred by such things as removing older persons from their familiar environment, separating them from important social contacts, or subjecting them to decreased ambulation - all risks that can compound the primary problem when elderly persons are institutionalized.
Nurse practitioners could provide much of the needed ambulatory and home care, but the regulations are set up to favor payment for institutional care. Nurses could provide home care for those with mobility and transportation problems, but nurses are not eligible for third-party payment for services provided. Thé Social Security Administration (SSA) groups nurses with other physicians' assistants under the term of "physician extenders." SSA recently announced a two-year "experimental program" permitting payment to physicians for services rendered by "physician extenders" employed by them. The physician does not have to provide direct supervision but must assume "full legal and ethical responsibility" for services provided by the so-called "extenders."7 Thus, the nurse may legitimately provide the care, but only the physician may legitimately collect the payment for that care.
If ANA can convince the SSA that nurses are licensed and certified as distinct health professionals who are accountable for their own standards of practice and code of ethics, that much of the care needed by the elderly is really nursing care and health maintenance which falls in the realm of nursing practice not medical practice, and that more health care can be delivered to elderly persons at less cost if nurses can be reimbursed directly, then nursing stands to compete for a take of the Medicare/ Medicaid monies. Nursing interest groups will be major providers as well as middlemen who share in the monies provided by aging appropriations through planning and implementing research and training programs. ANA will also have gained the collective benefit of governmental recognition of nursing as an autonomous profession, and of nurses as professionals capable of functioning as independent practitioners. This will greatly increase the visibility of nursing and the ANA. Morever, its effects will extend far beyond health care of the elderly to provide a model of nursing's role in health care to all age groups.
What are some of ANA's resources in their participatory effort to influence policy on health care of the aged? ANA recently created a nurses political action committee with a $50,000 budget. This committee succeeded in raising $40,000 in contributions from nurses.7 They contributed small amounts to 95 candidates in the last election. These amounts are almost negligible compared to the American Medical Association (AMA). The AMA Political Action Committee was the largest single contributor to Congressional campaign funding in both 1974 and 1976, and AMA is certain to oppose ANA in efforts to change the distribu ti on and reimbursement policies governing Medicare and Medicaid.
In terms of numbers, there are an estimated 1.4 million nurses currently licensed and only 380,000 physicians.7'8 A physician's average income is approximately $48,000 a year while a nurse's average income is $9,000.7 Thus, total numbers which can be viewed as potential votes might have to be bargained against potential dollar support for campaigns. Numbers can be misleading, though, since only 192,291 of the 1.4 million nurses licensed actually belong to ANA according to figures listed by the organization on May 15, 1977. Approximately 200,000 of the 380,000 physicians belong to the AMA.
The question of cohesion within the ANA is a serious one. There are nurses who join ANA because the state nurses association acts as a collective bargaining agency and a certain proportion of nurses working in an institution must belong to ANA for this collective bargaining function to be performed. Still others join because of insurance, travel packages, and other fringe benefits provided to members. There is also great condici created in nursing by the diversity of educational programs recognized as preparing nurses who qualify for the state licensing exam (associate degree, diploma, baccalaureate degree). Nursing has also had difficulty uniting within one professional organization, having two major ones and numerous smaller ones.
Status and prestige are other cardinal issues. Physicians individually and the medical profession colleclively have traditionally been accorded much higher prestige and status than nurses. They are viewed as the experts on medical and health issues. In fact, both physicians and the general public seem to believe physicians are both qualified and justified in making pronouncements regarding nursing education and practice.
Nursing, as a predominantly women's profession, has always had some difficulty with leadership. There is a tendency to look to males, even males in other disciplines for leadership. Some nurses choose to be associate members of medical organi2ations and to invest their time and energies in these organizations rather than in their professional nursing organization. Fortunately, the women's movement has raised many aurses' consciousness to this tendency.
Medicine has ready access to legislators through the strong lobbying efforts and large campaign funds maintained through AMA. Nurses and nursing are becoming more politically astute, and, as mentioned earlier in this paper, nurses have formed the Nurses Coalition for Action in Politics (N-Cap). This organization is but a small beginning, but it is a beginning.
In evaluating ANA's resources, the final consideration is the one of intensity or how central are the issues of changing Medicare and Medicaid policy interpretations and implementations to ANA's goals and concerns. If one were lulled into believing that the main issue at stake is health care for the elderly, then one might be convinced that this is a marginal concern for ANA. If one recognizes the potential which this has for gaining recognition of nursing as an autonomous profession, then it is a very central and intense issue indeed. This recognition includes the concept of nurses functioning as independent practitioners who are eligible for third-party payment. This, in turn, opens a broad range of possibilities for nurses to set up private practice in rural and underserved areas, providing care not only to elderly, but to all age groups.
Report of the Subcommittee on Health and LongTerm Care of the Select Committee on Aging of the House of Represen ta uves9 made a strong case for replacing the medical model of care for the elderly with a health and social services model. However, the model, along with the extensive hospital and nursing home system and the third party pay system of the health care insurance industry are firmly entrenched in our existing social and political system. What are some of the tactics which might be undertaken by ANA to increase their probabilities for changing this existing system? First, the 1 .4 million nurses need to be alerted to the real issue at stake. Every effort needs to be made to build cohesion within the ranks of nursing. In educational and continuing educational programs, nurses should regularly be made aware of the necessity of political influence and of concentrating the expenditure of that influence where it has the greatest potential for success. ANA should also consider with what other interest groups it might align itself. The various "aging groups" should be considered. The Women's Health Movement may aid nursing's cause. The present time may be especially prime with the sky-rocketing cost of care based on the medical model and a federal administration that has avowed to contain health care costs.
- 1. Binstock RH: Interest group liberalism and the politics of aging. Gerontologist 12:265-280, 1972
- 2. Binstock RH, Levin MA: The political dilemmas of intervention policies, in Binstock, Shanas (eds): The Handbook of Aging and the Social Sciences. New York, Van Nostrana Reinhold, 1976, ?? 511-535.
- 3. Mendelson M, Hapgood D: The political economy of nursing homes. Ann 415:95-105, 1974.
- 4. American Nurses' Association. The American Nurse 9(1) 1977, Kansas City, Missjouri.
- 5. Banfield EG: Political Influence. New York, The Free Press of Glencoe, 1961.
- 6. Isaacs M: Letter to the editor. Am Nurs 8(16):5, 1976.
- 7. American Nurses' Association. The American Nursei 9(5). 1977, Kansas City, Missouri.
- 8. The American Nurses' Association: The American Nurse, 8(16) 1976, Kansas City, Missouri.
- 9. New Perspectives in Health Care for Older Americans. Recommendations and Policy Directions of the Subcommittee on Health and Long-Term Care. Select Committee on Aging, House of Representatives, Ninety-Fourth Congress. Washington, D.C., U.S. Gov Print Off, Jan 1976.