Feb 23, 2024 NURS 8100 Discussion: Federalisms Impact on Policy
A Sample Answer For the Assignment: NURS 8100 Discussion: Federalisms Impact on Policy
In the state of Maryland some of the advanced practice registered nurses (APRNs) include certified midwives, nurse anesthetist, certified nurse practioner (NP) and a clinical nurse specialist. This should be similar to other states too. At a minimum and from personal experience Maryland board of nursing has to give permission to practice as an NP and there are basic requirements that have to be met to qualify to be certified. Not all the regulations that are set forth by the state of Maryland for APRN to practice are recent but they are however all currently used.
Code of Maryland regulations (COMAR) are the compilation of the state of Maryland regulations that help govern the state, (Maryland.org, n.d). Health care is not an exception and APRNP have to abide by the COMAR regulations. According to COMAR, (2020), APRNs can perform multiple functions independently.
These include comprehensive assessments, complete a death certificate, do not resuscitate orders, interpret diagnostic and laboratory tests, prescribe medications, provide care and give referrals to other providers. An NP can also practice as a registered nurse and for those who have certifications for mental health, they can admit a client on an involuntary basis for treatment.
How State Regulations Are Supported within Place of Employment
The place of employment has set standards at the same level of practice as expected by the state but for some treatment approaches the expectation is to defer to the primary physician or the medical director. Establishing this baseline helps achieve the expected standards and also remain in compliance with the COMAR and federal regulations. The place is very supportive that when the NP completes an admission assessment, the doctor does not have to double check unless there is a concern.
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As a nurse practioner, at the place of work there are multiple activities that can be performed independently. These tasks include but not limited to giving orders for medications and treatment, reviewing diagnostic tests, and responding to families as required. One task that is permitted by the state of Maryland but not encouraged at the place of work is signing of certificates of incapacity. (A. Speer, personal communication, July 26, 2021). The primary physician and the psychiatrist sign the Maryland order for life sustaining treatment (MOLST) also and only encourage the NP to sign it if they are not available. This is a task that is authorized by COMAR regulations.
NURS 8100 Discussion Federalisms Impact on Policy
How States Differ in Terms of Scope of Practice
Different states have different prescriptive authorities and conditions that they give to their APRNs. There are those states that are referred to as independent states which allow APRN independent prescribing and there are those which do not, (Schirle & McCabe, 2016).
Barriers to practice are not uncommon even when the states are flexible, health care settings can still impose different strict policies and procedures. This leads to restriction of some aspects of patient care and limited access to providers despite the states having full practice authority, (Schorn, Myers, Barroso, Hande, Hudson, Kim & Kleinpell 2022).
Impact on Professional Nurses across the United States.
Some nurses have opted to relocate or work where there is more prescriptive authority. Some nurses also have opted not to relocate but get licensures in neighboring states that can give them more autonomy. There are also nurses who have opted to work in other areas where they are needed. These areas include working as lobbyists, researchers, nurse educators and consultants. In this aspect their full potential is more effectively utilized.
References
COMAR 10.27.07.00 (2020) Practice of the Nurse Practitioner , http://www.dsd.state.md.us/comar/comarhtml/10/10.27.07.03.htm
Maryland.org (n.d), Division of state documents. http://www.dsd.state.md.us/COMAR/ComarHome.html
Schirle, L., & McCabe, B. E. (2016). State variation in opioid and benzodiazepine prescriptions between independent and nonindependent advanced practice registered nurse prescribing states. Nursing Outlook, 64(1), 86–93. https://doi.org/10.1016/j.outlook.2015.10.003
Schorn, M. N., Myers, C., Barroso, J., Hande, K., Hudson, T., Kim, J., & Kleinpell, R. (2022). Results of a National Survey: Ongoing Barriers to APRN Practice in the United States. Policy, Politics & Nursing Practice, 23(2), 118–129. https://doi.org/10.1177/15271544221076524
The fragmentation of the U.S. health care system, with its differing modes of financing and service delivery, is a reflection of a dispersed government structure. Policy making is shared and distributed across various branches and levels of government. As a result, policy making processes can be slow to respond, manipulated towards personal interests, and often redundant.
Consider, for example, the public entitlement programs such as Medicaid, Medicare, the State Children’s Health Insurance Program (SCHIPS), and the PPACA of 2010. Where is there overlap between these policies? How do they demonstrate a dispersed government structure?
This week, you will analyze the role of the federal government in health care policy making.
To prepare:
Review this week’s Learning Resources focusing on the France article and the textbook readings.
Identify two nursing or health care policies that address similar needs, one passed at the federal level and the other at another level of government (state or local).
By Day 3
Post a cohesive response that addresses the following:
Provide an example of two policies that address similar needs, passed at two levels of government (i.e., federal, state, or local).
What are the advantages and/or disadvantages of this duplication? How does this example reflect the implications of federalism? Provide support from the literature for your position.
To what degree should the federal government get involved in health care policy making? Provide concrete examples to support your position.
Read a selection of your colleagues’ postings.
By Day 6
Respond to at least two of your colleagues in one or more of the following ways:
Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Note: Please see the Syllabus and Discussion Rubric for formal Discussion question posting and response evaluation criteria.
Return to this Discussion in a few days to read the responses to your initial posting. Note what you learned and/or any insights you gained as a result of the comments made by your colleagues.
Be sure to support your work with specific citations from this week’s Learning Resources and any additional sources.
RE: Discussion – Week 8
The Affordable Care Act (ACA) provided a modern-day opportunity for Federalism to demonstrate its ability to move policy forward. It is a seemingly simple concept, but not one that is understood by all, myself included. Huberfeld (2019) describes federalism using the terms sovereignty (authority of a state to govern itself) and accountability (responsibility of policymaking). Among multiple goals of the ACA was the idea of universal health care.
The expansion proposal in the ACA created national standard for eligibility but continued the tradition of state adoption of federal rules (Butler, 2019). The ACA identified public and private insurance standards but looked to individual states to adjust to their market and needs.
Although states could decide to participate, and if they opted in, there was federal money and resources available to accomplish the goal of expansion (Medicaid specifically) and well as building insurance exchanges where citizens could apply for aid and purchase commercial insurance plans. Most states achieved this with the assistance of Health and Human Services (HHS).
Gluck et. al., (2018) discussed several states including Indiana and Connecticut who demonstrated the appearance of not opting in (to expansion) but were actually working behind the scenes (with HHS) to accomplish expansion goals all the while negotiating federal monies and support. An example of how Federalism in health care may allow for shifting responsibility.
This scenario demonstrates possible disadvantages of duplication as several states were manipulating the situation for their own gains. It does make sense however, that the federal government be involved in health policy development. The Congress and Senate are made up of leaders from across the U.S. and are representative of their States. One would hope they have the best interest of their constituents in mind.
References
Butler, S. M. (2019). Federalism as an Antidote to Polarization Over Health Care Policy. JAMA, 322(12), 1131–1132. https://doi.org/10.1001/jama.2019.14114
Gluck, A. R., & Huberfeld, N. (2018). What Is Federalism in Healthcare For? Stanford Law Review, 70(6), 1689–1803.
Huberfeld, N. (2019). Epilogue: Health Care, Federalism, and Democratic Values. American Journal of Law & Medicine, 45(2–3), 247–252. https://doi.org/10.1177/0098858819860612
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Discussion: Federalism’s Impact on Policy
The fragmentation of the U.S. health care system, with its differing modes of financing and service delivery, is a reflection of a dispersed government structure. Policy making is shared and distributed across various branches and levels of government. As a result, policy making processes can be slow to respond, manipulated towards personal interests, and often redundant.
Consider, for example, the public entitlement programs such as Medicaid, Medicare, the State Children’s Health Insurance Program (SCHIPS), and the PPACA of 2010. Where is there overlap between these policies? How do they demonstrate a dispersed government structure?
This week, you will analyze the role of the federal government in health care policy making.
To prepare:
Review this week’s Learning Resources focusing on the France article and the textbook readings.
Identify two nursing or health care policies that address similar needs, one passed at the federal level and the other at another level of government (state or local).
By Day 3
Post a cohesive response that addresses the following:
Provide an example of two policies that address similar needs, passed at two levels of government (i.e., federal, state, or local).
What are the advantages and/or disadvantages of this duplication? How does this example reflect the implications of federalism? Provide support from the literature for your position.
To what degree should the federal government get involved in health care policy making? Provide concrete examples to support your position.
Read a selection of your colleagues’ postings.
By Day 6
Respond to at least two of your colleagues in one or more of the following ways:
Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Note: Please see the Syllabus and Discussion Rubric for formal Discussion question posting and response evaluation criteria.
Return to this Discussion in a few days to read the responses to your initial posting. Note what you learned and/or any insights you gained as a result of the comments made by your colleagues.
Be sure to support your work with specific citations from this week’s Learning Resources and any additional sources.
Federalism’s Impact on Policy
Federalism challenges and stabilizes public policy by introducing innovation that would otherwise not have been introduced. Understanding it is critical in understanding the current healthcare policy-making entangled in a complex maze of shared and competing powerstructures. In the United States, the impact of federalism is vital, particularly in the healthcare sector, where policies passed at the Federal level have overlapping enactments at the State or local level. Medicare, Medicaid, SCHIPS, and PPACA are all health insurance programs.
They are designed to subsidize healthcare for Americans, but their operationalization is based on different factors. For instance, Medicare is a federal health insurance program based on age, while Medicaid is open to needy Americans without age restriction. On the other hand, PPACA introduces rights and protection designed to ensure fairness in health coverage. At the same time, SCHIPS is intended to offer a range to children, and each state administers it under different names.
These policies address the same population’s health needs, but they are differentiated using different names and eligibility criteria. State Health Insurance Assistance Program (SHIP) and Medicare are examples of overlapping healthcare policies because the State and Federal governments offer them. This overlap arises because SHIP gets funding from the Federal government to provide people with Medicare-free coverage at the state level.
On one side, it creates better service delivery, mainly because the states better understand the population’s needs (Frankel, 2019). Nevertheless, it results in underexploited economies of scale that impede innovation for better service delivery (France, 2018). Again, given that the beneficiaries of SHIP are already covered under Medicare, it raises questions about why more money is channeled to the States via SHIP. Yet, it could be used to help vulnerable populations without any coverage.
According to Bodenheimer & Grumbach (2020), federalism has sparked controversies in the American healthcare policies’ political contentiousness and divergent interests from the public and private sectors. This creates conflicts that reduce efficiencies in the delivery of services. To streamline these challenges, the stakeholders involved ought to work in harmony so that they can benefit the consumers through efficient service delivery to avoid service duplication (Kennedy, 2017).
The policy overlaps between the Federal and State levels are proof of the bureaucracy at both levels of governance. France (2018) notes that the Federal government championed policy initiatives during the liberal period, which changed in the conservative era after power was devolved to the States. Therefore, initiatives by the state can be argued as the best for delivering services to the people.
References
Bodenheimer, T., & Grumbach, K. (2020). Understanding health policy: A clinical approach (7thed.). New York, NY: McGraw-Hill Medical.
France, C. (2018). The form and context of federalism: Meaning for health care financing. Journal of Health Politics, Policy & Law, 33(4), 649-705. doi: 10.1215/03616878-2008-012
Frankel, M. S. (2019). Commentary: Public outreach by the FDA: Evaluating oversight of human drugs and medical devices. Journal of Law, Medicine & Ethics, 37(4), 625-628.
Kennedy, E. M. (2017). The role of the federal government in eliminating health disparities. Health Affairs, 24(2), 425-428.
RE: Discussion – Week 8
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There is no health care without mental health care and “access to mental health services is one of the most important and most neglected civil rights issues facing the Nation” (Haffajee et al., 2019). In the United States, about 1 in 5 people in the United States suffer from a mental health condition, and 10% of children and youth have serious mental health treatment needs.
These causes significant functional impairment in their lives, with their peer and most of them being children of color (NAMI, 2015). The COVID-19 pandemic highlighted the need for mental health and mental health parity, when Americans suddenly lost their jobs, experienced financial pressures, and became isolated, and their mental disorder symptoms were exacerbated (Haffajee et al., 2019).
Many state health policy decisions are made in the context of the US federalist system, where both the federal and state governments share responsibility for administration, funding, and oversight. The two examples of policies that are addressed both at the federal and state level are the Mental Health and Substance Use Disorder Benefits of 1996 and the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 (Haffajee et al., 2019).
The State and federal laws attempted to address discriminatory practices in health insurance by creating requirements around parity, with the basic idea that mental health and addiction care should be covered at the same level as other health conditions (Andrews et al., 2019). The Mental Health Parity (MHPA) was the first federal law to create parity standards and was enacted in 1996, to eliminate discriminatory insurance practices, and establish the no disparity principle, in health insurance between mental health and general medical benefits(Mulvaney-Day et al., 2019).
In 2003, under President Bush, a parity recommendation was introduced which resulted in the Mental Health Parity and Addiction Equity Act (MHPAEA), adopted in September 2006, and in 2008, the Act was passed (Andrews et al., 2018). The act applied the MHPAEA parity requirements to the existing plans, mandating them to cover preventive services, and mental health screenings, and the individual and small group plans were also required to meet the provider network adequacy standards. The plans also ended the annual and lifetime benefit caps, eliminating medical underwriting in the individual and small-group markets with, stipulations that the insurers could not deny coverage or imposed fines (Busch, 2012).
What are the advantages and/or disadvantages of this duplication? How does this example reflect the implications of federalism? Provide support from the literature for your position.
The duplication expanded to cover more people, and about1.2 a million individuals in small group plans were set to receive mental health and substance use disorder benefits. They eliminated historical health coverage differences, between mental health and substance use disorder benefits (Beronio et al., 2013). The policies mandated insurance to cover mental health and substance use disorders, and to provide similar benefits, just like any other medical benefits (Friedman et al., 2017).
The plans were positively associated with improved access, and utilization of behavioral health outpatient services, with subsequent increases in spending, driven primarily by the overall increases in utilization (Mulvaney-Day et al., 2019) There was a notable increase of 1000 additional individual psychotherapy visits, which expanded the application of the federal parity to cost-sharing, deductibles, limits on inpatient days, and outpatient visits for services both in, and out of network conditions (Friedman et al., 2017).
The disadvantage of the policies was in the implementation, because, unlike most state laws, the federal parity law specifically includes substance abuse treatment services, while state parity laws did not apply to plans, in which the employers assume the risk services like self-insured plans (Busch, 2012). There were concerns expressed that the new federal law would relatively increase the cost, while a study reported continued increased disparities, between the behavioral, and the primary health care coverage, indicating possible evidence of non-compliant insurance practices (Shana, 2020).
The mental health services remained insufficient, and in high demand, the root cause being, lack of access, inability to find care, and poor insurance coverage, as the top barriers, to obtaining effective mental health services. The federal law regulated different types of self-insured health plans, while the state-controlled many health insurance plans, which were subjected to different regulations without a way to enforce parity (Shana, 2020).
There was a clear lack of oversight, and efforts to ensure compliance with the health plans, with a large number of competing for-profit insurers, which created more variation in parity enforcement. An example of an implication of federalism is the healthcare fraud where a provider bills a patient for services that were not provided or for inaccurate medical procedures compared to the actual procedures performed.
The defrauding of the federal government, an insurer, or a federal or state benefit program is a serious offense at both the federal and state levels and can result in significant penalties, fines, and imprisonment terms when an individual or company defrauds the federal government, an insurer, or a federal or state benefit program (Clark & George, 2017).
To what degree should the federal government get involved in health care policymaking? Provide concrete examples to support your position.
The federal government should be fully involved in health care policymaking, because. the free market has often proved that it does not have the interests of the people, its responsibility to preserve and protect the interests of the citizens, by supplementing the market gaps and regulating the market where there was notable inefficiency or unfairness (Schmidt et al., 2017).
This involves effective and adequate healthcare laws, regulations, and policies, which had major direct and indirect influences on healthcare delivery (Schmidt et al., 2017). The federal government has the maximal advantage because of its unique position as a health regulator, purchaser, provider, and sponsor of applied health services, to set and implement quality standards for the health care sector (Schmidt et al., 2017).
It is through its regulator role that the body establishes minimal health care standards, and effective regulatory requirements to protect the beneficiaries from incompetent, impaired, and inadequately trained clinicians, and from healthcare organizations, which lack the requisite capabilities and processes, to provide the minimal level of quality care (Schmidt et al., 2017).
It has a key role in modeling the health care policies to ensure that they are beneficial and fair to everyone in the society, without discrimination by regulating them, while focusing on quality health care improvement. The body also evaluates the care quality with purchasing strategies, to promote the adoption of the best policies, by providing funding and resources to institutionalize quality improvement and patient safety practices (Schmidt et al., 2017).
References
Andrews, C. M., Grogan, C. M., Smith, T. B., Abraham, A. J., Harold A. Pollack, H. A., Humphreys, K., Melissa A. Westlake, M. A., & Friedmann, P. D. (2018). Medicaid Benefits for Addiction Treatment Expanded After Implementation of The Affordable Care Act Health Affairs 2018 37:8, 1216-1222
Busch S. H. (2012). Implications of the Mental Health Parity and Addiction Equity Act. The American journal of psychiatry, 169(1), 1–3. https://doi.org/10.1176/appi.ajp.2011.11101543
Beronio, K., Po, Rosa., Skopec, L., and Glied, S. (2013). Affordable Care Act will expand Mental Health and Substance Use Disorder Benefits and Parity Protections for 62 million Americans. Retrieved from http://aspe.hhs.gov
Clark, K., & George, A. (2017). Home Healthcare and the MEDICARE FRAUD STRIKE FORCE. Home Healthcare Now, 35(10), 549–553. https://doi.org/10.1097/NHH.0000000000000620
Friedman, S., Xu, H., Harwood, J. M., Azocar,
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