Health care Legislation


  • This paper was excerpted from the Senator's speech presented before the 22nd Annual Convention of ACNM, New York City.

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There is no question in my mind that the vast majority of our nurse-midwives are professionally trained and fully capable of performing their services independent of the supervision of other medical professionals. I am also most pleased to be able to report that in my experience, the vast majority of our physicians personally share my enthusiasm and confidence in your skills and dedication. In our private conversations, they have repeatedly told me that they welcome working with you as true professional colleagues — as individuals who can bear their own share of the oftentimes heavy responsibility of patient care, and as individuals who know full well when it is appropriate to refer more complicated cases.

However, the specter of possible medical malpractice suits has put a whole different light on this matter. With the fear of malpractice suits, I am afraid that our physicians and hospitals have opted for steadily increasing control over your activities, instead of backing off and respecting your professional autonomy. Instead of granting nurse midwives greater independence they insist on greater supervision.

For example, under the Department of Defense's Civilian Health and Medical Program of the Uniformed

Now is the time for nurse-midwives to demand independent financial recognition and positions of policy-making authority on our national boards and commissions

Services — commonly called the CHAMPUS program — nurse midwives have been receiving independent reimbursement for their services. However, the proposed regulations of April 4, 1977 have now specifically classified your profession as an “other paramedical provider” and proposes that “in order to be considered for benefits on a fee-for-service basis, [your services] may be provided only if the beneficiary/patient is referred by a physician for the treatment of a medically-diagnosed condition and a physician must also provide continuing and ongoing oversight and supervision of the program or episode of treatment.” In my view this is a major step backwards, but one that unfortunately reflects our institutions’ concern with malpractice suits. Accordingly, as a member of the Senate Defense Appropriations Subcommittee, I am presently planning on offering a specific amendment to the FY 1978 appropriations which will insure that nurse midwives will be independently reimbursed for their services.

But the real battle ahead is whether or not your services will be independently reimbursable under our nation's forthcoming national health insurance program.

There is no doubt in my mind that the proverbial handwriting is now clearly on the wall. Our nation is gearing up for the adoption of National Health Insurance. Now is the time for your profession to become increasingly vocal and outspoken in your efforts to be accorded independent financial recognition and positions of policy-making authority on our national boards and commissions. To succeed, you must demonstrate that there is considerable grass-roots support for your services. As a politician, I can assure you that you have the numbers and the favorable public image to succeed; however, you must now do the hard work that is also required.

Accordingly, I have recently introduced five bills which I hope will serve as a catalyst for your eventual independent inclusion under national health insurance. These five bills represent three distinct categores: The first includes S. 104 and S. 233. Both of these measures would amend the Medicare and Medicaid Acts. S. 104 would provide for the independent reimbursement of all registered nurses; S. 233 is a more restrictive measure which would single out the psychiatric or mental health nurse practitioner.

The second category of legislation is reflected by S. 223, a bill which I introduced to assure your profession's active participation in all phases of our Professional Standards Review program. My bill would mandate that at least 30 percent of the voting membership of all PSROs would be registered nurses.

Finally, I introduced S. 617 and S. 618, which would amend the Civilian Health and Medical Program of the Uniformed Services — commonly called the CHAMPUS program — of the Department of Defense. This program provides basic health care benefits for the dependents of our Armed Forces active duty personnel whenever such care is not available in Uniformed Service facilities. Approximately 8.6 million individuals are eligible for these services, and last year around $500 million was spent in the private market on their health care. I would suggest to you that if we are able to insure for your independent recognition under this program, then we have indeed made a rather significant step forward towards our eventual success under national health insurance.

With a considerable amount of diligence and old-fashioned hard work, I honestly believe that your chances of eventual success are good. As you may know, President Carter's recent budget request included the specific recommendation that the Medicare law be amended so that rural clinics would be reimbursed for the cost of services provided by nurse practitioners and physician assistants who are working under the general supervision of a physician. This is indeed a significant modification of the current restrictive requirement of having onsite supervision. This is a good first step. Now all we have to do is to convince the Administration to take the next step and remove the entire supervision requirement. But again, the real battle is up to you. You need to prove to Members of Congress that their constituents support your cause. By working together, we will hopefully be successful in moving one of these bills out of committee this session.

Senate Bill Seeks Inclusion of Nurse-Midwife Under Medicare, Medicaid.

WASHINGTON, D.C.-On June 15, 1977 Senator Daniel K. Inouye introduced legislation to allow independent reimbursement under Medicare and Medicaid for the services of professional nurse-midwives.

The bill, S. 1702, would give separate statutory recognition for a group of “highly qualified and increasingly necessary health practitioners” now reimbursable only when acting under direct supervision of a physician, Inouye said in a statement.

“Nurse-midwives today deliver 80 percent of the world's babies. In the United States, the demand for their services in the past five years has risen incredibly,” he said.

“This bill is designed to afford even further utilization of such an important health service,” Inouye said. “It has been determined that 30 percent of the nurse-midwives in the United States work in communities with populations under 30,000; they fill the gap left by obstetricians who tend to locate in larger population centers because of the necessity for a sizable service area to support an obstetrical service.”

“Additionally, in our large innercity public hospitals nurse-midwives have alleviated the huge patient loads which would without question become unmanageable without their services,” he said.

The bill also would help contain escalating health costs because hospital obstetrical services utilizing nurse-midwives “are able to provide complete care through the birth cycle for one third to one half of the costs of the same care provided by obstetricians,” he said.

Inouye said he wants to emphasize the mutually complimentary nature of the obstetrician-nurse-midwife system, however. “The question at hand is not the competence of the obstetrician versus that of the nurse-midwife; they are recognized as equally competent in the care and mangement of normal pregnancies. In abnormal or high risk cases, the nurse-midwife consults the obstetrician with whom she is affiliated, and if necessary transfers her patient to the physician's care.”

Inouye said nurse-midwives handle all teenage maternity cases in Harlem Hospital in New York, as well as cases in sex counseling and early infant care. Throughout the country they “fulfill the increasing demand among mothers for closer and more personal meaning to the birth experience,” he added.

Today there are about 2000 nurse-midwives in the United States and 18 institutions, including Yale, Columbia and Johns Hopkins, offering accredited nurse-midwifery programs. Forty-eight States permit or facilitate the practice of nurse-midwifery. Nurse-midwives are registered nurses who have completed post-R.N. or Master's degree level studies.