94 ■ I: HISTORICAL AND THEORETICAL FOUNDATIONS FOR ROLE DELINEATION
■ SUMMARY: FROM SILOS TO COMMON VISION
On March 23, 2010, President Barack Obama signed into law the Patient Protection
and ACA, the first overhaul of the American health care system since Lyndon Johnson
signed Medicare and Medicaid into law on July 30, 1965. The ACA’s planned focus
on better access to and affordability of health insurance, health services integration
and coordination, expanded use of electronic health records, expansion of primary
care services, and redefinition of health care team member roles, especially those
of NPs (Kocher et al., 2010) has helped solidify the importance of advance practice
nurse providers in improving the health of American citizens. Despite controversies
and state- level discrepancies related to its implementation, this historic legislation
has indeed helped millions of Americans access health insurance and thus health
care services, and has promoted expansion of primary care and chronic care man-
agement services (Blumenthal, Abrams, & Nuzum, 2015); APNs will continue to be
needed to provide these crucial services (IOM, 2010). During the past two decades,
significant changes that mesh with this historic health care reform have occurred.
Advanced practice nursing has matured into a powerful force ready to determine
its own future. Once separated by practice in separate professional silos, 100,000
APRNs (nurse- midwives, nurse anesthetists, NPs, and CNSs) stand ready to join
forces under a uniform umbrella to push the profession forward through a common
vision (Pearson, 2010).
During the past 15 years, APRNs have continued to fight for 100% insurance par-
ity with physicians, universal coverage, and expansion of APRN practice to increase
access to care, especially for the underinsured and underserved (Advance for Nurse
Practitioners, 2010; Pearson, 2010). Utah and then Iowa adopted the APRN Compact,
which allows APRNs in one compact state to practice in other compact states to further
increase access to care (NCSBN, 2010). In several states, APRNs have decreased barriers
to practice and have won the ability to receive Medicaid reimbursement for health care
services. Progressive legislation has resulted in permitting APRNs to write prescrip-
tions for the handicapped, placards for the disabled, order home health care, perform
physical exams for drivers and students, sign death certificates, write “do not resusci-
tate” (DNR) orders, and become recognized as primary care providers. In many states,
APRNs have won the ability to write for Schedule II through V controlled substances,
and have their names printed on prescription labels.
Although there have been some losses, APRNs have held their ground in their
struggles with Boards of Medicine across the United States to physicians’ grip on regula-
tion, supervision, and authority over their profession (Advance for Nurse Practitioners,
2010; Pearson, 2010). In several states, APRNs have managed to change legal language
from “physician supervision” to “collaboration,” or to “independent practice,” and
have removed mandatory APRN- to- physician ratios. Increasingly, state legislatures are
removing barriers to independent NP practice; however, at this writing, fewer than half
of the states allow fully independent practice. APRNs have continued to extend their
scope with regard to referrals to other health care providers, prescribing rights, billing,
and providing direction to RNs, school nurses, occupational therapists, and respiratory
therapists.
APRNs have also increased their numbers in leadership positions on state boards
of nursing. In several states, advanced practice nurses have won the protection of
the title of APRN (Advance for Nurse Practitioners, 2010; Pearson, 2010). In addi-
tion, they have increased their involvement in the business of state legislatures and
the federal government. Four NPs have been elected to powerful positions as state