1. Leavitt, Judith K. MEd, RN, FAAN


Which candidate is really going to fix health care?


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Regardless of whether you're a political junkie or not, it's hard to ignore the excitement surrounding the presidential primary elections. Voter turnouts are higher than they've been in many years, especially among young and independent voters.1 The unprecedented mix of candidates-which includes a woman, an African American, and one who would be the oldest person to assume the office-contributes to the electricity of the moment. February 5, Super Tuesday, left two candidates in the field for the Democrats: Hillary Clinton and Barack Obama. On March 4 ("Junior Tuesday"), John McCain became the sole remaining Republican candidate and is the party's nominee.


So why is this presidential race so important? Because the candidates' stances on health care can have a tremendous impact on nursing, as well as on the entire health care system. Candidates proposing health care reform have concentrated on controlling costs, improving quality, and expanding access. Clinton has spent more time than the others explaining how she plans to accomplish these reforms; no other candidate has focused on the role of nursing in the discussion.


Nurses should be asking how we will achieve an adequate workforce, what working conditions will be as we expand access to patients, what the roles and responsibilities of different health care professionals will be, and how providers and plans will be accountable. How do the candidates propose to "fix" the nursing shortage, particularly the nursing faculty shortage? And how do the candidates plan to use our expertise to make their reforms?


The issues of greatest concern to the electorate are the recent economic downturn and the Iraq War, according to the most recent public opinion polls. Among Democrats health care ranks almost evenly with the war and the economy; among Republicans it is second after Iraq.2 Cost and coverage are the major concerns for Democrats, while cost alone dominates Republicans' concerns. But there is no consensus among voters on which solution is best.2 The salient issues in this election cycle appear to be universal health care, effective cost control, and affordable insurance.



Here is a synopsis of how the leading candidates in each party define their health care platforms and whether or how they acknowledge nursing in their health care plans. This information has been collected from individual campaign sites as well as the Henry J. Kaiser Family Foundation's dedicated Web site (, which gives a side-by-side comparison of the candidates' positions in depth.


John McCain ( favors giving Americans a choice about insurance, favors health savings accounts and tax credits to encourage purchasing insurance, and encourages competition among insurers. He supports continuation of employer-sponsored plans. His proposals don't include anything about the nursing or physician workforce and mention nurses only in terms of supporting clinics in retail outlets, which would "provide greater market flexibility" by "permitting appropriate roles for nurse practitioners, nurses, and doctors," according to his Web site.

Figure. John McCain.... - Click to enlarge in new windowFigure. John McCain.

Hillary Clinton ( says that her health care plan is the only universal plan because everyone would be required to have insurance coverage, either as individuals or through their employers. To accomplish this, she would provide income-related tax subsidies for affordable coverage and enable individuals without employer coverage to buy into a plan similar to the Federal Employees Health Benefits Program (FEHBP). The primary difference between her plan and Obama's is the requirement that everyone be covered. Clinton supports mental health parity, forbidding insurers from denying coverage because of preexisting conditions. Both would reduce costs through electronic medical records, focus on best practices, and require public reporting of outcomes. As for the health care workforce and nursing, she would provide federal funding for education and mentoring programs to improve retention and innovation and encourage diversity through recruitment initiatives, scholarships, and loan-forgiveness programs. She would use nurses in prevention programs, including workplace wellness. She specifically mentions the supermarket chain Safeway as an example of how a 24-hour hotline staffed by RNs manages chronic conditions through care management and promotes more healthful lifestyles. She mentions nurses as examples in all of her speeches on health care. And last August she "spent a day with a nurse in Nevada" (view a video discussing the day at In January 2008 the American Nurses Association Political Action Committee endorsed Clinton, an unusual move so early in the primaries.3 Clinton has cited nurses and their expertise more than any other candidate.

Figure. Hillary Clin... - Click to enlarge in new windowFigure. Hillary Clinton

Barack Obama ( would create a new national plan modeled on the FEHBP to enable those without insurance to buy in. His Web site says he would provide affordable and high-quality universal coverage through private and expanded public insurance. He would require employers to provide coverage for employees (except for small businesses and start-ups, in which case employers would be required to contribute to the cost of new public programs). For children he supports expanding the State Children's Health Insurance Program (SCHIP) and Medicaid or providing assistance to families in purchasing private insurance. He would also require insurance plans to cover prevention services, and he mentions diversifying the workforce but does not indicate how. Like Clinton, Obama supports mental health parity. He mentions physicians in the context of patient safety, medical malpractice, disease management programs, and "comparative effectiveness research." He mentions nurses in the context of requiring transparency in quality and costs, which would include data on nurse staffing ratios. Nurses are included, though not specifically, in his support for increased funding of biomedical research and workforce "training in health-related fields."

Figure. Barack Obama... - Click to enlarge in new windowFigure. Barack Obama


We can encourage candidates to speak more about nursing and health care issues by repeatedly asking them for details on how they plan to expand access, improve quality, and lower costs. We need to be offering solutions that work. For instance, if programs in your state are moving nurses into faculty positions, share that information with the candidates. Are there programs that have been successful in retaining nurses? Give candidates enough written information to learn about and refer to the programs. Has legislation, regulation, or voluntary compliance improved staffing? Explain to the candidates (or their staff) how it worked; ask that such ideas be included in their platforms.


Nurses are critical to the debate and critical to the solutions. Demonstrate our expertise and our value. Participate-and speak out-as the campaigns advance through the remaining primaries to the general election in November.


Drastic Cuts to Health Care and Nursing

President Bush's 2009 budget.


President Bush sent his $3.1 trillion 2009 budget to Congress on February 4. It increases military spending but barely increases health care spending-and in fact proposes big cuts to Medicare and Medicaid and to the Department of Health and Human Services. The federal deficit will grow by $250 billion, and the impact on nursing could be devastating. The proposal eliminates much of the workforce money: only $110 million is allocated for Title VII and VIII of the Public Health Service Act, compared with $350 million last year (and despite a request by the Health Professions and Nursing Education Coalition for $550 million).


Specifically, Title VII programs that were eliminated focused on underserved populations and included programs


* to increase the diversity of the workforce.


* for primary care providers, especially in rural areas.


* at Area Health Education Centers and for geriatric training and allied health.


* for public health, supporting public health traineeships, preventive-medicine residencies, dental public health training, and health administration traineeships.



The Title VIII cuts for nursing education, practice, and retention programs would eliminate


* Advanced Education Nursing grants to schools for all advanced practice nurses.


* grants for graduate nurse traineeships.



On the bright side, Congress is not expected to approve the budget. There is speculation that it may not be passed by the end of the fiscal year on September 30 and may be carried over until a new president is sworn in in January 2009.


For more information on these cuts, go to




1. Harris C. Super Tuesday youth voter turnout triples, quadruples in some states. MTV 2008 Feb 6. [Context Link]


2. Deane C. Public opinion: health care and election '08. Washington, D.C.:, Henry J. Kaiser Family Foundation; 2008. [Context Link]


3. American Nurses Association. The American Nurses Association endorses Senator Hillary Rodham Clinton (D-NY) [press release]. 2008 Jan 25. [Context Link]