Columbia Nursing Helps Fill Gaps in Primary Care as Affordable Care Act Extends Coverage



Arlene SmaldoneColumbia Nursing prepares nurses to fill primary care gaps, said Arlene Smaldone, assistant dean of scholarship and research, at a forum on the ACA.

The great promise of the Affordable Care Act (ACA) is that it will extend health coverage to millions of uninsured Americans. Because demand is for care is going to outstrip the supply of providers in many places across the country, there’s a real danger that having a pathway to insurance for the first time still won’t mean that people get care, according to Arlene Smaldone, PhD, assistant dean of scholarship and research at Columbia University School of Nursing.

“Advanced practice nurses, particularly those with the type of skills we teach in our clinical doctorate program, are prepared to provide primary care,” Smaldone said last month at a Columbia University Medical Center Healthcare Forum on the ACA’s impact on practitioners and patients. “Certainly, nurses will be part of the solution.”

Most U.S. physicians practice in specialties such as cardiology or endocrinology. The doctors that do focus on primary care are heavily concentrated in cities, leaving a shortage of providers in many rural areas, Smaldone said. About 7 million Americans live in communities where the demand for primary care already outstrips the supply of doctors by at least 10 percent, and an additional 44 million live where the deficit is at least 5 percent, she said at the forum. The shortage is only going to get worse as ACA takes effect and more people access care for the first time.

“For the promise of the Affordable Care Act to be realized, creative solutions and better utilization of the primary care workforce must be seriously entertained,” she said. “For some of the people who gain access to the health care system through ACA, their primary care provider will be the traditional provider, but for others it will be an advanced practice nurse.”

Most nurse practitioners are educated to provide primary care, and their ranks are expected to swell to 244,000 by 2025 from about 155,000 today, Smaldone said.

In a report on the future of nursing, the Institute of Medicine (IOM) recommended that nurses practice to the full extent of their education, she said. While scope of practice for nurse practitioners remains restricted in more than half of states, legislative efforts are underway to remove these barriers to practice, Smaldone said.

John Rowe, MD, professor of health policy and management at Mailman School of Public Health, another panelist at the forum, offered an anecdote to show how nurses are already filling a crucial role in primary care. One of his daughters was at school and got sick. She went to Harvard University Health Services, where what her doctor initially told her to do didn’t work. Her doctor sent her to a specialist at a nearby hospital.

This happened over the course of a month, Rowe said, and when he saw his daughter over the Thanksgiving break, he asked how she was doing. “She says she’s fine, and she was really happy with the health service and really likes her doctor,” Rowe recalled. “And then she says, `Dad, did I tell you that my doctor is a nurse?’”

In recognition of the expanded role nurses are filling in the health care system, education is also changing, Smaldone said. A decade ago, Columbia Nursing was at the forefront of developing the clinical doctorate as the standard for entering the profession at the advanced practice level. The masters program that had traditionally served as the entry to advanced practice is now being transitioned to the clinical doctorate.

“We recognize that providing high quality care for individuals is complex, and it requires a high level of skill in a wide variety of areas,” Smaldone said. “To prepare our advanced practice nurses to fill a crucial role in providing primary care, our clinical practitioners must be educated at the doctorate level, just as our nurse scientists are educated at the PhD level.”

Nursing research will also evolve as the ACA extends coverage to more Americans and encourages providers to improve coordination of care, she said.

“The ACA is creating extensive new research opportunities for nurses to both lead and be members of interdisciplinary teams,” Smaldone said. “This is an incredibly exciting time.”