Inside the Beltway – April 2021

Policy Approaches to Grow the Pediatric-focused NP Workforce

Contributed by: Health Policy Committee Member Kristin Gigli, PhD, RN, CPNP-AC, CCRN

There are significant concerns about the ability of pediatric-focused physicians and advanced practice providers to meet the healthcare needs of children.1 The nurse practitioner (NP) workforce is considered to be more adaptive and responsive to meeting workforce needs than the physician workforce, however, in recent years the pediatric NP workforce has not experienced growth at the same rate as other NP specialties.2,3 In times of nursing shortage, policies and federal funding have historical precedence to grow the workforce and meet patient needs.4 These policies can be leveraged to ensure children have access to pediatric-focused providers now and in the future.

Funding Nurse Practitioner Education 

There are two primary streams of federal funding for nursing education, Medicare and Title VIII. Medicare payments to hospitals for nursing education are the largest single source of funding for nursing education and have been part of the Medicare program since it’s development.5 However, this funding is allocated in a way that no longer aligns with most nursing education. Hospital-operated nursing programs receive funding as part of the hospital’s general revenue for prelicensure, undergraduate, nursing education programs only, excluding most educational programs from eligibility.4 Additionally, as NPs came into existence after the creation of Medicare, there is no specific funding stream in Medicare allocated to support nurse practitioner education.5

The Nursing Workforce Development programs (authorized under Title VIII of the Public Health Service Act), colloquially referred to as Title VIII, play a significant role in supporting nursing workforce development.6 Through multiple funding mechanisms a range of programs support nursing education, including the Nurse Faculty Loan Program which supports the education of aspiring faculty members. For the first time in more than a decade Title VIII funding increased in 2020, allotting nearly $260 million dollars to nursing workforce development as part of the Further Consolidated Appropriations Act, 2020.7

In addition to these programs, the Patient Protection and Affordable Care Act included a Graduate Nurse Education demonstration program that funded NP education.8 This demonstration program allocated funding to 5 sites comprised of: hospital, school of nursing, and community-based care partners to implement innovated models of clinical graduate nursing education and included preceptor engagement aimed at increasing the number of primary care NPs.8 A recent review found the demonstration program increased graduate nursing enrollment and graduation rates in the partner program, suggesting a positive influence on the available workforce.5,8

Opportunities to Advocate for Investment in the Nurse Practitioner Workforce

Advocacy for nursing education is always important but the need for engagement feels particularly urgent as we grapple with the pandemic and are at the precipice of a pediatric provider shortage. Here are some opportunities to engage and advocate:

    • Funding for Title VIII must be allocated each year in the federal budget. This year you can advocate for increased funding to support the growth of the pediatric-focused NP workforce to increase the capacity to care for children.
    • With successful results from the Graduate Nurse Education demonstration program, consider advocating for the continuation and expansion of these programs to specifically include acute and primary care pediatric NP programs.
    • New legislation, sponsored by Representative Underwood, the Future Advancement of Academic Nursing Act (FAAN Act) could provide $1 billion in grants to schools of nursing to increase their capacity and enhance nursing education programs if passed. Consider asking your legislator to co-sponsor and support this legislation.


$1.9 Trillion COVID-19 Relief Package Launched

Relying on legislative procedures that enabled them to avoid a Republican filibuster, congressional Democrats passed President Biden’s massive $1.9 trillion coronavirus recovery plan without a single Republican vote, giving his administration its first significant legislative achievement. Biden signed the “American Rescue Plan Act” (H.R. 1319) Mar. 11 as he marked the pandemic’s one-year anniversary. In addition to providing $1,400 checks to low- and middle-income families, extending increased unemployment benefits and increasing child tax credits, the legislation included $200 million for Nurse Corps scholarships and loan repayment and $800 million for National Health Service Corps loan forgiveness and scholarships to primary care clinicians in health professional shortage areas.

The massive package also provided $350 billion in pandemic aid to states, cities, territories and tribal governments, as well as more than $70 billion for COVID-19 vaccine, testing and workforce efforts and $8.5 billion in provider relief funds to reimburse rural health care professionals for pandemic-related revenue losses. The legislation provides an incentive for states that have not already done so to expand Medicaid by temporarily increasing the state’s Federal Medical Assistance Percentage (FMAP) by 5 percent for two years, meaning that a state that expands coverage during the public health emergency can receive both the COVID-related 6.2 percent boost and the new 5 percent increase. It also gives states, for five years, the option to extend Medicaid and Children’s Health Insurance Program (CHIP) eligibility to pregnant individuals for 12 months postpartum, along with increasing premium subsidies for eligible individuals purchasing health coverage in Affordable Care Act marketplaces.


Legislation Seeks to Improve Vaccines for Children Program

NAPNAP and its chapters joined the American Academy of Pediatrics and other children’s advocates in supporting the bipartisan “Strengthening the Vaccines for Children Program Act of 2021” (H.R. 2347) introduced Apr. 1 by Reps. Kim Schrier (D-WA) and John Joyce (R-PA). The measure would strengthen the Vaccines for Children (VFC) program by providing additional federal funding to states to increase payment for vaccine administration from the Medicaid and Children’s Health Insurance Program (CHIP) to match Medicare payment rates for two years. The bill would also offer incentive payments to participating VFC providers to help cover operational costs, as well as extending VFC eligibility to children enrolled in CHIP and clarifying Medicaid payment for multi-component vaccines. Supporters are hoping to include the bill in a health infrastructure package later this year.


Agencies Struggle with Influx of Unaccompanied Immigrant Children

Preliminary data released Apr. 2 by Customs and Border Protection officials confirmed that the number of migrants crossing into the U.S. in March skyrocketed to the highest levels in at least 15 years, including record numbers of teenagers and children arriving without parents, overwhelming the government’s ability to care for them. Border agents took more than 171,000 migrants into custody in March, the agency reported, including more than 18,800 unaccompanied minors, a 99 percent increase from February. Reports indicated that the federal government was spending at least $60 million a week to care for thousands of migrant teenagers and children in HHS-operated shelters.

President Biden on Mar. 24 tasked Vice President Kamala Harris with overseeing efforts with Central American countries to stem the flow of migrants to the southern border and was reportedly preparing to nominate Tucson police chief Chris Magnus, a critic of the Trump administration’s immigration policies, to be commissioner of U.S. Customs and Border Protection.

NAPNAP worked with Washington Democratic Rep. Pramila Jayapal on a letter from congressional Democrats to top officials in the Health and Human Services and Homeland Security departments recommending policies to govern influx facilities for unaccompanied children, including requiring that facilities have on-site pediatric health specialists including pediatric-focused advanced practice registered nurses. NAPNAP also joined First Focus on Children and other advocates in urging the administration to end the misuse of Title 42 public health authority to expel children and families at the border, returning them to dangerous conditions in their home countries without legal protections.


Senate Confirms Key HHS Nominees

The Democratic-majority Senate confirmed former California Attorney General Xavier Becerra to be Secretary of Health and Human Services Mar. 18 on a narrow vote of 50 to 49, installing a progressive in President Biden’s Cabinet who is expected to aggressively roll back Trump administration policies and oversee a major expansion of health coverage. Becerra, who served in the House for more than two decades and helped author the 2010 Affordable Care Act, became the first Latino to head HHS.

Senators also confirmed the appointment of former Pennsylvania Health Sec. Rachel Levine as the Assistant Sec. for Health at HHS Mar. 24, a day after approving the nomination of Dr. Vivek Murthy to be U.S. Surgeon General. Levine, confirmed by a vote of 52 to 48, became the highest-ranking openly transgender official in U.S. history despite opposition from religious rights groups, while Murthy returned to the post that he previously held in the Obama administration as well as playing an expanded role in the Biden administration on health and pandemic policies.

The Senate Finance Committee also held a confirmation hearing Apr. 15 on the nominations of Obama administration veterans Andrea Palm to be Deputy Secretary of Health and Human Services and Chiquita Brooks-LaSure to be administrator of the Centers for Medicare and Medicaid Service.


Biden Takes Initial Steps Seeking to Rein in Gun Violence

In the wake of another series of mass shootings, President Biden announced a series of executive actions Apr. 8 to curb gun violence while pledging to push for sweeping changes to the country’s firearms laws. Calling gun violence “an epidemic” and “an international embarrassment,” Biden released new rules on “ghost guns” – firearms that are assembled at home without serial numbers, making them harder to track. He also directed the Justice Department to draft a new rule regulating a device that can turn a pistol into a short-barreled rifle, to create a template for states to enact “red flag” laws, allowing judges to seize firearms from people deemed a threat to themselves or others and to repeat of a landmark 2000 gun-trafficking study that helped police identify the source of guns used in crimes. Biden said his moves do not relieve Congress of the responsibility to act, urging lawmakers to take up gun-control measures already passed by the House that would require more gun buyers to undergo background checks.

The President’s budget blueprint (detailed below) also proposed to double funding for firearms violence prevention research at the Centers for Disease Control and Prevention and the National Institute of Health in fiscal 2022 and includes an additional $100 million for the CDC to initiate a new Community-Based Violence Intervention initiative in collaboration with Justice Department to implement evidence-based community violence interventions at the local level.


HHS Halts “Sunset Rule” Facing Legal Challenge

Responding to a lawsuit filed by NAPNAP and a coalition of county and tribal governments and consumer and environmental advocates, the U.S. Department of Health and Human Services (HHS) on Mar. 18 issued a one-year stay of the effective date of the “Securing Updated and Necessary Statutory Evaluations Timely (SUNSET)” rule. More than 18,000 regulations governing federal health, drug and tobacco policies issued by HHS and agencies ranging from the Centers for Medicare and Medicaid Services to the Food and Drug Administration and the Centers for Disease Control and Prevention would face automatic expiration dates under the rule, requiring agencies to divert resources to review long-standing policies. In its response to the litigation, HHS acknowledged that the lawsuit raised questions about whether the rule is “consistent with the policies and goals of the current administration” and expects to issue a notice of proposed rulemaking repealing the SUNSET Rule in the coming months.


In Other News

Biden Asks Congress for $1.52 In Trillion Fiscal 2022 Spending

Although his administration won’t release a full budget proposal for the 2022 federal fiscal year until next month, President Biden on Apr. 9 sent a blueprint for top-line discretionary spending totaling $1.52 trillion, including a 16 percent increase over current funding levels for domestic programs while slowing defense spending with only a 1.7 percent increase. The plan proposes to increase funding for the Department of Health and Human Services by roughly 23 percent, including more than $8.7 billion for the Centers for Disease Control and Prevention, but doesn’t identify specific funding levels for nursing education and workforce development programs – those details will be provided in the more comprehensive budget plan.

The request marks Biden’s first discretionary spending blueprint, a precursor to the full annual budget that will also address mandatory spending programs like Social Security, Medicare and Medicaid. Many of the programs Biden wants to fund at higher levels are initiatives that former President Donald Trump tried unsuccessfully to cut, while also reversing Trump’s buildup in military spending.

Administration Pushes Two-Part Infrastructure Growth Plan

On the heels of signing into law the $1.9 trillion “American Rescue Plan Act,” President Biden on Mar. 31 unveiled his “American Jobs Plan,” a $2.25 trillion proposal comprising the first of a sweeping two-part infrastructure and economic stimulus plan that will include a second package of roughly equal size expanding health care coverage, boosting subsidies for child care, offering free access to community colleges and addressing other domestic priorities. The jobs proposal would provide $650 billion to rebuild transportation infrastructure, $400 billion to expand home care for the elderly and the disabled, $300 billion to modernize housing infrastructure and $300 billion to revive U.S. manufacturing. It also calls for billions to bolster the nation’s electric grid, provide nationwide high-speed broadband and restore the nation’s water systems.

Republicans and prominent business groups such as the U.S. Chamber of Commerce raised immediate concerns about the plan, particularly tax increases proposed to pay for the investments.

While most of the President’s plans for expanding health care coverage are expected in the second “human infrastructure” package, the initial plan calls for expanding access to home- and community-based care for seniors and people with disabilities, extending the Medicaid “Money Follows the Person” program to move elderly residents out of nursing homes and back into their own homes or into the care of loved ones.


References from lead story:

  1. Vinci R. J. (2021). The Pediatric Workforce: Recent Data Trends, Questions and Challenges for the Future. Pediatrics, e2020013292. Advance online publication. https://doi.org/10.1542/peds.2020-013292
  2. Auerbach, D. I., Staiger, D. O., & Buerhaus, P. I. (2018). Growing Ranks of Advanced Practice Clinicians – Implications for the Physician Workforce. The New England Journal of Medicine378(25), 2358–2360. https://doi.org/10.1056/NEJMp1801869
  3. Gigli, K. H., Beauchesne, M. A., Dirks, M. S., & Peck, J. L. (2019). White Paper: Critical Shortage of Pediatric Nurse Practitioners Predicted. Journal of Pediatric Health Care,33(3), 347–355. https://doi.org/10.1016/j.pedhc.2019.02.008
  4. Aiken, L. H., Cheung, R. B., & Olds, D. M. (2009). Education policy initative to address the nurse shortage in the United States. Health Affairs, 28(4), w6460656. doi.org/10.1377/hlthaff.28.4.w646
  5. Aiken, L. H., Dahlerbruch, J., Todd, B., & Bai, G. (2018). The graduate nurse education demonstration – Implications for Medicare policy. The New England Journal of Medicine, 378(25), 2360-2363.
  6. Nursing Community Coalition. (2018). Answering the call for care: Investing in nursing workforce and research matters. Retrieved from: https://docs.wixstatic.com/ugd/148923_9817084bf5ae40119279402c2f17e295.pdf
  7. American Association of Colleges of Nuring. (2020). AACN Applauds Increased Federal Investments in Nursing Education and Research. Retrieved from: https://www.aacnnursing.org/News-Information/Press-Releases/View/ArticleId/24546/Federal-Investments-FY20
  8. U.S. Department of Health and Human Services [HHS]. (2018). Evaluation of the graduate nurse education demonstration project: Report to Congress. Retrieved from: https://innovation.cms.gov/Files/reports/gne-rtc.pdf
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