On February 13, 2009, the United States (U.S.) Congress approved the conference report that became the American Recovery and Reinvestment Act of 2009 (H.R. 1). The Recovery Act was signed into law by President Barack Obama on February 17, 2009, setting in motion a series of events that will make $789 billion available to jumpstart the falling economy by creating jobs and mending a crumbling national infrastructure. Daily reports in the media document the billions of dollars to be transferred to the states to implement shovel-ready projects, such as repairing bridges and highways; to fund education; and to alleviate growing state budget deficits. Less well known however are myriad other plans for federal stimulus dollars including a significant amount of money that will benefit nursing.
As we all know by now, the current shortage of nurses is well documented. In an earlier article for this column Glazer and Alexandre (2008) defined the current shortage as a public health issue. Our failure to find a resolution to this shortage will likely have long-term consequences for the U.S. healthcare system. A recent report of the Association of American Medical Colleges (2008) predicted an impending shortage of physicians lasting at least through 2025. Advanced practice nurses, specifically nurse practitioners, are poised to fill this gap as primary care practitioners. In fact, a recent issue brief from the Robert Wood Johnson Foundation (2009) reported nurse practitioners make more primary care patient contacts than any other Medicare B fee-for-service provider.
The value of nursing to the overall success of the U. S. healthcare system has been long recognized by the federal government. Washington has demonstrated its support for nursing by funding nursing education since the inception of the Nurse Corps in 1943 (Willever-Farr & Parascandola, 1994). Through the ensuing decades Congress has continued to support nursing education through Titles VII and VIII of the Public Health Service Act providing funds for construction grants for schools of nursing, grants for education, student loan assistance, and traineeships for advanced practice nurses (Reyes-Akinbilege & Coleman, 2005). The Recovery Act continues federal support of nursing by expanding the funding of current programs and creating new opportunities for nursing practice, education, and research.
Acknowledging the need to educate sufficient numbers of nurses to meet the expected demand in the coming years, the Recovery Act allocates $500 million, of which $300 million targets the National Health Services Corps, with the remaining $200 million divided between the Title VIII Nursing Workforce Development Programs and the Title VII Health Professions Training Programs. Each of these programs will be discussed further in the paragraphs below. This money is in addition to that allocated in the fiscal year 2009 budget and to what is anticipated in the President’s 2010 budget proposal. In addition, $10 billion dollars has been awarded to the National Institutes for Health, with $7.4 billion of that allocated directly to the Institutes, including the National Institute for Nursing Research (AACN, 2009). The Recovery Act has infused an unprecedented bolus of federal funding in programs that can benefit nursing. What does this really mean for nurses and who will actually benefit from this infusion of cash?
The $500 million allocated to the National Health Services Corps and workforce development and training will be administered by the Health Resources and Services Administration (HRSA). Oversight by HRSA is especially significant because President Obama recently named a nurse, Mary Wakefield, PhD, RN, FAAN, as HRSA Administrator, reinforcing the Obama Administration’s commitment to the profession and ensuring nursing’s seat at the policy table. The mission of the National Health Services Corps (NHSC) is to improve the health of the underserved (U.S. Department of Health and Human Services [DHHS], n.d.a.) Through a process of competitive scholarships and loan repayment programs, the NHSC provides tuition assistance to students and clinicians who agree to work in federally designated health professional shortage areas upon graduation. By definition individuals living in these areas have little to no access to healthcare and the NHS works with these communities to recruit primary care providers, including advanced practice nurses, to ensure quality healthcare. HRSA has identified 6,080 primary care Health Professional Shortage Areas that will require 16,585 practitioners to meet the need for primary care providers (U.S. DHHS, n.d.c.). The money allocated through the Recovery Act will provide additional scholarships to students in nursing and other health professions education above the level allocated in the 2009 budget.
Nursing Workforce Development Programs, funded through Title VIII of the Public Health Services Act, support the supply and distribution of qualified nurses. Through the years Title VIII funds have attempted to combat the nursing shortage through support for education, practice, retention, and recruitment. Health Professions Training Programs, funded through Title VII of the Public Health Services Act, support nursing education through scholarships and loan repayment programs. Specific programs funded with Title VII money include the Faculty Loan Repayment Program/Minority Faculty Fellowship Program which repays loans for health profession graduates from disadvantaged backgrounds who commit to teach at eligible colleges or universities for two years post graduation. The Nurse Faculty Loan Program awards grants to schools of nursing that require the school to establish a fund to provide loans for nursing students in advanced degree programs. Up to 85% of the loan may be forgiven if the nurse is employed as full-time faculty at a school of nursing over a four-year period (U.S. DHHS, n.d.b.). The Nursing Education Loan Repayment Program is a need-based, competitive loan program targeting registered nurses working in critical shortage areas.
The Recovery Act is infusing an additional $10.4 billion, to be available through September 2010, to the National Institutes for Health, of which $8.2 billion will support scientific research priorities, including those of the National Institute for Nursing Research (NINR, n.d.). Areas of scientific priority for the NINR include health promotion and disease prevention, symptom management, self-management, care giving, end-of-life and palliative care, integrating technology into clinical practice, and reducing and eliminating health disparities. The NINR plans to provide support for recently reviewed R01 grant applications capable of making significant progress within a two year period; new R01 grant applications submitted for as yet unreleased requests for applications; and ongoing grants so as to accelerate currently funded research programs. NINR funding priorities include competitive revisions to current grant recipients to support the development and growth of scientific partnerships; supplements for current NINR-funded research programs to support the purchase of equipment and scientific instrumentation; and supplemental funding to current grant holders to encourage elementary, middle school, and high school teachers, community college faculty, and faculty from non-research institutions to participate in short term research experiences (NINR, n.d.).
The Recovery Act will provide much needed funding to strengthen the nursing workforce by increasing monies available to support the education of new nursing faculty, provide scholarships and loan repayment to nursing students, and encourage diversity within the profession through loans and scholarships targeting minorities and students from disadvantaged backgrounds. The current Administration in Washington has demonstrated a strong commitment to nursing through the allocation of stimulus money to boost funding to nursing education and research and through the appointment of a nurse to head the federal agency with oversight of these funds. Especially encouraging is the Administration’s ongoing commitment to healthcare in general and nursing in particular. The budget proposed by the Obama Administration for fiscal year 2010 allocates $330 million to bolster the health professions workforce and increase the capacity of nursing schools; $1.5 billion in prevention and wellness programs; $73 million to improve access to healthcare in rural areas, and $6 billion to the NIH for cancer research (ANA, 2009).
Opportunities for registered nurses and advanced practice nurses will likely expand under the proposed 2010 budget. For example, within the Departments of Veterans Affairs and Defense, the Administration proposes to increase the overall funding for veterans’ healthcare. Specifically, the proposed budget calls for expansion of eligibility of coverage for veterans while targeting those veterans with mental health and cognitive injuries such as post-traumatic stress disorder and traumatic brain injuries. The proposed budget would also direct $330 million to increase the Department of Health and Human Services allocation to support an increase in the number of health professionals, including nurses, practicing in underserved areas. The 2010 budget narrative provides that the outcomes of funds directed to healthcare will promote prevention and wellness, patient safety, quality improvement, and a broad expansion of health information technology, thus providing opportunities for nurses in practice, education, and research.
In summary, the American Recovery and Reinvestment Act of 2009 has made a significant investment in expanding the ability of our healthcare system to meet the needs of all Americans. The allocation of stimulus funds to the National Health Services Corps, Nursing Workforce Development Programs, and Health Professions Training Programs demonstrates the current Administration’s acknowledgment that a viable healthcare workforce is dependent on sufficient numbers of registered nurses in practice, education and research. According to Milstead (2004), nurses are “the watchdogs as programs are implemented so target groups are served and services are appropriate” (p. 19). Although federal funds are targeting programs beneficial to nursing at this time, it is important that nurses remain vigilant to ensure stimulus funds are spent wisely on programs designed to improve access to healthcare. Nurses are an integral piece of the healthcare system, and as such must be prepared to access Recovery Act funds to increase the numbers of nurse researchers, educators, and practitioners.
Charles Alexandre, RN, MS
Charles Alexandre is a doctoral candidate at the College of Nursing and Health Science at the University of Massachusetts Boston. He received his BS in Nursing from Rhode Island College and his MS in Nursing Administration from the University of Rhode Island. He is the Chief, Health Professions Regulation at the Rhode Island Department of Health.
Greer Glazer, RN, CNP, PhD, FAAN
Dr. Greer Glazer is Dean and Professor of Nursing and Health Sciences at University of Massachusetts Boston. She received her BSN from University of Michigan, and MSN and PhD from Frances Payne Bolton School of Nursing, Case Western Reserve University. She became particularly interested in collaboration and partnerships while serving as a Robert Wood Johnson Executive Nurse Fellow in 2001. Since then she has developed an interdisciplinary, PhD-level, leadership course; partnered with agencies in Israel to improve women's health; and engaged in partnerships and collaborations with the following Massachusetts agencies and organizations: Partners Healthcare; Children's Hospital of Boston; The Massachusetts Board of Higher Education; Bunker Hill Community College; Roxbury Community College; and Dana Farber Harvard Cancer Center.
American Association of Colleges of Nursing. (2009). AACN applauds Congress for passing the American Recovery and Reinvestment Act that includes funding for nursing education. Retrieved February 18, 2009 from www.aacn.nche.edu/Government/Stimulus.htm.
American Recovery and Reinvestment Act of 2009. (H. R. 1). (2009) (enacted) Retrieved March 1, 2009 from http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h1enr.pdf.
A new era of responsibility: Renewing America’s promise. (2009). Washington, D. C.: U. S. Government Printing Office, Retrieved March 9, 2009 from www.whitehouse.gov/omb/assets/fy2010_new_era/A_New_Era_of_Responsibility2.pdf.
Association of American Medical Colleges. (2008). The complexities of physician supply and demand: Projections through 2025. Retrieved April 30, 2009 from https://services.aamc.org/Publications/showfile.cfm?file=version122.pdf&prd_id=244&prv_id=299&pdf_id=122.
Glazer, G., & Alexandre, C. (2008). Legislative: The nursing shortage: A public health issue for all. OJIN: The Online Journal of Issues in Nursing, 14(1), Retrieved March 1, 2009 from www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Legislative/NursingShortage.aspx.
National Institute of Nursing Research (n.d.). NINR’s role in the American Recovery & Reinvestment Act. Retrieved April 30, 2009 from www.ninr.nih.gov/Recovery/Home.htm.
Robert Wood Johnson Foundation (March 2009). Charting nursing’s future. Retrieved April 30, 2009 from www.rwjf.org/files/research/20090408chartingnursing9.pdf.
U. S. Department of Health and Human Services (n.d.a) National health service corps. Retrieved April 30, 2009 from http://nhsc.hrsa.gov/join_us/.
U. S. Department of Health and Human Services (n.d.b) Nurse faculty loan program guidance. Retrieved April 30, 2009 from www.hrsa.gov/grants/nflp/description.htm#description.
U. S. Department of Health and Human Services (n.d.c). Shortage designations: HPSAs, MUAs & MUPs. Retrieved April 30, 2009 from http://bhpr.hrsa.gov/shortage/.