Nurses should be full partners with physicians in reforming the health care system by using workplace planning and policy (Institute of Medicine, 2011). When the National Academy of Medicine, formerly the Institute of Medicine, made this declaration in their report, The Future of Nursing, they envisioned a health care system that provides access to high quality care for all patients using a payment system that prioritizes value over volume at an affordable price for consumers and the country (Institute of Medicine, 2011).  While the United States has taken incremental steps toward improving quality and lowering costs, we have yet to agree on a payment system that works for everyone. The Socialist Party first introduced the idea of public financing in 1901 to insure accidents, unemployment, illness and events related to old age (Birn, Brown, Fee, & Lear, 2003).  This proposal set the stage for a long debate, especially amongst members of the American Nurses Association (ANA) and the American Medical Association (AMA). Nurses and physicians are uniquely guided by their respective code of ethics which has caused professional organizations to have diverging positions on healthcare financing over the years. The Code of Ethics for Nurses states the nursing profession believes health is a universal right and therefore, we must protect and ensure everyone has access to healthcare (American Nurses Association, 2015). The Code of Medical Ethics states that healthcare is a human good and therefore, physicians should offer expertise on what healthcare services should be made available to the public (American Medical Association, n.d).  To support my claim, I will analyze how the AMA and the ANA’s respective code of ethics have influenced their policy positions during the 1930s, 1960s and 2010s on Social Security, Medicare and Medicaid, and the Affordable Care Act, respectively.

The Need for Change

The first debate during the turn of the 20th century focused on the quality of healthcare in light of growing concern over unaccredited medical education programs (Sammons, 1980). Following World War II, the conversation shifted towards access, namely increasing the number of healthcare facilities and healthcare professionals graduating from accredited programs. As the barriers to access were reduced, it became abundantly clear costs were skyrocketing. The increase in healthcare expenditures were largely attributed to the growing cost of care delivery, the increase in population, the volume of care, and the type of care delivered per capita (Sammons, 1980). Healthcare dollars were being shifted away from physician offices to hospitals. New technology and treatments became available and life expectancy increased which led to a larger population of older adults who required more frequent and longer hospitalizations. In 1946, Congress passed the Hill-Burton Act which provided grants and loans (nearly $4 billion in federal funding and $9 billion in state funding) for more than 10,000 new healthcare facilities (Thomas, 2006). These changes substantially increased total health expenditures due to the high cost of hospital care delivery (Sammons, 1980).

Decades later, the United States has become the leader in healthcare expenditures, but lacks the quality and health outcomes to show for it (Salmond & Echevarria, 2017). In 2018, 17.7% of the gross domestic product (GDP) was spent on healthcare which equated to roughly $11,000 per person (Hartman et al., 2020).  The net cost of health insurance and the health insurance tax accounted for the fastest growth in expenditures. Personal healthcare spending accounted for the majority (84%) of total national health expenditures with the largest demands in hospital care, clinician services, and retail prescription drugs (Hartman et al., 2020). Economy wide inflation in 2018 triggered the fastest medical price growth (2.1%) since 2011. The federal government and individual households spent the most on healthcare (28% each). The remainder of spending was seen in the private industry (20%), by state and local governments (17%), and from private revenues (7%) (Hartman et al., 2020). Medicare spending reached $750 billion (an increase of 6.4%) while Medicaid spending reached almost $600 billion (an increase of 3%). The largest portion of Medicare dollars were spent on fee-for-service expenditures like physician-administered drugs and durable medical equipment, and the Medicare Advantage plan. The bulk of Medicaid dollars covered hospital payments, and clinician and personal health services. More than $700 billion dollars were spent on clinician services as the demand for clinical services outpaced the demand for physician services. The $350 billion dollars spent on retail prescription drugs came from private health insurance (40%), Medicare (32%), out-of-pocket expenses (14%), and Medicaid (10%) (Hartman et al., 2020). There has been evidence things needed to change for a long time.

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The American Nurses Association

The industrialization period following the Civil War included hospital reform and the advent of trained nursing programs in America. Three major nursing models were developed that led to division within the profession and a lack of recognition by society. Linda Richards (America’s first trained nurse) created a model in 1878 that put physicians in control of supervision. Then, Isabel Hampton created the professional model which was based on self-determination and regulation by nursing. She strongly believed in the necessity of professional organization, standards, precision and uniformity. At the 1893 World’s Fair she shared her vision for the future which included the creation of an American Nurses’ Association (Baer, 1985). In the same year, Edith Draper, a training school superintendent, released a paper entitled, The Necessity of an American Nurses’ Association. She called for a system of registering nurse graduates based on a set of competence standards (adopted in 1923). Three years later the National Associated Alumnae was formed; it would eventually be called the American Nurses’ Association in 1911 (Baer, 1985).    

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The Code of Ethics for Nurses

Modern American nursing has a large collection of ethical literature that dates back to 1870. There were a number of early modern nurse leaders during this time that were by “necessity, involved in a politicized, even radicalized, activistic conceptualization and enactment of social ethics and social justice” (Fowler, 2017, p. 302). They were committed to providing sound education for women who desired to work outside of their home. The social injustices nurses faced everyday helped shaped the social ethics we see in nursing today. These social ethics have always included the whole society and gone beyond the healthcare structure to include social structure, specifically equity, inequity, justice, and injustice (Fowler, 2017, p. 302-303).

The ANA officially adopted their first code of ethics in 1950 (American Nurses Association, 2015). ANA’s Code of Ethics for Nurses with Interpretive Statements informs both the nursing profession and the individual lives of nurses. It is a nonnegotiable, dynamic document that has changed in parallel with the profession and society. It is divided into two sections, the provisions which are nine broad declarations and the interpretive statements which offer more specific details about nurses’ obligations and the application to practice. The ANA routinely releases position and policy statements on a regular basis to accompany the Code of Ethics (American Nurses Association, 2015).

Provision 8 may be the most important declaration in today’s political climate, it states, health is a universal human right, and “the highest attainable standard of health is a fundamental right of every human being” (American Nurses Association, 2015, p. 31). This right to health includes access to healthcare which has economic, political, societal and cultural implications (Interpretive statement 8.1) (American Nurses Association, 2015). Nurses must collaborate with others to identify innovative solutions to reduce health disparities, improve unjust structures, and eliminate social and institutional inequalities (Interpretive statement 8.3). Furthermore, we must address barriers to health, including lack of access, by educating the public and informing legislation (American Nurses Association, 2015). Just as Linda Richards believed, the Code of Ethics states it is imperative that professional nursing organizations stand united and collectively communicate shared values to one another and the public. Interpretive statement 9.1 reminds nurses the profession has the power to improve social justice and global health when we stand in solidarity (American Nurses Association, 2015).

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American Medical Association

The Spaniards in Mexico wrote the first medical book (1570) published in North America and found the first medical school (1578). It took more than 100 years for the New England colonies to release their first medical publication, Thatcher’s Brief Rule in 1677. The first medical school, the University of Pennsylvania, was founded in 1765 and by the end of the eighteenth century there were a total of five (Fishbein, 1946).  By 1845 the number of schools doubled along with the competition to graduate the most students in the shortest time (averaging between 13 to 16 weeks). However, concern grew over the quality of medical school education and the conflicting interest of schools teaching and licensing their students. Dr. Nathan Smith Davis offered a resolution (1845) to hold a national convention whereby medical schools would devise and adopt a set of standards for medical education. Although it wasn’t the first time someone made this attempt, Davis’ persistence and outreach to medical societies was considered the first steps in the creation of the AMA. In 1846, his committee brought forth four initial proposals including the need to expedite the formation of a national medical association, the requirements for preliminary education, and a code of ethics to govern medical professionals (Fishbein, 1946). Then in 1847, Dr. Smith, now credited as the founder, officially started the American Medical Association. He stated, there was no other “voluntary social organization in our country in a position to exert a wider or more permanent influence over the temporal interests of our country” (Fishbein, 1946, p. 636). Initial members were state medical societies, colleges, hospitals, and religious institutions. Over time, the primary members were individual physicians, while medical societies and specialty associations made up the policy-making body of the organization (the House of Delegates) (Fishbein, 1946).

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‍The Medical Code of Ethics of the American Medical Association

Since 1855 physician members have been required to follow the Principles of Medical Ethics, now known as the Medical Code of Ethics of the AMA (Rodwin, 1992, p. 707). It is composed of two components: The Principles of Medical Ethics, and the Ethical Opinions of the Council on Ethical and Judicial Affairs (American Medical Association, n.d, p. 1). Similar to the Code of Ethics for Nurses, it is considered a living document that has been revised several times to reflect changes in medicine and society (Riddick, 2003). The last revision took place in 2001 (Riddick, 2003). The Principles of Medical Ethics contains nine core components, one of which states physicians have a responsibility to actively help improve the community and the betterment of public health. More importantly, they should “support access to medical care for all people” (American Medical Association, 2001, p. 1).

Chapter eleven specifically addresses finance and healthcare delivery. Here, health is defined as a human good because it affords people the opportunity to live life, reduce pain, and improve morbidity (AMA, n.d.). In conjunction, it states society must provide access to care regardless of one’s economic means. Physicians are advised to offer expertise on which healthcare services should be made available and advocate for the interest of all patients, especially those who are vulnerable and disadvantaged (AMA, n.d.). They are obligated to promote access to care and be prudent stewards of shared healthcare resources (Section 11.1.2) (AMA, n.d., p.2). Similar to nurses, physicians should collaborate in decision making regarding the proper allocation and management of healthcare resources. Additionally, they should remain up-to-date on healthcare costs and how their decisions impact healthcare expenditures. Most importantly, they should advocate for policy reforms and address systemic barriers that interfere with responsible stewardship (AMA, n.d.).

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Policy Positions in the 1930s on Social Security

The American Medical Association

In the 19th century, while society agreed that social and political reform was needed to improve population health, there was no consensus on how to do it. Historians have cited physician opposition, workplace sustainability, and decentralized politics as barriers to comprehensive health legislation in the early 1900s (Brosco, 2012, p. 1853). The Socialist Party endorsed the idea of a national healthcare system (in 1901, 1904, 1908, and 1912) to insure accidents, unemployment, illness and events related to old age (Birn et al., 2003).  Then the Progressive Party’s candidate, Theodore Roosevelt, ran on a similar platform calling for a system of social insurance in 1912. Soon to follow was the American Association for Labor Legislation who believed the next step in social legislation was the adoption of sickness insurance. The AMA, the American Public Health Service, and the American Hospital Association initially supported the idea, but then the AMA reversed their position at the beginning of World War I (Birn et al., 2003; Oberlander, 2019). They feared government control, socialism, higher taxes, and a loss of income, quality care, individuality, dignity, and autonomy. The goal was to protect their economic interests (Oberlander, 2019, p. 1498).

In response, many states lost interest as reform was no longer socially acceptable (Birn et al., 2003; Oberlander, 2019). Furthermore, few people trusted government interventions and the intentions of middle-class reformers (Kearney, 2005). The onset of the Great Depression soon changed popular opinion as many realized government intervention was critical to ending economic hardship (Brosco, 2012). However, because of previous opposition from organized medicine (including the AMA) and its allies, Roosevelt intentionally excluded social security legislation from his first New Deal proposal (Birn et al., 2003). During this time in the early 1930s, Dr. Francis E. Townsend wrote a proposal for adults 60 years and older to receive a federal pension. His proposal would later be called the Townsend Old-Age Revolving Pension Plan and the catalyst for a national movement. Soon after, Roosevelt formed the Committee on Economic Security to look into social insurance. A week later the AMA released ten recommendations calling for the medical profession to remain in control with few interruptions in current practice, no third-party interference, patient choice, confidentiality, relief for low-income patients, and patient financial responsibility (Schlabach, n.d.).  The Committee on Economic Security drafted legislation for Social Security in 1935 which included “federal old-age pension and federal-state unemployment insurance,” but excluded a universal health insurance plan in direct response to the AMA’s opposition (Kearney, 2005, p. 185). Roosevelt would continue to advocate for national health insurance during his entire presidency (1933-1945), but resistance from the AMA would constantly stand in his way (Oberlander, 2019).

The Medical Code of Ethics of the AMA is not a set of laws, but rather a guide for physician behavior and an explanation of how the organization frames issues (Rodwin, 1992). At the time, the code did not define healthcare as a human good nor did it advise physicians to ensure access to care. Instead, it stated physicians had a responsibility to both individual patients and society at large to participate in activities that improved the health and well-being of all (Riddick, 2003). This is a broad statement that could be interpreted a number of ways. It does help explain the AMA’s response to Social Security in which they focused solely on the well-being of physicians and what they could lose, instead of how much society stood to gain. Furthermore, the AMA long denied the need for government intervention as they claimed they were a self-regulated profession guided by a strong code of ethics, which by my assessment could easily be interpreted to support their position (Rodwin, 1992, p. 703).

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The American Nurses Association

In comparison to the AMA, the ANA endorsed national health insurance during the Progressive Era (1912-1918) and then it declined during the years of a republican administration. While many believed nurses should be apolitical and any government involvement in healthcare conflicted with the values of the ANA, others found it appealing (Woods, 1996). In the 1920s, many nurses actively participated in lobbying for legislation for licensure, education, and federally-sponsored programs for the underserved and children. Then during the early 1930s, liberal programs like the New Deal tapped into the working-class origins and social consciousness of so many nurses. They formed a culture of cohesiveness and felt nurses needed to be beneficial forces in society (Woods, 1996). This belief would later be reflected in the formal Code of Ethics which was explicit in its mandate between nurses and society (Interpretive statement 9.2). It stated, nurse’s primary commitment was to patients, families, communities, and populations that received healthcare services (Provision 2).  Nurses were obligated to participate in advancing the profession and improving local, regional, state, national or international health policies as advocates, and elected or appointed representatives (Interpretive statement 7.3).  In doing so, they were to demand improvements in public health and the healthcare system globally by vigilantly soliciting policy makers at the local, national and international level (Interpretive statement 9.3) (American Nurses Association, 2015).  

In contrast to the AMA, the ANA wholly supported including health insurance in the Social Security bill. In 1934, the ANA president was named the president of the Advisory Committee for the National Committee on Economic Security by Roosevelt. Suddenly, nurses were considered imperative to the development of health insurance programs. Soon after, the American Hospital Association announced that government sponsored health insurance was a threat to the preservation of private physicians, hospitals and welfare agencies (Woods, 1996).   As a result, the Roosevelt administration omitted it from the Social Security Act of 1935 and 1938. But the nursing profession was not dismayed. The Joint Committee of the ANA and National Organization of Public Health Nurses (NOPHN) to Study Health Insurance and Its Implications for Nurses and volunteer nurses continued to evaluate insurance plans, study state programs, and disseminate information on the benefits of health insurance to the state nurses’ associations (Woods, 1996). They solicited other professional groups, Social Security officials (Wilbur Cohen and Robert Ball), and national leaders who supported government health insurance (Woods, 1996). Then, after World War II, the Joint Committee of the ANA and NOPHN to Study Health Insurance and Its Implications for Nurses merged to become the ANA/NOPHN Committee on Nursing in Prepayment Health Plans and then the Joint Committee of the ANA and NOPHN on Nursing in Medical Care Plans. Although, they started the decade optimistic about the role of nursing in a national health plan, the group later doubted their membership’s ability to effectively support government insurance (Woods, 1996).

It is possible the heated rhetoric and intimidation tactics (sometimes at nurses’ meetings) from the AMA impacted their decision to remain silent on the topic from 1944 to 1958 (Woods, 1996). The AMA continued to oppose national health insurance using large sums of money and questionable tactics to impose their stance. This campaign was led largely by the editor of the Journal of the American Medical Association, Dr. Morris Fishbein (an author I have quoted in this paper) (Woods, 1996). By the 1950s the ANA realized their stake in government affairs was ever increasing. In 1951, the ANA adopted its first Code of Ethics. It warned nurses about the potential of conflict of interest from physicians and advised them to examine those conflicts that interfered with the nurse’s commitment to the patient (Interpretive statements 2.1 and 2.2) (American Nurses Association, 2015). Then in 1952, the ANA House of Delegates reaffirmed nurses’ right to express their individual thoughts regarding health insurance without fear or favor; this would change their political course forever (Woods, 1996).

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Policy Positions in the 1960s on Medicare and Medicaid

The American Medical Association

Later that year, the Truman Commission acknowledged that access to healthcare was a human right and then proposed for Social Security to include old-age insurance (Woods, 1996).  There was increasing demand from the public for a health insurance plan for the elderly. In response, a Medicare strategy was coupled to a plan for a national hospital insurance program for adults older than 65 years of age. Soon after, John F. Kennedy endorsed the proposal during his presidential campaign (1960). He faced immediate opposition from providers, the insurance industry, businesses, conservative organizations, and some members in Congress (Birn et al., 2003, p. 88). They felt Medicare would only lead to rationing healthcare. The presidents of the AMA and the Association of American Physicians and Surgeons said it would cause the deterioration of quality care and was complicit in evil (Kristof, 2009). Kennedy, supported by the senior citizens movement and labor organizations, went on national television from Madison Square Garden to pitch Medicare to the American public in 1962. Later that night, the AMA rented the same arena (now empty) and filmed the AMA president making his rebuttal. Over time, several leaders and organizations came out in support of national health insurance following the assassination of President Kennedy, and in response to the rise of the civil rights and labor movements.  As expected, the AMA, along with the American Hospital Association and President Nixon, released opposing legislation (Birn et al., 2003). They opposed government intervention because it would restrict physician self-referrals and hinder physician autonomy; an argument they started in the 1930s and that would continue for decades (Kristof, 2009; Rodwin, 1996).

Physicians were very suspicious of anything or anyone that stood in between them and their money. The decade before Social Security was enacted, the AMA admitted that physicians were preoccupied with their economic insecurity. Soon after, an AMA poll revealed 43% of patients agreed their doctor overcharged them for healthcare services. So, to appease the AMA, Medicare included physician payments based on “a local calculation of a customary, prevailing and reasonable fee” (Millenson, 2015, p. 1). Physicians were also allowed to refuse Medicare payments which helped them maintain professional self-control (they made a similar request in the 1930s). By the end of the 1960s, physician fees were rising so fast the Senate scheduled hearings on Medicare and Medicaid fraud, and Nixon announced the first healthcare crisis (Millenson, 2015, p. 1). The hearing exposed the pervasiveness of fee-splitting or kickbacks, which were later prohibited (Millenson, 2015). Perhaps the AMA predicted this outcome. Back in 1952, they repeatedly asked for interpretations of the Principles of Medical Ethics and for amendments to liberalize and legitimize these previously condemned practices. Later that decade, the AMA defined fee-splitting more broadly, normalized the practice, and essentially silenced those who opposed it (Rodwin, 1992).

Physicians believed payment models and financial incentives threatened the patient-physician relationship as they could promote both undertreatment and overtreatment (AMA, n.d.). Very little had changed within the AMA from the time Social Security was proposed to the time Medicare and Medicaid were introduced. The Medical Code of Ethics would not be revised again until 1980 (Riddick, 2003).  As such, they continued to make the same arguments and used the code as evidence of their ability to remain self-regulated.

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The American Nurses Association

After forming the ANA Committee on Legislation, the traditionalist subculture shrank and fewer members were opposed to the idea of national health insurance. Afterwards, the ANA supported the Social Security bill (1956) including disability insurance. Then, the ANA House of Delegates voted for nursing services to be included in any prepaid insurance program.  This stance, again in opposition to the AMA, marked a shift in organizational culture. Nurses recognized their own need for health insurance and public opinion shifted in favor of protecting the elderly (Woods, 1996). Therefore, with the formation of a legislative committee, a mandate to freely express their opinion in the Code of Ethics for Nurses, and a shift in consciousness, it wasn’t surprising they supported Medicare from the initial proposal until its enactment (1958-1965) (American Nurses Association, 2015; Woods, 1996).

Unfortunately, the ANA lacked the resources to sufficiently analyze proposals or influence legislation, and the data to demonstrate nurse’s impact; unlike the AMA (Woods, 1996). But they found a staunch ally in Wilbur Cohen (previous Social Security official). He was contacted numerous times by Julia Thompson, the only lobbyist for the ANA for two decades. He later became an insider for the ANA, writing journal articles on their behalf to increase membership in the 1950s. Then in 1960, he became President John F. Kennedy’s chief strategist on Medicare. By 1965 Thompson was ANA president. She was invited to witness the signing of the Medicare Part A and Part B and Medicaid bill when it became law (Woods, 1996). While a number of nursing provisions were not included in the bill, the ANAs’ prestige and recognition grew among the public and the AMA. Nurses were appointed to advisory councils and government task forces to help implement policy (Woods, 1996).

Policy Positions in the 2010s on the Patient Affordable Care Act

The American Medical Association

Soon after opposing Social Security, the AMA formed the National Commission on the Cost of Medical Care (1975) and the Voluntary Effort for Health Care Cost Containment (1977). These moves were the first sign of a change of heart within the AMA who became increasingly aware of the need to control the cost of medical care (Sammons, 1980). This may have prompted the 1980 revision to the Medical Code of Ethics (Riddick, 2003). By the 1990s, there was a shift away from the one unified opinion about healthcare policy towards a collection of voices represented by the diverse body of medical professionals which included women and minorities (Millard, Konrad, Goldstein, & Stein, 1993). Fast forward to 2009 where the predominant reimbursement system at the time incentivized physicians and institutions to treat the sick, while offering few rewards for preventive care or population health (Birn et al., 2003). Millions of Americans lacked health insurance and employer-based insurance plans were too costly. Part-time employees, undocumented workers, and even the middle-class were directly impacted. No one was immune from the threat of a financial crisis in the event of a medical emergency. Rising costs and insufficient access to care left many Americans without the ability to pay for primary healthcare forcing them into overcrowded and costly emergency rooms (Rashford, 2007). It was time for a change, but health reformers didn’t want to face the same obstacles as Truman, Nixon, Carter and Clinton who failed to pass national health insurance (Oberlander, 2010).

Enter the Obama Administration and the Patient Affordable Care Act (ACA) of 2010, the most important piece of healthcare legislation since 1965 (Oberlander, 2010). The administration spent time building a consensus from historically influential stakeholders like the AMA who endorsed the ACA in advance of the 2009 debate (Oberlander, 2010). In fact, a survey of more than 500 AMA members revealed the majority of physicians (89%) believed all Americans should have access to healthcare regardless of their ability to pay. Many believed a government-run, single-payer system (42%) should be combined with tax incentives and penalties to encourage consumers to purchase medical insurance (49%) (McCormick et al., 2009). They believed incentive-based plans would help lower costs, increase coverage, improve quality, and protect their autonomy and compensation (McCormick et al., 2009). This was a huge departure from their stance during the 1930s and 1960s. They went further on to support state Medicaid expansion (2015), and a sustainable plan to cover the uninsured, health equity for underserved populations, and reforms to Medicaid and Medicare (2016). Then when the Trump Administration took office, they notified Congressional leaders of their unwavering position for healthcare reform and the necessary core components (2017) (American Medical Association, 2019). Per the 2001 version of the Principles of Medical Ethics, physicians were to respect the law, but maintain their responsibility to seek changes when the law conflicted with the best interest of the patient (American Medical Association, 2001). To this day, the AMA has continued to oppose repeal of the ACA going as far as filing an amicus brief (California v. Texas) calling for the ACA to remain intact even if the individual mandate is removed (Deutsch, 2020).

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The American Nurses Association

The ANA endorsed the ACA largely because it paralleled their Health System Reform Agenda of 2008 (Haney, 2010). The ACA improved access to care for almost 40 million Americans and expanded coverage for qualifying Medicaid recipients. It removed discriminatory practices like excluding coverage from those with pre-existing conditions and increased funding for a number of community care centers and programs (Haney, 2010). The ACA adopted many of the strategies and aligned with some key players the ANA already supported like the National Academy of Medicine’s six requirements for quality (safe, effective, patient-centered, timely, efficient and equitable care), the National Quality Forum, and the Center for Quality Improvement and Patient Safety. It incentivized primarily nurse-based services like preventive care, wellness programs, chronic disease management, and care coordination (Haney, 2010). When it came to the cost of care, the ACA outlined provisions for consumer protections, cost-sharing, and eliminated deductibles for preventive care.  Most importantly, the ANA supported the ACA because it included provisions to strengthen the healthcare workforce. It increased funding (loans and grants) for nursing education, workforce diversity, loan repayment, scholarships, professional development, leadership, and financial incentives for those working with special populations (Haney, 2020). Per the Code of Ethics for Nurses, nurses are to demand improvements in public health and the healthcare system by vigilantly soliciting policy makers (Interpretive statement 9.3) (American Nurses Association, 2015).  Prior to the AMA, the ANA sent a letter to the Trump Administration (2016) outlining their Principles for Health System Transformation which echoed their support of the core components of the ACA: increased access to care, improved quality, reduced cost of care, and a strong healthcare workforce (Cipriano, 2016). In accordance with Provision 9 of the Code of Ethics for Nurses, they offered to lend their expertise to “improve the healthcare system and the health of the nation” by integrating principles of social justice into health policy (American Nurses Association, 2015; Cipriano, 2016, p.1). To this day, the ANA is guided by their core ethics as they continue to outline their vision for the future of the American healthcare system and advocate for policy makers to recognize nurses’ true value.

Conclusion

Nurses and physicians are uniquely guided by their respective code of ethics which have caused professional organizations to have diverging positions on Social Security in the 1930s, and Medicare and Medicaid healthcare financing in the 1960s. Fortunately now, the debate is over between the ANA and the AMA who are finally able to be full partners in reforming a healthcare system that increases access to care, improves quality, and lowers costs (Institute of Medicine, 2011). Both the Code of Ethics for Nurses and the Code of Medical Ethics endorse the belief that nurses and physicians must protect and ensure everyone has access to healthcare (American Medical Association, 2001; American Nurses Association, 2015). This historical review of the different policy positions the ANA and the AMA have had since the early 1900s demonstrate the power ethics can have when it comes to passing or opposing major healthcare legislation in the United States.

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Kimberly Madison, DNP, AGPCNP-BC

I am a nurse practitioner with a passion for writing, entrepreneurship, education, and mentorship. I created this blog to share my journey as source of motivation and as a blueprint as you embark on your journey. Most importantly, I’m looking forward to increasing access to dermatology education and clinical training for aspiring and practicing nurse practitioners. I invite you to view the mission and vision statement on the homepage to see how we can best partner to make our dreams align.

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References

AMA. (n.d.). Chapter 11: Opinions on Financing and Delivery of Health Care.

American Medical Association. (2001). AMA Code of Medical Ethics: AMA principles of medical ethics.

American Medical Association. (n.d.). Code of Medical Ethics overview.

American Medical Association. (2019). The American Medical Association and health system reform, 2007-2019.

American Nurses Association. (n.d.). The history of the American Nurses Association.

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.

Baer, E. (1985). Nursing’s divided house – An historical view. Nursing Research, 34(1), 32-38.

Birn, A., Brown, T., Fee, E., & Lear, W. (2003). Struggles for national health reform in the United States. American Journal of Public Health, 93(1), 1848-1857.

Brosco, J. (2012). The enduring historical legacy of federal children’s health programs in the United States. American Journal of Public Health, 102(10), 1848-1857.

Cipriano, P. (2016). ANA’s principles for health system transformation. American Nurses Association.

Deutsch, J. (2020). AMA, physician groups defend ACA gains in new Supreme Court filing. American Medical Association.

Fishbein, M. (1946). History of the American Medical Association. JAMA, 132(11), 636-638.

Fowler, M. (2017). Why the history of nursing ethics matter. Nursing Ethics, 24(3), 292-304.

Haney, C. (2010). Health system reform: Nursing’s goal of high quality, affordable care for all. American Nurses Association.

Hartman, M., Martin, A., Benson, J., Catlin, A., & members of the National Health Expenditure Accounts Team. (2020). National health care spending in 2018: Growth driven by accelerations in Medicare and private insurance spending. Health Affairs, 39(1), 8/17.

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. The National Academies Press.

Kearney, J. (2005). Social security and the “D” in OASDI: The history of a federal program insuring earners against disability. Social Security Bulletin, 66(3), 1-27.

Kristof, N. (2009). The wrong side of history. The New York Times.

McCormick, D., Woolhandler, S., Bose-Kolanu, A., Germann, A., Bor, D., & Himmelstein, D. (2009). U.S. physicians’ views on financing options to expand health insurance coverage: A national survey. Health Policy, 24(4), 526-531.

Millard, P., Konrad, T., Goldstein, A., & Stein, J. (1993). Primary care physicians’ views on access and health care reform: The situation in North Carolina. Journal of Family Practice, 37(5), 439-444.

Millenson, M. (2015). Medicare, fair pay, and the AMA: The forgotten history. Health Affairs.

Oberlander, J. (2010). Long time coming: Why health reform finally passed. Health Affairs, 29(6), 1112-1116.

Oberlander, J. (2019). Lessons from the long and winding road to Medicare for all. American Journal of Public Health, 109(11), 1497-1500.

Rashford, M. (2007). A universal healthcare system: Is it right for the United States? Nursing Forum, 42(1), 3-11.

Riddick, F. (2003). The code of medical ethics of the American Medical Association. The Ochsner Journal, 5(2), 6-10.

Rodwin, M. (1992). The organized American medical profession’s response to financial conflicts of interest: 1890-1992. The Milbank Quarterly, 70(4), 703-741.

Salmond, S. & Echevarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopedic Nursing, 36(1), 12-25.

Sammons, J. (1980). Medicine’s role in health care cost containment. West Journal of Medicine, 132(5), 392-398.

Schlabach, T. (n.d.). Rationality & welfare: Public discussion of poverty and social insurance in the United States 1874-1935. Chapter 4: Medical men: Personalized prescription for institutional illness. Social Security.

Thomas, K. (2006). The Hill-Burton Act and Civil Rights: Expanding hospital care for black southerners, 1939-1960. Journal of Southern History, 72(4), 823-870.

Woods, C. (1996). Evolution of the American Nurses Association’s position on health insurance for the aged: 1933-1965. Nursing Research, 45(5), 304-310.

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