Globalization of healthcare marches merrily onward with a Michigan bill hearing this week. Corporate lobbies always play a strong role at these events. This time, there’s a twist.

Big Healthcare lobbied for Obamacare in Congress, and drives most healthcare bills in DC and Lansing. More obscure healthcare lobbies are leading centralization of state health occupational licensure. It still violates market principles, and it’s important to your healthcare.

Individual healthcare rights are losing out to population care. Given what’s at stake, we should probably make an effort to push back on this one.

Here are some talking points:

The State of Play in Lansing

A long list of health profession licenses are on track to hand rule-making authority over to yet another layer of regulators — independent new commissions, designed by current regulators and backed by corporate lobbies.

• Last fall, between a rock and a hard place, MI physicians accepted the Interstate Medical Licensure Compact as part of “a crummy deal” to curb manipulative accreditation practices.
• The enhanced Nurse Licensure Compact (eNLC) is up for second hearing Thursday, June 6, before the MI House Health Policy Committee.
• The bill adds MI to a nationwide compact, governed by an independent commission, for an annual fee of $6000. It foists additional IT mandates and paperwork, with no additional revenue, upon Michigan’s Department of Licensing and Regulatory Administration (LARA), which was none too pleased at the time of the first hearing on April 11.
• I was present and testified against the bill on behalf of Michigan Healthcare Freedom. Moving rule-making power away from individuals and elected state officials is against free enterprise, federalism, and representative government.

Licensure in the big picture

Health profession licensure is a market barrier: in the name of safety, we limit who may work. In the grand scheme of barriers to healthcare job entry, licensure is only one of many; it has say over some of the others. LARA is no defender of free enterprise. Still, we the people can hold it accountable through those we elect. None of healthcare’s other job-entry barriers have the same accountability.

Not to put too fine a point on it, the other job-entry barriers associated with licensure are controlled by professional elites. They have high qualifications, high standards, and the best intentions in the world as they determine entry to higher education, control licensure exams, and administer formal disciplinary procedures… but they are not elected to represent the people as legislators, and we cannot hold them accountable at the ballot box for how well they secure our individual rights.

By no coincidence, these are exactly the same experts who ask for more power over nurses with this bill.
*Note: some people truly, passionately, in their heart of hearts believe in the rule of experts. Experts, in particular, fall into this camp.
**Note too: the rule of experts is not the same as self-governance, even when and despite the fact that experts label their system “professional self-governance.” Self-governance allows individual autonomy to innovate, most notably restricted in front-line healthcare today. Standardization is the goal of today’s healthcare experts.

Their other policy goals? Ever hear of msn vs dnp nursing categories? Essentially some categories are being revamped and they are requiring a doctorate for nurse practitioners(already in short supply) and nursing instructors (in even shorter supply, and the major bottleneck to the supply of more nurses).

Expect shortages to worsen long-term under such policies.

Mission Creep

Some will say, “But participation in compact licenses is voluntary.”

Licensure has always suffered from mission creep. How long will a duplicate structure last under state budget crunches? Especially given our prevailing faith in the rule of experts?

The Nurse Registries of a century ago began as optional, and then grew into mandatory licensure. Michigan added fees, increased them, added mandatory Continuing Education hours (CE) and increased fees again, added voluntary online renewal and a CE computerized filing system, and increased fees yet again. Current nurse licenses require online renewal, $121, and 26 CE.

Given the trend, online CE filing may be mandatory by the time you’ve finished reading this. Or maybe we’ll just hand the filing system over along with the rest of licensure to the eNLC Commission for centralized efficiency and the rule of experts.

Mission creep and control. It’s what licensure is all about.

Who Asked for This Bill? Not Bedside Nurses.

Only 8% of nurses travel for a living. Assuming minimal data entry competency – and nurses have become data entry experts under Obamacare – those entering MI are legal to practice within two weeks. One day for an emergency.

Bill sponsor claims that the bill helps the nurse shortage were thoroughly debunked at the first hearing. Nurse shortages are nationwide.

State to state mobility is no barrier to real-world practicing nurses. It’s so low on their concerns radar, it doesn’t even make the list. Licensure barriers could be minimized by reducing associated mandates and fees, but MI already engages in nurse license reciprocity with other states. Nurses near the MI border have even hacked a vehicle registration trick and maintained their nurse licenses in neighboring states with lower fees.

Who benefits? Corporate interests.

Lacking voter accountability, independent compact commissions are wide open to industry influence.

• The top national regulator of US nurses is the National Council of State Boards of Nursing (NCSBN).
  NCSBN advertised its 2018 global nursing regulatory atlas as a service to global customers, but how much more efficient to actually deliver an entire nation of nurses under one regulatory regime? Naturally, global regulation would be even more efficient, if national lines could be erased. Besides controlling nurse licensure exams, NCSBN is the author of the eNLC, and provided the lead expert testifying in support of Michigan HB 4042.
• Other supporters include major Michigan healthcare lobbies: Michigan Health and Hospital Association, AARP, and an assortment of regional health and provider networks. Labor unions were divided. Interestingly, hearing minutes only listed supporters, not opponents whose cards were read into the record. Does that indicate a boost from the legislature’s dominant party?
• Corporate interests already exert a high level of control over individual practice through the ACA, and they have reason to want state borders gone. Hospital and insurance mergers crossed state lines long ago. They have now gone vertical with acquisitions of their own pharmacy and pharmaceutical middleman operations. The latest hot deals are trans-national healthcare mergers and acquisitions (including travel nurse agencies), all of whom benefit from reducing license negotiations to one entity.
• Sponsors of a recent Detroit summit included the Michigan Economic Development Corp., Beaumont Health, and the Wayne State University School of Medicine, and featured “… a regional health care innovation cluster comprising health care providers, universities, and economic development organizations in southeast Michigan and southwest Ontario.”
• Wayne State University is home to a second potential compact beneficiary: the Dean of Nursing testified in support, citing benefits to incoming grad students and faculty who taught an out of state clinical.

Healthcare Rights are Experienced Locally (or not)

Having our choice of care, attuned to our local culture, that offers our family and friends their choice of healthcare employer and work environment, is a blessing we owe to free enterprise.

Choices disappear under monopoly mergers, and even more with acquisitions of allied industries. Monopolies of multiple service lines produce “coal towns,” where people have no choice of where to work or where to shop. They owe their souls to the company store.

By benefiting monopolies, centralized licensure sets us up for violation of individual rights. State lines stand in the way of globalization. State lines, and state elected officials, exist to defend our individual rights.

Representation, and “But Compacts are Constitutional!”

We elect legislators to represent us. We expect them to secure our individual rights against narrow-interest demands of big businesses and regulators, whether they speak for institutions of higher learning, certification, or corporate healthcare.

As far back as 1999, the Kansas Attorney General ruled that a licensure compact represents an unconstitutional delegation of legislative (rule-making) authority. The non-delegation principle traces all the way back to John Locke, a physician as well as a primary source of American founding political philosophy.

Compacts were intended for states to take over what is ordinarily a federal power. Advocates of health-licensure compacts are not the first to use a constitutional provision for an unconstitutional goal.

Granted, good license-related oversight and legislation is hard work. (Has anyone gotten a detailed spending report from LARA lately?) If the job has become too much for the Michigan legislature, they have a different option. Send power back to the individual instead of towards the elites. Peel back excess licensure. Term limit all licensure. Last in, first out. Restore entry-level healthcare jobs like nurse’s aide and pharmacy tech to their proper, unlicensed place in healthcare.

Allowing the right to work and the right to contract a little more freedom fits the needs of our day. We are in no danger of regulation shortages, but the staffing and health shortage areas are a daily problem.

It’s time we grew some teeth to defend the foundations of individual healthcare rights. If your legislator doesn’t know a reason to vote No on HB 4042 and all future licensure compacts, please give them one.