The evidence is strong that the growth of advanced nurse practice has contributed to improved access to general care (Aiken et al., 2009). Over the past decade advanced practice nurses have largely staffed the new retail clinics that currently provide about 3 million ambulatory visits a year at an estimated per visit cost of below the average cost to a physician office. Additionally, advanced practice nurses have enabled the largest expansion of Community Health Centers (CHCs) since the Great Society Program; CHCs currently provide over 16 million visits in 7,300 sites to largely underserved people. In total, advanced practice nurses are estimated to provide up to 600 million ambulatory patient visits a year, a national primary care capacity enhancement that will become increasingly critical to access in a context of primary care physician shortage.

The rate of production of new advanced practice nurses (APNs) which had been growing steadily since the 1970s has been flat in recent years. Interest among nurses in advanced practice roles appears strong but the shortage of student financial aid for graduate nurse education has a chilling effect on enrollment growth. It is difficult for many nurses to forego employment income to attend graduate programs full time without scholarships or loans which are in short supply. The major source of funding for graduate nurse education is Title VIII annual appropriations which currently total about $60 million (estimate for graduate education only, not all of Title VIII funding), compared to $2.4 billion for direct graduate medical education for physicians. A large proportion of APN students pursue graduate education on a part-time basis which slows the production of new graduates. Employer tuition benefits, an important source of educational assistance for practicing nurses, have been reduced during the economic downturn, eroding available financial support for graduate nurse education, particularly at the master’s level which is generally required for advanced nurse clinical practice.

Medicare, since its inception, has paid for a share of graduate medical education. It has also reimbursed some hospitals for a portion of their nursing education costs. An analysis we conducted of 2006 HCRIS data from the Centers for Medicare and Medicaid Services (CMS) suggested that Medicare funding for nursing education was slightly less than $160 million annually, a small amount compared to medical education investments, but almost as much as all of Title VIII funding for nursing in that year. CMS has a larger estimate of $300 million in Medicare payments for nursing education but we cannot verify that estimate with publicly available data. But whether Medicare funding is $160 million or $300 million annually, policies governing expenditures are very different from how the funds are spent in support of medical education, the amount is large relative to other sources of federal support for nursing education, and the funding does not materially affect the supply of nurses or the quality of nursing

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