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The national dialogue on the "fiscal cliff" brings into question the long-term sustainability of Medicare as the primary source of medical care for older adults in the United States. Yet, significant problems threaten Medicare's efficacy today, as many older adults are unable to get the care they need.

Take the case of Katie's father, who recently signed up for Medicare. He could not find a primary care provider willing to take a new patient with Medicare. With multiple chronic diseases, he suddenly found himself with chest pain, no doctor, and unsure where to go to get care.

Three main problems hinder older adults' access to quality medical care: ineffective reimbursement of providers, a shortage of primary care providers, and inadequate systems to leverage the role of nurse practitioners in health care delivery.

Medicare reimbursement has remained stagnant for nearly 10 years, while costs have increased by over 20 percent. Sequestration could result in significant cuts to this already inadequate reimbursement.

Congress often waits until expiration deadlines to renew Medicare allocations to physicians, thus creating uncertainty. Because reimbursement is too low, many providers refuse to take patients on Medicare, and consider accepting them to be "charity work."

The Medicare Payment Advisory Commission reported earlier this year that the number of Medicare patients reporting they had a "big problem" finding a primary care doctor nearly doubled — from 12 percent in 2009-2010 to 23 percent in 2011.

The shortage of primary care providers is skyrocketing due to population growth and the increased number of insured Americans that will result from the Affordable Care Act. The Association of the American Medical Colleges predicts this shortage will reach 90,000 by 2015 and leap to 130,000 by 2025.

Some governmental programs such as the National Health Services Corps promote an increase in primary care providers by supporting education for medical students choosing primary care. The ACA provides additional but limited support to promote primary care medical education, and the estimated impact of an additional 500 primary care physicians is sorely inadequate.

Also, potential caps on funding of graduate medical education from the Center for Medicare and Medicaid Services, or CMS, will decrease medical education when we need it most. A broader view of the primary care workforce is essential.

Licensed primary care providers such as nurse practitioners and physician assistants are prepared and licensed to provide primary care to older adults.

We applaud CMS for extending the graduate medical education model to fund education for nurse practitioners. Through a new demonstration project designed to expand the nation's primary care workforce, CMS is funding five hospitals to offset the costs of clinical training for nurse practitioner students. This model should be expanded.

In Utah, laws support the role of the nurse practitioner to provide primary care to the full extent of their training. However, Medicare reimbursement policies result in inequitable compensation to these practitioners serving Medicare beneficiaries.

NPs are positioned to play a critical role in health care homes and accountable care organizations planned as part of health care reform.

Recent decisions by CMS to include nurse practitioners in providing transitional care are on target to leverage the role of NPs in the healthcare workforce. Opportunity also exists for nurses to provide care coordination to improve patients' clinical outcomes and reduce costs.

It is essential for Medicare to make some major changes in reimbursement and spending practices to provide more accessible and effective health care for older adults. An aggressive plan to increase the primary care workforce that includes physicians, nurse practitioners and physician assistants is urgently needed.

Patients need access to care today and plans to ensure their health care needs will be met tomorrow.

Susan L. Beck is a professor and holds the Robert S. and Beth M. Carter endowed chair at the University of Utah College of Nursing; Gail Towsley is an assistant professor in the College of Nursing. The op-ed is a collaborative effort by doctoral students and faculty in the college's Leadership and Health Policy class. The students are Sharifa Al-Qaaydeh, Katie Baraki, Deborah Himes, Kevin Langkiet, Ann Lyons, Susan Matney, Katie Moore, Nancy Thum-Thomas and Dawn Wold.