534494
research-article2014
NSQXXX10.1177/0894318414534494Nursing Science QuarterlyReed / Health and Public Policy
Health and Public Policy
Affordable Care Act: Overview and Implications for Advancing Nursing
Nursing Science Quarterly 2014, Vol. 27(3) 254–259 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414534494 nsq.sagepub.com
Deborah Vincent, RN; PhD1 and Pamela G. Reed, RN; PhD; FAAN2
Abstract The Affordable Care Act (ACA) confronts nursing with opportunities as well as challenges. The authors provide an overview of the ACA and highlights opportunities for nursing practice, research, and doctoral education. The importance of disciplinary foundations is also addressed as relevant to envisioning the future of practice and education in the context of healthcare reform. Keywords advanced practice nursing, Affordable Care Act, healthcare reform, health policy
As nurses, we need to be able to articulate our understanding of the Patient Protection and Affordable Care Act (PPACA) or ACA for short, in terms of how our work and values interface with this new healthcare policy. This policy confronts nursing with critical changes in healthcare. Where there is change, there is opportunity for growth. It is likely that among some of the difficult changes nurses will experience, nursing as a discipline may also find new applications of its philosophical and theoretical ideas in research and practice. Nurses are situated in various roles and healthcare contexts where they can influence the future of healthcare. The authors provide an overview of key components of the ACA and then address some of the opportunities and challenges this policy presents for nursing and nurses.
Patient Protection and Affordable Care Act (PPACA) Overview The Patient Protection and Affordable Care Act, often known as the Affordable Care Act (ACA), is a landmark piece of legislation enacted in 2010. Although the ACA was signed into law in 2010, its various components will be phased in over nearly 10 years (USDHHS, 2014b). The goal of the law is to improve the affordability, availability, and quality of health insurance for Americans through a variety of mechanisms such as consumer protections, regulations, taxes, subsidies, health insurance exchanges, and healthcare delivery reforms. While the law is complex, the key elements can be classified into two main categories: Insurance Reform and Health System Reform (USDHHS, 2014a).
Insurance Reform The first component of the ACA, insurance reform, is probably the most widely known and many of the elements remain controversial. Key insurance reform features of the ACA that were enacted in the first few years after the legislation was signed into law are the following: prohibitions against denial of health insurance coverage for children with preexisting conditions, elimination of lifetime limits on insurance coverage, a requirement for insurance companies to cover select preventive care services without charging deductibles, co-pays or coinsurance, extending parental insurance coverage to adult children up to age 26, and the individual mandate (Jost, 2014). Other reforms include premium tax credits designed to make health insurance affordable for families (Assistant Secretary for Planning and Evaluation, 2012), gradual closure of the Medicare Part D prescription drug “doughnut hole,” expansion of the Medicaid program, and development of healthcare exchanges. In eliminating the two cost-controlling mechanisms, preexisting condition exclusions and lifetime limits, insurance companies were at greater risk for large financial losses due to adverse risk selection. Adverse selection occurs when a 1
Associate Professor, The University of Arizona Professor, The University of Arizona
2
Contributing Editor: Pamela G. Reed, RN; PhD; FAAN, Professor, University of Arizona College of Nursing, 1305 N. Martin St., Tucson, AZ 85721-0203. Email: [email protected]
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Reed / Health and Public Policy greater proportion of unhealthy individuals purchase health insurance (Chandra, Gruber, & McKnight, 2011). An example is when an uninsured person who has just been diagnosed with cancer and knows that he or she will need expensive treatment, purchases health insurance without revealing the cancer diagnosis to the insurance company.
The Individual Mandate The individual mandate was designed to offset adverse selection by both increasing the size of the risk pool and by decreasing the level of risk through the inclusion of healthy individuals in the risk pool. Many policy-makers and insurance companies argued that without an individual mandate, insurance premiums for healthy people would increase and ultimately lead them to exit the insurance market, causing premiums to rise even higher (Chandra et al., 2011). The individual mandate requires that all Americans buy health insurance coverage beginning in 2014 or pay a penalty. Wakefield (2013) provided a helpful perspective and information for guiding patients on enrollment. Individuals who cannot afford coverage (that is, whose cost of premiums would exceed eight percent of household income) and those eligible for Medicaid under the Medicaid expansion provision are exempt from the mandate. While the individual mandate has been upheld by the Supreme Court, it remains controversial (Jost, 2014). Evidence from Massachusetts, which underwent health reform with an individual mandate in 2006, suggested that the mandate did result in improving risk selection and that healthy people did enroll (Chandra et al., 2011).
Medicaid Expansion Another insurance reform is the expansion of Medicaid. Under the ACA (and prior to the 2012 Supreme Court decision described below), Medicaid was planned to expand coverage to nearly all low income Americans under the age of 65, with each state receiving substantial federal support for the expansion. The Medicaid expansion would have largely benefited low-income, childless adults who were ineligible for Medicaid coverage in more than 40 states (American Public Health Association, 2014; Sommers, Kenney, & Epstein, 2013). Before ACA, only 30% of poor non-elderly adults had Medicaid and 42% of all poor adults were uninsured (Kaiser Commission on Medicaid and the Uninsured, 2013). However, the 2012 Supreme Court decision halted the Medicaid expansion by permitting states to opt out of the Medicaid expansion. Low-income individuals are now at a distinct disadvantage in states that have chosen to opt out of the Medicaid expansion. Tax subsidies for insurance purchased on the Exchanges are available only to those with incomes 100 percent above the federal poverty level. People whose income falls below that cut point are eligible for insurance through
Medicaid unless they live in an opt-out state. For those in the opt-out states, there will be a coverage gap for approximately 5 million poor uninsured adults. Those who fall into the coverage gap are likely to face significant barriers in accessing necessary healthcare services, and clinics and hospitals that care for the uninsured will face serious financial consequences (Kaiser Commission on Medicaid and the Uninsured, 2013). As of February 2014, 19 states have declared they will not expand Medicaid, while 26 states and the District of Columbia have begun expansion along with another six considering expansion (Kaiser Family Foundation, 2014). Findings from a study of four early adopter states suggest that Medicaid enrollment is steady and has become more robust over time; indications are that enrollment may exceed expectations in those states (Somers, 2014).
Healthcare Exchanges Another major type of insurance reform is the development of healthcare exchanges. Problems with the federal government health insurance exchange website in Fall of 2013 brought much attention to the healthcare exchanges. Exchanges are organizations designed to facilitate the purchase of health insurance. Some states, such as California and Massachusetts have set up their own exchanges, while other states, such as Arizona will participate in the federal exchanges. Exchanges can be thought of as marketplaces that provide consumers with standardized healthcare plans and provide transparency of benefits and costs. “These marketplaces fill a gap for individuals without employer-provided coverage, those not old enough or poor enough to qualify for Medicare or Medicaid.” (Ewoldt, 2014, p. 9). The exchanges are not health insurance companies but they do determine which companies are allowed to sell polices and what these policies must cover. As of January 31, 2014, 3.3 million people have selected insurance plans through the exchanges. Nearly two million people have selected their plans through the federally administered exchanges (Jost, 2014). In summary, three major insurance reforms were discussed: the individual mandate, Medicaid expansion, and healthcare exchanges. These were designed to increase the number of those with insurance, enhance benefits and protections, and lower costs. Health system reforms are the second arm of the ACA and have purposes that differ from insurance reform.
Health System Reform Probably less well-known than the ACA insurance reforms are the health system reforms designed to improve quality and efficiency, enhance the healthcare workforce, and increase public health and prevention services. Health system reform is a necessary component of the ACA given the
256 expectation that the ACA insurance reform will generate more people who have insurance coverage, and thus more people will seek healthcare. The Patient-Centered Medical Home (PCMH) and Accountable Care Organizations (ACO) are healthcare delivery models promoted by the ACA to expand access to care, especially primary care, and to improve quality and efficiency of healthcare. In addition, increased funding for Federally Qualified Health Centers, National Health Service Corps, and school-based health centers will increase quantity and quality of public health services.
Patient-Centered Medical Homes Patient-centered medical homes promote a team based approach to health care with a primary provider serving as a care provider and coordinator. The team may include a workforce mix of physicians, advanced practice nurses [similarly called nurse practitioners (NPs) or advanced practice registered nurses (APRNs)], other nurses, physician assistants, pharmacists, dieticians, social workers, educators, and therapists (Auerbach et al., 2013). While the medical home concept is not new (Stokowski, 2012) passage of the ACA has provided a new impetus for the creation and dissemination of medical homes. The medical home approach to healthcare delivery has five features: 1. It is patient-centered and emphasizes a partnership among provider, patient and family where patients are informed and active decision-makers. 2. Care is comprehensive in addressing physical and mental healthcare needs, from wellness to acute and chronic illnesses, to end of life. 3. Care is coordinated and continuous across the healthcare system, from specialty and hospital care to community-based and home healthcare. 4. Services are accessible in terms of both place and time, through use of electronic and 24/7 phone communication as well as in-person visits during regular business and expanded hours. 5. There is a commitment to safe care and quality improvement practices. Information technology, open communication, and culturally competent care are other hallmarks of this delivery model. The interdisciplinary team is led by the primary care provider such as a nurse practitioner or medical doctor (Klein, Laugesen, & Liu, 2013).
Accountable Care Organizations (ACO) Under the ACA, Accountable Care Organizations (ACO) have become part of the Medicare program and are being promoted as a way to reduce healthcare costs and improve quality of care (DeVore & Champion, 2011). ACOs
Nursing Science Quarterly 27(3) incentivize providers (primary care providers, specialists, and hospitals) to form networks to coordinate care. Penalties are assessed by Medicare if pre-established goals (set by the ACO) are not met, whereas incentive payments are provided if the goals are met (Graham, 2011). ACO members are jointly accountable for the quality of care, cost, and overall care of their patients. Nurse practitioners initially were authorized as ACO professionals under the ACA but “a last minute change in the statute limits patients assigned to [Medicare ACOs]” to those treated only by a primary care physician (American Academy of Nurse Practitioners (AANP), 2012). As currently organized, ACOs provide nurses with increased opportunities to engage in care coordination and patient education, but nurse practitioners are not (yet!) recognized by ACOs as primary care providers (Burns & Pauly, 2012; AANP, 2012). In sum, the PCMH and ACO models of healthcare delivery can work together to provide quality, cost-effective care. The PCMH provides and coordinates direct care while the ACO incentivizes team-based communications and collaboration across the spectrum of health services, including primary care and specialties. Other goals include healthcare that is more complete, more responsive, and timelier for patients. These health system reforms provide both opportunities and challenges for nurses.
Issues and Implications Medical Home and Nursing Philosophy of Care The medical home model presents policy-related issues for healthcare disciplines other than medicine. For example, the American Psychological Association (2009) expressed concern over inclusion of psychologists on the primary care team, and suggested that the delivery model more appropriately be called the “health home model.” Similarly, nurses have proposed use of neutral provider language such as health care homes” (Keeling & Lewenson, 2013, p. 365), and they identified important policy issues regarding who will lead the team, type of care, and location of care. Historically, many of the attributes of what was called a nursing model of care delivery are found in today’s medical home. Nursing has significant history in delivering care that reaches out to the underserved and culturally-diverse groups, is community-based and family-centered, and promotes health and self-care while providing comprehensive, compassionate, and coordinated care. These historical practices align with the nursing philosophy of practice. According to the philosophy, for example, nursing is a distinct and collaborative discipline. Nurses focus on health experiences of individuals in the contexts of family, community, and culture. Health and well-being can occur within illness. Health promotion is not a practice that is focused only on the medically well, but focused across the trajectory of health and illness, and across the lifespan from birth to end of life.
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Increase in the Practice and Roles of Nursing The ACA will dramatically expand opportunities in nursing practice. Increasing capacity and modernizing the healthcare workforce is a major aim of the ACA (Robert Woods Johnson Foundation, 2012). The ACA contains many programs that will expand and re-envision the healthcare workforce. The ACA will create a National Health Care Workforce Commission and National Center for Health Care Workforce Analysis. Together these commissions will identify workforce priorities and goals, identify effective local and state strategies for improving the health-care workforce, and make recommendations to Congress and the White House. Under the ACA, primary care is recognized as vital to controlling costs and increasing access to care. The implication for nursing is that this will result in the need for more primary care providers, namely advanced practice nurses (Green, Savin, & Lu, 2013). While a shortage of primary care physicians is predicted, advanced practice nurses have an opportunity to become the preeminent primary care workforce of the future (Rickets, 2013). The quality of care provided by nurse practitioners in primary care settings is already well-documented (Horrocks, Anderson, & Salisbury, 2002; Newhouse et al., 2011). The majority of health system reforms focus on teambased care and enhanced roles for nursing. For example, there are provisions in the ACA for wellness models of care such as community and school health centers and nursemanaged centers, all of which logically would be under the leadership of advanced practice nurses (Auerbach et al., 2013). The ACA defined nurse-managed health centers in the law and created a federal grant program to provide funding for 10 nurse-managed centers with APRN-led primary care. Additional funds are available for states to develop innovative methods for expanding primary care at the state and local levels. As the ACA is implemented, opportunities for new roles for providers, and potentially new provider types, are likely to develop. Restructuring of the healthcare delivery system will emphasize primary care and management of chronic conditions, and will deemphasize acute care. Quality initiatives under ACA include patient-centered, coordinated care across the health trajectory. These are all strengths of nursing.
Nursing Research The ACA has implications for research in nursing practice. Whether the medical home will achieve its philosophical and pragmatic goals is a focus for scientific inquiry. The ACA contains provisions that support demonstration projects for medical homes. Nurse practitioner-led medical homes are developing in those states that permit independent nurse practitioner practice (Cassidy, 2010; Stokowski, 2012). Currently the ACA is funding many demonstration projects
for the purpose of assessing what are effective and innovative models for delivering high quality, cost-effective, patient- centered care. In addition to the demonstration projects that examine the effectiveness of healthcare delivery models, research can occur on a smaller scale into specific healthcare problems and experiences of patients, health outcomes, and patient satisfaction. Nursing research can target studies on empowering patients through the increased transparency in healthcare information and open communication of the ACA. Nursing theories are sources of knowledge that could be tapped to design models of care and communication that improve patient care experiences and health outcomes. Theory-guided studies may examine for example, factors and innovative approaches that facilitate active engagements and partnerships of patients and family caregivers in healthcare, and that help nurses organize complex care needs of patients while championing patient priorities for well-being, meaning, and respect throughout their healthcare experience.
Continued Challenges for Nursing Practice Despite these opportunities, nurses face challenges in implementation of the ACA. Variations in scope of practice and other regulations continue to impede nurses in practicing to their full potential (Pohl, Hansen, Newland, & Cronenwett, 2010; Rickerts & Fraher, 2013). Scope of practice laws and regulations vary across the states and often result in serious restrictions for advanced practice nurses. For example, some states prohibit nurse practitioners from prescribing medications (IOM, 2010). This variability will hinder the increased access to care promised under the ACA and will likely constrain efforts to develop innovative primary care delivery models. And as already mentioned, Medicare financed ACOs limits patients only to those under treatment of a primary care physician not nurse. Reimbursement barriers will also impede the increase growth of advanced practice nurses in primary care and the development of innovative delivery models. Medicare and Medicaid reimbursement remains a challenge. Medicaid is administered by the states, so reimbursement varies from state to state, with some requiring nurse practitioners to have a collaborative agreement with a physician. This can result in physician supervision rather than physician collaboration (Pohl et al., 2010). Medicare’s reimbursement policies are also problematic. Medicare reimbursement in general is low and nurse practitioners are reimbursed at 85% of the fee schedule for physicians (AANP, 2013). In summary, although initiatives to strengthen the primary care workforce that call for advanced practice nurse as key providers will provide greater opportunities for nursing, regulatory and reimbursement policies in many states are obstacles to greater reliance on nurses (IOM, 2010; Green et al., 2013). Restrictions on reimbursement to nurses may be
258 resolved by the ACA but that remains to be seen. Nurses will need to persevere in their vigilance and organized efforts to change regulatory and reimbursement policies that impinge on their scope of practice and its benefit to human health and well-being.
Ending with Nursing Education–Where It All Begins The ACA contains many education-based provisions for expanding the nursing workforce beginning with lifting the cap on Advanced Education Traineeships that previously was limited to giving no more than 10 percent of its funding to doctoral students. The Nurse Faculty Loan Program, the Student Loan Program, and the Nursing Workforce Diversity Programs all receive support under ACA (Wakefield, 2010). The law also provides education and training funds to expand the number of advanced practice nurses and other primary care providers (USDHHS, 2013). There are three-year grants of $50 million each to five hospitals to train advanced practice nurses, including nurses in community-based settings (White House Fact Sheet, 2012). Recognizing the increased complexity of healthcare, the IOM (2010) report, The Future of Nursing, calls for advanced practice nurses to be educated at the doctoral level, the highest level to ensure that they provide safe, patient-centered care. But also beyond this, the ethical, theoretical, methodological, and empirical foundations of doctoral education help nurses acquire the ability to become creative and visionary leaders in knowledge development for practice and policy, and leaders who bring something to the table of their interprofessional peers. Healthcare reform entails interprofessional work and savvy, and the IOM Report (2010) advocates for interprofessional education. Nurses will need not only the practice skills and science-based knowledge of patients’ healthcare problems and standard treatment approaches; they must be wellgrounded in the theories and research methods of their discipline and related disciplines that inform their practice policies. The implications of both the ACA and the IOM Report (2010) point to greater roles and leadership in practice, but also in administration and policy. Nursing education must prepare leaders of the future – nurses who can navigate boardrooms, health policy think tanks, and legislative halls. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this column.
Funding The author received no financial support for the research, authorship, and/or publication of this column.
Nursing Science Quarterly 27(3) References American Academy of Nurse Practitioners (AANP). (2012). Fact Sheet: Accountable Care Organizations. Retrieved from http:// www.aanp.org/component/content/article/68-articles/343accountable-care-organizations. American Association of Nurse Practitioners (AANP). (2013).Fact Sheet: Medicare reimbursement. Retrieved from http://www. aanp.org/component/content/article/68-articles/325-medicarereimbursement. American Psychological Association. (2009). Health care reform: Congress should ensure that psychologists’ services are key in primary care initiatives. Retrieved from http://www.apapracticecentral.org/advocacy/medical/health-care-reform American Public Health Association (2014). Advocacy & policy. Medicaid expansion. Retrieved from http://www.apha.org/ advocacy/Health+Reform/ACAbasics/medicaid.htm. Assistant Secretary for Planning and Evaluation. (2012). 2012 HHS Poverty guidelines. US Department of Health and Human Services. Retrieved from http://aspe.hhs.gov/ poverty/12poverty.shtml. Auerbach, D., Chen, P. Friedberg, M., Reid, R., Lau, P., Buerhaus, P., Mehrota, A. (2013). Nurse-managed centers and patientcentered primary care. Health Affairs,32(11), 1933-1941. Burns, L., & Pauly, M. (2012). Accountable Care Organizations may have difficulty avoiding the failures of the integrated delivery networks of the 1990s. Health Affairs,31(1), 24072416. Cassidy, A. (2010). Patient-centered medical homes. Health Affairs Health Policy Brief, 1-6. Retrieved from www.healthaffairs. org Chandra, A., Gruber, J., & McKnight, R. (2011). The importance of the individual mandate –evidence from Massachusetts. New England Journal of Medicine, 364(4),293-295. DeVore, S., & Champion, R.W. (2011). Driving population health through Accountable Care Organizations. Health Affairs, 30(1), 41-50. Ewoldt, L.L. (2014). Healthcare reform: resolve to increase your knowledge in 2014. American Nurse Today, 9 (1), 8-11. Graham, M.C. (2011). Accountable Care Organizations: The future of health care? The Nurse Practitioner, 36(8),11. Green, L., Savin, S., & Lu, Y. (2013). Primary care physician shortages could be eliminated through use of teams, nonphysicians and electronic communication. Health Affairs, 31(1),11-19. Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324, 819–823. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap. edu/openbook.php?record_id=12956&page=R1. Jost, T. (2014). Implementing Health Reform: A January Exchange enrollment update. Health Affairs Web First. Retrieved from http://healthaffairs.org/blog/2014/02/13/implementing-healthreform-a-january-exchange-enrollment-report/ Kaiser Commission on Medicaid and the Uninsured (2013). The uninsured: A primer. The Henry J. Kaiser Family Foundation. Retrieved from www.kff.org. Kaiser Family Foundation. (2014). Status of State Action on the Medicaid Expansion Decision, 2014. State Health Facts.
Reed / Health and Public Policy Retrieved from http://kff.org/health-reform/state-indicator/ state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Keeling, A., & Lewenson, S.B. (2013). A nursing historical perspective on the medical home: Impact on health care policy. Nursing Outlook, 61(5), 360-366. Klein, D., Laugesen, M., & Liu, N. (2013). The patient-centered medical home: A future standard for American healthcare? Public Administration Review, 73(s1), S82-S92. Newhouse, R.O., Stanik-Hutt, J., White, K.M., Johantgen, M., Bass, E.B., Zangaro, G., Wilson, R., Fountain, L., Steinwachs, D., Heindel, & L., Weiner, J. (2011). Advanced practice nurse outcomes 1990-2008: A systematic review. Nursing Economics, 29(5), 1-22. Pohl, J., Hansen, C., Newland, J., & Cronenwett, L. (2010). Unleashing nurse practitioners’ potential to deliver primary care and lead teams. Health Affairs, 29(5), 900-905. Rickerts, T., & Fraher, E. (2013). Reconfiguring health workforce policy so that education, training, and actual delivery of health care are closely connected. Health Affairs, 31(11), 1874-1880. Robert Wood Johnson Foundation. (2012). How can we expand the primary care workforce? Health Policy Snapshot Series. Retrieved from http://www.rwjf.org/en/research-publications/ find-rwjf-research/2012/01/how-can-we-expand-the-primarycare-workforce-.html.
259 Sommers, B., Kenney, G., & Epstein, A. (2013). New evidence on the Affordable Care Act: Coverage and impact of early Medicaid expansions. Health Affairs, 33(1), 78-87. Stokowski, L. (2012). Nurse practitioners and medical homes: A natural Fit. Medscape. Retrieved from http://www.medscape. com/viewarticle/772300. U.S. Department of Health and Human Services (USDHHS). (2014a). Key features of the Affordable Care Act. Retrieved from http://www.hhs.gov/healthcare/facts/timeline. U.S. Department of Health and Human Services (USDHHS). (2014b). Key features of the Affordable Care Act by year. Retrieved from http://www.hhs.gov/healthcare/facts/timeline/ timeline-text.htmlU.S. Department of Health & Human Services (USDHHS). (2013). Creating jobs by addressing primary care workforce needs. Retrieved from www.hhs.gov/helathcare/facts Wakefield, M. (2010). Nurses and the Affordable Care Act. American Journal of Nursing, 110 (9), 11. Wakefield, M. (2013). Nurses and the Affordable Care Act: A call to lead. Reflections on Nursing Leadership. 39 (3). Retrieved from http://www.reflectionsonnursingleadership.org/ White House Fact Sheet (2012). Creating health care jobs by addressing primary car workforce needs. Office of the Press secretary. Retrieved from www.Whitehouse.gov.
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research-article2014
NSQXXX10.1177/0894318414534494Nursing Science QuarterlyReed / Health and Public Policy
Health and Public Policy
Affordable Care Act: Overview and Implications for Advancing Nursing
Nursing Science Quarterly 2014, Vol. 27(3) 254–259 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414534494 nsq.sagepub.com
Deborah Vincent, RN; PhD1 and Pamela G. Reed, RN; PhD; FAAN2
Abstract The Affordable Care Act (ACA) confronts nursing with opportunities as well as challenges. The authors provide an overview of the ACA and highlights opportunities for nursing practice, research, and doctoral education. The importance of disciplinary foundations is also addressed as relevant to envisioning the future of practice and education in the context of healthcare reform. Keywords advanced practice nursing, Affordable Care Act, healthcare reform, health policy
As nurses, we need to be able to articulate our understanding of the Patient Protection and Affordable Care Act (PPACA) or ACA for short, in terms of how our work and values interface with this new healthcare policy. This policy confronts nursing with critical changes in healthcare. Where there is change, there is opportunity for growth. It is likely that among some of the difficult changes nurses will experience, nursing as a discipline may also find new applications of its philosophical and theoretical ideas in research and practice. Nurses are situated in various roles and healthcare contexts where they can influence the future of healthcare. The authors provide an overview of key components of the ACA and then address some of the opportunities and challenges this policy presents for nursing and nurses.
Patient Protection and Affordable Care Act (PPACA) Overview The Patient Protection and Affordable Care Act, often known as the Affordable Care Act (ACA), is a landmark piece of legislation enacted in 2010. Although the ACA was signed into law in 2010, its various components will be phased in over nearly 10 years (USDHHS, 2014b). The goal of the law is to improve the affordability, availability, and quality of health insurance for Americans through a variety of mechanisms such as consumer protections, regulations, taxes, subsidies, health insurance exchanges, and healthcare delivery reforms. While the law is complex, the key elements can be classified into two main categories: Insurance Reform and Health System Reform (USDHHS, 2014a).
Insurance Reform The first component of the ACA, insurance reform, is probably the most widely known and many of the elements remain controversial. Key insurance reform features of the ACA that were enacted in the first few years after the legislation was signed into law are the following: prohibitions against denial of health insurance coverage for children with preexisting conditions, elimination of lifetime limits on insurance coverage, a requirement for insurance companies to cover select preventive care services without charging deductibles, co-pays or coinsurance, extending parental insurance coverage to adult children up to age 26, and the individual mandate (Jost, 2014). Other reforms include premium tax credits designed to make health insurance affordable for families (Assistant Secretary for Planning and Evaluation, 2012), gradual closure of the Medicare Part D prescription drug “doughnut hole,” expansion of the Medicaid program, and development of healthcare exchanges. In eliminating the two cost-controlling mechanisms, preexisting condition exclusions and lifetime limits, insurance companies were at greater risk for large financial losses due to adverse risk selection. Adverse selection occurs when a 1
Associate Professor, The University of Arizona Professor, The University of Arizona
2
Contributing Editor: Pamela G. Reed, RN; PhD; FAAN, Professor, University of Arizona College of Nursing, 1305 N. Martin St., Tucson, AZ 85721-0203. Email: [email protected]
255
Reed / Health and Public Policy greater proportion of unhealthy individuals purchase health insurance (Chandra, Gruber, & McKnight, 2011). An example is when an uninsured person who has just been diagnosed with cancer and knows that he or she will need expensive treatment, purchases health insurance without revealing the cancer diagnosis to the insurance company.
The Individual Mandate The individual mandate was designed to offset adverse selection by both increasing the size of the risk pool and by decreasing the level of risk through the inclusion of healthy individuals in the risk pool. Many policy-makers and insurance companies argued that without an individual mandate, insurance premiums for healthy people would increase and ultimately lead them to exit the insurance market, causing premiums to rise even higher (Chandra et al., 2011). The individual mandate requires that all Americans buy health insurance coverage beginning in 2014 or pay a penalty. Wakefield (2013) provided a helpful perspective and information for guiding patients on enrollment. Individuals who cannot afford coverage (that is, whose cost of premiums would exceed eight percent of household income) and those eligible for Medicaid under the Medicaid expansion provision are exempt from the mandate. While the individual mandate has been upheld by the Supreme Court, it remains controversial (Jost, 2014). Evidence from Massachusetts, which underwent health reform with an individual mandate in 2006, suggested that the mandate did result in improving risk selection and that healthy people did enroll (Chandra et al., 2011).
Medicaid Expansion Another insurance reform is the expansion of Medicaid. Under the ACA (and prior to the 2012 Supreme Court decision described below), Medicaid was planned to expand coverage to nearly all low income Americans under the age of 65, with each state receiving substantial federal support for the expansion. The Medicaid expansion would have largely benefited low-income, childless adults who were ineligible for Medicaid coverage in more than 40 states (American Public Health Association, 2014; Sommers, Kenney, & Epstein, 2013). Before ACA, only 30% of poor non-elderly adults had Medicaid and 42% of all poor adults were uninsured (Kaiser Commission on Medicaid and the Uninsured, 2013). However, the 2012 Supreme Court decision halted the Medicaid expansion by permitting states to opt out of the Medicaid expansion. Low-income individuals are now at a distinct disadvantage in states that have chosen to opt out of the Medicaid expansion. Tax subsidies for insurance purchased on the Exchanges are available only to those with incomes 100 percent above the federal poverty level. People whose income falls below that cut point are eligible for insurance through
Medicaid unless they live in an opt-out state. For those in the opt-out states, there will be a coverage gap for approximately 5 million poor uninsured adults. Those who fall into the coverage gap are likely to face significant barriers in accessing necessary healthcare services, and clinics and hospitals that care for the uninsured will face serious financial consequences (Kaiser Commission on Medicaid and the Uninsured, 2013). As of February 2014, 19 states have declared they will not expand Medicaid, while 26 states and the District of Columbia have begun expansion along with another six considering expansion (Kaiser Family Foundation, 2014). Findings from a study of four early adopter states suggest that Medicaid enrollment is steady and has become more robust over time; indications are that enrollment may exceed expectations in those states (Somers, 2014).
Healthcare Exchanges Another major type of insurance reform is the development of healthcare exchanges. Problems with the federal government health insurance exchange website in Fall of 2013 brought much attention to the healthcare exchanges. Exchanges are organizations designed to facilitate the purchase of health insurance. Some states, such as California and Massachusetts have set up their own exchanges, while other states, such as Arizona will participate in the federal exchanges. Exchanges can be thought of as marketplaces that provide consumers with standardized healthcare plans and provide transparency of benefits and costs. “These marketplaces fill a gap for individuals without employer-provided coverage, those not old enough or poor enough to qualify for Medicare or Medicaid.” (Ewoldt, 2014, p. 9). The exchanges are not health insurance companies but they do determine which companies are allowed to sell polices and what these policies must cover. As of January 31, 2014, 3.3 million people have selected insurance plans through the exchanges. Nearly two million people have selected their plans through the federally administered exchanges (Jost, 2014). In summary, three major insurance reforms were discussed: the individual mandate, Medicaid expansion, and healthcare exchanges. These were designed to increase the number of those with insurance, enhance benefits and protections, and lower costs. Health system reforms are the second arm of the ACA and have purposes that differ from insurance reform.
Health System Reform Probably less well-known than the ACA insurance reforms are the health system reforms designed to improve quality and efficiency, enhance the healthcare workforce, and increase public health and prevention services. Health system reform is a necessary component of the ACA given the
256 expectation that the ACA insurance reform will generate more people who have insurance coverage, and thus more people will seek healthcare. The Patient-Centered Medical Home (PCMH) and Accountable Care Organizations (ACO) are healthcare delivery models promoted by the ACA to expand access to care, especially primary care, and to improve quality and efficiency of healthcare. In addition, increased funding for Federally Qualified Health Centers, National Health Service Corps, and school-based health centers will increase quantity and quality of public health services.
Patient-Centered Medical Homes Patient-centered medical homes promote a team based approach to health care with a primary provider serving as a care provider and coordinator. The team may include a workforce mix of physicians, advanced practice nurses [similarly called nurse practitioners (NPs) or advanced practice registered nurses (APRNs)], other nurses, physician assistants, pharmacists, dieticians, social workers, educators, and therapists (Auerbach et al., 2013). While the medical home concept is not new (Stokowski, 2012) passage of the ACA has provided a new impetus for the creation and dissemination of medical homes. The medical home approach to healthcare delivery has five features: 1. It is patient-centered and emphasizes a partnership among provider, patient and family where patients are informed and active decision-makers. 2. Care is comprehensive in addressing physical and mental healthcare needs, from wellness to acute and chronic illnesses, to end of life. 3. Care is coordinated and continuous across the healthcare system, from specialty and hospital care to community-based and home healthcare. 4. Services are accessible in terms of both place and time, through use of electronic and 24/7 phone communication as well as in-person visits during regular business and expanded hours. 5. There is a commitment to safe care and quality improvement practices. Information technology, open communication, and culturally competent care are other hallmarks of this delivery model. The interdisciplinary team is led by the primary care provider such as a nurse practitioner or medical doctor (Klein, Laugesen, & Liu, 2013).
Accountable Care Organizations (ACO) Under the ACA, Accountable Care Organizations (ACO) have become part of the Medicare program and are being promoted as a way to reduce healthcare costs and improve quality of care (DeVore & Champion, 2011). ACOs
Nursing Science Quarterly 27(3) incentivize providers (primary care providers, specialists, and hospitals) to form networks to coordinate care. Penalties are assessed by Medicare if pre-established goals (set by the ACO) are not met, whereas incentive payments are provided if the goals are met (Graham, 2011). ACO members are jointly accountable for the quality of care, cost, and overall care of their patients. Nurse practitioners initially were authorized as ACO professionals under the ACA but “a last minute change in the statute limits patients assigned to [Medicare ACOs]” to those treated only by a primary care physician (American Academy of Nurse Practitioners (AANP), 2012). As currently organized, ACOs provide nurses with increased opportunities to engage in care coordination and patient education, but nurse practitioners are not (yet!) recognized by ACOs as primary care providers (Burns & Pauly, 2012; AANP, 2012). In sum, the PCMH and ACO models of healthcare delivery can work together to provide quality, cost-effective care. The PCMH provides and coordinates direct care while the ACO incentivizes team-based communications and collaboration across the spectrum of health services, including primary care and specialties. Other goals include healthcare that is more complete, more responsive, and timelier for patients. These health system reforms provide both opportunities and challenges for nurses.
Issues and Implications Medical Home and Nursing Philosophy of Care The medical home model presents policy-related issues for healthcare disciplines other than medicine. For example, the American Psychological Association (2009) expressed concern over inclusion of psychologists on the primary care team, and suggested that the delivery model more appropriately be called the “health home model.” Similarly, nurses have proposed use of neutral provider language such as health care homes” (Keeling & Lewenson, 2013, p. 365), and they identified important policy issues regarding who will lead the team, type of care, and location of care. Historically, many of the attributes of what was called a nursing model of care delivery are found in today’s medical home. Nursing has significant history in delivering care that reaches out to the underserved and culturally-diverse groups, is community-based and family-centered, and promotes health and self-care while providing comprehensive, compassionate, and coordinated care. These historical practices align with the nursing philosophy of practice. According to the philosophy, for example, nursing is a distinct and collaborative discipline. Nurses focus on health experiences of individuals in the contexts of family, community, and culture. Health and well-being can occur within illness. Health promotion is not a practice that is focused only on the medically well, but focused across the trajectory of health and illness, and across the lifespan from birth to end of life.
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Increase in the Practice and Roles of Nursing The ACA will dramatically expand opportunities in nursing practice. Increasing capacity and modernizing the healthcare workforce is a major aim of the ACA (Robert Woods Johnson Foundation, 2012). The ACA contains many programs that will expand and re-envision the healthcare workforce. The ACA will create a National Health Care Workforce Commission and National Center for Health Care Workforce Analysis. Together these commissions will identify workforce priorities and goals, identify effective local and state strategies for improving the health-care workforce, and make recommendations to Congress and the White House. Under the ACA, primary care is recognized as vital to controlling costs and increasing access to care. The implication for nursing is that this will result in the need for more primary care providers, namely advanced practice nurses (Green, Savin, & Lu, 2013). While a shortage of primary care physicians is predicted, advanced practice nurses have an opportunity to become the preeminent primary care workforce of the future (Rickets, 2013). The quality of care provided by nurse practitioners in primary care settings is already well-documented (Horrocks, Anderson, & Salisbury, 2002; Newhouse et al., 2011). The majority of health system reforms focus on teambased care and enhanced roles for nursing. For example, there are provisions in the ACA for wellness models of care such as community and school health centers and nursemanaged centers, all of which logically would be under the leadership of advanced practice nurses (Auerbach et al., 2013). The ACA defined nurse-managed health centers in the law and created a federal grant program to provide funding for 10 nurse-managed centers with APRN-led primary care. Additional funds are available for states to develop innovative methods for expanding primary care at the state and local levels. As the ACA is implemented, opportunities for new roles for providers, and potentially new provider types, are likely to develop. Restructuring of the healthcare delivery system will emphasize primary care and management of chronic conditions, and will deemphasize acute care. Quality initiatives under ACA include patient-centered, coordinated care across the health trajectory. These are all strengths of nursing.
Nursing Research The ACA has implications for research in nursing practice. Whether the medical home will achieve its philosophical and pragmatic goals is a focus for scientific inquiry. The ACA contains provisions that support demonstration projects for medical homes. Nurse practitioner-led medical homes are developing in those states that permit independent nurse practitioner practice (Cassidy, 2010; Stokowski, 2012). Currently the ACA is funding many demonstration projects
for the purpose of assessing what are effective and innovative models for delivering high quality, cost-effective, patient- centered care. In addition to the demonstration projects that examine the effectiveness of healthcare delivery models, research can occur on a smaller scale into specific healthcare problems and experiences of patients, health outcomes, and patient satisfaction. Nursing research can target studies on empowering patients through the increased transparency in healthcare information and open communication of the ACA. Nursing theories are sources of knowledge that could be tapped to design models of care and communication that improve patient care experiences and health outcomes. Theory-guided studies may examine for example, factors and innovative approaches that facilitate active engagements and partnerships of patients and family caregivers in healthcare, and that help nurses organize complex care needs of patients while championing patient priorities for well-being, meaning, and respect throughout their healthcare experience.
Continued Challenges for Nursing Practice Despite these opportunities, nurses face challenges in implementation of the ACA. Variations in scope of practice and other regulations continue to impede nurses in practicing to their full potential (Pohl, Hansen, Newland, & Cronenwett, 2010; Rickerts & Fraher, 2013). Scope of practice laws and regulations vary across the states and often result in serious restrictions for advanced practice nurses. For example, some states prohibit nurse practitioners from prescribing medications (IOM, 2010). This variability will hinder the increased access to care promised under the ACA and will likely constrain efforts to develop innovative primary care delivery models. And as already mentioned, Medicare financed ACOs limits patients only to those under treatment of a primary care physician not nurse. Reimbursement barriers will also impede the increase growth of advanced practice nurses in primary care and the development of innovative delivery models. Medicare and Medicaid reimbursement remains a challenge. Medicaid is administered by the states, so reimbursement varies from state to state, with some requiring nurse practitioners to have a collaborative agreement with a physician. This can result in physician supervision rather than physician collaboration (Pohl et al., 2010). Medicare’s reimbursement policies are also problematic. Medicare reimbursement in general is low and nurse practitioners are reimbursed at 85% of the fee schedule for physicians (AANP, 2013). In summary, although initiatives to strengthen the primary care workforce that call for advanced practice nurse as key providers will provide greater opportunities for nursing, regulatory and reimbursement policies in many states are obstacles to greater reliance on nurses (IOM, 2010; Green et al., 2013). Restrictions on reimbursement to nurses may be
258 resolved by the ACA but that remains to be seen. Nurses will need to persevere in their vigilance and organized efforts to change regulatory and reimbursement policies that impinge on their scope of practice and its benefit to human health and well-being.
Ending with Nursing Education–Where It All Begins The ACA contains many education-based provisions for expanding the nursing workforce beginning with lifting the cap on Advanced Education Traineeships that previously was limited to giving no more than 10 percent of its funding to doctoral students. The Nurse Faculty Loan Program, the Student Loan Program, and the Nursing Workforce Diversity Programs all receive support under ACA (Wakefield, 2010). The law also provides education and training funds to expand the number of advanced practice nurses and other primary care providers (USDHHS, 2013). There are three-year grants of $50 million each to five hospitals to train advanced practice nurses, including nurses in community-based settings (White House Fact Sheet, 2012). Recognizing the increased complexity of healthcare, the IOM (2010) report, The Future of Nursing, calls for advanced practice nurses to be educated at the doctoral level, the highest level to ensure that they provide safe, patient-centered care. But also beyond this, the ethical, theoretical, methodological, and empirical foundations of doctoral education help nurses acquire the ability to become creative and visionary leaders in knowledge development for practice and policy, and leaders who bring something to the table of their interprofessional peers. Healthcare reform entails interprofessional work and savvy, and the IOM Report (2010) advocates for interprofessional education. Nurses will need not only the practice skills and science-based knowledge of patients’ healthcare problems and standard treatment approaches; they must be wellgrounded in the theories and research methods of their discipline and related disciplines that inform their practice policies. The implications of both the ACA and the IOM Report (2010) point to greater roles and leadership in practice, but also in administration and policy. Nursing education must prepare leaders of the future – nurses who can navigate boardrooms, health policy think tanks, and legislative halls. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this column.
Funding The author received no financial support for the research, authorship, and/or publication of this column.
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