In the
NEWS The Year in Review
2013
The Top Health Care News Story of 2013: The Affordable Care Act and Us A maturing conversation.
I
t’s easy to forget that the implementation of the Patient Protection and Affordable Care Act (ACA) has been under way since 2010, when children with preexisting conditions were first guaranteed coverage and young adults up to age 26 were allowed to remain on parents’ health care plans. In 2011, new prescription drug discounts began to save seniors millions of dollars. In 2012, plans were required to cover women’s preventive services such as mammographies; insurers were required to start providing short, clear summaries of benefits and costs; and many accountable care organizations (ACOs)—networks of hospitals and physicians that share responsibility for providing coordinated and cost-effective care to a group of patients—were formed. The early October 2013 news coverage was dominated by a failed Republican effort to force last-minute changes to the ACA through a government shutdown. This coincided with the October 1 start of open enrollment in the health care marketplaces, in which U.S. residents without affordable employersponsored health insurance or 12
AJN ▼ January 2014
▼
Vol. 114, No. 1
coverage from federal programs have until April 1, 2014, to choose from a menu of qualified health plans. It quickly emerged that the federal health care exchange Web site, www.healthcare.gov, as well as some of the state sites, had serious usability issues. Opposition to the law took on new life; this was further fueled by outrage over cancellations of plans not meeting ACA quality standards, a problem the Obama administration had not fully anticipated. While these are real problems, most likely they will eventually be solved and have little to do with the substance of the law or the long-term issues the law set out to address: • Health care spending consumes an ever-increasing portion of the federal budget (most recently, nearly 20% of U.S. gross domestic product) and of personal incomes. According to recent reports in JAMA and Health Affairs, we are already seeing a reduction in overall Medicare spending in early evaluations of ACOs, a trend that is increasingly convincing now that it has persisted past the end of the recession.
• The United States is still a leader in medical innovation, but in terms of outcomes on quality measures like life expectancy and infant mortality, we consistently perform below countries spending far less per capita on health care. ACA measures designed to promote greater reliance on evidencebased guidelines, coordination of care for those with multiple chronic conditions, and preventive medicine are showing promising results. For example, the Centers for Medicare and Medicaid Services has reported reductions in hospital readmission rates since the imposition of reimbursement penalties. We are also seeing reports of reductions in hospital-acquired infection rates. • Our insurance industry has long had few consumer protections and free reign to cancel plans at will, impose steep increases in premiums, and set conditions for insurability that excluded vast numbers of people. Now, under the ACA, all plans sold on the exchanges must meet minimum standards of cost sharing, affordability, and cov erage. • Millions have had no access to affordable insurance coverage or federal programs like Medicaid and Medicare. As of January 1, the ACA expands Medicaid eligibility to those who make up to 133% of the poverty level, as well as to low-income childless adults. This expansion is projected to lead to coverage for millions. For those who make too much to qualify for Medicaid, health insurance exchanges offer more affordable health care plans. Many will also receive tax credits to defer the cost ajnonline.com
News Director: Gail M. Pfeifer, MA, RN E-mail: [email protected]
of insurance. Unfortunately, many states with Republican governors have chosen to opt out of the Medicaid expansion, a decision that will deprive as many as 5 million low-income Americans of affordable coverage. No one believes the ACA is a perfect law. Nurses will surely
Nursing News
The Top Nursing News Stories of 2013
P
rogress and stasis in nursing roles. The Campaign for Action (CFA), organized to pursue the goals of the Institute of Medicine 2010 report The Future of Nursing: Leading Change, Advancing Health, celebrated three years of progress last year. CFA “action coalitions” became a reality in all 50 states and the District of Columbia; enrollment in advanced degree programs for nurses increased, including a jump of more than 50% in enrollment in doctor of nursing practice programs between 2010 and 2012; and 16 state-level bills were introduced in 2013 to remove barriers to advanced practice RN practice. Attendees at a national CFA summit in February 2013 left with a list of coalition imperatives for the coming year, including a call for action coalitions to “deliver short-term results in the next 18 months, even as you develop long-term plans.” Given the changing health care landscape, nurses at every level will be called upon to act as leaders. [email protected]
e xperience both negative and positive effects of the law— demanding new Medicare quality measures, emerging care coordination roles, new primary care opportunities for NPs, stressful institutional reorganizations. Many adjustments may be necessary. But there’s little doubt that through this
Despite the progress in primary care, experts estimate that only 2% of hospital board members are nurses, which led the CFA to call for leadership development programs and strategies to increase the number of nurses on hospital, state, and federal boards. For more on this effort, see http://bit.ly/ HxO0kk. One avenue for greater opportunities and leadership may be in telehealth, a growing field of care. Some questions have arisen about the cost-effectiveness of telemedicine, most notably a study in the March 20, 2013, BMJ, but several studies have found the practice to be both cost-effective and clinically successful. Regardless, telehealth is expected to reach 1.8 million Americans annually by 2017, according to the market research firm InMedica, and the Centers for Medicare and Medicaid Services will expand provider payments for telehealth services in 2014. Staffing ratios. In the context of health care reform, the debate regarding nurse–patient ratios con tinued on this past year. Two federal bills on nurse staffing (S 739 and HR 1821) were proposed this spring but have languished in committee. Although state legislation may have a greater chance of success, the battle is still uphill. • California. Still the only state with mandated nurse–patient ratios, California’s example
ngoing process, a powerful light o has been turned on many areas of our health care system, from quality to cost to accessibility. Fresh reductionist promises or claims are sure to be tested by data and experience. The conversation has, very slowly, begun to grow up.—Jacob Molyneux, senior editor
RNs stage an informational picket line outside Tufts Medical Center in Boston. Photo by Wendy Maeda / The Boston Globe via Getty Images.
has led to more hiring, greater job satisfaction and retention, and less burnout for nurses. But the evidence surrounding patient outcomes has been less definitive. Most recently, a review of eight studies published in the November 2013 Journal of Nursing Administration showed mixed outcomes and calls for further research. • Other state activity. Seven states plus the District of Columbia introduced bills modeled after California’s in 2013, but none has yet succeeded. Minnesota passed a compromise law in May in which AJN ▼ January 2014
▼
Vol. 114, No. 1
13
NEWS The Year in Review
2013
The Top Health Care News Story of 2013: The Affordable Care Act and Us A maturing conversation.
I
t’s easy to forget that the implementation of the Patient Protection and Affordable Care Act (ACA) has been under way since 2010, when children with preexisting conditions were first guaranteed coverage and young adults up to age 26 were allowed to remain on parents’ health care plans. In 2011, new prescription drug discounts began to save seniors millions of dollars. In 2012, plans were required to cover women’s preventive services such as mammographies; insurers were required to start providing short, clear summaries of benefits and costs; and many accountable care organizations (ACOs)—networks of hospitals and physicians that share responsibility for providing coordinated and cost-effective care to a group of patients—were formed. The early October 2013 news coverage was dominated by a failed Republican effort to force last-minute changes to the ACA through a government shutdown. This coincided with the October 1 start of open enrollment in the health care marketplaces, in which U.S. residents without affordable employersponsored health insurance or 12
AJN ▼ January 2014
▼
Vol. 114, No. 1
coverage from federal programs have until April 1, 2014, to choose from a menu of qualified health plans. It quickly emerged that the federal health care exchange Web site, www.healthcare.gov, as well as some of the state sites, had serious usability issues. Opposition to the law took on new life; this was further fueled by outrage over cancellations of plans not meeting ACA quality standards, a problem the Obama administration had not fully anticipated. While these are real problems, most likely they will eventually be solved and have little to do with the substance of the law or the long-term issues the law set out to address: • Health care spending consumes an ever-increasing portion of the federal budget (most recently, nearly 20% of U.S. gross domestic product) and of personal incomes. According to recent reports in JAMA and Health Affairs, we are already seeing a reduction in overall Medicare spending in early evaluations of ACOs, a trend that is increasingly convincing now that it has persisted past the end of the recession.
• The United States is still a leader in medical innovation, but in terms of outcomes on quality measures like life expectancy and infant mortality, we consistently perform below countries spending far less per capita on health care. ACA measures designed to promote greater reliance on evidencebased guidelines, coordination of care for those with multiple chronic conditions, and preventive medicine are showing promising results. For example, the Centers for Medicare and Medicaid Services has reported reductions in hospital readmission rates since the imposition of reimbursement penalties. We are also seeing reports of reductions in hospital-acquired infection rates. • Our insurance industry has long had few consumer protections and free reign to cancel plans at will, impose steep increases in premiums, and set conditions for insurability that excluded vast numbers of people. Now, under the ACA, all plans sold on the exchanges must meet minimum standards of cost sharing, affordability, and cov erage. • Millions have had no access to affordable insurance coverage or federal programs like Medicaid and Medicare. As of January 1, the ACA expands Medicaid eligibility to those who make up to 133% of the poverty level, as well as to low-income childless adults. This expansion is projected to lead to coverage for millions. For those who make too much to qualify for Medicaid, health insurance exchanges offer more affordable health care plans. Many will also receive tax credits to defer the cost ajnonline.com
News Director: Gail M. Pfeifer, MA, RN E-mail: [email protected]
of insurance. Unfortunately, many states with Republican governors have chosen to opt out of the Medicaid expansion, a decision that will deprive as many as 5 million low-income Americans of affordable coverage. No one believes the ACA is a perfect law. Nurses will surely
Nursing News
The Top Nursing News Stories of 2013
P
rogress and stasis in nursing roles. The Campaign for Action (CFA), organized to pursue the goals of the Institute of Medicine 2010 report The Future of Nursing: Leading Change, Advancing Health, celebrated three years of progress last year. CFA “action coalitions” became a reality in all 50 states and the District of Columbia; enrollment in advanced degree programs for nurses increased, including a jump of more than 50% in enrollment in doctor of nursing practice programs between 2010 and 2012; and 16 state-level bills were introduced in 2013 to remove barriers to advanced practice RN practice. Attendees at a national CFA summit in February 2013 left with a list of coalition imperatives for the coming year, including a call for action coalitions to “deliver short-term results in the next 18 months, even as you develop long-term plans.” Given the changing health care landscape, nurses at every level will be called upon to act as leaders. [email protected]
e xperience both negative and positive effects of the law— demanding new Medicare quality measures, emerging care coordination roles, new primary care opportunities for NPs, stressful institutional reorganizations. Many adjustments may be necessary. But there’s little doubt that through this
Despite the progress in primary care, experts estimate that only 2% of hospital board members are nurses, which led the CFA to call for leadership development programs and strategies to increase the number of nurses on hospital, state, and federal boards. For more on this effort, see http://bit.ly/ HxO0kk. One avenue for greater opportunities and leadership may be in telehealth, a growing field of care. Some questions have arisen about the cost-effectiveness of telemedicine, most notably a study in the March 20, 2013, BMJ, but several studies have found the practice to be both cost-effective and clinically successful. Regardless, telehealth is expected to reach 1.8 million Americans annually by 2017, according to the market research firm InMedica, and the Centers for Medicare and Medicaid Services will expand provider payments for telehealth services in 2014. Staffing ratios. In the context of health care reform, the debate regarding nurse–patient ratios con tinued on this past year. Two federal bills on nurse staffing (S 739 and HR 1821) were proposed this spring but have languished in committee. Although state legislation may have a greater chance of success, the battle is still uphill. • California. Still the only state with mandated nurse–patient ratios, California’s example
ngoing process, a powerful light o has been turned on many areas of our health care system, from quality to cost to accessibility. Fresh reductionist promises or claims are sure to be tested by data and experience. The conversation has, very slowly, begun to grow up.—Jacob Molyneux, senior editor
RNs stage an informational picket line outside Tufts Medical Center in Boston. Photo by Wendy Maeda / The Boston Globe via Getty Images.
has led to more hiring, greater job satisfaction and retention, and less burnout for nurses. But the evidence surrounding patient outcomes has been less definitive. Most recently, a review of eight studies published in the November 2013 Journal of Nursing Administration showed mixed outcomes and calls for further research. • Other state activity. Seven states plus the District of Columbia introduced bills modeled after California’s in 2013, but none has yet succeeded. Minnesota passed a compromise law in May in which AJN ▼ January 2014
▼
Vol. 114, No. 1
13
