The Affordable Care Act's impact on nursing practice and healthcare reform

Health Care Reform Effecting Public Health United States

Healthcare reform is an integral part of the United States healthcare system. Below is an evaluation of the effects healthcare reform has had on healthcare in the U.S. Internet sources as well as peer-reviewed journals will be looked at so as to see the effects.

The cost of healthcare has been on the rise. Issues of healthcare quality ought to be paid attention to and healthcare access equity improved upon (Health Care Transformation). Given these causes, while some differences exist on what reforms to carry out, a majority of Americans hold the belief that the U.S. Healthcare delivery systems need some improving. For a long time ANA has been advocating for reforms in healthcare and several of the Affordable Care Act (ACA) provisions are in line with the Health System Reform Agenda of the ANA. The ANA gave a chart that gives information concerning the recently proposed changes to healthcare and the implications they will have on nurses (Health Care Transformation). As of now, a majority of the proposed changes are a reflection of the Patient Protection and Affordable Care Act (Public Law 111-148) (ACA) provisions. ANA has invited Americans to follow updates they will make on the chart that show the progress in nursing influences on regulations as well as other activities so as to ensure the implementation of health reform as well as certain provisions in the ACA as the Supreme Court makes a decision that upholds most of the law's provisions. The chart also highlights the opportunities Registered nurses and APRNs can exploit to use new programs and healthcare innovation pilots, and grant funding for their education and the funding for development of the nursing workforce (Healthcare Transformation).

Provisions of the Affordable Care Act

The law subsidizes 100% of the states expense to take care of the added population, slowly lowering it to 90% by the 2020 financial year. As the court decided, states can opt-out of the Medicaid expansion as well as the added funding without putting their prevailing levels of funding in danger (Healthcare Transformation). Registered nurses form the bulk of the professionals in clinical care and they practice and are educated within the healthcare system. Registered nurses take their education within a holistic environment that establishes the family, individual as well as the community as one in a system that is interconnected so as to be able keep citizens well and heal them (Healthcare Transformation). Registered Nurses are important to the push for changes required in healthcare, with the aim of transformation of the "sick care" in its current state to a future real "health care." The ANA is currently engaging with makers of policy at the federal level and other regulators so as to advocate for a transformation system that encompasses the contributions nurses and nursing make and continue to make.

On June 28, 2012, nearly all the ACA provisions were upheld by the Supreme Court, including the provisions on "shared responsibility" in the purchasing of health insurance (the so-called "individual mandate"). Through upholding this fact, several provisions survived challenges, including the advances made for and by nurses and nursing (Healthcare Transformation). The Court did away with an aspect of the ACA which would have called for states to expand the eligibility for Medicaid by the year 2014 to every person whose income is below 133% of the federal poverty level, or forgo all Medicaid matching funds from the federal government. Federal health reform makes use of a systematic approach which begins the current health insurance system in the country (What Is Health Care Reform). Health reform seeks to improve on the current system of health insurance so as to give health insurance access to a lot more individuals, build consumer protection legal structures and put up measures that will ensure consumers are shopping knowledgeably about health insurance (What Is Healthcare Reform).

Aspects of Health Care Reform

Health care reform encompasses the following steps:

Expansion of Medicaid so as to afford more individuals with small incomes access to coverage

Encouraging the employers to give coverage to their employees

Provision of credits for the purchase of health insurance by Americans who get moderate incomes so that they can qualify for Medicaid

Streamlining the buying of health insurance by establishing Health Insurance Exchange

Strengthening protection of consumers and make transparency a requirement

Encouraging preventive and primary care

Requiring a majority of Americans to buy health insurance

As was the case in the past, the debate on health insurance right now puts the emphasis on treating individuals when they become sick. This focus on treatment does not appreciate the importance of maintenance of health in the economy, national security as well as the nation's success. The advantages of a population that is healthy far outweigh the costs that will be incurred (Kemp, 2012). While illness treatment is a key component of health care, strengthening and reforming the healthcare system is equally crucial to bettering the health of the nation's population and to the effective management of the resources we have (Kemp, 2012).

Significance of Health Care Reforms to Public Health

Actually, the Partnership for Prevention outlines the three major aims of public health as promoting better health for every citizen, preventing the consequences due to a person suffering from various illnesses and protecting the safety and health of the population (Kemp 2012). While some overlap might exist, public health as a discipline varies greatly from healthcare practice, which encompasses health assessment, symptoms diagnosis, treatment of illnesses and the management of impairments due to chronic conditions. The primary obligation of public health is protecting and promoting the health of the population by prevention, public policies and regulations as well as protection of the environment (Kemp 2012). The same view was expressed by Kenneth Arrow in an essay he penned in 1963 when he gave a description of medical care as nothing but taking care of shelter, sanitation, clothing and nutrition. These aspects are key to medical care especially when an individual does not have them. Debates about medical care right now are overshadowed by competitive politics and discussions about technologies and medical interventions (Kemp 2012). As this happens, the cost of healthcare in the country is out of reach to many people and is continuously being inflated, even growing from 5.2% of GDP in the year 1960 to 17.6% in the year 2009, a growth trajectory which is expected to continue.

A report released in 2009 on local health departments (LHDs) roles indicates that reform in health care is important to public health. It gives an illustration of the contradiction that exists between the expansion of healthcare coverage while lowering resources being channeled to LHDs. It gives data that shows that health care can claim only 10% of health outcomes, the rest is determined by a range of health factors that include socioeconomics, physical environments and behavior (Kemp 2012). Even though medical care can extend survival and lead to an improvement on prognosis following serious illnesses, more crucial to the population's health is the economic and social conditions which cause illnesses and make people require medical care. Bad economic and social circumstances have effects on health for a person's entire life. People who are low on the scale have two times the risk of contracting illnesses and suffering premature deaths as the members of the population who are higher up on the scale (Kemp, 2012). The report indicates that an agreement can be reached on what to target in the basic economic and social issues and asserts that raising LHD funding could probably save $20 in healthcare costs for every dollar spent on prevention. This can be attained by having a focus on the fundamental causes of poor health such as abuse of substances, smoking, poverty, pollution, homelessness, violence and abuse of substances (Kemp, 2012).

Gotison and Jacobson are also calling for secure and adequate long-term funding for public health. They opine that the public health system is in shambles and should be rebuilt from the ground up. They assert the significance of promotion of health and the prevention of diseases. As opposed to conventional wisdom, lack of healthcare isn't the main cause of illnesses and death (Kemp 2012). They are in agreement that causes of illnesses involve the environment, socioeconomics and behaviors. Furthermore, they agree that the main aim of any health system ought to be improvement of the health of the population, which might not result from interventions in Medicare (Kemp 2012). They indicate that there is a lot of evidence demonstrating the cost effectiveness of public health interventions, while this is not the case for the current costly health care system.

Findings of the RAND Report

RAND Corporation released a series of reports that outlined the effect that reform of national health care will have on specific states, giving an estimation of the increased coverage and costs that are probably going to be realized in 5 different states following the implementation of the reform in the year 2016 (How National Health Care). In all the studied states -- California, Illinois, Texas, Connecticut and Montana -- the percentage of residents who are not insured falls significantly with the reform on health care. Costs for the government will increase in 4 of the studied states, basically a function of the Medicaid spending increase (How National Health Care).

Reports at the state-level estimates the impact that the Patient Protection and Affordable Care Act provisions has had on the 5 states, including the estimations of where individuals will get insurance and the way this will alter spending of the states (How National Health Care). The sponsors of this work were the Council of State Governments, a group that assists leaders of states to share insights and ideas (How National Health Care). Researchers made use of a model for micro-simulation that was made by RAND to help in the estimation of the effect of policies for the expansion of health coverage on the number of residences in a state who access health insurance, the kinds of plans roles out and the changes recorded in both the public and private sector spending (How National Health Care).

The findings that were made from the report include the following (How National Health Care):

Significant portion of those who are not old will opt to purchase coverage through the insurance exchanges that are being put up in states to assist individuals buy health coverage

In a majority of the cases, most enrollees of Medicaid will be freshly eligible, but a rise in enrollments of those who were already eligible will result in higher costs for the states since the federal government is heavily subsidizing for the freshly eligible.

Total expenditure in health care will shoot up in 4 states. There will be a drop in spending in Connecticut since people of low income previously covered by the insurance program of the state will now be covered by Medicaid which will be funded mostly by the federal government.

Other Potential Effects of Affordable Care Act of 2010

States, New York included, do have a role to play in health care reform. For instance, an option exists for them to establish their own state's health insurance exchange (What Is Health Care Reform). Generally, reforms to healthcare at the federal level establishes a minimum thereby giving the states an opportunity for the provision of protection far outweighing the one established in federal law. In the year 2011, the legislature in the state of New York passed A8460/S5800 that updated the Public Health and insurance laws of the state in line with the provisions of the federal law as relates to policies of health insurance as well as contracts (What Is Health Care Reform).

The health care reform legislation gives funding to help individuals who are not insured but have conditions that pre-existed by developing temporary high risk pools. As the program operates, the individuals of this nature will be capable of accessing coverage without the restrictions of waiting periods that characterize pre-existing conditions (What Is Health Care Reform). It also establishes a reinsurance program that is temporary (till the availability of the exchanges) which assists employers and the sponsors of the plans they offer offset any costs incurred for early retirees aged 55 and above that are ineligible for Medicare (What Is Health Reform). The health care reform legislation makes it lawful for adult children to still be under the insurance policies of their parents till the age of 26, if the parents allow it. Student status, financial dependency, residency, employment and marital status cannot be used in the determination of eligibility for a child's coverage on the policy of the parent.

The Affordable Care Act of 2010 (ACA) has the potential to expand the coverage for health insurance to an approximate 30 to 34 million individuals. Nonetheless, an increase in coverage will not necessarily translate to an expansion of care, the difference is actually becoming clearer (Anderson, 2014). When Congress passed the law, an influx of freshly insured individuals flooded the system -- a system that was then very fragile and strained. Health care in the United States has had personnel shortages for several years and isn't prepared to meet the need of such an influx efficiently or effectively (Anderson 2014). Training of new nurses, physicians as well as other professionals in the field will take several years, maybe decades. With the absence of a high number of fresh graduates from medical and nursing schools and increase in innovation in shared responsibilities and roles among nurses, doctors and other professionals in the field, patients will experience extended waiting times, great pains in gaining access to providers, short periods with the providers, an increase in the costs and fresh frustrations which come with delivery of health care (Anderson, 2014).

In spite of the efforts put by medical professionals as well as educators to raise the number of people in the workforce over the years, shortages continue to be projected in every part of the field. The supply projections cannot meet demands associated with the growth in the population and the number of the aging population. Given the fresh demand for health services for the expected millions who are to enroll in state as well as federal insurance exchanges and Medicaid, the shortages in workforce reports and studies clearly state the need for more physicians. There is a shortage of primary care specialists and physicians. All the fields in the health care sector face shortages in personnel, mental, dental, allied health, pharmacy -- to name a few. Before the enactment of the ACA, a collection of factors had led to the problems in labor force. This law will result in even more problems for the health care personnel (Anderson, 2014). Physicians are stopping their practices, moving into bigger physician groups and seeking hospital employment. Under frustration with more and more regulations, the cost of practicing, increased workloads, liability and work place stress, they are abandoning practicing independently (Anderson, 2014). By the year 2011, 50% of physicians worked for insurers, corporations or hospitals -- a notable change in the delivery of healthcare in a magnitude not yet witnessed in the recent past. The migration of physicians raises costs of operations while lowering profits and increases prices for players and consumers.

Does Insurance Guarantee Access to Quality Care?

While several Americans will buy insurance on exchanges that are well regulated, insurance alone cannot guarantee that the individual will access quality care (Anderson, 2014). Exchange plans that have narrow networks mean a reduced access to the needed specialist and good programs for treatment. Patients might have limited choices in care and treatment. Hospitals are being shut, and those in rural areas as well as critical access facilities risk being closed (Anderson, 2014). Several hospitals now need that payment be made up-front for deductibles as well as co-pays for services that are non-emergent and so limiting the access to care. Entrenched professional organizations have undercut reforms in several states, in spite of the fact that the coming shortage will require APRN full use (Anderson, 2014). Government agencies and insurance companies ought to do away with obstacles that hinder certification and also eliminate any payment problems. Legislators at the state level should evaluate APRNs potential role as a way of increasing access and achieving more savings. Because of the current state of supply and demand for health services, it is important that everybody is working towards caring for the increased number of patients (Anderson, 2014).

Changes in healthcare policy that is sensible could solve the issues of the few without inconveniencing the many. Legislation in healthcare should abide to the premium non-nocere principle ("first do no harm") through careful targeting of the main issue, not through giving power to regulate to government officials who are not accountable and give arbitrary directives (Anderson, 2014). Every day that the ACA is the applicable law, the health care sector risk being damaged permanently. There isn't a shortage of possible policy paths that could ensure a rational and massively consequential reform in health care: reforms in taxes, tort reform, reforms in payments, insurance portability, transparency in pricing as well as eliminating barriers to care and coverage (Anderson, 2014). As this happens, the consequences that were not intended caused by ACA can't be ignored. The people ought to have the right of self-determination when it comes to health care. In securing this right, the Congress should repeal this law.

Problems Posed By the Expanded Coverage

The ACA began changing the system of healthcare in the nation right from the moment of its signing into law in March of 2010. It resulted to an enlarged coverage for young adults by affording them the chance to be on the plans of their parents till they are 26, legalized lifetime limits on what exactly is to be covered by insurance, made the cost of drugs for the elderly on Medicare lower, made thirteen million consumers get premium rebates to the tune of $1.1 billion, and established an expanded access to free preventive care for everyone regardless of the age (Update on Healthcare Reform). The legislation withstood a challenge in the Supreme Court in the summer of 2013, but that is just preface to the coming transformations, when nearly every American will be guaranteed access to health insurance that is affordable and takes care of essential care. Insurers should spend a minimum 80% of the premiums paid on improving quality and on medical care either as individuals or in their plans of small-groups (Update On Healthcare Reform). The base line for the large groups is 85%. Failure to do this, should have the difference being refunded to contributors by way of a reduction on premiums or issuing refunds directly. In the year 2012, when the rule became effective, almost thirteen million American got rebates totaling to $1.1 billion. This rule is inapplicable to plans for self-insurance given by employers who incur the health expenses on behalf of their employees (Update On Healthcare Reform). Inquiring from the employer is the only avenue of knowing if an individual is self-insured. You can know by just checking the insurance card. All plans are required to use a consumer friendly and standardized form in summarizing the coverage and benefits, including co-payments information, deductibles as well as limits to out-of-pocket expenses. This eases the comparisons of plans. The insurers may have to calculate and make a disclosure about a typical patient's out-of-pocket expenses for two scenarios: child delivery and the treatment of type 2 diabetes (Update On Healthcare Reform).

Qualifications for Subsidies

The intention of the law was the expansion of health programs that are run by the government for Americans who have low incomes so as to bring an additional sixteen million people under the net -- covering people up to 133% of the poverty line ($14, 856 in the case of individuals and $30, 657 for families of four). The figure included several people who are under the poverty line who are not eligible currently (Update On Healthcare Reform). Nevertheless, the expand or not to expand Medicaid in such a manner option was given back to the states in the Supreme Court ruling of 2012 which upheld the legislation's constitutionality (Update On Healthcare Reform). Even though several states have made announcements that they will proceed with the expansion of Medicaid, some other states are still deliberating while others have out-rightly rejected the expansion (the states can change their positions whenever they fancy). In the sates that declined Medicaid expansion, poor households might end up not having health coverage. Households who fall between 100% and 133% of the poverty line are allowed by law to purchase subsidized coverage on the marketplaces of their states (Update On Healthcare Reform). A lack of health insurance attracted tax penalties, beginning at $95 an individual, $285 for a family or 1% of income, whichever of the three is greater for the year 2014. (The figures will rise to $695 for an individual, $285 for a family or 2.5% of income in the year 2016). Since a majority of the population will be possessing qualifying health insurance at the time, few will be penalized. Furthermore, the penalty won't be applicable if no tax returns are filed because of too little income (Update on Healthcare Reform). Americans residing abroad and those serving terms in jails, are exempted from this. There is no need to worry that you might not afford health insurance. If the insurance is bought on the marketplace of the state in individual capacity, you might qualify for subsidies if you have a household income falling between 100% and 400% of the poverty line of the federal government (Update on Healthcare Reform). The subsidy is kind of like a tax credit that can be made use of on the spot to incur less on premiums. (The tax system is already subsidizing for people whose coverage comes from their jobs by not including the health plan costs in their taxes). For example, a four-member family whose income is 200% of poverty level, approximately $46,000, will not pay a cent above $235 in monthly premiums. Individuals of household incomes below 250% of poverty line shall also be granted subsidies so as to reduce out-of-pocket expenses, like coinsurance and deductibles (Update On Healthcare Reform). A person will know if he/she qualifies for subsidized insurance as they shop on their marketplace, and if they do qualify, they will know the amount.

The Case for PCPs and Hospitalists

One recognizable change in medical care delivery in the U.S. In the years past has been primary care physicians (PCPs) nearly disappearing from general inpatient care and being substituted by generalists: hospitalists (Goroll and Hunt, 2015). Several things can explain this shift from revenue seeking actions like increasing office visits to minimizing the length of stays in the hospitals (Goroll and Hunt, 2015). Several young professionals in the field with aspirations to become generalists, particularly those graduating from general internal medicine residences, currently opt for hospitalist opportunities instead of primary care chances that are office-based.

These challenges give the suggestion that the prevailing labor division between PCPs and hospitalists ought to be considered, though any other approach taken should take care to respect the achievements made under the system we have now like a reduction in stay lengths, enhancement of care for inpatients, development of a fresh breed of generalist educators who ply their trade in hospitals, as well as the adoption of practices of primary care in medical homes (Goroll and Hunt, 2015). Solutions come up with in the past addressing continuity of health care and the transfer of information have always included the designation of primary care members to serve on rotation as the physicians attending to the patients (Goroll and Hunt, 2015). A similar option is assigning to a group for primary care a few hospitalists or integrating the hospitalists into the group. Professional and logistic barriers like equity in the scheduling of payments, needs for cross-coverage as well as the challenge of interacting with medical environments that are complex and unfamiliar have hampered the model's adoption (Goroll and Hunt, 2015).

Observers who are conscious of budgets might be concerned about the PCPs payments for work done in inpatient care might lead to an increase in costs. Some savings should be made, however, due to a better diagnostic accuracy and efficiency; from the lowering of stays, unwarranted tests, admissions that can be prevented and discharging appropriately; and from compliance that is enhanced, satisfaction of patients and follow-ups -- quantifiable parameters which can be made use of in examining the reform's efficiency (Goroll and Hunt, 2015). We can expect that savings will accrue in outpatient and inpatient settings. Initial studies of the model that is proposed will be focused on clinical outcomes, costs and other metrics for operations (e.g. prenoon-discharge rates, 30-day readmissions and length of stay) as well as satisfaction of patients. The currently operating hospitalist-ambulist wing of general care has contributed greatly to care of patients, but there is still much to be achieved, particularly as concerns continuity and personalization of health care (Goroll and Hunt, 2015). A model that is collaborative and integrates PCP in teams consisting of hospitalists for consultation can improve experience of patient care as well as other metrics in a cost effective manner, and improve satisfaction of medical professionals at this crucial juncture for PCPS and hospitalists.

"References"

1)

Kemp, C. (2012, October 11). Public Health in the Age of Health Care Reform. Retrieved January 21, 2015, from http://www.cdc.gov/pcd/issues/2012/12_0151.htm

2)

How National Health Care Reform Will Affect a Variety of States. (2011, April 5). Retrieved January 21, 2015, from http://www.rand.org/news/press/2011/04/05.html

3)

What is Health Care Reform? (2012, April 1). Retrieved January 12, 2015, from http://www.healthcarereform.ny.gov/summary/

4)

Anderson, A. (2014, March 18). The Impact of the Affordable Care Act on the Health Care Workforce. Retrieved January 21, 2015, from http://www.heritage.org/research/reports/2014/03/the-impact-of-the-affordable-care-act-on-the-health-care-workforce

5)

Update on health care reform. (2013, March ). Retrieved January 21, 2015, from http://www.consumerreports.org/cro/2012/06/update-on-health-care-reform/index.htm

6)

Goroll, A., & Hunt, D. (2015). Bridging the Hospitalist -- Primary Care Divide through Collaborative Care. The New England Journal Of Medicine, 372, 308-309. Retrieved January 22, 2015, from http://www.nejm.org/doi/ref/10.1056/NEJMp1411416#t=article

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Johnson, T. (2012, March 26). Healthcare Costs and U.S. Competitiveness. Retrieved January 22, 2015, from http://www.cfr.org/competitiveness/healthcare-costs-us-competitiveness/p13325

8)

Health Care Transformation: The Affordable Care Act and More. (2014, June 18). Retrieved January 22, 2015, from http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/AffordableCareAct.pdf