1. Webb, Jo Ann K. MHA, RN
  2. Marshall, David R. JD, RN, NEA-BC, CENP

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The Patient Protection and Affordable Care Act (PPACA), which became Public Law 111-148, is probably the most significant legislation affecting healthcare since the passage of the Social Security Act of 1965. This historic legislation marks a watershed moment for the nursing profession. Through the extension of health insurance coverage to 32 million previously uninsured individuals over the next 3 years, the demand for nursing services will markedly increase in all facets of the delivery system-acute inpatient and outpatient care, chronic and transitional care, primary care, preventive care, home care, and long-term and palliative care. This comes at a time when we are dealing with major shortages throughout the health professions and as our country struggles to recover from a crippling recession that has forced the reexamination of American healthcare. In the view of some, the passage of healthcare reform is a major step toward the "socialized medical model" of our Canadian neighbor and some European and Asian countries. To others, it was finally right thing to do after years of protracted debates and eye-popping expenditures that threatened to bankrupt the American way of life. The controversy and debate will likely continue, but for nursing, the PPACA has provided the opportunity of a lifetime-to finally showcase the true value of nursing.


The new law provides coverage through a combination of public and private sector insurance expansions. This includes Medicaid coverage to single childless adults and the creation of state health insurance exchanges to provide affordable options for individuals and small businesses. It also provides subsidies for low-income families and individuals. It puts into place insurance reforms that will ensure continued coverage by prohibiting lifetime limits on plans, exclusions based on preexisting conditions, and discrimination based upon on one's health status. The law prohibits copays on preventive services and insurance policy cancellation when an individual becomes ill. The law will also permit the inclusion of dependents up to the age of 26 years on a parent's health plan.


The expansion in coverage may not necessarily lead to greater access to care, if workforce issues are not addressed. Specifically on the nursing front, the law significantly expands education and training opportunities in a number of arenas. On the traditional educational funding front, PPACA reauthorizes and strengthens Title VIII of the Public Health Service Act. Although many in the nursing community viewed Title VIII as a useful tool to educate America's nurses, the law was never funded at a level that would prevent or reverse the nursing shortage. It has, in fact, indirectly contributed to the faculty shortage by capping the amount of funds that could go to nursing doctoral programs. This is changed under the PPACA with the expansion of the Loan Repayment and Scholarship program and the elimination of the 10% doctoral cap on advanced nursing education grants. In addition, PPACA changes make it possible for nursing faculty to participate in repayment and scholarship grants by permitting them to serve as faculty as a term of loan repayment. Doctoral students can receive up to 85% of loan cancellation under the Nurse Faculty Loan program. Under the new School of Nursing Student Loan Fund, loan amounts have increased from $30,000 to $35,000. The Eligible Individual Student Loan Repayment program is for graduated master's or doctoral students who agree to serve as full-time faculty to receive loan forgiveness for a commitment of 4 years in an accredited school of nursing. The Nursing Student Loan program, which is directed toward accredited baccalaureate, associate, and diploma nursing programs, will offer increased loan amounts. The total will go from $13,000 to $17,000 and will increase the loan amount from $4,000 to $5,200 for students in their last 2 years of school. The Comprehensive Geriatric Education section of Title VIII has also been improved to create a new geriatric traineeship that will provide tuition, books, and stipends to eligible students. The Workforce Diversity Grant program will offer bridge programs to minority students in associate and diploma programs to allow them to enter accelerated degree, preentry, and advanced education programs to continue their education. Although the changes are significant to Title VIII programs, the battle for increased appropriations for these specific programs in our deficit-riddled economy will remain a challenge.


A major new demonstration program to address the role of nursing in primary care has been authorized under the PPACA with a $200 million grant funded through the Medicare Graduate Medical Education program. Under the 3-year demonstration, hospitals would reimburse nursing schools and community-based care settings for the clinical costs of educating advanced practice nurses. The program, which has a start date of October 1, 2011, directs the secretary to establish 5 sites.


A major victory for nursing occurred with the designation of nurse-managed health clinics as eligible for federal funding in addition to a $50 million grant through the Department of Health and Human Services (HHS). Nurse-managed health clinics will help train more nurses in primary and preventive care while strengthening the nation's healthcare safety net. The nurse practitioners who staff nurse-managed health clinics are by far the nation's fastest growing segment of primary care providers. Offering cost-effective, high-quality care to patients regardless of their ability to pay, these clinics are perfectly positioned to fill the provider gap that has been well documented by the shortage of primary care physicians.


Other program opportunities created by the PPACA are the increased funding for the National Health Service Corps (PHSC) and the creation of the Public Health Workforce Recruitment and Retention program, which are aimed at ensuring an adequate supply of public health professionals and eliminating shortages in the federal, state, local, and tribal public health agencies. Nurses are vital to the missions of these programs, and the service obligation for PHSC grants can be fulfilled by working in designated "health professional shortage areas." Also, a Ready Reserve Corps was created within the Commissioned Corps for service in times of national emergency. Members of the Ready Reserve Corps may be called to active duty to respond to national emergencies and public health crises.


The PPACA establishes 45 commissions, committees, boards, and advisory panels to advise the secretary of HHS and the Congress on a number of critical issues ranging from health workforce shortages to interagency access to healthcare in Alaska. On some commissions, there are specific requirements for registered nurses. On others, the contributions of nurses with expertise in fields such as women's health and elder care would prove to be particularly invaluable.


The focus on primary care and prevention within PPACA will add to the growing need for nurses through the expansion of school-based health centers. Obviously, our schools play a critical role in the detection and surveillance of communicable diseases and can play an even larger role in efforts to keep communities safe in emergency situations. The expansion of school-based health centers will provide a vital link to controlling healthcare costs while increasing access to care for some of our most vulnerable populations.


The role of nursing will also be highlighted in a number of programs directed at transitional and chronic care management, diabetes care and prevention, as well with maternal, infant, and early childhood visitation programs. Programs such as these will capitalize on the ability of nurses to intervene within the home environment to support at-risk patients and provide consistent care management that can lower costs, prevent complications, and provide better patient outcomes.


As reimbursement moves to encompass the entire episode of care, nursing should see its role expand in new models of care such as in accountable care organizations, the medical home, and other demonstrations such as the Independence at Home program, which will test payment incentives for home-based primary care teams aimed at reducing the cost of care and improving health outcomes.


The establishment of the Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services with its $10 billion funding stream over 10 years should provide opportunities for nursing researchers to play a role in the development of innovative delivery models. The stated goal of the new center is to provide research funding to develop, test, and expand innovative payment and delivery models to improve the quality and reduce the cost of care for patients in the Medicare and Medicaid programs. This could be the opportunity for nursing to finally and unequivocally prove its economic value that for too long has been buried with the cost of hospital room and board.


One provision of the PPACA requires the secretary of HHS to establish a National Strategy on Quality to be implemented at the local, state, and federal levels. The National Strategy on Quality would improve healthcare service quality, delivery of healthcare services, health outcomes, and the health of the overall population. The collection and public reporting of quality measures would be included in the strategy. There is a strong body of evidence that inextricably links nursing care to quality, allowing nursing to have its voice in developing the National Strategy on Quality.


Within the hundreds of pages of healthcare reform law are opportunities for the nursing profession at every level. Like it or hate it, a new chapter is being written on the delivery of healthcare in America. Now is the time and the challenge to keep nursing's influence strong, its actions bold, and its voice heard as we manage-and shape-the impact of the PPACA through appropriations, pilot projects, and regulations to be implemented over the next several years.