As President Obama signed the Patient Protection and Affordable Care Act into law on March 23, 2010, he stated that the core principle of healthcare reform is that "everybody should have some basic security when it comes to their healthcare."1 The legislation, including the reconciliation bill, the Health Care and Education Reconciliation Act (signed March 30, 2010), is designed to reform healthcare insurance policies and practice, and expand coverage to the insured in the United States. The 2 bills together are known as the Affordable Care Act (ACA).
The legislation increases coverage to those previously uninsured by prohibiting insurance companies from refusing coverage to those people with preexisting medical conditions, removing upper limits of care costs, and allowing adult children up to the age of 26 years to remain on the insurance policies of their parents. The ACA also provides coverage for people who cannot afford insurance by increasing the income level qualifying for Medicaid to 133% of the poverty level and expanding Medicaid coverage to childless adults. The bill includes mandated coverage without co-pays or out of pocket payment for preventive care including annual physicals, immunization, and gynecological examinations.2
This column will summarize the key provisions of the ACA related to nursing, including work force development and expansion of care. In this column, the components of the ACA are assumed to be established and funded. This is by no means certain. This column will also discuss recent report published by the Institute of Medicine (IOM), The Future of Nursing: Leading Change, Advancing Health.3 This report contains recommendations and solutions for the challenges facing nursing during this period of healthcare reform and was sponsored and funded by the Robert Wood Johnson Foundation. The committee developing the report is chaired by Donna Shalala, former secretary of the Department of Health and Human Services, and currently president of the University of Miami, Florida. The report defines healthcare reform in terms of quality, access, and value.
THE AFFORDABLE CARE ACT
To provide more coverage for people with illness, the insurance pool must enlarge to include more people who are healthy. The legislation mandates coverage for all individuals and requires employers to offer coverage to employees. By mandating coverage for all individuals, the aim of the reform is to include more healthy people paying into the system so that more people with illness can be covered by insurance.
The Affordable Care Act reforms do not all take effect immediately, but are set to phase into policy during the next 4 years. The ACA does not provide for a public option for health insurance, also called government funded health insurance, for all individuals in the United States. Healthcare in the United States will remain primarily for profit at this time.
The 2010-midterm elections have brought much uncertainty to the healthcare reform process. The 2 bills passed authorized money and programs but the appropriations for the funds have not occurred.2 A bill can suggest the amount of money to be spent on a program, but the authorization for the dollars is usually in a separate bill that must pass the appropriations committee.2,4 The Republican Party now controls the House of Representatives, while the Democratic Party retains control of the Senate. It is unclear what steps the Republican Party will take and what parts of the new reform bills the Republican Party will attempt to defund or drop completely.
Expanding the healthcare workforce
As healthcare reform expands insurance coverage for more individuals in the United States, the assumption is that more individuals will obtain healthcare, including acute and preventive care. This expansion of care will need an expanded workforce.5 Webb and Marshall6 describe the increased need for nursing services as healthcare is reformed. All facets of the healthcare system, including acute inpatient and outpatient care, chronic and transitional care, preventive care, home care, and palliative care, among others, will need more nurses and more nursing care. To expand the nursing workforce, changes in nursing education are needed. The ACA includes educational loan provisions as well as career incentives for those studying nursing and planning a career in some areas of healthcare.
Mason7 describes the emphasis in the ACA on expanding the number of primary care providers in the US system. There has been financial support for graduate medical education for many years, recognizing the primary role physicians have been given in healthcare in the United States. There has not been equivalent support for undergraduate or graduate nursing education, until now. The ACA formally recognizes the primary roles nurses play in the healthcare system, especially regarding preventive care.
The ACA reauthorizes and expands Title VIII of the Public Health Service Act. Title VIII was originally legislated to increase educational loan repayment for nurses. The Act was not adequately funded and placed a cap on the funds that go on to provide repayment for nursing doctoral program loans.6 The ACA legislates several important changes to Title VIII. A 10% cap on educational grants for nursing doctoral programs was removed. Nurses who serve as faculty are now eligible to apply service as faculty for loan repayment. The ACA allows the secretary of the Department of Health and Human Services to increase the amount of loan repayment for nursing studies as the cost of attendance at schools or universities increases, without the need for new legislation.
Title VIII has been expanded by the ACA to include a geriatric nursing traineeship program. This traineeship program anticipates the increasing need for services to older adults as the population ages and expects that nursing care will be a necessary component of the comprehensive care for older adults. Those nurses who accept these grants must agree to teach or practice in geriatrics, long-term care, or chronic care management. Title VIII now also includes a Workforce Diversity Grant program encouraging minority students to bridge into accelerated nursing degree and advanced nursing practice degree educational programs, hopefully changing the face of the nursing workforce to more accurately mirror the diversity of the American society.
Maintaining and documenting the quality of healthcare
Expanding healthcare coverage and maintaining quality is a focus of the ACA. Transparency in planning, staffing, and outcomes is directed in the legislation. Some specific mandates direct the Nursing Home Compare Medicare Web site8 to publish data for each nursing home or long-term care facility including staffing, resident census, hours of care provided per resident per day, staffing turnover, and staffing tenure. The format for this report is designed to enable consumers to compare facilities and also to compare a facility to national and state averages. The report is also designed to help the consumer understand the relationship between staffing levels and quality of care. The ACA also authorizes the creation of a national standardized complaint form to be used in long-term facilities and provides whistle-blower protection for employees of these facilities who complain "in good faith" about the quality of care provided in these facilities.
Furthermore, the ACA requires nursing facilities that are paid with Medicare and Medicaid funds to disclose information regarding their ownership and organizational structures. The aim of these transparency measures is to create a culture change within long-term skilled nursing facilities.9
The new legislation recognizes the role and importance of nursing within any system of primary care. Nurse-managed health centers are supported with an appropriation of $50 million in the fiscal year 2010 with increases authorized through fiscal year 2014. Nurse-managed health centers provide care for low income and vulnerable populations and also, crucially for nursing education, provide clinical sites for training advanced-practice nurses. The expansion of school-based health clinics is encouraged with new grants providing for new construction and equipment for these clinics.
Advanced practice nurses
As fewer physicians complete primary care residencies, the US population's healthcare needs will bring about the increasing use of nurse practitioners who can provide primary care.2 The ACA established a program that allows groups of providers and suppliers to form Accountable Care Organizations to coordinate care for Medicare patients. The Accountable Care Organizations may be eligible for incentive payments when certain quality standards are met. Providers eligible to participate include physician assistants, nurse practitioners, and clinical nurse specialists. The ACA provides for a 10% Medicare bonus payment for primary care providers, including nurse practitioners and clinical nurse specialists, who practice in health professional shortage areas.
The ACA increases the reimbursement rate for certified nurse-midwives for covered services from 65% of a physician's rate to 100% of the physician's rate. The American College of Nurse-Midwives has worked for this legislation for many years. The recognition of certified nurse-midwives care as equivalent and valuable care is an important landmark within the ACA.
The healthcare reform legislation adds to current medical home legislation. A medical home provides comprehensive health management, care coordination, and primary healthcare. A medical home site is responsible to the patient for managing referrals and appointments and is designed to serve as a clearing house for the patient for all referrals and appointments. The medical home would a one-call/stop point of reference for the patient. At this time, medical homes operate under the direction of physicians. Although the language of the ACA does not exclude advanced practice nurses (APN) from leadership of medical homes, physicians are expressly mentioned. This has been interpreted by some states to mean that only physicians are eligible to direct the operations of a medical home.7 There is current legislation proposed to include APNs in the Medical Home Demonstration Project, but this legislation has not been brought to a vote.
Although the ACA represents what has been called the broadest changes in the US healthcare system since the creation of the Medicare and Medicaid programs in 1965,3 it is not clear as this column is being written, what parts of the ACA will be implemented and what provisions will be substantially rewritten and changed by the newly elected majority in the House of Representatives. Even though the Senate remains under control of the Democratic Party, senators may feel that support for healthcare reform is politically risky.
THE FUTURE OF NURSING
Nurses must continue to work for changes in the healthcare system that will benefit patient care in the United States for all sectors of the American society. The recent report by the IOM creates a vision for healthcare that values nursing contributions to the nation's health and hopes to build on the capacity of nursing to initiate, implement, and facilitate improvements in the healthcare system. The report is bold in its recommendations and its conclusions. Four key messages are brought forth in the report.
The first is that nurses practice to the full extent of their education and training. The report describes the maze of state laws governing advanced practice, creating a system in which APNs practice not according to education and training but rather by statute. It is recommended that the federal government take leadership and promote reform and wider scope of practice for nurse practitioners, certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists. According to Donna Shalala, chair of the IOM group, the federal government cannot force a state to change the legislated scope of practice for APNs, but the federal government could lead by including APNs in the Centers for Medicare & Medicaid Services reimbursement panels.10 The report recommends that transition to practice residency programs be developed and evaluated in community settings, helping new graduate nurses develop skills needed.
The second recommendation of the IOM is that nurses achieve higher levels of education and training through an improved education system that promotes seamless academic progression. As patient care becomes more complex, including the addition of evidence-based care, information management systems, and increasing team strategies, the report calls for nurses to attain competencies in leadership, health policy, system improvements among other fields. The IOM recognizes that the majority of the 3 million nurses in the United States are educated at less than the bachelor's degree level. To improve the quality of nursing education, a seamless transition into programs providing higher degrees needs to be developed. The report states that nurses should be educated with physicians and other healthcare professionals as students and during continuing education. This dual pathway can increase team building and respect among professionals of different disciplines.
The third recommendation calls for nurses to be full partners, with physicians and other healthcare professionals, in the redesign of healthcare in the United States. Building on the previous recommendation for education and team building, the IOM recognizes that nursing has not been fully represented in the reform process and that true reform is not possible without the input of nursing. Nurses must work to be included on advisory teams and boards, must be active in decision-making processes, and must be willing to take responsibility for identifying problems, inefficiencies, and needed improvements in the system.
The final recommendation of the IOM report recognizes that effective workforce planning and policy will require better data collection and an improved information structure. The ACA mandates workforce data collection and analysis. If this initiative is not a funded portion of the ACA, other opportunities to develop a national database will need to be explored.
The IOM Committee on the Robert Wood Johnson Foundation Initiative on the future of nursing explores the transformation of the nosing profession in the current healthcare climate in the United States. This is a time to build on opportunities and have a voice and contribution in the healthcare system of the future.
NURSING LEADERSHIP
Nursing leaders have attempted to position nurses and nursing in the debate for healthcare reform. Not all nursing leaders are optimistic about reform capabilities. Mary Mundinger, former dean of the Columbia University School of Nursing and a leader in the development of nurse run clinics, points out that true reform is difficult for many to accept. Dr Mundinger states that with the ACA, the only facet of healthcare that may be changed is the requirement for every individual to have insurance. True system reform would mean that every patient would have the right care at the right time.11 She echoes the IOM Report, stating that while nursing can respond to the increased need for primary care providers, the current system is fragmented and regulatory barriers inhibit the full participation and contribution that nurses could make to the nation's health. The healthcare system at this time provides care too late and in the wrong place at high cost, according to Dr Mundinger.11
Healthcare providers, including nurses, are divided about the correct course the United States should take for reform of the healthcare system. Issues that strain the system include the cost of insurance, the inability of many people to obtain insurance, the shortage of primary care providers especially for vulnerable populations, the barriers to the utilization of nursing to the fullest, and the difficulty some systems have in recognizing the contributions nurses could make. Reform does not stop with the Obama ACA, regardless of any changes that may be made in its provisions.
It is difficult for anyone to keep up with the changes in legislation. Good sources of information for nurses include the American Nurses Association and each state association. Specialty organizations such as the Association of Women's Health, Obstetric and Neonatal Nurses have updates on legislation that may impact the specialty. Web sites that nurses can access to obtain information and analysis that is pertinent to their specialties or interests are included in Table 1.
The healthcare system in the United States is one of the best in the world, at least technologically. The infant mortality rates and the lifespan are not the best in the world. If the American system is to reach its enormous potential, issues of coverage, access, and value must be addressed and viable solutions developed.
Deeper philosophical questions drive the healthcare debate. Is healthcare a right of all US citizens? Should healthcare, insurance, or both be maintained as a for profit system? What is the government's role in the healthcare system? As the US system, people, and lawmakers struggle with these issues, nurses can contribute to the solutions and make our voices and opinions heard.
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