1. Molyneux, Jacob senior editor


The Supreme Court's decisions on the ACA won't undo the realization that how we deliver and pay for care must change.


Editor's note: Each January AJN examines the major stories affecting nurses and health care during the previous year. This year's top stories aren't too different from those we highlighted last January: the continuing debate over the Patient Protection and Affordable Care Act and how to fix the floundering economy continue to top our list. And while we hoped that Congress would move past its partisan squabbling to address these incredibly important issues, it didn't happen, even among members of the bipartisan deficit "super committee," which failed to find a compromise solution to reduce the deficit. For nursing, it was all about whether the Institute of Medicine's Future of Nursing report would create change. Clinical news shows that consumers are still wary of vaccines and confused about screening guidelines; on a global level, the focus seems to have shifted from AIDS to noncommunicable diseases.


Article Content

In November of last year, the U.S. Census Bureau reported that the increasing burden of health care costs had impoverished millions of Americans. One has only to sample the personal stories of financial hardship that have been collected on the We Are the 99% blog ( to see how frequently the solvency of an American family depends on staying healthy. Many of these accounts mention medical bankruptcies, skipped operations and medications, inability to afford insurance, or insurance that fails to adequately cover treatment.


Scotus gets into the act. About a week after the Census Bureau report, the U.S. Supreme Court announced that in March it would set aside time to consider several legal challenges against various aspects of the Patient Protection and Affordable Care Act (ACA) that President Obama signed into law in 2010. Many of the cases involve the legality or implications of the ACA clause that would require all Americans to purchase some form of health insurance by 2014 or face a penalty.


The individual mandate, which has already been upheld by three of four appeals courts, is widely considered crucial for funding the historic health care reform legislation. The Supreme Court decision is expected to come in late June, several months before the presidential election. Mitt Romney, a leading Republican candidate for president, has vowed, if elected, to repeal the ACA on the first day of his presidency.


But undoing the ACA's influence may not be so simple, either for a right-leaning Supreme Court or a potential Republican president. Despite the refusal of some states such as Florida to accept ACA-related funds, many of the law's provisions have already taken effect, with others to be implemented in the next three years.


By August 2011 the law had provided coverage to as many as a million young adults through the provision allowing them to stay on their parents' coverage up to age 26; many preventive services-including those specific to women's health-are now guaranteed coverage, uninsured Americans with preexisting conditions can now purchase coverage through a new program, many states have been awarded grants for programs to regulate the fairness of the health insurance market and protect consumers, insurers are required to spend at least 80% of operating costs on providing care, and Medicaid has been expanded to cover more low income people.


In turn, the expanded number of covered Americans, coupled with the influence of other provisions related to such central issues as Medicare reimbursement and the creation of accountable care organizations (ACOs), has prompted many hospitals and medical systems to consolidate and focus on streamlining costs, integrating all levels of care, adding numerous primary care physicians and nurses, and improving quality.


Nurses and the ACA. Acknowledging the centrality of nurses to the future and quality of our health care system, the ACA includes an array of provisions supporting nurse staffing and retention, including more funding for advanced education nursing grants and teacher training, a repayment program that covers 60% of student loans in exchange for two years of work in an area with a nursing shortage, support for nurse-managed clinics, and others.


The elephant in the room, with or without the ACA, is how to control the continued rise of health care costs (currently 16% of our gross domestic product, higher than in any other industrialized nation) and provide higher-quality care. The Commonwealth Fund reported last October that the United States, despite some progress in targeted quality improvement areas, remains well behind many other nations in such measures as mortality, preventable deaths, cost, and accessibility of care. While the funding provided by the individual mandate may prove essential to ACA provisions designed to address these issues, some states such as Massachusetts and Vermont are pushing ahead with more comprehensive plans for either replacing the traditional fee-for-service model with a flat "global" fee to providers or implementing a proposed single-payer system to expand access and control costs.


As expected, pushback from industry and special interest groups against efforts to control costs is strong. Decisions made in the coming year may influence the U.S. health care system for many years to come, and nurses should stay informed and get involved.-Jacob Molyneux, senior editor