1. Molyneux, Jacob Senior Editor


A maturing conversation.


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It'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 employer-sponsored health insurance or 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,, 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 evidence-based 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 coverage.


* 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 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 experience 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 ongoing process, a powerful light 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