1. Wilmont, Sibyl Shalo BSN, RN


Perhaps, but that could spell trouble for nurses.


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The 2010 Affordable Care Act (ACA) is the direct descendent of the health care reform law enacted in Massachusetts in 2006. Studying the results of the Massachusetts law may be a good predictor of the ACA's impact on national patient outcomes, as well as the nursing workforce.

Figure. Dr. Stelios ... - Click to enlarge in new windowFigure. Dr. Stelios Maheras examines a patient at East Boston Neighborhood Health Center. Studies have shown that the mortality rate in Massachusetts dropped after the state overhauled health care in 2006. Photo by Dominic Chavez / New York Times.

The results of a recent study suggest that the expansion of health insurance to those formerly uninsured may decrease population death rates. Sommers and colleagues compared average mortality rates among adults 20 to 64 years of age in Massachusetts counties at five years before and four years after implementation of the commonwealth's health care reform law with rates in closely matched counties in states without such reform. They found a 2.9% decrease in all-cause mortality, and a 4.5% decrease in deaths from causes considered "amenable to timely health care," such as heart disease, stroke, cancer, and infections. The impact was more robust in several subgroups: ethnic minorities (-4.6% among Latinos and nonwhites), low-income counties (-3%), and counties with high rates of uninsured residents (-3.3%). These are important findings when considering that the ACA was largely modeled after the Massachusetts law.


The study's authors cautiously offer a "plausible causal pathway" to explain these results: insurance coverage expands access to health care services, which leads to greater use. As simplistic as that may sound it's precisely what concerns Judith Shindul-Rothschild, associate professor at Boston College's William F. Connell School of Nursing and a proponent of both laws. She calls the increased patient demand in Massachusetts a "tsunami," as people unable to access primary care tend to overwhelm EDs-an "unintended consequence of a well-intentioned law." A longitudinal analysis she published earlier this year with Matt Gregas found that as hospital admissions in Massachusetts increased after enactment of the state law, there was no commensurate increase in RN staffing. In contrast, in California, where minimum nurse-staffing ratios were mandated, RN staffing grew from 2000 to 2011.


"No one disagrees that we need to provide access to the millions of Americans who've been denied, but there are strings attached to that," she says. "These are perilous times for providers. We, as nurses, must recognize this as a challenge to our ability to provide high-quality care and to patients' access to that care. To minimize that is to do a tremendous disservice to everybody."


Nursing advocates are addressing the challenge at the state and federal levels. In November, Massachusetts residents may finally get to vote on state nurse-staffing ratios, and a federal bill was recently introduced in the U.S. Congress.-Sibyl Shalo Wilmont, BSN, RN




Sommers BD, et al. Ann Intern Med 2014;160(9):585-93;


Shindul-Rothschild J, Gregas M Policy Polit Nurs Pract. 2013;14(3-4):151-62