1. Carroll, V. Susan Editor

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A challenge for nearly all journal editors is the need to work in the future. JNN publishing deadlines mean that I write in the present with an eye on events that are still unfolding. That said, issues and trends in healthcare that affect us now, and likely in the future, include the 2010 Institute of Medicine (IOM) report on the future of nursing, the U.S. Supreme Court's consideration of subsidies linked with the 2010 Accountable Care Act (ACA), and the 50th anniversary of Medicare. Decisions related to these programs, changes in the infrastructure that supports them, and fiscal concerns about their future may impact each of us and our practice as we move forward.

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Five years after the release of the IOM report, Susan Hassmiller, the Robert Wood Johnson Foundation senior advisor for nursing, reports that the number of employed nurses with a bachelor's degree or higher has inched up by 2% between 2010 and 2013. Recommendation 4 of the IOM report calls for an increase in the proportion of nurses who hold a baccalaureate degree to increase from 50% to 80%. Although the increase seems small, nursing schools have increased capacity and implemented new educational models that will accommodate more students moving forward. Looking beyond the BSN to recommendation 5-double the number of nurses with a doctorate by 2020, significantly more nurses are pursuing this level of education. This is likely linked directly to the proliferation of doctor of nursing practice programs since 2010. Enrollment in PhD programs has also increased but to a lesser degree. Together, these initiatives will ultimately change the level of nursing education we see at the bedside.


As I write this editorial, the U.S. Supreme Court has just finished hearing arguments related to the legality of healthcare subsidies that are a part of the ACA. More than 16 million individuals have gained coverage under the ACA, a program that offers subsidized private coverage for people without employer-provided insurance as well as an expanded Medicare program. Opponents of the ACA argue that subsidies are illegal in states that did not establish their own insurance markets. If the Supreme Court rules that subsidies are indeed illegal, between 7 and 9 million individuals could lose their coverage. What might be the effects of their losses? Insurance premiums costs would rise. Individuals who could not afford the costs would revert to their previously uninsured status, resulting in sicker patients who again require more care. Healthcare spending for infrastructure could plummet as costs rise. Healthcare worker hiring would likely stagnate.


Medicare has been with us for 50 years; many of us cannot remember healthcare without it. As millions of Americans-the Boomer generation-begin to register for and use its benefits, this popular federal program faces serious challenges to its effectiveness and sustainability. These challenges include rising expenditures, quality-of-care concerns, program fragmentation, and coverage gaps. Proposals to improve Medicare include incremental provider-payment reform, value-based purchasing, blended and/or bundled payments, and premium support for individuals. Any one of the challenges or proposals for improvement affects us as nurses and, more importantly, the patients for whom we care; each of them is far more complex than my simple list.


Given the issues, what can each of us do to push progress forward? Support education. Help colleagues identify affordable, manageable degree programs. Discuss the ways in which more education creates outcomes-focused, evidence-based nursing care. Advocate politically. Write and call your state and federal congressional representatives. Join your professional organizations and work with their advocacy groups. We are millions strong, and our voices can make a difference. Just remember that sometimes progress is slow, but change is inevitable.


The Editor declares no conflicts of interest.

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