The turbulence for the U.S. health care system seems sure to continue in 2013, despite President Obama's reelection and the fact that the Patient Protection and Affordable Care Act (ACA), signed into law in 2010, weathered a major challenge before the U.S. Supreme Court in June of 2012.
Though recent studies suggest that many still have a poor understanding of the ACA, more Americans now favorably view the complex legislation, expected to eventually provide coverage to 30 million more Americans, than at any time since its passage. Even so, opposition to its implementation remains high in many states, with a number of them declining to set up health care exchanges by October 2013 (exchanges will provide consumers reliable information about health care plans and available government assistance; by default, the federal government will set up exchanges in states that refuse to establish their own). Some states have also signaled their intention to opt out of the 2014 Medicaid expansion that's due to occur under the ACA—a choice allowed states by the Supreme Court decision upholding other ACA provisions.
An influx of patients. With the expansion of Medicaid to include those who earn up to 135% of the poverty threshold, as well as the mandated purchase of health care insurance starting in 2014, the ACA will increase health care access (it's already done so for those with preexisting conditions, those ages 26 and under who want to stay on their parents’ health care plans, and others).
Expect an “influx of patients with even more complex, chronic needs into the system,” said Susan Hassmiller, Robert Wood Johnson Foundation senior adviser for nursing, in a recently published interview. Nurses are poised to play an expanded role at many levels. As Hassmiller puts it, the ACA “accelerated delivery system reforms that focus on increased primary, preventive and care coordination (including transitional care), all of which have nursing at their core.” (See The Top Nursing News Story of 2012: Health Care Reform Goes Hand in Hand with Expanded Nursing Roles.)
The money problem. While the United States offers some of the most sophisticated treatment in the world, per capita health care costs top the scale compared with those of other countries, and we still lag behind on many basic measures, such as infant mortality rate, hospital readmission rates, and patient and provider satisfaction. Cost control is a central issue in all policy discussions—the dominant fee-for-service model often leaves the door open to overtreatment and overtesting, much of it not just expensive but perhaps even harmful to patients (consider the ongoing debates about prostate and breast cancer screening guidelines).
ACOs. The ACA lays important groundwork for future changes. A crucial aspect of the law is its support for new payment and delivery models, called accountable care organizations (ACOs). These organizations would, as described by Kaiser Health News, “agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries,” making providers “jointly accountable for the health of their patients and giving them financial incentives to cooperate and save money by avoiding unnecessary tests and procedures.”
A diverse range of ACOs are already in development in many states. They are intended to replace the fee-for-service model with one that ties payment to outcomes and focuses on care coordination, quality improvement, and cost control—all areas where nurses can play a crucial role.
With or without the ACA, the problem of rising health care costs and an aging population beset by multiple chronic illnesses will have to be faced. There's sure to be pain for both providers and patients. Budget negotiations that include possible Medicare and Medicaid cuts are ongoing as we go to press. As in recent years, the best choice for nurses is to stay open-minded, informed, and engaged in a changing system.—Jacob Molyneux, senior editor