With unemployment lingering above 9% in the wake of the recession, Republicans in 2010 found a scapegoat for the public's frustration in the vast and complex legislation known as the Patient Protection and Affordable Care Act, which was passed last March by Congress and signed into law by President Obama. But the claims and counterclaims made about specific aspects of the law in the period leading up to the November 2010 midterm elections made it all too easy to forget that the problems facing the U.S. health care system will not magically disappear.
The United States spends more per patient than any other country but has a lower average life expectancy and a higher infant mortality rate than most developed countries. At the same time, we have few reliable mechanisms for determining whether constantly updated—and aggressively marketed—treatments and medications are the most evidence-based and cost-effective ones available.
Many health insurance plans have double-digit yearly premium increases, the number of uninsured Americans is now almost 60 million, according to the Centers for Disease Control and Prevention, and—until initial provisions of the health care law took effect in September 2010—those with preexisting conditions have often been unable to find affordable coverage and those who fell ill while already insured have been routinely kicked off coverage.
The Affordable Care Act is a multipronged, profoundly compromised, and gradually implemented first move in attempting to address the twin issues of efficiency and fairness. The real question is this: Do we build on it or devote all our energies to returning to square one? (See this month's Policy and Politics for more on this question.)
The law's first wave of benefits went into effect in 2010 and included the following provisions, among others: coverage for live-at-home children up to age 26; no refusal of coverage for children with a preexisting condition; access to affordable coverage for adults who've been refused coverage for preexisting conditions; no lifetime limits; free preventive care, including such services as mammograms and colonoscopies; significant investment in comparative effectiveness research; more money to states to examine and regulate the quality and fairness of the insurance policies on offer; a closing of the "doughnut hole" in Plan D prescription-drug coverage for the elderly; and expanding Medicaid coverage for low-income individuals and families.
Other important aspects of the law won't go into effect until 2014 (see www.healthcare.gov for more details); these include providing tax credits to small businesses and to middle-income individuals and families (those above 133% and below 400% of the poverty level) for purchasing coverage, creating health insurance exchanges where individuals and small businesses not covered by employers will be able to compare and shop for plans that meet reasonable parameters of cost and quality, and requiring individuals to purchase coverage or face a penalty for not doing so.
This latter provision, unpopular but considered by most experts to be crucial to paying for the law, is particularly controversial and remains under threat as Republicans attempt to impede appropriations for it (this is one of numerous provisions for which they've vowed to do so), as a number of newly elected governors appoint insurance commissioners who can weaken the mandate to regulate insurers, and as a number of states initiate lawsuits against the constitutionality of various aspects of the law.
Debate has also arisen around complicated provisions—and related laws not part of the Affordable Care Act—affecting Medicare reimbursements; these are intended to slow the yearly increase in Medicare spending in order to keep the plan solvent in the coming decades as the population ages.
What about nurses? The aspects of the health care law perhaps most likely to directly affect the nursing profession are substantial increases in funding for nursing education and incentives designed to increase primary care availability through promotion of community health centers and the medical home model. These dovetail with The Future of Nursing: Leading Change, Advancing Health, a report from the Institute of Medicine, released in October 2010, which envisions a crucial role for RNs and advance practice nurses in the coming decades—if, that is, their voices are heard, their training improves, and their skills are used as broadly as they could be. (For more, see this month's Editorial.)—Jacob Molyneux, senior editor