If one of your patients has been without health insurance in the last year, they aren't alone. 46.7 million people of all ages in the United States were without health insurance from January to March 2010. Anyone without coverage probably knows the difficulty of obtaining quality healthcare. In the last two decades, many have tried to change our current system. In late March 2010, the Affordable Care Act became a law. This law protects consumers and promotes better access to health insurance. It also helps those who have coverage but an inadequate amount. The Affordable Care Act was designed to ensure insurance coverage for all Americans and increase the quality of care.
Statistics show that children age 17 and younger have the lowest uninsured rate, but the highest percentage of uninsured individuals falls within ages 18 to 24 (31.4% based on a March 2010 National Health Interview Survey). This age group is typically in a transitional phase, moving out of parents' homes, or they're underemployed. Many young adults are dropped from their parents' insurance policy at age 18. They're now able to stay on the parents' policy up to age 26, regardless of marital status, unless they're employed and coverage is offered through their employer.
Starting in 2011, seniors will receive new benefits, such as free screenings for colorectal cancer and mammograms. Another valuable addition to the new law is the Elder Justice Act, which focuses on long-term-care facility quality and prevention of elder abuse and neglect. One of the biggest changes that will affect seniors is closing the Medicare prescription drug "donut hole." The donut hole is a coverage gap for Medicare D only. A patient starts out paying a deductible of $310. Then he or she pays 25% of costs up to a $2,840 limit. From this point, seniors must pay 100% of drug costs until they reach out-of-pocket costs of $4,550. The Affordable Care Act plans to close this coverage gap over the next 10 years and, in the meantime, seniors will receive a $250 rebate check if eligible. Seniors will also receive discounts on brand name and generic drugs until the gap is closed in 2020. Other measures include stopping Medicare fraud and strengthening the Medicare Advantage program.
There are also provisions that will protect people with disabilities from discrimination. A new program called Community First Choice will decrease the percentage of people with disabilities who have to live in institutional settings. Individuals may qualify if they're Medicaid eligible and don't exceed 150% of the poverty level. They'll be able to receive necessary home and community services, including assistance with activities of daily living, maintenance of skills, and backup systems for additional support. The Community Living Assistance Services and Supports program, or CLASS, will create a voluntary long-term insurance program for adults who become disabled. CLASS should be effective in late 2012.
One important change is stopping denial of coverage or price increases because of preexisting conditions. High-risk insurance pools, or risk pools, are available in many states. However, these are expensive because those individuals entered in the risk pool don't qualify for private insurance. The Affordable Care Act has set up preexisting condition insurance plans and premiums. Individuals will be able to appeal insurance company decisions and insurance companies won't be able to discontinue coverage without first proving fraud. Insurers will no longer be able to set a maximum lifetime payout on benefits.
A large chunk of healthcare reform is focused on preventive care. We'll be moving away from the sick care model to a model that's prevention oriented. For example, one study estimated that spending for obesity-related health issues alone reached $147 billion in 2008. Obesity leads to many secondary diagnoses and accounts for 6% of our total healthcare dollars per year. The Prevention and Public Health Fund will tackle national health problems such as obesity through comprehensive education and early intervention.
Nurses on the frontline
Nurses are key players in healthcare reform, so it isn't surprising that 43 professional nursing organizations supported the law's passage. The Affordable Care Act provides expansion of the nursing workforce with student loan repayments, education and retention grants, and scholarship programs. The National Nurse Service Corps has a program to repay 60% of student loans for a 2-year exchange in underserved areas. Specific scholarships will be available to students of disadvantaged backgrounds. The Quentin N. Burdick American Indians Into Nursing grant promotes diversity in the workforce and provides care for an underserved population.
Big changes are coming in primary care settings. You can expect to see more advanced practice nurses (APRNs) due to removal of certain practice restrictions and improved reimbursement rules. More nurse-managed health clinics will be opening as an important resource for families living in rural areas. APRNs can implement changes in our healthcare delivery system in preventive, primary, and long-term care. APRNs can also improve the coordination of care and reduce medication errors. Nurse-managed care settings create a more competitive healthcare environment by allowing patients the autonomy to choose what kind of provider to visit.
You may be doing more home visitations. There are provisions to provide care in the home for expecting mothers, infants, and children, but this coverage is optional. Nurses will also be making more home visits for elderly patients and patients with disabilities. This will reduce hospital stay and ED visit costs. Readmissions can also be reduced with better in-home care.
3.1 million nurses in the healthcare community can have a major impact. Rebecca M. Patton, MSN, RN, CNOR, president of the American Nurses Association, said in an April 2010 interview, "Because of their widely recognized role as staunch patient advocates, nurses are in a unique position to counsel and educate patients on how the reform provisions will affect them directly." It's important for nurses to use research skills and all available and trustworthy sources to stay current on healthcare news. As nurses, we can ease the transition and help educate our patients.
There has been miscommunication about healthcare reform that leads to fear and mistrust. Many worry that Medicare benefits will be affected. Others think illegal immigrants will be covered medically. A major hot-button issue is abortion and fears of federal funding. However, there are no cuts planned for Medicare beneficiaries. Nothing states that federal money will be used to provide healthcare to undocumented aliens. The law doesn't state that abortion will be funded through federal dollars, except in cases of rape, incest, or out of necessity to save the mother's life. Another concern is for healthcare rationing, but rationing already exists. Healthcare systems can't pay for every procedure, and often there's a wait list for elective procedures, even with the best private insurance.
You may have heard the term "socialized medicine" used when discussing healthcare reform. This term is used loosely and often incorrectly, and those opposing healthcare reform use it negatively. Socialized medicine is defined as a publicly administered system of national healthcare. This means the government owns the hospitals, hires the physicians and nurses, and pays patients' bills. This isn't the healthcare system that we currently have or what's written into the new law. The Affordable Care Act doesn't assume the role of insurance provider but will establish insurance exchanges, or marketplaces, to find insurance that provides certain benefits and meets cost requirements.
A turning point for change
The majority of Americans support some type of healthcare reform. The Affordable Care Act will make a difference for over 50 million Americans. Nurses can expect to be involved with the changes at every level. As trusted allies, we can help our patients understand what's to come.
Glossary of terms
- APRN: Advanced practice registered nurse, including nurse practitioners, certified nurse midwifes, certified registered nurse anesthetists, and clinical nurse specialists.
- Beneficiary: The person named to receive the benefits of the insurance policy.
- Deductible: A clause in an insurance policy that relieves the insurer of responsibility for an initial specified loss, or the amount of the loss specified in such a clause.
- Industrialized nation: A nation having highly developed industries, or a developed country.
- Medicaid: A program of medical aid designed for those unable to afford regular medical services, financed jointly by the state and federal government.
- Medicare: A government program of medical care specifically for the elderly.
- Medicare Advantage: Health plans offered by private companies approved by Medicare. They must follow rules set by Medicare but can charge different out-of-pocket costs and have different rules for how services are received.
- Medicare D: A prescription benefit plan that provides supplemental healthcare coverage for medications.
- Premiums: Payment for contract of insurance.
- Poverty level: Approximately $14,000 (yearly income) for an individual or $29,000 for a family of four.
- Universal healthcare: A government-run healthcare system that pays for everyone through general taxation, also referred to as the single-payer option.
Learn more about it
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. Barclay L. Healthcare reform legislation effects in nursing: an expert interview with Rebecca M. Patton, MSN, RN, CNOR.
. Centers for Medicare and Medicaid Services. Medicare and the new health care law—what it means for you.
. Cohen RA, Martinez ME. Health insurance coverage: early release of estimates from the National Health Interview Survey, January-March 2010.
. Families USA. Long-term services health reform provisions: community first choice option.
. HealthCare.gov. About the law: provisions of the Affordable Care Act, by year.
. HealthCare.gov. Understanding the Affordable Care Act.
. Jackson B, Henig J, Novak V, Robertson L. Seven falsehoods about health care: big myths over the current debate.
. Martin DS. Obesity, smoking add immense burden to health care costs.
. Oncology Nursing Society. Letter to Nancy Pelosi and Harry Reid.
. Robertson L. The abortion issue.
. Stokowski LA. Healthcare reform and nurses: challenges and opportunities.