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In March 2010, health care reform legislation titled The Patient Protection and Affordable Care Act (PPACA) was signed into law (HR 3590, 2010). This act has been lauded as empowering the aver- age citizen, reviled as socialized medicine, predicted to change the way health insurance companies operate and to drive the United States into deeper debt, and resulted in some positive changes while enduring lawsuits by multiple states’ attorneys-general. Regardless of one’s political stance on the topic, the PPACA is certain to impact the medical-surgical nurse personally and professionally.
The words nurse, nursing, and nurse practitioner (NP) are used liberally throughout the 2,300 page PPACA document. Although not all of the implications for nurses and nursing practice are spelled out in the legislation, it is a certainty that 32 million newly insured people will affect the health care system and nurses at the core of this system. As such, the full impact may not be known for quite some time. Judicial rulings stating aspects of the law are unconstitutional and a movement by conservative members of the House and Senate may again change the face of the law.
This article will highlight several aspects of the PPACA that will affect medical-surgical nursing. Funding for the programs dis- cussed here is not guaranteed; budgetary discussions have stalled the implementation of all the changes and it is almost cer- tain that any funds received will be at markedly reduced levels from fiscal year 2011 funding. Five articles of the act will be dis- cussed to inform the medical-surgical nurse and to serve as a call to action. 1. Reauthorization of Title VIII Workforce
Development Programs There are grants for workforce diversity providing stipends
for racial and ethnic minorities with diplomas or associate degrees in nursing to enter bridge or degree completion pro- grams. Provisions for grants to train family nurse practitioners in primary care to work in federally-qualified health centers or nurse-managed health clinics and grants for state partnerships to address health care workforce issues were also included in the act. Current discussions will decrease Title VIII funding to 2004 or 2008 levels, resulting in a significant cut in funds for these grants. 2. Increased Funding for Nurse-Managed Clinics
Much of the new law revolves around community care that is external to the acute care setting. Programs for school-based and nurse-managed clinics, transitional care, and services for
The PPACA and its Impact on Medical-Surgical Nursing
Robin Hertel
rural areas are outlined. There is a clear focus on prevention and chronic disease management rather than a “sick” model. Funding for this program is also in question and may not move forward unless the current stalemate in the House is resolved.
This change in focus will likely result in a higher demand for advance practice nurses and may even prompt many existing nurse practitioners to enter private practice; this being com- pleted with the presumption that the American Medical Association (AMA) and legislators will enhance NP privileges. Time will tell as the expansion of NP privileges is a highly polar- ized topic in which the AMA feels that allowing NPs to do more would invade physician turf. Presently, there are at least 28 state legislatures that are contemplating expanding the role of the NP, which presents an excellent opportunity for the registered nurse (RN) interested in seeking the additional education and licensing requirements necessary to become an NP. 3. Demonstration Provision for Graduate Nursing
Education This article of the PPACA increases funding for clinical edu-
cation for graduate nursing students. In keeping with this, the new Institute of Medicine report (2010), states that nurses’ roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by health care reform and to advance improvements in America’s increasingly complex health system. Nurses should be fully engaged with other health professionals and assume leadership roles in redesigning care in the United States.
To handle greater responsibilities and the increasing com- plexity of health care, nurses are called to achieve higher levels of education and training, and participate in a residency program for transition from education to practice. Additional opportuni- ties for lifelong learning should be sought out through atten- dance at annual conventions and participation in free continuing nursing education offerings such as offered by the Academy of Medical-Surgical Nurses (AMSN) as a benefit of membership. 4. Creation of National Health Care Workforce
Commission The expansion of care available to individuals will necessi-
tate an expansion of the nursing workforce. All facets of the health care system, including (but not limited to) acute inpatient and outpatient care, chronic and transitional care, preventive care, home care, and palliative care, will require more nurses and more nursing care. The National Healthcare Workforce Commission will monitor the need as well as the growth of the nursing base and make recommendations on funding. The Commission may be another potential victim of budget cuts with its request of $3 million for startup monies.
Health Care Reform & ISSUES IN NURSING
Editor's Note: Are you positioned for your future role in nursing? In this new MedSurg Matters! column, “Health Care Reform & Issues in Nursing,” we plan to inform AMSN members of recent changes in health care and focus on how these changes will influence nursing practice and the future of nursing education. Be informed and be proactive in preparing for the future. Comments or suggestions related to this column can be sent to msmnews@ajj.com.
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5. A Paradigm Shift from Treatment Model to Prevention Model Title III of the PPACA, Improving the
Quality and Efficiency of Health Care, makes provisions for models that link payment to quality outcomes, development of improvements in quality measurement, and in systems for data collection and reporting. Title III further provides for pro- grams that reduce hospital readmissions, testing of transitional care models, and hospice care reform. Areas that will impact medical-surgical nursing directly include provisions to facilitate patient shared decision-making, practice improve- ments in medication management, and the integration of quality improvement and patient safety into clinical training.
Current and Future Changes to Health Care Policy
The changes mandated in the PPACA are designed to be implemented over a period of years. The first set of changes has already been initiated and is summa- rized in Table 1. Table 2 summarizes health care changes to be implemented in 2014.
Until now, those with pre-existing conditions were unable to obtain medical insurance, either because of prohibitive cost or outright rejection. When patients with pre-existing conditions are included in the health coverage pool, they will most likely be sicker and have greater health care needs than similar patients who have had access to a continuum of care.
Treatment of pre-existing conditions requires nurses to have in-depth knowl- edge of illnesses such as diabetes, asthma, chronic pulmonary obstructive disease (COPD), human immunodeficiency virus (HIV), autoimmune deficiency syndrome (AIDS), cancer, obesity, and so forth. With a sicker population comes a greater need for patient education. Nurses will need strong case management knowledge pre- senting an opportunity for nurses to be engaged in the transition of care from the acute care setting to community settings.
On the other side of the coin, it is likely that the demand for nurses in acute care settings will increase with respect to workload amounts. The increased avail- ability of health insurance is likely to result in the demand for health care access which will require admission to
acute care settings for active management of a chronic disease or a surgical condi- tion.
PPACA Initiatives An emphasis on preventive care will
lead to a greater demand for the serv- ices of general practitioners, primary care providers and their support staff, and require nurses to have strong gener- alist skills. Preventive care strategy will
center on the following aspects: building healthy and safe community environ- ments, expanding quality preventive services in both clinical and community settings, helping people make healthy choices, and eliminating health dispari- ties. Recommendations listed in the strategy include tobacco-free living, drug and excessive alcohol use prevention,
There is no cap on health insurance benefits.
Insurance companies cannot drop individuals who become ill.
There are no more annual limits on health insurance benefits for those with a catastrophic illness.
Children up to the age of 26 can stay on a parent’s plan.
Small businesses offering insurance can apply for a 35% tax credit for premiums paid.
New insurance plans must offer preventive care with no co-pays or deductibles.
Medicare Part D participants will receive a $250 credit to help with the “doughnut hole.”
Retirees aged 55-64 will be offered access to a reinsurance program.
Medicare must provide plans that include preventive care with no co-pays or deductibles.
Medicare Part D participants will receive 50% off drugs falling in the “doughnut hole.”
Health insurance companies will have to justify any premium increase or risk the possibility of being taken out of the state’s insurance exchange pool.
Table 1. 2010 Changes in Health Care Policy
An IRS penalty of $750 per individual or 2% of income (whichever is greater) will occur for those who choose not to purchase health insurance.
The federally subsidized, high-risk pools established in 2010 will require states to have their insurance exchanges in place.
Annual caps on benefits will be banned completely.
No one can be denied insurance for pre-existing conditions.
Table 2. Proposed 2014 Changes in Health Care Policy
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healthy eating, active living, injury and violence-free living, reproductive and sexual health, and mental and emotional well-being. Awareness of these initiatives and education of patients and their fam- ilies is one aspect the medical-surgical nurse can implement to meet these ini- tiatives.
There are important initiatives in the PPACA addressing improved quality in hospitals, such as increasing the capacity for trauma care and the capacity for pre- vention, wellness, and disaster prepared- ness. Safety and quality are foremost on everyone’s minds and medical-surgical nurses should be more involved in assur- ing a safe and high-quality environment. Medical-surgical nurses will need to strengthen their skills in cultural compe- tency to meet the needs of an increasingly diverse and aging population.
The Role of Nursing Science Dr. Carol Hall Ellenbecker, an expert
on public policy and nursing practice, gave the following statement in a recent inter- view regarding the role of nurses in light
of health care law (Clarke & Ellenbecker, 2011):
We need to know more about what kinds of treatment and prevention and wellness promotion interventions are the most effective. We need to know more about effective ways to manage patients with chronic and long- term-care needs, about which discipline of provider is best suited for delivering different kinds of care; and where that care should be delivered. Questions remain about the measurement and evaluation of systems of care; what information is needed to best monitor and improve care. And in our research we need to always explore the most efficient use of resources to deliver care. (p. 34)
Nurses Must Be Vigilant and Proactive
The passage of the PPACA provides a superb opportunity for RNs (in general) and NPs (in particular) to be involved in bringing positive change to our health care system. As patient advocates, all nurses must continue their role in the
debate since the redesign of our health care delivery model is far from over. As the PPACA takes shape, nurses from all specialties must be part of the process; otherwise, nurses will find themselves being reactive rather than proactive to the demands that the new law and regu- lations will make on the profession of nursing.
References Clarke, P.N., & Ellenbecker, C. (2011). Nursing
research and the impact on healthcare reform: Dialogue with Carol Hall Ellenbecker. Nurse Science Quarterly, 24(1), 31-34.
HR 3590. (2010). The Patient Protection and Affordable Care Act. Retrieved from http://dpc.senate.gov/dpcdoc-sen_health _care_bill.cfm
Institute of Medicine. (2010). A summary of the 2009 forum on the future of nursing. Retrieved from http://www.nap.edu/ openbook.php?record_id=12855&page=1
Robin Hertel, MSN, RN, CMSRN, is a nursing faculty member, North Central Kansas Technical College, Hays, KS. She is chairperson of the Legislative, Policies, and Issues Committee of AMSN.
Aging nursing workforce
Aging patient population
Alzheimer’s
Assertive behavior and unsafe practice
Bariatric surgery
Cancer (any type)
Cardiac issues
Care of aggressive patients
Clinical leadership
Cultural humility
Dementia
Diabetes/glucose management
Discharge readiness education
Disseminated Intravascular Coagulation (DIC)
Electronic medical records/online documentation
Emergency preparedness
End-of-life care
Ethical issues and case studies
Gastrointestinal diseases
Genitourinary disorders
Health care reform
History of nursing
Image of nursing portrayed in media
Increasing acuity of patients
Infection control
Interpreting the Nursing Code of Ethics
Joint/hip replacements
Lead placement
Medication developments
Motivating nursing staff
Musculoskeletal health
Obesity
Orthopedic care
Patients with multiple co-morbidities
Pet therapy
Process and effects of hospitals going green
Quality of care
Racism, sexism, or other bias in nursing
Recruitment and retention
Renal failure/nephrology topics
Respiratory care
Rhabdomyolysis
Salary concerns and the recession
Sexually transmitted diseases
Shift work and nurse burnout
Skincare and dermatology
Social health care disparities
Spiritual support for patients
Sports injuries
Stroke in young adults
Time management strategies
Transplants and transplant care
Uninsured/underinsured patients
Venous access devices
Verbal and physical abuse from patients toward nurses
Veteran care/war trauma
Wound/ostomy care
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