Affordable Care Act (ACA)

Affordable Care Act (ACA)

Healthcare issues have always been at the center stage of politics in the United States. They include healthcare insurance, Medicare and Medicaid Services, premium cost, healthcare reforms, and healthcare access to underserved and vulnerable populations. Interests in universal healthcare insurance came up in political spheres before the mid-19thcentury, but none of the proposed plans came into effect. It was during Harry S. Truman’s presidency that Congress presented the most notable proposal on universal coverage and its implementation. It was not until the passing of the Patient Protection and Affordable Care Act, also referred to as the Affordable Care Act (ACA) or “Obamacare” in 2010 by President Obama that a significant step was made to achieving universal healthcare insurance.

The main goals included reducing the number of uninsured Americans, making healthcare coverage more affordable, and expand access to care. The healthcare policy achieved these goals through amending Medicare, expanding eligibility for Medicaid, providing subsidies for insurance purchase for people of moderate income, creating new market places where individual without the coverage of employers could purchase policies directly from insurers, establishing health insurance exchanges, and imposing new requirements for insurers to improve access to insurance. The ACA requires most adults to have health coverage or penalized with a fine (Obama, 2016). For the decade that the ACA has been in effect, over 20 million people have gained access to insurance, and about 24 million individuals have accessed subsidies or free care through Medicaid expansion and market place tax credits.

Benefits of the ACA

ACA has transformed the insurance industry due to its broad range of impacts, notably increasing premium deductibles and out-of-pocket costs, especially with plans sold on the health insurance exchanges (Uberoi, Finegold & Gee, 2016). The ACA impacts the choice of healthcare plans by employers; for example, it requires employers to offer their employees information about the market place regardless of whether they provide them with insurance or not.

The primary benefit of the ACA is its expansion of healthcare insurance to low-income Americans by making it more affordable. Other benefits of the ACA include reducing Medicare and Medicaid abuse, providing free preventive services and wellness examinations, supporting quality improvement initiatives for hospitals and providers, and lowering the cost of prescription drugs (Obama, 2016).

The provision of near-universal health coverage is the most significant impact of the ACA. The health policy ensures that all Americans have access to affordable insurance, preventative services, and emergency care, as well as receiving the necessary continued care and care for pre-existing conditions (Obama, 2016). The younger generation, early retirees, and people with pre-existing conditions are the populations that benefit the most from the ACA.

Children and young adults remain under cover of their parents’ insurance until the age of 26 years. The cover gives them enough time to study without having to worry about paying for insurance. Before the ACA, insurers would deny or charge higher premiums to people with pre-existing conditions. Provisions in the ACA prohibit insurance companies from overcharging people with pre-existing conditions. Furthermore, the provisions make it illegal to deny this group of people insurance due to mistakes and technical errors, which were common in previous practice. The action contributes to the primary goal of ACA of increasing the number of insured Americans (Obama, 2016). The Trump administration has been pushing for the removal of the provisions of ACA that protects the interests of people with pre-existing conditions (RAND Health Care, 2019).

The ACA extends coverage to early retirees below the age of 65, the eligibility age for Medicare. It achieves this by creating programs that preserve employer coverage for the early retirees as well as their spouses and dependents. The existence of such programs safeguards early retirees from losing their savings to the high insurance rates in the market place (Obama, 2016). Additionally, the elderly also benefit from the ACA as it creates programs and guidelines that combat elder abuse such as the Elder Justice Coordinating Council and Advisory Board and the Adult Protective Services.

Healthcare providers also benefit from the ACA. In its implementation of the ACA also aims to restructure the healthcare workforce through incentives to raise the number of doctors, physician assistants, health managers, nurses, and alternative health clinicians by funding grants, loans, and scholarships (Obama, 2016). Also, the ACA aims at increasing Medicaid payments to primary care providers following an increase in the number of people the program covers.

Challenges in Implementing ACA

The ACA creates a national framework through which states can finance insurance for low-income Americans. However, implementation of ACA is a whole new level of complexity as it involves states, the government, and changes affecting the healthcare industry. States have the freedom to determine the extent to which they implement provisions of ACA. However, differences in the level of commitment between states have led to disparities in the changes in the system of healthcare delivery. Some states implemented ACA and expanded access to affordable insurance, but other states did little or even obstructed the implementation of the law.

So far, the greatest challenge to ACA since its inception has been the political divide among Americans. Bill passed through Congress without the support of Republicans. Additionally, the implementation of ACA has been challenged by a series of lawsuits. Opponents of the ACA argue that the health policy weakens federalism by blurring the lines between federal and state laws. In the case of ACA, there is little separation between the two as states participate in federal law (Bagley, 2017).

The decision to create an insurance exchange and expand Medicaid was left to the states. Initially, the ACA compelled states to expand Medicaid and create insurance exchanges, but a Supreme Court ruling allowed states to make decisions on these matters. The impact of the provision was the inclusion of 16 million into the program, which as a 50% increase in enrollment, with some states having a higher margin (Weil & Scheppach, 2010). Other responsibilities left for the states include opportunities for grants, finding a dozen options, and requirements of how they implement the federal law reform.

Federal Court rulings are another stumbling block to the implementation of the ACA. The Supreme Court ruling in National Federation of Independent Business (NFIB) v. Sebelius made Medicaid expansion a state option (Bagley, 2017). The Supreme Court ruling in Hobby Lobby v. Burwell allowed the exclusion of contraceptives from medical packages for medical reasons. In 2018, a federal District judge in a ruling in Texas v. Azar suggested that the ACA is invalid because of the $0 tax penalty tied to its individual mandate (Keith, 2018). Judge Reed O’Connor declared the ACA unconstitutional for eliminating the penalty on uninsured people. Following the ruling, the Trump administration called for the repeal of the ACA.

Calls to Repeal, Replace and Modify the ACA

When President Obama signed the ACA into law, the health policy was revolutionary because of its requirement for healthcare insurance for all Americans. A decade later, after its passing, the law has expanded the number of insured Americans by more than 20 million. Despite its benefits, some Americans continue to raise questions about its implementation and effectiveness. There have various calls to repeal the ACA, replace it with other policies, or modify its provisions. However, from a patient perspective, the benefits of ACA outweigh its limitations; therefore, it should not be repealed.

Repealing the ACA with no replacement would lead to the 20 newly insured Americans losing insurance coverage. Also, the current average of $3,200 out-of-pocket costs would rise by $4,200 to $7,400 (RAND Health Care, 2019). Another consequence of repeal would be a rise in the federal deficit by $33.1 billion annually due to the elimination of the revenue-raising provisions of the ACA.

The American Health Security Act and the Health-Insurance Solution are two proposed options for replacing the ACA with a single-payer plan. The American Health Security Act proposed the replacement of the ACA, Medicaid, Medicare, and SCHIP with a Medicare-for-all plan, which is a uniform, single-tired coverage managed by the federal government. The disadvantage of this plan is that it would not allow private health insurance, and there would be little or no cost-sharing for enrollees (RAND Health Care, 2019). The Health-Insurance Solution is a plan that proposes the continuation of Medicare and Medicaid and all other U.S. citizens to have insurance coverage that is income-dependent. In this plan, individuals would have the option of purchasing additional private coverage. But the plan is similar to what ACA offers with only individual contributions replaced by government contribution, and the income-dependent coverage would limit the number of eligible enrollees.

Alternatives to the ACA include the Patient Choice, Affordability, Responsibility, and Empowerment Act (CARE) which proposes elimination of the individual mandate of the ACA and employer mandates, removal of the ACA’s fees and taxes, cutting funding for Medicaid expansion, and flexing regulations om insurers (RAND Health Care, 2019). Also, CARE would offer tax credits to low-income individuals that differ from those of ACA to assist them purchase insurance. However, despite being based on income and family size, the premium support provided by CARE does not take into account growth in healthcare cost and regional variation in premium levels, and enrollees would pay the difference between actual premium cost and the amount of tax credits. Further analysis of CARE reveals that it would reduce federal spending but raise the deficit by $17 billion compared to ACA due to the elimination of ACA’s revenue-raising provisions. CARE would raise the number of uninsured Americans by 9 million and increase the cost of insurance for vulnerable groups such as older adults and low-income individuals.

The American Health Care Act is another alternative to the ACA. The House passed the law after several amendments in 2017. AHCA makes changes to the ACA which include repeal of the employer and individual mandates; establishing a requirement to maintain continuous coverage otherwise face penalties; changes to the ACA’s age-based rate banding to 5:1 from 3:1; replacing income-dependent subsidies with age-dependent subsidies; and converting federal Medicaid funding to a per capita allotment and eliminating the need for states to expand Medicaid (RAND Health Care, 2019). A key feature of AHCA is allowing states to apply for waivers to establish work requirements. Evidence from states that implement waivers on work requirements shows that contrary to what the Trump administration claims, there is a reduction in the number of people insured as the requirements lockout people out of insurance otherwise eligible under ACA. The unintended consequences of work requirements facilitated by AHCA go against the objective of ACA and Medicaid of increasing access to healthcare coverage.

ACA and Nursing Practice

Nurse practitioners have a critical role to play in the transformation of the healthcare industry in line with the ACA. The role and responsibilities of nurse practitioners as nurse managers spread across three main areas of influence: nurses and other professionals, patients, and their families, and systems (Sonya, 2014). The ACA mandates hospital management to ensure that there is a safe nurse-patient ratio, a view supported by professional organizations such as the American Nurses Association. According to the ACA, hospitals need to establish effective and more flexible staffing models that can be adjusted to meet both the needs of individual units and the entire hospital (Kuwata, 2016). The ACA requires nurses to continue transformational leadership, innovation, and care coordination as they play a central role in quality advances, cost containment, and patient access improvement (Cleveland, Motter & Smith, 2019).

According to the ACA, healthcare reform has three aims: reducing healthcare expenses, elevating the quality of care, and increasing access for all Americans. The ACA offers a legislative framework that links priorities in nursing, such as quality of care, availability of resources, and value in health spending to payment initiatives (Cleveland, Motter & Smith, 2019). Nurses’ understanding of patient care within the hospital and community, their proximity to bedside, and their team approach uniquely place them in a position to shape healthcare.

The ACA points to the priority of nurses and reveals the disconnect that exists in the delivery of healthcare in the U.S. Regulatory requirements imposed on insurance industry including penalties for low-quality care, quality reporting, and expansion of regulation set the foundation for nurses to share expertise in patient education and program planning with plan administrators with a focus on financial savings. The paradigm accelerates the development of advanced practice roles and the expansion of nursing education while promoting the development of policy and administrative skills in nursing curricula and administrative practice (Cleveland, Motter & Smith, 2019). As a result, nurse leadership positions have exponentially increased across healthcare organizations, insurance boards, government boards of health, community programs, and government roles. Nurses in these positions contribute to and come up with solutions to enhance the regulatory environment by formulating health policies.

An increase in the partnerships advanced practice registered nurses (APRNs) with health systems and physicians and allowing APRNs to practice at the full scope of their education have had a positive impact on cost reduction from a patient perspective (Cleveland, Motter & Smith, 2019). Nurse administrators utilize their expertise in patient navigation and health integration to effectively use available resources.

The four messages contained in the report The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011): the need for nurses to attain higher education; practicing at the full extent of their education; becoming full partners with other healthcare professionals, and developing effective workforce planning and policymaking, influence nurses to lead in healthcare change. For example, an increase in the level of education of nurses addresses the requirement of ACA on quality improvement. Also, nurse practitioners have a high level of education that enables them to apply evidence-based practices to improve the quality of care and patient outcomes as well as reducing the cost of care.

The goal of ACA to promote state control of insurance markets helps in linking quality to reimbursement. Removing barriers to the full scope of nursing practice and increasing levels of nursing education advance quality initiatives. The team approach by nurses also improves the quality of care through population management (Cleveland, Motter & Smith, 2019). The nursing unit in the patient care team is a clinical, nurse-managed team with high skills supported nurse-led utilization teams, nurse-led response teams, and nurse-friendly financial teams.

Future of the ACA

Challenges facing the ACA can only be adequately addressed once politics are kept aside and looking at the legislation through a perspective of public health. The initial step would be a close examination of the ACA and its impacts to identify the most effective areas and those that are least effective. The second step would involve formulating strategies to enhance the areas considered ineffective and costly for society (Long et al., 2013). The final step would include drafting solutions that make weak areas effective without affecting other working areas. A practical framework that can provide a comprehensive overview and meaningful evaluation of the ACA is the 3 P’s (people, price, and products).

An example of an area of weakness in ACA is on undocumented migrants. Despite the mandate of the ACA being the provision of “affordable health care to all,” undocumented immigrants are blocked from purchasing health insurance (Zuber, 2011). The only law that does not discriminate against undocumented migrants is the Emergency Medical Treatment and Active Labor Act (EMTALA), which mandates hospitals to provide treatment to all patients during emergencies regardless of their migration status. The lack of provisions to cater for undocumented migrants is not limited to ACA. Health policies seeking to replace ACA, such as the AHCA, also do not address this issue.

In conclusion, the ACA has revolutionized the healthcare industry through its goals of reducing the number of uninsured Americans, making healthcare coverage more affordable, and expand access to care. The health policy has contributed significantly to achieving near-universal health coverage in the United States. Despite the benefits of the ACA, it has faced stiff political opposition. Politicians’ continued calls include repealing the law, replacing it with alternative reforms, or modifying it to address other goals. It is worth noting that calls to repeal the ACA revolve around its implementation rather than its outcomes, and nearly all of the proposed changes will lead to a reduction in the number of insured Americans. How long the ACA remains the healthcare law of the United States depends on political opinion, stakeholder debate, and legislative action. However, from a patient perspective, the benefits of ACA outweigh its limitations; therefore, it should not be repealed. Additionally, the goals of ACA on healthcare cost reduction and quality improvement promote the expansion of the role of nurse practitioners to practice to the full extent of their education.