The Nurse’s Guide to the Affordable Care Act

When the Affordable Care Act (ACA) became law in 2010, it transformed the entire fabric of the U.S. healthcare system, including how nurses and other healthcare professionals approached their jobs.

This guide offers an overview of the ACA and examines what this historic reform means for nurses. This resource consults experienced nurses, who share how nurses’ roles are evolving as the American healthcare system continues to change. We also highlight what this means for you and your nursing career.

Former President Barack Obama signed the ACA into law in 2010. Sometimes colloquially known as “Obamacare,” this healthcare reform law effectively overhauled the nation’s entire healthcare system. The law’s purpose was to lower insurance costs and ensure that no American went without health insurance. Under the initial law, every family had to possess a healthcare plan or pay a penalty.

The ACA also introduced several other provisions. The law expanded eligibility for Medicare and allowed individuals up to age 26 to stay on their parents’ healthcare plan. The law also offers subsidies to low-income individuals to minimize healthcare costs. In addition, the ACA prevented health insurance companies from raising costs or denying coverage to people with preexisting conditions. Given its complexities, the ACA was phased in over the course of five years.

As the 2020 presidential election approaches, the future of the ACA hangs in the balance. Each major party candidate has a clear stance on whether they oppose or support the ACA.

Unsurprisingly, Democratic candidate Joe Biden supports the ACA. He served as former President Obama’s vice president when the legislation passed, and he plans to support and expand the ACA if elected. Biden’s campaign promises to offer policies that lead to health insurance coverage for 97% of Americans.

One major component of Biden’s healthcare proposal involves implementing a public option. In other words, individuals would be able to buy a public health insurance option like Medicare if they don’t like their employer’s plan. The plan also proposes increasing tax credits that would lead to lower insurance premiums. In addition, under Biden, low-income Americans could take advantage of Medicaid, even if they live in states that did not expand Medicaid eligibility.

President Donald Trump, on the other hand, has taken the opposite stance in his time as president. In the past, the Trump administration has attempted to reverse the ACA and its policies. For example, President Trump eliminated the ACA’s required individual mandate.

President Trump continues to support repealing the ACA heading into the 2020 election. In June, he asked the Supreme Court to overturn the ACA, although the court will not hear arguments until November.

The ACA achieved many of its goals. The federal government helped with state funding for Medicare, with 37 states expanding Medicare after the ACA became law. Individuals without insurance from an employer could obtain insurance from a private marketplace, and insurance companies could not charge extra for preexisting conditions. Additionally, the price of premiums decreased as the law stabilized.

One of the most controversial aspects of the ACA involved the individual mandate, which required everyone to possess insurance or pay a penalty. The rationale behind the mandate was as follows: if both healthy people and unwell or at-risk people buy from the same health insurance pool, then costs would stay low. Otherwise, the cost of healthcare plans could increase significantly for older, vulnerable individuals, or anybody with a chronic health condition.

Since the ACA increased access to healthcare, the quality of care has changed along with it. Under this law, health insurance now covers far more chronic health conditions, including behavioral and mental health disorders.

One significant consequence of the ACA involves preventative care. More people are caring for their health before they get sick. For example, many receive flu shots or cancer screenings before they become ill. This means that fewer people end up in emergency rooms or suffer preventable death. It also puts less of a financial strain on the healthcare system.

In addition, the Medicare payment system shifted to value-based care.

“The Medicare program adjusts payments based on the value of the care,” says Deborah Weatherspoon, an advanced practice nurse and nurse educator. “The better the quality of care, the higher the payment.”

If a hospital does not meet certain benchmarks for factors, such as 30-day mortality rates or high readmission rates, the system lowers payments for that hospital, Weatherspoon explains.

The ACA places a greater focus on outcomes, with more pressure on nurses to show they can give effective care. This means the demand for advanced practice nurses (APNs) and nurse practitioners (NPs) has also increased. NPs need advanced education to practice; as a result, they generally have better patient outcomes than other nurses.

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“Many patients prefer APNs to physicians for preventative care because nurses are trained to treat the whole person as compared to a medicine approach, which bases care on diagnoses.”

—Dr. Debra Sullivan, a nurse and nurse educator

Higher education levels also help nurses perform better in the workplace. Individuals can become RNs with either a bachelor’s or an associate degree, but a bachelor’s degree provides a more advanced education. Therefore, the Institute of Medicine recommended that at least 80% of nurses should hold a bachelor’s degree instead of just an associate degree. Experts are aiming to meet this goal by 2025.

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“While this sounds good, it may escalate the nursing and physician shortage.”

—Deborah Weatherspoon, an advanced practice nurse and nurse educator

In the case of Medicare for All, more people would likely take advantage of preventive care, which is often the responsibility of nurses. In addition, more RNs may pursue a bachelor’s degree or an advanced degree to become an NP. This all leads to an industry that will require more nurse educators, according to Sullivan.

While the ACA is fully implemented, the law remains a work-in-progress.

For example, the ACA accomplished its purpose of insuring more Americans and decreasing the price of insurance premiums, however the ACA faces other challenges beyond the repeal of the individual mandate. A greater number of people do not have adequate insurance coverage, with about 45% remaining underinsured, according to a Commonwealth Fund study. In addition, some of ACA’s progress — such as fewer adults struggling to pay their medical bills — has stalled in the last few years.

One of the law’s most controversial parts was the individual mandate, which required citizens to pay a penalty if they did not possess insurance.

—Dr. Debra Sullivan, a nurse and nurse educator

Under the Trump administration, Congress repealed the individual mandate almost a decade later. The future of the ACA remains uncertain, and may largely depend on the political party in power.

Nurses view the healthcare industry from a privileged perspective. They not only help patients, but, given the amount of charting and paperwork they encounter, they also gain insight into the workings of the health insurance industry.

“Nurses offer a unique, expert, bedside perspective on the healthcare system and, as one of the largest healthcare professions, can be effective in healthcare political action,” Weatherspoon says. “Working at the point of care, nurses see the good things and the areas that need improvement.”

Nursing professionals can use this knowledge to improve the healthcare industry by advocating and taking political action, Weatherspoon adds. One way to do this is by contacting representatives from your state legislature.

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“Nurses can be more active in nursing organizations. As a group, their voices will be heard.”

—Dr. Debra Sullivan, a nurse and nurse educator

This means joining state associations or the American Nurses Association, which incorporate political action as part of their mission. These groups host state advocacy days during which nurses campaign for their causes at the state legislature. Alternatively, members can donate money if their schedules do not allow them to participate.