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A Nurse’s Guide to the Affordable Care Act

June 3, 2020 | Staff Writers

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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 has meant for nurses. This resource consults experienced nurses, who share how nurses’ roles are evolving as the American healthcare system continues to change– and what that means for you and your nursing career.


Table of Contents


What is the Affordable Care Act? (ACA)

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 this law, every family must 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 lower healthcare costs. In addition, the ACA prevented health insurance companies from raising costs or denying coverage to people with preexisting conditions. With all its complexities, the ACA was phased in over the course of five years.

How the Affordable Care Act Changed Healthcare

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

One of the most controversial changes involved the individual mandate, which requires everyone to possess insurance or pay a penalty. The rationale behind the mandate comes from the following premise: 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.

How Has the Affordable Care Act Affected the Quality of Care?

Since the ACA has increased access to healthcare, the quality of care has changed along with it. Under this law, health insurance now covers more for chronic health conditions as well as 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, they get flu shots or cancer screenings before they become ill. This means that fewer people end up in emergency rooms or suffer preventable deaths. It also puts less of a financial strain on the healthcare system.

In addition, the Medicare payment system shifted to value-based care. Deborah Weatherspoon, advanced practice nurse and nurse educator, says, “The Medicare program adjusts payments based on the value of the care. 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 Affordable Care Act and Its Impact on the Nursing Profession

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 in order to practice and therefore generally have better patient outcomes than other nurses.

Dr. Debra Sullivan, a nurse and nurse educator, says, “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.”

The ACA places a greater focus on outcomes, with more pressure on nurses to show they can give effective care.

Higher education levels generally 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 trains students with more advanced education.

Because of that, the Institute of Medicine recommended that at least 80% of nurses should hold bachelor’s degrees instead of just associate degrees. Experts are aiming to meet this goal by 2025.

The ACA and the Future of Nursing

The ACA has been fully implemented — although some aspects of the law have been repealed as well.

Although the ACA has accomplished its goals of insuring more Americans and decreasing the price of insurance premiums, 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 — for instance, fewer adults struggling to pay their medical bills — has stalled in the last few years.

Although the ACA has accomplished its goals of insuring more Americans and decreasing the price of insurance premiums, the ACA faces other challenges beyond the repeal of the individual mandate.

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.

“Many people did not like being forced to purchase insurance or pay the penalty,” says Sullivan. “This created political controversy. There [have] been congressional proposals to repeal the law and it has been tested in the courts.”

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

The Increasing Demand for Nurses

Even before the ACA took effect, the U.S. faced a nursing shortage — a need for more nurses and not enough aspiring nurses to fill that need. As the ACA has increased the number of people insured by Medicare and therefore the demand for healthcare, the need for nurses has only continued to grow.

Although this demand is positive for job-seeking nurses, it also presents negative consequences. A nursing shortage has led to nurses working long hours with inadequate nurse-to-patient ratios, Weatherspoon says. This can lead to nurse burnout and lower quality care.

Many people now call for greater healthcare measures, such as the universal healthcare system proposed by the Medicare for All bill, that would provide health insurance for all Americans.

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

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 bachelor’s degrees or RNs might decide to earn advanced degrees to become NPs. Because of this, the industry will need more nurse educators, according to Sullivan.

How Nurses Can Help to Shape Future Healthcare Reforms

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.

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

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.

Weatherspoon believes that nurses have the numbers to make a tangible difference. “The nursing profession is more than three times the number of physicians in the U.S.,” she says. “It is time our collective voice is heard and respected for the knowledge of healthcare we possess.”

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