Insured With Limited Income
Figure 2-3 Health-care access barriers.
come into play as potential explanations for different user experiences with the health care system and the outcomes attained” (Docteur & Berenson, 2009, p. 2).
Shortages of health professionals exist in all states, including urban areas. The Health Resources and Services Administration (HRSA) defines health professional shortage areas (HPSAs)as “areas or populations designated by HRSA as having too few primary care providers, high infant mortality, high poverty or a high elderly population” (HRSA, n.d.). Figure 2-4 shows HPSAs in primary care, which includes physicians, nurse practitioners, and physician assistants.
Lack of Health Insurance and Insurance With Limited Income
Before the implementation of the ACA, 32 million people in the United States lacked health insurance even though many worked multiple jobs or full-time jobs (Jacobs & Skocpol, 2012). Millions of other individuals had health insurance but were considered underinsured. Out-of-pocket costs for the underinsured were
Health Professional Shortage Areas - Primary Care
Prepared by: HRSA, Office of Information Technology from the
HRSA Data Warehouse, datawarehouse.hrsa.gov HPSA Geographic
HPSA Population
HPSA Geographic High Needs Not Primary Care HPSA Legend
Health Professional Shortage Areas - Primary Care Alaska
US Virgin Islands Puerto Rico Republic of
Palau
Guam Hawaii
American Samoa
Figure 2-4Health professional shortage areas (HPSAs) in primary care provided by the Health Resources and Services Administration data warehouse (additional interactive maps can be found at datawarehouse.hrsa.gov/topics/shortageAreas.aspx).
estimated at 29.1% of total health-care costs in the United States in 2009 (Davidson, 2013). The number of uninsured persons in 2013 rose to 42 million (Smith &
Medalia, 2014). In the first half of 2014, the rate of the uninsured among adults 18 to 65 years of age decreased substantially. The ACA is credited with this decline (AHRQ, 2015).
Although the ACA mandated that residents within the United States have health insurance or face a tax imposed by the Internal Revenue Service, the cost of health insurance for those who did not qualify for a health-care tax subsidy remained an obstacle for many persons, especially those not receiving health-care benefits through an employer. The percentage of persons receiving health insurance through their employer was 53.9% in 2013 (Smith & Medalia, 2014).
Individuals are often blamed for their own circumstances, including their inabil- ity to have an adequate income or to find better employment to obtain adequate health insurance. They are often stigmatized for health issues that could be managed by exercise and other lifestyle decisions (Davidson, 2013), yet the OECD found that the health-care system fell short with regard to incorporating these recommenda- tions in primary care (OECD, 2015). Frequently, this is an example of the influence of social determinants of health that consist of patients’ lifestyles and incorporate their social and physical environment. Lifestyle and environment are then modified by patients’ access to public health services and medical and mental health care.
Individual responses to these determinants interact with human biology to influence overall health status further (Arah et al., 2006). These individuals may be powerless to facilitate the changes necessary to overcome these obstacles and collectively have little support to facilitate change within the system.
THE PATIENT PROTECTION AND AFFORDABLE CARE ACT
The ACA was enacted into law on March 23, 2010, after a lengthy political battle.
The ultimate goal of this law was to reduce the number of uninsured persons in the United States by expanding Medicaid and implementing health-care exchanges. The health-care exchanges would allow the uninsured and other eligible persons to select health insurance coverage, which would include essential health benefits (Box 2-1), through state or federal exchanges. Many eligible persons would also receive government subsidies that would make health care affordable to those who qualified based on their income (Henry J. Kaiser Foundation, 2016).
BOX 2-1
BOX 2-1 Ten Essential Health Benefits Required Ten Essential Health Benefits Required by the Affordable Care Act
by the Affordable Care Act 1. Ambulatory patient services
2. Emergency services 3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative services and devices 8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care From Centers for Medicare and Medicaid Services, 2011.
Provisions included in the ACA guarantee availability of insurance with the elimination of pre-existing conditions as a means of denial for insurance. Other requirements of the ACA include the following: no annual limits on coverage;
mandated coverage by employers with at least 50 full-time employees; extension of coverage to adult children to age 26 years with individual and group health policies; the inclusion of preventive services without cost sharing, if recommended by the U.S. Preventive Services Task Force; and limitation of annual cost sharing to the maximums allowed for health savings accounts ($5,950 for individual plans and $11,900 for families) (Henry J. Kaiser Foundation, 2016).
Lesser-known stipulations of the ACA are annual taxes for individuals without health insurance coverage, a 10% tax on indoor tanning services, an annual fee paid by the pharmaceutical industry, an excise tax of 2.3% on any taxable medical device, and a fee of no less than $2,000 per employee for an employer not offering health insurance where an employee receives a tax credit (Henry J. Kaiser Foundation, 2016).
On June 28, 2012, the U.S. Supreme Court, in National Federation of Independent Business v. Sebelius, determined that the ACA was constitutional with the excep- tion of the portion requiring states to participate in Medicaid expansion. This portion was deemed coercive because all Medicaid funds would be at risk, and states were not given adequate notice to consent voluntarily (Holahan, Buettgens, Carroll, & Dorn, 2012). Before the U.S. Supreme Court ruling on the constitution- ality of the ACA, expansion of Medicaid by the states was required or states would forfeit their federal Medicaid funding (Diamond, 2012). After the Supreme Court ruling, states would forfeit new Medicaid funding only if they opted out of Medicaid expansion. The requirement to expand Medicaid by the states was left to the discretion of each individual state after the court’s ruling. In 2015, 21 states had continued to decline expansion of Medicaid secondary to the Supreme Court’s ruling. Medicaid expansion by states can be tracked at www.statereforum.org/
medicaid-expansion-decisions.
MEDICARE AND MEDICAID
In the United States, Medicare and Medicaid are forms of government-provided health insurance, primarily for disabled persons, older persons, and economically disadvantaged persons, including children. Both programs are overseen by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Depart- ment of Health and Human Services. Medicare provides health insurance for disabled persons and persons age 65 and older and consists of four components:
Parts A, B, C, and D. Table 2-1 provides brief explanations of the components of Medicare.
LEARNING ACTIVITY 2-1
How Health-Care Reform Affects Nurses Review ANA’s information on health-care reform at www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform.
Identify two to three ways the nursing profession is affected by health-care reform.
Component Part A
Original Medicare
Part B
Part C
Medicare Advantage
Part D Medications
Table 2–1 Costs of Medicare Components in 2015
*Benefit period: Day of admission to hospital or SNF until 60 days in a row when the recipient has not received inpatient hospital or SNF care;
there is no limit to the number of benefit periods.
†Lifetime reserve days: Up to a maximum of 60 days per lifetime.
From Medicare.gov, n.d.
Basic Cost
“Premium Free”
for most; up to
$407/month if purchased (income based)
$104.90
Varies by plan
Tiered drug plan with premiums based on income and IRS
Deductible
$1,260 per benefit period*
● 0–60 days ($0 per benefit period)
● 61–90 days ($315/day per benefit period)
● 91 or more days† ($630 per day)
$147/year
Varies by plan; may include:
monthly premium in addition to Medicare Part B premium;
yearly deductible; co-pays per each visit or service
Formulary based; co-pays vary by plan/tiers and income/tax filing status
Coverage Type
Medicare Part A (hospital insurance) covers inpatient care at a hospital, skilled nursing facility (SNF), and hospice; Part A also covers services such as laboratory tests, surgery, doctor visits, and home health care
Medicare Part B (medical insurance) covers doctor and other health-care providers’ services, outpatient care, durable medical equipment, home health care, and some preventive services
Each year, plans establish the amounts charged for premiums, deductibles, and services; the plan (rather than Medicare) decides how much is charged for covered serv- ices; the plan may change only once a year, on January 1
Services dependent on plan specifics; plan premium only if in- come less than $85,000 per year (single or married filing jointly)
To be eligible for Medicare without a disability, U.S. citizens must have worked a minimum of 10 years and paid into the Medicare Trust Fund. As of 2016, the eligibility age is 65 years, although there has been discussion about amending eligibility criteria for many years (Medicare.gov, n.d.).
Medicaid provides health care coverage to low-income people (primarily for children, nondisabled adults, and pregnant women) and is one of the largest payers for health care in the United States. The Children’s Health Insurance Program, also known as CHIP, is the Medicaid program for children and provides federal matching funds to states who provide health care coverage to children in families who cannot afford private insurance but have incomes too high to qualify for Medicaid. As of May, 2016, there were more than 8.3 million children enrolled in CHIP (Medicaid.gov, n.d.).
At the time the ACA became law, 32 million Americans lacked health insurance, and although provisions were provided in the ACA to allow greater access to Med- icaid, many states were allowed to opt out of expanding Medicaid, a key provision
within the law, as a result of the Supreme Court ruling in June 2012. Although this situation has denied a large percentage of the uninsured access to the system, pres- sure from health-care providers and health-care systems will likely prevail in expanding Medicaid after initial implementation (Jacobs & Skocpol, 2012).
A key provision of the ACA’s Medicaid expansion was the eligibility of adults without dependent children to qualify for Medicaid. Before the ACA, Medicaid eligibility was available only to low-income individuals such as children, older adults, or disabled persons. The income eligibility level for Medicaid, before the ACA, was significantly less than required by the ACA, which extended eligibility to 138% of poverty guidelines (Kaiser Commission on Medicaid and the Uninsured, 2014). The Kaiser Commission on Medicaid and the Uninsured (2014) identified another unfortunate consequence of states’ not expanding Medicaid. The original law required Medicaid expansion by all states and did not anticipate the gap that would occur between those eligible for Medicaid at current state levels and those who would not be eligible for Medicaid if a state opted out of Medicaid expansion.
The persons within this gap, which equated with the state’s established income eligibility for Medicaid through incomes up to 138% of poverty guidelines, would subsequently not qualify for marketplace tax credits, even though they were not eligible for Medicaid. Those numbers equated with 5.2 million persons nationwide who would be denied access to the new health-care system (Kaiser Commission on Medicaid and the Uninsured, 2014).
HEALTH POLICY
Health policy is developed at the local, state, national, and international levels. It can be developed by the following: citizens’ actions, local policies, and proceedings; leg- islation at the state or federal level; or international arrangements and policies of international groups, such as the WHO. The incorporation of walking or biking paths in a locality is an example of implementation of local health policy. State health policies are developed by the local health department or through the legislative body of state government. The ACA is a legislative action or health policy conducted at the national level. International health policies are often the result of foundations, such as the Clin- ton Foundation or the Bill and Melinda Gates Foundation, or individual philanthropy.
Some organizations are primarily devoted to the business of health policy, such as the Robert Wood Johnson Foundation or the Henry J. Kaiser Family Foundation. The WHO develops many policies associated with international public health.
A call has been made for nurses to be active in the formation of public health pol- icy. As Byrd and colleagues found, “the importance of nurses’ involvement in shap- ing public policy to promote population health is widely documented in nursing and public health” (2012, p. 433). In fact, the AACN established specific requirements addressing health policy through their Essentials documents that guide schools of nursing in developing curricula at all levels: The Essentials of Baccalaureate Education for Professional Nursing Practice (2008), The Essentials of Master’s Education in Nursing (2011), and The Essentials for Doctoral Education for Advanced Nursing Practice (2006).
Nurses at all levels must be involved in health policy to advance health care in the United States. It is critical for all nurses to see health policy “as something they can shape rather than something that happens to them. Nurses should have a voice in
health policy decision making” and participate in implementation efforts (IOM, 2011, p. 9). Further, nurses and nurse leaders and managers have an ethical respon- sibility to be involved in policy development and implementation by serving on committees within their practice settings. Nurse leaders and managers can contribute to health policy by serving as elected or appointed representatives in health-care activities at the local, state, national, and global levels (ANA, 2015).
Byrd, M. E., Costello, J., Gremel, K. Schwager, J., Blanchette, L, & Malloy, T. E.
(2012). Political astuteness of baccalaureate nursing students following an active learning experience in health policy. Public Health Nursing, 29(5), 433-443.
Aim
The aim of this study was to measure undergraduate nursing students’ level of political astuteness before and after they participated in a series of public policy learning activities, as well as to describe changes in conceptual factors and the extent to which other factors predict political involvement.
Methods
A one-group pretest/posttest design was used to measure changes in political as- tuteness in 300 undergraduate nursing students after three public policy learning experiences:
1. Students attended information sessions at the Rhode Island Department of Health.
2. Students composed a letter or e-mail to their legislators about a health-related issue they were concerned about.
3. Students completed a public policy project.
Students were administered the Political Astuteness Inventory (PAI) before and after they participated in the learning activities.
Key Findings
Students’ political astuteness increased after they participated in the public policy activities. The findings suggest that students were more knowledgeable about governmental and political processes that are essential for policy making related to community health after the learning experiences than before. Further, the expe- riences promoted self-reflection and raised students’ awareness of the importance of public policy and political involvement for nurses.
Implications for Nurse Leaders and Managers
This study substantiates the need to ensure that learning activities related to public policy and health policy are included in nursing education at all levels. Nurse leaders and managers can apply this evidence with their staff to promote political involvement. All nurses can participate in activities at the local, state, and national levels. Active involvement can promote competency development in health policy.
E X P L O R I N G T H E E V I D E N C E 2 - 1
Many nursing professional organizations are involved in health policy advo- cacy, and “more than ever before nurses are crucial to building and strengthening the health care systems within which they work” (Bryant, 2012, p. 438). Byrd and colleagues (2012) concluded, “active learning in public policy can increase the knowledge and skills that future nurses need to influence public policy”
(p. 433).
LEARNING ACTIVITY 2-2
State Nurse Legislators
Review the ANA’s information on nurse state legislators at www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Nurse-Legislators.
How many states have nurse legislators? Does your state have a nurse legislator?
SUMMARY
Nurses at all levels are impacted by the rapidly changing health-care environment, rising costs of care, safety and quality issues, and access to care. Nurses must be aware of the consequences of inadequate access to health care for patients. Nurse leaders and managers need to develop effective communication and relationship building skills to be able to advocate for patients as they attempt to navigate health care systems. All nurses must have a basic understanding of the broader context of health care and health-care policy. The ACA was intended to assist those uninsured and underinsured, help with controlling costs of health care, expand access to care, expand the Medicaid gap, and improve the safety and quality of care. Population heath is fueled by health policy. Effective nurse leaders and managers will develop competencies in financial management, human resource management, strategic management, and information management and technology. Further, nurse leaders and managers have an ethical responsibility to take an active role in developing and implementing health policy.
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State Reforum: Map: Where States Stand on Medicaid Expansion Decisions: www.
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