Medicaid, which ideally covered most of the population. And there was consensus on services to be covered. During the first half of the 20th century, medical technology and innovation proliferated—often because of advances in treatment developed during wartime in response to battle injuries and communicable illnesses. Simultaneously, economic prosperity led to improved living conditions and social policy changes, which had beneficial health effects for the population, including the development of vaccines, clean water and sewage treatment extended to most of the country, refrigeration and preservation of food, worker safety policies and the elimination of child labor, development and use of antibiotics, and improved nutrition. These medical and public health advances led to an increase in life expectancy of over 30 years between 1900 and 1965 when Medicare and Medicaid were enacted (CMS, 2015).
Thus, to use Milio’s language, the health policy options of the late 1960s were focused on an assumption of continued access to safe water, good food, immunizations, antibiotics, and medical treatment. Medicare and Medicaid were designed to ensure that most American would have access to medical treatment. Once these were enacted, the policy challenges shifted to new and emerging treatments, and coverage under insurance, whether privately or governmentally supported. Physicians were the primary providers of medical treatments, and increasingly, such treatments were provided in hospitals. The policy challenge then came in the form of costs. With new medical technologies, pharmaceuticals, and innovations, along with new coverage for many people, medical costs began to rise.
Ethical dilemmas arose, such as, should Medicare coverage be provided for the new procedure of renal dialysis? This issue became very controversial, as it was a policy debate addressing the intersection of costs and ethics. Who should be covered for this procedure?
Those who had the greatest need (either medical or financial), or those with the most potential for productive life moving forward? In the end, the policy decision for that issue was that Medicare and Medicaid would cover renal dialysis costs for all eligible clients, which lead to a large number of people surviving end-stage kidney disease who previously would have died and a new and expensive innovation being used for a large number of people, thus increasing costs greatly (Swaminathan, Mor, Mehrotra, & Trivedi, 2012).
This scenario arose for numerous new medical procedures and pharmaceuticals leading to a crisis in rising costs.
Other policy concerns addressed included funding for long-term care, for the increase in the population living longer, and debates on specific services to be covered by insurance.
Medicare and Medicaid, as the largest insurers with one payer, became the standard setters for such decisions, and big private insurers followed their direction. Medical specialties proliferated to address new care needs brought about by technological advances, driving costs even higher. The policies leading to coverage for medical care spurred technological and pharmaceutical innovations, which had individual impacts on specific diseases, but led to ever-increasing costs. During this time, outcomes were examined for individuals, with dramatic successes of people with previously fatal illnesses, saving infants born earlier, and an increasing demand for high-end, technological services to extend life, despite the cost.
Policy makers talked about providing all Americans with the same access to services that were affordable for the very wealthy, and research funds supported development of increasingly technological, specialized treatments. Additional concerns came about when people lost their jobs and thus lost insurance or had jobs that didn’t provide insurance coverage. National health insurance continued to be discussed, but was opposed by a wide variety of groups including fiscal conservatives, those who wanted limited government, some physician provider groups, and insurance companies (Nickitas et al., 2016; Rambur, 2015).
This debate continued until the passage of the ACA, and since its enactment, concerns persist regarding whether this is the best solution to ensuring access and controlling costs of care. However, in the past decade, policy and public health researchers have begun to examine seriously the health outcomes that have derived from the U.S. health care system as configured, with access to care largely through employer-based insurance and a focus on medical treatment. Although the system has spawned innovations in pharmaceuticals and technological innovations, these services have often been effective for a small number of people, in acute need and at a large cost. Thus, the system has developed to be expensive and largely ineffective for the overall population and more widespread disease prevention and chronic disease management needs. As mentioned earlier, the U.S. health care system options included
Fee-for-service care
Choice among physician providers Employment-based insurance
Development and use of innovative technological and pharmacological interventions Individual responsibility for health promotion
Prevention not cost-effective for consumers Focus on medical treatment
These options have been very successful as measured in terms of education of medical specialists, pharmacological treatments for many illnesses, surgical innovations, and diagnostic technologies. As discussed earlier, however, these options have not led to overall positive health outcomes for the population as a whole. Recent passage of the ACA (Medicaid.gov, n.d.) has led to policy changes designed to address these concerns.
The Affordable Care Act (ACA) and PHN Practice
The Patient Protection and ACA provided a dramatic change in U.S. policy options.
Recognizing that the U.S. health care system was not addressing all the factors necessary to improve the health of the public, and that it was costing U.S. taxpayers an ever-increasing and sustainable proportion of the national budget, the Obama administration moved to pass health care reform legislation in 2010. The focus of the ACA, in the minds of the public, was to mandate health insurance coverage for all U.S. citizens, via a required minimal health insurance package, a mandate on employer provision of health insurance or employer contribution to a marketplace of insurance options for individuals to access, and government provision of subsidies for long income people without employer insurance coverage. Indeed, data indicate that the ACA has been successful at insuring those previously uninsured, with a recent Rand Corporation study indicating that the number of newly insured has risen by 16.9 million people as of 2015 (Rand Corporation, 2015).
Provisions in health care reform also limit insurance companies from excluding persons because of preexisting conditions and provide for a broader array of coverage for preventive services, such as wellness programs and making nutritional information a requirement for chain restaurants. However, lesser known, but equally critical, changes in options available to people included regulations to improve quality of care provided, cost control mechanisms including future plans for moving from paying for services provided to paying for health outcomes achieved, and beginning efforts to focus health care policy and services on prevention of disease and health promotion (Knickman & Kovner, 2015).
As part of the ACA efforts to move to a culture of disease prevention, the ACA mandated formation of a National Prevention Council, composed of cabinet officials representing the social determinants of health, chaired by the Surgeon General of the United States. The council is charged with development of a National Prevention Strategy (Surgeon General, n.d.a). This strategy was introduced in June 2011 and addressed core strategic directions and priorities for an increased focus on public health and well-being.
See Figure 13–5 for the National Prevention Strategy model.
FIGURE 13–5 National Prevention Strategy model. (Adapted from Surgeon General.
(n.d.). Retrieved from http://www.surgeongeneral.gov/priorities/prevention/strategy/) At the core of the strategy is the overall goal of “increasing the number of Americans who are healthy at every stage of life” (para. 5). To achieve this, the strategy outlines four strategic directions, which address health care, health equity, and the social determinants of health and include
Healthy and safe community environments: This strategy encompasses access to care, community health and development, neighborhood safety, environmental health and all the various social conditions that impact health.
Clinical and community preventive services: Included in this strategy are those clinical screening and prevention services that are evidence based, with the goal of making these services accessible and affordable for all Americans.
Empowered people: This addresses the need for community involvement in health
and health care, from the level of schools and businesses being able to see the importance of health to their work to individuals and families being empowered to act to improve their health and well-being.
Elimination of health disparities: This strategy examines health inequities and recommends beginning prevention efforts in communities where disparities are greatest (para. 7).
Each of these four strategic directions included seven strategic priorities, based on data indicating that two thirds of premature deaths are due to chronic illnesses that can be prevented or controlled with prevention measures. For each strategic direction and priority, evidence-based recommendations are provided for all partners/stakeholders to address, including clinicians, businesses, elected officials and local/state/national government, church leaders and community service providers, educators, and individuals and families, thus highlighting that health promotion and disease prevention are the business of all Americans in every walk of life. The seven strategic priorities include (para. 9)
Tobacco-free living
Preventing drug abuse and excessive alcohol use Healthy eating
Active living
Mental and emotional well-being Reproductive and sexual health Injury and violence-free living
Subsequent work by the National Prevention Council and the federal advisory group appointed to advise and guide these efforts has included work to disseminate the strategies, document successes and lessons learned, and assist in promotion of model and exemplary interventions and policies to promote health and prevent disease across all levels of government (Surgeon General, n.d.a). The federal advisory group, appointed by the president, includes two nurses, who have worked to disseminate the NPS to PHNs across the country so that it may be incorporated as part of their practice initiatives (Surgeon General, n.d.b).
Additional components of the ACA that have the potential for great changes in health and health policy at the community level include value-based purchasing and accountable care organizations (ACOs), along with the expanded Internal Revenue Service (IRS) requirement for nonprofit hospitals to conduct regular community health needs assessments and develop implementation plans based on this data for improving the health of their communities (Knickman & Kovner, 2015). Nonprofit hospitals have a long history of providing care in the United States as part of a community or charitable mission. Often run by religious organizations, these facilities served communities, often caring for patients with no reimbursement for services. To support and encourage such work, local municipalities provided tax exemptions for such organizations, because of their benefit to
the community. The U.S. Government Accountability Office (GAO) has estimated that tax-exempt status saved hospitals $12.6 billion in federal, state, and local taxes in 2002 ($16.1 billion in 2012 dollars). With implementation of the ACA, medical insurance coverage has been achieved for an additional 16.9 million Americans who previously would have required charity care and now will have their care reimbursed (Rand Corporation, 2015). Hence, the ACA includes new IRS regulations to guide nonprofit hospitals in using their savings from the decrease in uninsured patients to conduct regular community assessments and develop a plan to work with others in their community to improve overall community health (Horwitz & Cutler, 2015). This process has great potential for PHN involvement, to assist local hospitals in conducting such assessments and being involved in planning for implementation of interventions to improve community health. Indeed, this is the cornerstone of public health practice, and PHNs can play key roles in this work.
Value-Based Purchasing and Accountable Care Organizations
The ACA began a movement away from the traditional fee-for-service care where health providers diagnose and treat individuals and are paid for each service provided (e.g., office visits, lab fees, prescriptions, follow-up visits) and that has thought to have led to increasing health care costs (James, 2012). This style of reimbursement for care has had the problem of indirectly encouraging additional care, as each service is reimbursed separately. National health policy has begun to reverse this by mandating no reimbursement for specific services required because of medical error. The ACA expands this with a move toward value-based purchasing, or reimbursing a specific amount based on achieving the likely outcome for clients within specific diagnostic categories. For example, instead of fees for office visits, lab fees, and prescriptions, the federal government is proposing paying for achievable health outcomes in a bundled manner based on the client’s demographics and diagnosis. A diabetic would not have each service reimbursed, but rather a lump sum reimbursement would be provided upon the client achieving a level of stability in the disease (e.g., lab values for hemoglobin A1c within normal limits). This reimbursement would cover whatever services were required to achieve this outcome, which might be lab tests and medications, but might also include PHN-provided chronic disease self-management training or clinical nutrition counseling. Such a change in reimbursement mechanisms would have a large impact on health care services, as clinical agencies would need to begin looking at what services and providers were most effective at achieving the desired outcomes. This would provide an opportunity for PHNs to demonstrate the effectiveness of their practice interventions in improving health outcomes for individuals and populations (California Directors of Public Health Nursing, 2015; Knickman & Kovner, 2015; Kulbok, 2013; Porter & Lee, 2013; Rambur, 2015; Washington State Nurses Association, 2011). When a national sample of public health nurses were asked about their involvement with components of the ACA, over 65% responded that they were actively involved with integration of public and primary health care, and nearly as many were working in clinical preventive services. Almost 60% noted activity with patient navigation,
care coordination, and establishing public/private collaborations. Slightly fewer mentioned involvement with population health strategies and data, along with community health assessments (Edmonds, Campbell, & Gilder, 2015).
Accountable Care Organizations (ACOs) are another feature of health care reform that is intended to emphasize quality over quantity. Physicians and other health care providers are forming groups, sometimes in conjunction with hospitals, and will be paid based on patient’s treatment outcomes (not the number of visits or tests). Thus, duplicative tests or procedures should be avoided, as a more coordinated form of treatment is available. One goal of ACA is to provide 30% of Medicare services to alternative payment models, such as ACOs, and away from fee-for-service models. In addition to cost savings, quality is also a focus. In 2014, Medicare ACOs demonstrated $411 million in cost savings, while 27 out of 33 quality measures were improved between 2013 and 2014 (USDHHS, 2016). Newer types of ACOs not only pay based on quality outcomes but also penalize for negative outcomes, shifting risk to providers and away from the government. The number of ACOs is growing, with 121 new participating groups in 49 states announced in 2016.
Policy Competence as an Integral Part of PHN Practice
The U.S. health care system is undergoing significant changes to improve the health of the public and contain costs. These changes are impacting health care across the system, but are particularly critical for those who work in communities with the increased emphasis on population health and disease prevention. The PHN can be an integral part of these efforts and help lead the way in addressing the social determinants of health and focusing efforts on prevention and long-term health promotion for families and communities. Along with other public health professionals, PHNs need to do this by understanding the policy process and then determining where their efforts would be most effective in improving overall population health (Haughton & Stang, 2012). This is a critical time for nursing in general, and PHN specifically, as the health care system focuses attention on what has always been at the core of PHN concern—health where people live, work, play, and pray.