Nursing News

Health Reform Implementation Underway

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By Jennifer Larson, contributor

February 18, 2011 - What changes can nurses expect to see as a result of health care reform during the rest of this year?

As 2011 gets underway, a number of provisions of the Patient Protection and Affordable Care Act (ACA) are taking effect. Some provisions of the landmark health care reform law, which passed last March, took effect in 2010, including the elimination of the lifetime limits on insurance coverage and the prohibition on denying children coverage based on pre-existing conditions.

This will also be a busy year, with the following key provisions slated to take effect:
• Subsidies and drug discounts to help close the Medicare coverage gap;
• Grants for states to establish health insurance exchanges;
• Increased premiums for higher-income Medicare beneficiaries;
• Establishment of medical-loss ratios for health plans, which will require that 85 percent of premiums collected by companies for large employer plans be spent on health care and quality improvement (and 80 percent for individual and small employee plans).

Eileen Sullivan-Marx, Ph.D., CRNP, a professor and associate dean at the University of Pennsylvania School of Nursing, hopes that nurses will be excited about the possibilities afforded by the law. Many nursing organizations contributed to the creation of the law, she noted, and nurses are well aware of the drawbacks of having millions of people unable to get insurance or receive preventive care.

“They should think of it as a nurse reform plan, and therefore they should take some ownership of it,” she said.

The provisions to develop, educate and expand the nursing workforce are often cited, but there are other provisions that will affect the nursing workforce that are notable, too. Jan Towers, Ph.D., CRNP, federal director of health policy and professional affairs for the American Academy of Nurse Practitioners, noted there may also be more opportunities for nurse practitioners to make major contributions.

“There are a lot of provisions in there for our patients and for nurse practitioners to be able to function more fully at their full scope,” she said. “There are many things in it that we don’t want to lose.”

For example, Towers noted that she was glad that the law included a nondiscrimination section that prohibits health plans from discriminating against providers acting within the scope of that provider’s license or certification (under applicable state law).

“We have a huge track record or how well we do things,” she said. “Being able to function more fully and participate more fully in the provision of care is going to be very important.”

Also, a significant part of the law will provide grants for the creation of more nurse-managed health clinics, or NMHCs, to provide primary care.

Sullivan-Marx noted that some nurse-led centers are already showing signs of success which could encourage people. A leader with the American Academy of Nurses’ Raise the Voice campaign, she helped establish an innovative nurse-led program at UPenn called the Living Independently for Elders (LIFE) Center which provides comprehensive services for frail elderly people. The center, which is a Program of All Inclusive Care for the Elderly (PACE),  has reduced hospitalizations and reduced costs.

Controversy and challenges

However, the new law’s future is not entirely certain.

Two significant provisions with a 2014 implementation deadline have been controversial: the establishment of health insurance exchanges to offer insurance to people whose employers don’t offer insurance, and the requirement for people to buy basic health insurance, unless affordable coverage is unavailable, or face a tax penalty. 

Since the beginning, the law’s most contentious provision has been the individual mandate, as recently noted in a Perspective column for the New England Journal of Medicine. Many lawmakers have challenged the constitutionality of that requirement. And other legal challenges have already been mounted.

Republican lawmakers held a long-promised vote on the law in the U.S. House of Representatives in January, and the law was voted down, even though a similar effort in the Senate, which is controlled by the Democrats, failed.

Two district courts have upheld the constitutionality of the individual mandate, but in December, the U.S. District Court, Eastern District of Virginia, struck down the individual mandate as unconstitutional in the case of Commonwealth of Virginia v. Sebelius. However, that court did leave the rest of the ACA intact. On January 31, the Northern District Court in Florida ruled that the entire law is unconstitutional because of the individual mandate; the court said the mandate was so essential to the law that the provision couldn’t just be removed and leave the rest of the law to stand.

Many believe that challenges to the law will eventually make it all the way to the Supreme Court. It’s also possible that a legal challenge could get to the Supreme Court, and the court could refuse to hear it.

Additionally, 21 Republican governors recently sent a letter to U.S. Health and Human Services Secretary Kathleen Sebelius, expressing their displeasure with the health insurance exchanges prescribed by the law. Their letter claimed that the exchanges could threaten the private insurance market.

Sullivan-Marx said that nurses could shape public opinion of the law by helping their patients understand the benefits and the role that nurses played in creating the law. Nursing is routinely cited as one of the most trusted professions in national polls and surveys, and people do say they respect nurses’ opinions, she said.

“You could gain a lot of trust from this,” she said.

And while opening insurance rolls to millions of previously uninsured people may result in an initial uptick in services, eventually “we’ll be able to settle that out,” she said, noting that her PACE program has demonstrated that phenomenon.

Beyond 2011: What’s next?

Assuming the implementation of the law continues, many providers are likely to be consumed with meeting the delivery system reforms required this year, said John McDonough, a public policy expert who worked with the late Sen. Edward Kenney and the Senate committee that pushed for health care reform. Those reforms include reducing unnecessary hospital readmissions for Medicare beneficiaries and linking payment to quality outcomes for hospitals to improve the quality of care.

But many will still be paying attention to the launch of Medicare’s accountable care organizations (ACOs) next year. ACOs, which are integrated networks of hospitals and physicians that coordinate care, are intended to reduce unnecessary cost and improve the quality of care, with savings to be shared among the involved parties.

According to Jennifer Tolbert, associate director of the Kaiser Commission on Medicaid and the Uninsured, many hospitals are closely monitoring the ACO model, deliberating over whether that is a path they want to pursue or not.

“A lot of providers are assuming that this is what’s going to happen down the road,” she said. “They are assuming that this is the direction that care delivery will be moving.”

A paper issued February 4 by the law firm McDermott, Will & Emery noted that health care providers and industry stakeholders cannot take a “wait and see” approach because the U.S. Centers for Medicare & Medicaid Services and the U.S. Department of Health and Human Services are continuing to implement the new law while the legal process plays itself out. In addition, the writers expect that “many ACA reforms unrelated to the insurance mandate, such as the reforms applicable to Medicare, including accountable care organizations, will proceed with almost any scenario.”

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