It has been one year since the Patient Protection and Affordable Care Act, or the Affordable Care Act of 2010 (ACA) was signed into law. It includes provisions that would expand coverage, control costs, and improve health care delivery, while providing insurance coverage for 32 million more Americans.
However, with all the protests about costs, allowable services, and the constitutionality of mandated insurance, I am beginning to doubt whether the ACA will ever be fully implemented. I keep my hopes up because, as many have noted, we are at an important crossroad in health care.
There is an ongoing discussion about how we will accomplish the change in access to health care. The big question is “Who will provide that care?” We have long faced a shortage of primary care providers (well, MDs, at least). However, we know that historically, PAs and NPs were overlooked when considering the provider-to-consumer ratio.
That oversight is beginning to dissipate, as legislators and other policymakers deliberate about how best to deal with the provider shortage. Finally, as part of these discussions, we are being included for the important role we play in health care—past, present, and future. It is somewhat comforting that NPs, but to a lesser extent (regretfully) PAs, are more often recognized as the solution to the health care conundrum.
Recently, Peter I. Buerhaus,1 PhD, RN, FAAN, explored the current and the future state of NPs. He identified key elements, such as independence, patient perception, and turf battles, that impact our role. It’s nothing new to many of us, but the expression of those elements reminded me that change is accomplished by maximizing the opportunity in place to make the change.
We “policy wonks” often refer to Kingdon’s window of opportunity—the point at which policy issues move onto the government agenda and toward decision and action—as the prime time to move on change. Kingdon notes that three converging streams are involved in opening that window: the identification of the problem; the development of alternative solutions and proposals; and changes in public opinion, administration, or interest groups that determine the outcome.2 The window opens, and the opportunity for action is there for the taking.
The converging streams that opened the health care reform window (taking liberty with Kingdon) were, as I see it, frustration with the current system, rising insurance premiums, and decreased access to health care. We know the problem; the solutions are what have us in limbo. When we discuss what we need to change, it is important to consider the attempts made in the past, and the success or failure of those attempts.
One success in the realm of better access to health care is the increase in nurse-managed clinics nationwide. On college campuses, in occupational health settings, and in retail locations, NPs have demonstrated their value and have produced patient outcomes comparable to those of our physician colleagues. There is evidence that patients of NPs are seen more often, have fewer emergency department visits, shorter hospital stays, and lower prescription costs, and have higher medication compliance.3
Therefore, it is not surprising that one provision in the ACA calls for funding of nurse-managed health centers. There are significant funds for nurse-managed health centers to continue and expand the care provided to vulnerable populations. This is an important milestone, because despite the ACA, millions of Americans will still lack coverage. Those of us who have always provided care to the most vulnerable populations will continue to do so, but we need fair reimbursement.
Payment reform is also necessary. NPs, and our PA colleagues, must be included in Medicare and Medicaid guidelines for reimbursement, in the same way physicians are. It is only right that all providers receive equal reimbursement for equally competent services. It is also necessary that third-party payers include us in primary care provider networks to ensure access to care.
Change does not come easily, and the preparation for reform is paramount. We must be sure that we are able to meet the expectations included in the ACA. We must also be realistic about how long those changes will take to implement. As was quickly realized when Massachusetts mandated universal coverage, it is imperative that there be a sufficient number of primary care providers and health care teams to care for the population.
In a plethora of published articles in the health policy literature, the authors suggest that NPs have the greatest potential to fill the needs in the primary care workforce. However, we must also include our other health care professional colleagues. Because our patients need us to help them navigate the complex health care system, we must build the team that can coordinate care across all disciplines, and ensure that team is well functioning.
The Affordable Care Act of 2010 places many demands on health professionals, but also offers us many opportunities to create a system that is more patient centered. Now is the time for all of us to pool our resources and face the reality that maximizing the potential of all providers is the solution to access to care for all Americans.
1. Buerhaus PI. Have nurse practitioners reached a tipping point? Interview of a panel of NP thought leaders. Nurs Econ. 2010;28(5):346-349.
2. Kingdon J. Agendas, Alternatives, and Public Policies. 2nd ed. New York, NY: Longman; 1995.
3. Hansen-Turton T, Line L, O’Connell M, et al. The Nursing Center Model of Health Care for the Underserved. HCFA Contract No. 18-P91720/3-01. Philadelphia, PA: National Nursing Centers Consortium; 2004.