Journal Article

African American Nurse Leaders and the American Public: Do We Really Understand the Healthcare Law?

MT, Dobal, Y, Wesley, M, Elias, J, Gulstone, LC, Archer

2017

Overview

Nurses make significant contributions to the American healthcare system and should have knowledge of major healthcare policies such as the Patient Protection and Affordable Care Act (PPACA), particularly those nurses in leadership. More nurse leaders of African descent need an understanding of PPACA to advocate for the policy provisions in the law as it relates to social determinants of health (SDH). This paper illustrates a need for a better understanding of PPACA among nurses of African descent to promote health equity. Keywords Patient protection and affordable care act; Social determinants of health; African American nurse leaders; Health equity; Health disparities. Introduction Nurses are the most trusted healthcare providers[1] and are ideally positioned to play an integral role in moving the U.S. healthcare system forward. With the passage into law, the Patient Protection and Affordable Care Act (PPACA) have provided opportunities that may help achieve health equity. Communicating aspects of the law with patients, families, and communities is a major objective of nursing leaders[2]. Fellows of the Leadership Institute for Black Nurses (LIBN) have a duty, as healthcare providers, to be equipped with the tools that promote health equity. LIBN Fellows were immersed in healthcare both professionally and educationally, and it was expected that they would have more knowledge of PPACA than those of the general public who were surveyed by Kaiser[3] in 2010. Understanding provisions in the law is fundamental to healthcare leadership, and nurse leaders have a mandate to remain current in policy and practice[2]. Kaiser[4] reported that by the end of 2015, the number of uninsured nonelderly adults had decreased by nearly 13 million since 2013 due to PPACA. The decrease was due, in part, to the removal of barriers such as pre-existing conditions and healthcare insurance coverage for dependent children up to age 26. In addition, the Department of Health and Human Services5 (DHHS) reported that PPACA has improved the quality of healthcare along with lowering the cost. For example, the cost of prescriptions for seniors has been reduced, and there are now tax credits for small business owners[5]. However, provisions in PPACA that improved access to care such as the health insurance exchanges remain a mystery to many. Moreover, awareness of the benefits of the law still eludes many currently including nurses and more importantly, those who it is intended to help the most. Therefore, this topic remains an issue and more education is needed among nurses as they advocate for healthcare consumers. Knowing fact from fiction is essential to effective leadership. It is necessary that nurses understand new and exciting programs in the U.S. healthcare system regardless of whether the nurse is: • providing direct patient care as a staff nurse, • directing patients’ care as an Advance Practice Nurse (APN), • overseeing a nursing department as a healthcare administrator, • preparing future nurses as a nurse educator, or • Generating nursing science as a scholar. Moreover, since many African American nurses work in urban settings and care for large minority populations, an understanding of PPACA is essential. Purpose The purpose of this paper is to (1) highlight policy provisions in PPACA; (2) discuss the link between social determinants of health (SDH) and PPACA; (3) compare knowledge levels of the American public in December, 2010 to nurses of African descent in December, 2013; and (4) recommend strategies to identify and improve areas of PPACA knowledge deficit. Summary of PPACA PPACA consists of two bills that were signed into law by President Barack Obama on March 23, 2010. The two bills consisted of the Patient Protection and Affordable Care Act (H.R. 3590) and Education Reconciliation Act of 2010 (H.R. 4872). Once signed by President Obama, the bills became Public Law 111-148[6] (Table 1) and Public Law 111-152[7] respectively (Table 2). Approximately two years later, on June 28, 2012, the Supreme Court rendered a final decision to uphold the healthcare law[8]. However, there are still efforts to repeal the law. PPACA focuses on provisions to expand coverage, control healthcare costs, and improve the healthcare delivery system. One key provision of PPACA bans discrimination against preexisting conditions[9]. There are ten titles in the law6 which address various areas in healthcare that contribute to the improvement of the U.S. healthcare delivery system (Table 1). The focus of the provisions of PPACA are quality of healthcare, affordable healthcare for all Americans, improved efficiency of healthcare, prevention of chronic disease, and improvement of public health. Title V of PPACA focuses on improving workforce training and development, and encompasses several areas targeting nursing education and training aimed at adequately preparing nurses at all levels to serve the population. Public Law 111-1527 adjusted revenue and financing schedules for private insurance coverage, Medicare, Medicaid; and reduced fraud, waste, and abuse in healthcare financing. In addition, key components of this law addressed investing in students and families through student loan reform, modifying financial assistance for higher education, and eligibility criteria for dependent children (Table 2). Together, Public Laws 111- 148 and 111-152 are referred to as the Patient Protection and Affordable Care Act. Quality Affordable Health Care for All Americans a.Eliminates lifetime annual limits on benefits. b.Prohibits rescissions of health insurance policies. c.Provides assistance for those who are uninsured because of a pre-existing condition. d.Prohibits pre-existing condition exclusions for children. e.Provides coverage of preventative services and immunizations. f.Extends dependent coverage up to age 26. g.Develops uniform coverage documents to help consumers better compare policies. h.Limits insurance company non-medical administrative expenditures. i.Ensures consumers have access to an effective appeals process. j.Creates a temporary re-insurance program to support coverage for early retirees. k.Establishes an internet portal to assist in identifying coverage options. l.Facilitates administrative simplification to lower health system costs. Role of Public Programs a.Expands Medicaid availability to consumers previously ineligible. b.Requires states to maintain eligibility levels for the Children’s Health Insurance Program (CHIP) through September 2019. c.Simplifies enrollment through state-run Web sites. d.Creates the availability of the Community First Choice Option. e.Reduces states’ Disproportionate Share Hospital Allotments (DSH). f.Improves federal and state coordination for individuals enrolled in Medicare and Medicaid. Quality and Efficiency of Health Care a.Links payment to quality performance on common, high-cost conditions. b.Establishes national strategy to improve service delivery, patient outcomes, and population health. c.Encourages development of new patient care, payment, and delivery models. d.Ensures beneficiary access to physician care. e.Offers rural protections. f.Improves payment accuracy. g.Rearranges Medicare Advantage (Part C) payment schedules. h.Reduces Medicare Prescription Drug Plan (Part D) costs. i.Ensures Medicare sustainability. j.Improves quality of community health care. Chronic Disease and Public Health a.Modernizes disease prevention and public health systems. b.Increases access to clinical preventive services. c.Creates healthier communities. d.Offers supports for prevention and public health innovation. Health Care Workforce a.Encourages innovative review of the workforce. b.Increases the supply of health care workers. c.Enhances health care workforce education and training. d.Supports the existing health care workforce. e.Strengthens primary care and other workforce improvements. f.Improves access to health care services. Transparency and Program Integrity a.Encourages physician ownership and transparency. b.Improves nursing home transparency. c.Targets enforcement. d.Improves staff training. e.Institutes nationwide program for background checks on direct patient access employees of long term care facilities and providers. f.Establishes patient-centered outcomes research. g.Establishes integrity provisions for Medicare, Medicaid, and CHIP. h.Enhances integrity provisions for Medicare and Medicaid. i.Encourages additional Medicaid program integrity provisions. j.Encourages additional program integrity provisions. k.Encourages enforcement of the Elder Justice Act. l.Expresses the sense of the Senate regarding medical malpractice. Access to Innovative Medical Therapies a.Establishes biologics price competition and innovation. b.Provides more affordable medicines for children and underserved communities. Community Living Assistance Services and Supports a.Establishes national voluntary insurance program for purchasing Community Living Assistance Services and Support (CLASS). Revenue Provisions a.Levies excise tax on high cost employer-sponsored health coverage. b.Increases transparency in employer W-2 reporting of health benefits values. c.Supports distributions for medicine qualified only if for prescribed drugs or insulin. d.Increases additional tax on distributions from HSAs and Archer MSAs not used for qualified medical expenses. e.Limits health-care related FSA contributions. f.Institutes requirement of corporate information reporting. g.Establishes new requirement for non-profit hospitals. h.Imposes a pharmaceutical manufacturer’s fee. i.Imposes a medical device manufacturer’s fee. j.Imposes an insurance provider fee. k.Instates requirement of Department of Veterans Affairs report. l.Eliminates the deduction for employer Part D subsidy. m.Modifies the threshold for claiming the itemized deduction for medical expenses. n.Limits executive compensation. o.Imposes additional hospital insurance tax for high-wag

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