When speaking about the Affordable Care Act (ACA) at the 2010 Legislative Conference for the National Association of Counties, House Speaker Nancy Pelosi stated, "But we have to pass the bill so that you can find out what is in it, away from the fog of controversy."1 The ACA ultimately was passed and the American public and health care professionals are beginning to come to terms with the content of this bill, and whether its intentions will ever come to fruition.

Beginning on or after September 23, 2010, provisions in the ACA will cover multiple preventive services for children and adults without individuals having to pay copayments, coinsurance, or meet a deductible. Among these preventive services is a screening colonoscopy for adults aged 50 years or older.2 A screening colonoscopy is considered important because of its ability to identify polyps or suspicious lesions before they develop into invasive malignancies. As more individuals have access to insurance and obtain screening colonoscopies, there is greater potential to decrease colorectal cancer morbidity.3 Patients with colorectal cancer often comprise a large portion of patients served by WOC nurses. Even if a precancerous polyp requires a colectomy and a temporary stoma with short-term intervention from a WOC nurse, the patient will not require a permanent colostomy and a lifelong relationship with a WOC nurse.4

Effective January 1, 2014, the ACA prohibited discrimination due to preexisting conditions or gender.5 This sweeping insurance reform will impact many patients with whom WOC nurses interact, including those with the inflammatory bowel diseases (IBD), ulcerative colitis, and Crohn's disease. Many of these patients struggle with getting or keeping insurance due to their conditions. The cost of their medications can be overwhelming when not covered by health care insurance. Patients with IBD and an ostomy often have no coverage for their ostomy supplies and may suffer from peristomal skin damage due to attempts to prolong wear time of an individual pouching systems. While 2 industry partners, Hollister6 and ConvaTec,7 have indigent support programs, not all patients who need assistance with ostomy supplies may be aware of or qualify for these programs. With the elimination of the preexisting condition discrimination, these patients should be able to obtain insurance so that their medications and ostomy supply needs can be covered.

Patients with IBD are also at increased risk for colorectal cancers and other complications, including enteric fistulas,4 and having insurance coverage would also allow them to be followed more closely by primary care and specialist providers so that their conditions can be controlled, rather than waiting for emergent issues to arise. The ACA also eliminates annual and lifetime limits,8 an issue of great concern for individuals with chronic diseases such as IBD.

With the ACA, both hospitals and home care agencies will see Medicare payments tied to performance and quality, not volume.9 Health care organizations with fewer hospital-acquired conditions, such as catheter-associated urinary tract infections and pressure ulcers, will have higher-quality scores. WOC nurses are uniquely qualified to lead teams in pressure ulcer and catheter-associated urinary tract infection prevention. A WOCN funded study compared patients of home health organizations with WOC nurses on staff to patients of home health organizations who did not have WOC nurses on staff.10 Among home health care agencies with a WOC nurse, the likelihood of improvement in patients with a pressure ulcer was approximately twice that of an agency without a WOC nurse (odds ratio = 1.9). The presence of a WOC nurse was also associated with improvements in urinary and fecal incontinence severity, lower extremity, and surgical wound healing than agencies without a WOC nurse on staff. Findings from this study provide a strong argument for including the expertise of WOC nurses in multiple health care settings as we transition to a performance quality-based payment system.

Finally, ACA supports the Nursing Workforce Development Programs, which the WOCN also supports. Goals of this program include recruitment of new nurses into the profession, promotion of career advancement within practicing nurses, and improvement of patient care delivery systems.11 The WOCN has developed multiple evidence-based guidelines to also aid in improving patient care delivery. The Wound, Ostomy, Continence Nursing Education Programs prepare RNs to become WOC nurses, allowing for career advancement. Continuing education opportunities via conferences, webcasts, and various other formats developed by the WOCN promote ongoing learning for WOC nurses, as well as other nursing professionals.

The passage of the ACA has been tumultuous, and the precise mechanism of its implementation remains to be seen. For example, many states, including South Carolina, have not endorsed the Medicaid component of the ACA.12 The impact of this decision on lower-income citizens of this state who would have qualified for Medicaid remains uncertain. According to the South Carolina Hospital Association, hospitals will be forced to shift more costs to the insured.13 So, will the newly insured under the ACA now be bearing the costs of the still uninsured due to no Medicaid? I suppose, as a WOC nurse practicing in South Carolina, I will still be contacting Hollister or ConvaTec for pouches for patients with no insurance. Hopefully, given the new policies afforded by the ACA, such contacts will happen less often.

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