The Affordable Care Act (ACA) has critics on both sides of the aisle, but three years into its enactment, patients report significant improvements in their care and well-being, according to a study in Health Affairs. Researchers focused on the experience of patients between 2013 and 2016 in three states: Kentucky, which expanded coverage via Medicaid; Arkansas, which used federal Medicaid funding to help low-income adults obtain private insurance; and, for control purposes, Texas, because it did not expand coverage to this population. After surveying 10,885 citizens ages 19 to 64 with family incomes below 138% of the federal poverty level (the ACA's Medicaid expansion eligibility threshold), the study found that Kentucky and Arkansas-the two states with expanded coverage-saw improved and more affordable access to primary care and medications and more frequent use by patients of preventive visits and screening tests. On average, a newly insured patient saved $337 per year in out-of-pocket costs, was 41% more likely to have a regular primary care provider, and was 23% more likely to self-report as being in excellent health. In addition, adults with chronic conditions such as hypertension, diabetes, depression, and cancer were more likely to receive regular care, adhere to medication regimens, and report improved health. Notably, the researchers found a 51% decrease in patients skipping medications because of cost.
Many fear that these gains may be undone if some elements of the American Health Care Act (AHCA) ultimately become law. According to the Congressional Budget Office, the Senate bill aims to cut Medicaid spending by $772 billion over 10 years, thereby leaving an estimated 49 million people uninsured in 2026, 22 million more than if the ACA had remained in effect. Moreover, according to Diana J. Mason, senior policy service professor at the George Washington University School of Nursing, nursing advances such as the Nurse-Family Partnership, which provides home visitation programs for high-risk pregnant women, and Living Independently for Elders, which supports older adults living at home, could be undermined. The House version of the AHCA eliminated funding for expansion of these nurse-designed initiatives, and this may also end up in the Senate bill.
Mason enumerated other possible harms, including a return to overcrowded EDs because of the projected increase in the number of uninsured people. "More importantly," she told AJN, "people would die prematurely." Because the AHCA under consideration allows states to opt out of requiring insurers to provide such essential benefits as women's reproductive services, there would likely be "an increase in unwanted pregnancies if contraception isn't covered," Mason said. People with preexisting conditions would be worse off, too, because of a provision in the bill that permits insurers to charge these patients more if they have a lapse in insurance coverage for more than six months in the previous year. The ACA "needs to be refined," Mason said, "not crippled or repealed."
Another threat to nursing, according to Mason, is President Donald Trump's budget, which proposes to cut funding for nursing education. "So look for worsening nurse-patient ratios, as nursing schools will be unable to maintain the past decade's increases in enrollments and graduations," she said.-Dalia Sofer
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