Commentary: From the Supreme Court Steps, a Nurse Assesses the Impact of the ACA Decision

July 2012Brandie Hollinger

I will always remember exactly where I was on June 28, 2012. In the humidity of a Washington, DC, summer, I stood in the crowd anxiously awaiting the Supreme Court ruling on the Affordable Care Act.

Advocates for both sides of the issue surrounded me. They rang bells, clinked chimes and beat loud drums, holding bright, patriotic signs that read, “We love Obamacare,” or “Strike down the mandate.” Prayers, songs and chants could be heard blocks from the Supreme Court steps.

Brandie Hollinger (second from left) outside the Supreme Court After a few painful moments of confusion about the final decision of the justices, those in support of the law began to scream, “Upheld! Upheld!” The hypothesizing and recurrent attempts to predict the fate of the law were over. The Affordable Care Act had passed the Supreme Court litmus test. Implementation would continue.

In my role as a health policy intern for the National Coalition on Health Care, the weeks leading up to this moment were consumed with anticipation and anxiety. Reviewing multiple press releases, analyzing and framing health care arguments, and evaluating predictions on the court’s decision were commonplace in my daily activities. So amidst the civil chaos that morning, I recall thinking, “What is it about this issue that elicits such a visceral reaction in people, and what does this decision mean for the future of health care?”

After the ruling, I immediately realized how much work still needed to be done. This was just the beginning.

Next Up: Containing Costs

The Affordable Care Act (ACA) contains many initiatives that work collectively to improve health care in the United States. These include improving access to health insurance, providing consumer protections for insurance beneficiaries, and investing resources in the ailing primary care system. However, among policymakers the big elephant remains in the room: How do we control rising health care costs? During my internship in DC, I’ve heard this argument often: “National health care reform without cost control is like moving furniture into a burning house.” Conversations about cost control seem to be the front and center issue of the policy discussion.

I attend congressional hearings on cost containment, where I listen to expert witnesses give testimony on how to remedy the problem. Health advocacy organizations hold forums and briefings about innovative programs that have reduced costs and provided quality patient outcomes. In attending these sessions, I’ve realized that the burning house metaphor is spot-on. What good are health reform efforts that don’t attempt to wrestle ballooning health care inflation rates and reign in provider payment variation? Shifting costs to consumers and businesses does not promote effective cost savings in the long run. It puts a small Band-Aid on the gaping wound of exorbitant health care costs.

The ACA contains mechanisms for providers to control costs in the form of Accountable Care Organizations and the Medicare Shared Savings Program. These programs incentivize providers to more efficiently and economically deliver more coordinated care and quality outcomes to a patient population. The incentive is the opportunity to share savings with the Medicare program. Additionally, the Centers for Medicare & Medicaid Services (CMS) has attempted to shift provider payment models from a fee-for-service to a value-based, outcomes-driven model through (1) penalties for hospitals with high readmission rates and (2) rewards to hospitals with quality patient outcomes. There are also budding private sector cost containment efforts, particularly in primary care, through methods such as Alternative Quality Contracts, which incentivize providers to keep patients healthier. However, these efforts remain isolated and have not been implemented on a national scale.

Individuals in Washington also frequently discuss the Supreme Court’s decision regarding the expansion of Medicaid. Five governors thus far have declared that their states will opt out of participation in the Medicaid expansion program. Collectively, this decision could remove roughly 4 million people from the estimated 16 million that would obtain health insurance through the initiative. Some policy experts have chosen a “wait and see” approach and believe it is far too early to predict what all states will do, especially since the law has the federal government absorbing most of the cost of the expansion. Others are concerned that without states’ early adoption of the Medicaid expansion, the currently uninsured will remain uninsured, diminishing the value of the program.

The Effect on and Responsibility of Nurses

Nurses must monitor the effects of the ACA and be prepared to adapt and have our voices heard.

It troubles me when some of my nursing colleagues tell me they don’t see what the ACA has to do with nursing. It has everything to do with nursing. As nurses, we are perfectly positioned to implement the innovations in care and delivery system reforms that the law dictates. As advanced practice nurses, we are uniquely suited to delivering the cost-effective, high-quality primary care necessary to meeting the needs of those newly insured by the ACA.

In addition, our experience is invaluable to policymakers because we have our proverbial ear to the health care streets. Nurses will continue to be on the front lines, implementing the reform measures of the ACA. We know what standard of care our patients deserve and can anticipate their needs promptly. We have a distinguished position at the bedside and in the community, and we are respected and sought out specifically for this perspective.

Throughout my time in Washington and as a bedside nurse, I’ve realized why people are so passionate about the health reform issue: Health care is personal. Nearly everyone has been affected by the delivery of health care in some form. It touches our families and loved ones and aligns our collective values. People want to be involved and have a say in the decisions that affect the most sacred and valuable individuals in their life. As nurses, we must understand not only health reform and why it matters, but also why it is important for the healthy outcomes of our patients.

Brandie Hollinger is a student in the UCSF School of Nursing Master’s Program in Health Policy Nursing and a pediatric intensive care unit nurse at UCSF Benioff Children’s Hospital. As part of the internship component of the Health Policy program, she is spending her summer as a Paul G. Rogers Memorial Scholar (Health Policy Analyst) at the National Coalition on Health Care. Her policy interests include hospital payment reform, chronic disease management in children, and cost containment in Medicare.

The opinions expressed are solely those of the author and do not represent the opinion of the National Coalition on Health Care.

Editor's Note: On August 29, UCSF School of Nursing Dean David Vlahov will be part of a panel discussion on “The Future of Health Care in the US,” at the UCSF Mission Bay Campus, from 6 to 8 p.m. He will be joined by Dean Stephen Shortell of the UC Berkeley School of Public Health and Professor (and former dean) Jesse Choper of the UC Berkeley School of Law. For details, click here.