Category: ACA

Recognizing the Value of Nursing Under Universal Health Care Coverage

  

The debate over how the nation structures its health care delivery system has waged on for decades. At the heart of this debate has been how to ensure coverage and access to needed health care services for patients. Looking at a system where most get their health needs covered by Medicare, Medicaid, or commercial, employer-sponsored covered, many recognized that too many Americans continued to be left behind. On one side of the debate, we have seen a push towards a single-payer system—like what is in place in Canada and the United Kingdom. Others, pushing for more market-based solutions to expand coverage through private plans.

At ANA, we have long supported movement toward adopting a single-payer health care system as the most desirable option. That is a health care system that is structured where services provided are financed by one payer, typically the government. Since that position was formally adopted in 1999, ANA has altered its advocacy on ensuring all Americans have access to health care coverage and nursing care, rather than focusing on how the health care system is financed. This evolution is a result of a shift in conversations about health care reform and delivery system, which was fully realized with the passage of the Affordable Care Act (ACA)—which celebrates its 11th anniversary this year. This landmark legislation made several critical reforms to the nation’s health care delivery system that continue to influence health care policymaking today.

The ACA adopted some market-based solutions to expand access to coverage through the creation of federal and state-based marketplaces, while at the same time expanding eligibility for the Medicaid program to vulnerable adult patient populations. In addition to focusing on coverage, the ACA has helped to trigger a broader movement to value and quality in how health care services are provided and paid. We know that many of our nurses are integral in leading and ensuring the success of value-based models and other innovations that better the care for patients, recognized through underlying payment structures.

As ANA engages with Congress and policymakers, it is key that the association’s position better reflect the current conversations and priorities, as well as allowing flexibility that allows the association to weigh in on proposed legislation and regulations. This will only serve to allow our voice to be more effective on behalf of our members—making it clear that the existing support of a single-payer system must be updated. Rather, we must adopt a replacement policy that endorses universal health coverage that recognizes the value of nursing. As defined by the World Health organization, universal coverage is a system wherein everyone has access to the health care services they need.

Through promoting universal health coverage that recognizes the value of nursing, ANA has the opportunity to continue to amplify the vital role nurses play in changing and improving the nation’s health care delivery system. Nurses are key to the provision of high-quality care to patients—regardless of the patient’s health care coverage. What is critical in these debates is the recognition of the nurse role through equitable payment for the services they provide to patients. Additionally, as policymakers continue to drive innovation and reform into the delivery system, nurses must be allowed to practice at the top of their license to fully contribute to the success of any system changes.

While our complex health care delivery system is far from perfect, there are many opportunities to shape policies that impact coverage, care, and ultimately the nursing profession. Over 30 million of our fellow Americans remain uninsured, a number likely to continue to grow due the economic challenges we all face due to the COVID-19 pandemic. This will likely lead to actions that work to ensure greater access to health care coverage. We also know that innovation and delivery system reform will continue to be an area of focus for policymakers. The role of the nurse must be forefront in these conversations and—most importantly—in any resulting legislation or regulations. Adopting a position that recognizes that access to health care coverage is most important, regardless of the underlying financing, lets us focus on ensuring that the value of nursing is fully recognized in our health care delivery system.

Over the next few weeks, members should watch ANA’s communication platforms as we near this year’s Membership Assembly. Dialogue forums are back, and we look forward to a robust conversation about moving ANA from endorsing a single-payer system to one that supports universal access to health care that fully recognizes the value of nursing.

Congress Aims to Keep Campaign Promises on Health Care as Courts Continue to Review Administration Policies

  

By: Gregory Craig and Matthew Fitting

Following a midterm election cycle in which voters consistently listed health care as their top issue priority, members of the 116th Congress have wasted no time in proposing, introducing, and debating several measures that would significantly impact the way Americans receive and pay for health coverage.

Health Care Legislation in the U.S. House of Representatives

Most recently, Rep. Frank Pallone, Jr. (D-NJ), the Chairman of the House Energy and Commerce Committee, on March 26, 2019 introduced H.R. 1884 – the “Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019”. This legislation would strengthen many of the consumer protections and pre-existing conditions provisions of the Affordable Care Act (ACA), promote individual health insurance enrollment on the ACA Marketplace, and roll back regulatory actions that the administration has implemented since January 2017. Some of the specific provisions would:

  • Expand income-based eligibility for premium tax credits used to purchase individual health insurance coverage and increase tax credits for all income brackets, allowing more individuals to purchase subsidized health insurance coverage;
  • Fix the so-called “family glitch” to make it easier for low- and middle-income individuals to purchase subsidized family coverage;
  • Rescind the administration’s final rule expanding the availability of Association Health Plans (AHPs) that can circumvent many of the ACA’s consumer protections, specifically those involving Essential Health Benefits (read ANA’s comment letter on AHPs here);
  • Rescind the administration’s final rule expanding the availability of short-term, limited duration insurance plans, which are not required to comply with any of the ACA’s consumer protections (read ANA’s comment letter on short-term, limited duration insurance here);
  • Require the Department of Health and Human Services to conduct marketing and outreach for open enrollment with $100 million in annual appropriations (read ANA’s plan year 2018 open enrollment report here);
  • Establish a state-based reinsurance program that would allow states to set up their own reinsurance programs, or to use the funds to provide premium subsidies or cost-sharing support, with a federal reinsurance program as a backstop.

ANA has publicly supported many of the provisions in H.R. 1884 and has consistently promoted a bipartisan proposal – similar to the reinsurance proposal included in H.R. 1884 above – that Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) introduced in the previous Congress that would have established a similar program and restored cost-sharing payment reductions that help low-income individuals afford co-insurance and deductible costs (the Administration canceled these payments in October 2017).

The proposal that has arguably grabbed the most headlines, however, is “Medicare for All,” a general campaign slogan that was recently introduced as legislation by Rep. Pramila Jayapal (D-WA) with a Senate bill soon to follow to be introduced by Sen. Bernie Sanders (I-VT). The bill would implement an expanded government-run Medicare program and do away with much of the private insurance system currently in place (well over half of Americans currently receive health insurance through their employer or in the Marketplace).

While the legislation is consistent with ANA’s support for universal access to health coverage, there are several provisions that could negatively impact the nation’s four million registered nurses, as well as the patients for whom they provide care. Some of these include:

  • A fee-for-service program that could significantly reduce payment rates and have a trickle-down effect on Advanced Practice Registered Nurses (APRNs), who are currently reimbursed at 85% the rate that Medicare reimburses physicians for the same work;
  • A Medicare Trust Fund that could lead to uncertainty around payments and impact access to care should beneficiary access to services exceed the fiscal year budget;
  • The establishment of regional offices charged with recommending changes in provider reimbursement and establishing quality assurance mechanisms for their regions, which could lead to a patchwork of coverage and tempt providers to practice where reimbursement rates are higher.

Federal Courts Reviewing ACA Provisions

The Department of Justice on March 25 unexpectedly sent a letter to the Fifth Circuit Court of Appeals to state that the Administration fully supports the December 2018 U.S. District Court decision in Texas v. Azar that would invalidate the entire Affordable Care Act (the U.S. District Court decision was stayed pending appeal; the Administration had previously only supported striking down parts of the ACA, including pre-existing conditions provisions). This case will likely make its way to the U.S. Supreme Court for a final decision, though that decision would probably not come until 2020 or later. Invalidating the entire ACA with no plan to replace it would be extremely disruptive to the U.S. health care system and would result in enormous insurance coverage and financial losses.

On March 27, the Federal District Court for the District of Columbia threw out Medicaid work requirements in both Kentucky and Arkansas. This is the second time that Kentucky’s Medicaid work requirements have been blocked in federal court. Arkansas’ work requirements were implemented in June 2018 and have resulted in 18,000 individuals losing coverage. The same federal court on March 28 issued a ruling that rejects the administration’s final rule that expands the availability of Association Health Plans. ANA has consistently opposed expanding the availability of these plans, as they represent an end-around of the ACA’s essential health benefits requirements for insurance coverage.

ANA’s Commitment to Universal Access to Quality Health Care

ANA is committed to a pragmatic approach to ensuring universal access to quality, affordable, and accessible health care for all Americans, particularly vulnerable populations and those with pre-existing conditions. As ANA stated in a recent press release: “Universal access to a standard package of essential health care services for all citizens and residents is of paramount importance to the American Nurses Association. Nurses have a critical voice in this debate, and ANA is committed to advancing policy initiatives that provide and expand access to affordable coverage and quality care for all.”

This is the latest chapter in the decades-old health care debate – we expect that many proposals will be offered before the 2020 election. ANA will continue to be involved and actively advocate for nurses and the patients for whom they provided care.

Courts Block Rules That Would Restrict Women’s Access to Reproductive Health Care Services

  

Federal courts this week blocked two Interim Final Rules (IFRs) from the U.S. Department of Health and Human Services (HHS) that would have significantly expanded the ability of employers to deny coverage of contraceptives for female employees on the basis of religious or moral objections.

On January 14th, the U.S. District Court for the Eastern District of Pennsylvania issued an order granting the motion for a preliminary nationwide injunction blocking the implementation of the two IFRs from HHS that would have expanded the ability of employers to cite moral and religious objections in seeking exemptions from the Affordable Care Act’s (ACA) contraceptive mandate. That mandate requires all employers that provide employer-sponsored insurance for their employees to cover contraceptives, with narrow exemptions (e.g., religious entities and closely held for-profit corporations).

The Pennsylvania ruling followed a January 13th ruling from the U.S. District Court for the Northern District of California also blocking the implementation of these two IFRs in the 13 plaintiff states in that lawsuit (California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Minnesota, New York, North Carolina, Rhode Island, Vermont, Virginia, Washington), plus the District of Columbia; the judge in the Northern District of California prominently cited ANA’s amicus curiae brief in his order granting the motion for a preliminary injunction.

These IFRs would be particularly damaging given the administration’s proposed regulatory changes to Title X funding, which provides grants for critical family planning services for millions of Americans, particularly low-income women. HHS itself notes in its analysis of the blocked IFRs that they would result in over 125,000 more women relying on Title X programs for reproductive health care services, even as the administration has taken steps that would restrict the ability of Title X programs to provide those services.

These injunctions block HHS from implementing the two IFRs, which were supposed to go into effect on January 14th; the narrower Obama-era exemption policy remains in place during the injunction. It is worth noting that two nearly identical IFRs were also blocked in the same district courts in December 2017. Experts widely expect the defendants in these cases to appeal to the U.S. Courts of Appeals in the Third Circuit and the Ninth Circuit, respectively.

ANA firmly believes in universal access to comprehensive and affordable health care services for all Americans. Access to basic, preventive reproductive health care, such as birth control, cancer screenings, STI testing and treatment, and well-woman exams is critical to the overall well-being of women of all ages and is an essential health benefit. ANA will continue to advocate for universal access to quality, affordable, and accessible health care services, including basic, preventive reproductive health care services, for all Americans.