Nurses historically respond to changes in regulation and financing of healthcare with innovation and professional responsibility. Nurses historically respond to changes in regulation and financing of healthcare with innovation and professional responsibility. The Patient Protection and Affordable Care Act (Public Law 111-148, 2010) addressed the most recent policy driven requirements of healthcare in the United States (U.S.). The ACA identified three aims of reform: reduced healthcare expenses, elevated quality of care, and increased access for all Americans (Collins & Saylor, 2018a; Penson, 2015). The goals of this historic legislation included: 1) expanding Medicaid, 2) preserving both employer/job-based coverage and Medicare, and 3) promoting state control of insurance markets (Luther & Hart, 2014).

Quality of care, value in health spending, and availability of resources are not new priorities to the profession of nursing. Nurses are integral in sustaining the financing of healthcare concerns through integrated activities with policy makers, legislators, and administrators because of the need to close the increased gap between funding the Medicare Trust, health related expenditures, and insurance plan instability. Quality of care, value in health spending, and availability of resources are not new priorities to the profession of nursing. The ACA provides an initial legislative framework that links these concepts directly to payment initiatives (Sultz & Young, 2014). Nurses remain uniquely situated to shape healthcare due to their team approach, proximity to the bedside, and understanding of patient care within the hospital and the community (Institute of Medicine [IOM], 2010; Luther & Hart, 2014).

The ACA highlights the priorities of nurses and exposes the disconnected nature in which healthcare is delivered in the United States (Luther & Hart, 2014). The insurance industry experienced the impact of health reform through the expansion of regulations, quality reporting, and penalties for low quality care (National Association of Insurance Commissioners [NAIC], 2011). These regulatory requirements became a platform for nurses to share expertise in program planning and patient education with plan administrators (Ariosto et al., 2018). The results were financial savings and focus on population management (Luther & Hart, 2014).

...nurses contribute to and develop solutions in an enhanced regulatory environment through the formation of health policy.This new paradigm accelerated the development of advanced practice roles and the expansion of nursing education while enhancing administrative and policy skills development in nursing curricula and administrative practice. The result has been an explosion of nurses in leadership positions across health organizations and insurance companies; on governing boards of both health related and non-health related companies, healthcare systems, and community programs; and in government roles. As such, these nurses contribute to and develop solutions in an enhanced regulatory environment through the formation of health policy.

The purpose of this article is to discuss the unique roles offering empowerment to nurses to drive and respond to financial concerns in healthcare through the lens of the three aims of the ACA: reducing cost, improving quality and increasing access. We discuss how nurses and the profession of nursing have harnessed the power of the discipline to make changes in these key areas, specifically the impact of nurses on national health cost reduction, value based healthcare reimbursement, and opportunities to impact healthcare quality. In addition, we consider the impact of nurses on healthcare quality and access to care, as well as continued opportunities for nurses to impact access and lead change.

Nurse Impact on National Health Cost Reduction

The Medicare Act of 1965 was the primordial legislation in American healthcare spending. Medicare and Medicaid began as a service for the elderly population and grew to include disabled people and individuals with end-stage renal disease (Centers for Medicare & Medicaid Services [CMS], 2018b). Finkelstein (2005) referenced the tripling of the healthcare expenditures share within the Gross National Product (GDP) from 1960 to 2000 as a result of increased access to medical care, more intensive treatments, and new technologies (specifically cardiac care), with little impact on the overall mortality rate for elders.

The first attempt to control healthcare costs was introduced in 1989, when the Diagnosis Related Group (DRG) system replaced cost-based reimbursement. The first attempt to control healthcare costs was introduced in 1989, when the Diagnosis Related Group (DRG) system replaced cost-based reimbursement. The DRG is a patient classification system that standardizes the cost of healthcare treatments and length of stay (Hawaii Medical Service Association [HMSA], 2018). The DRG system had some effect on slowing the healthcare expenditures share within the GDP, but lacks evidence of improved efficiency and quality of care (Bachnick et al., 2017). Zander, Dobler, and Busse (2013) noted DRG implementation was associated with a decrease in nurse satisfaction, nurse emotional exhaustion, and higher nurse-patient ratios. Nurse administrators and advanced practice registered nurses (APRNs) engaged to evaluate cost reduction beyond reorganization of billing health services.

Decreasing the cost of healthcare in the United States remains a necessity. In 2017, 3.5 trillion or $10,739 per person was spent on healthcare. This represents 17.9 percent of the GDP (CMS, 2018a). The ACA goals have realized some successes but challenges continue. Data from PricewaterhouseCoopers (PwC) shows that the medical cost trend has decreased from 9% in 2010 to a projected 6% in 2019.

On the business side, PwC projects that 2019 healthcare costs will continue rising based on increased access to care, provider megamergers, and physician consolidation and employment. (PwC, 2018). Increased access to care, one ACA goal, initially increased cost, however, over time, as healthcare shifts to prevention, increased access to care is projected to decrease long-term healthcare costs. Megamergers of healthcare agencies decrease opportunities for competition in pricing and services. Physician consolidation and employment results in more physicians employed by healthcare agencies. This traditionally increases the cost of physician services as compared to private practice. (PwC, 2018). Partnerships by APRNs and health systems and/or physicians (allowing APRNs to practice at the full scope of their education) have positively impacted of these challenges from the patient perspective, as have nurse administrators utilizing their expertise in health system integration and patient navigation to create efficient use of resources.

Integration of systems of care and efficient resources is a dynamic and complex process. Integration of systems of care and efficient resources is a dynamic and complex process. Salmond and Echevarria (2017) identified healthcare cost challenges focused on care delivery. These included: wasted healthcare spending as a result of fraud and abuse; failures of care coordination that resulted in duplicate tests and/or overtreatments; pricing failures; administrative complexities; and lack of care standards that now combine to exceed one trillion dollars (O’Neill & Scheinker, 2018). Additionally, an aging population that will increase to over 78 million by 2035 (U.S. Census Bureau, 2018); an increasing number of individuals diagnosed with one or more chronic diseases due to obesity and/or a sedentary lifestyle; and provision of care for those who have not previously had healthcare due to disparate status will further increase healthcare demands and the need for efficiency in care (Salmond & Echevarria, 2017).

In 2012, the ACA established the Hospitals Readmission Reduction Program (HRRP). The HRRP requires hospitals to collect and report the percentage of patients readmitted within 30 days after discharge on predetermined medical diagnoses. It is believed that poor quality of care and lack of coordinated care transitions lead to high 30-day readmission rates. The CMS track 30-day readmission rates for Acute Myocardial Infarction (AMI) at 15%; chronic obstructive pulmonary disease (COPD) at 19.7%; heart failure at 21.4%; pneumonia at 16.7%; and stroke at 11.8%. Additionally, the HRRP has added post coronary bypass graft surgery to the list (CMS, 2017)

The NP role includes daily rounding during the patient’s hospital stay, and participation in discharge planning. Warren, Lemieux, and Bittner (2019) developed a nurse-led Community-Based Care Transitions Program (CCTP) model to address coordination of care for vulnerable populations and to decrease 30-day hospital readmission rates. The CCTP is comprised of three team members: a transition facilitator (TF), a nurse practitioner (NP) and a pharmacist. A TF is an employee of a local community-based organization, such as an elderly service board. The NP role includes daily rounding during the patient’s hospital stay, and participation in discharge planning. Nurse practitioners make post-discharge phone calls and home visits if needed. They work closely with primary care physicians to increase patient adherence to the medication and treatment plan. The CCTP was successful in decreasing readmission rates for nearly 8,000 patients over a two year period to 13.9% and developing best practices for transitions of care (Warren et al., 2019)

The Dawn of Value Based Healthcare Reimbursement

In the VBP model, healthcare payments are based on quality care that is cost efficient, and patient and family centered. Dealy (2018) compared the current healthcare payment systems to a chess game. Hospital administrators must learn to navigate the variety of payment systems to remain profitable in the short and long-term environment. The ultimate goal for healthcare is to utilize the pay for performance or value-based purchasing (VBP) model in an effort to directly connect reimbursement to quality (Baker, Baker, & Dworkin, 2018). In the VBP model, healthcare payments are based on quality care that is cost efficient, and patient and family centered. The VBP model applies four domains of assessment: safety; clinical care; efficiency and cost reduction; and person and community engagement to determine the healthcare agency performance level (CMS, 2017; Salmond & Eschevaria, 2017).

The Hospital Acquired Condition Reduction Program (HACRP) is a CMS program that financially penalizes hospitals that continue to have poor patient outcomes based on hospital-acquired conditions (HACs) such as central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) (Collins & Saylor, 2018b).VBP measures impacted by nursing care include CAUTI; CLABSI; clostridium difficile infection; site infections for colon surgeries and abdominal hysterectomies; 30-day readmission rates; and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (CMS, 2017).

...nurses provide leadership in roles as care managers, care coordinators, and informatics experts by directing process changes and evidence-based interventions necessary to quantify and accurately report these quality measures VBP has reduced DRG payments by 2% with the opportunity for hospitals to earn back an incentive payment based on overall performance (Collins & Saylor, 2018a). Pay for Performance (P4P) is a reimbursement method for providers that gives incentive payments to those providers meeting certain predetermined quality and patient satisfaction outcomes (Baker et al., 2018). For VBP to produce cost reduction, processes are necessary to link patients, service, and care coordination through and within the many moving parts of healthcare. The power of nurses is established as they utilize their unique position within the health delivery system to link, measure, and re-engineer processes within and beyond the health system. Here, nurses provide leadership in roles as care managers, care coordinators, and informatics experts by directing process changes and evidence-based interventions necessary to quantify and accurately report these quality measures (Luther & Hart, 2014). Results associated with these roles exceed cost reduction by improving outcomes and challenging systems to push quality and safety initiatives further than previously envisioned by insurance payers or policy makers.

...nurses are essential to maximize the financial return to and through these organizations.Accountable Care Organizations (ACO) are provider networks that partner with the purpose of providing cost efficient, quality care for a designated population of patients over time. These organizations focus on preventive care, communication, and resource stewardship that avoids waste. (Baker et al., 2018). Nurses increase quality in these environments by assessing patients’ healthcare goals and resources and identifying the need for referrals and consultations with other specialties (Collins & Saylor, 2018). Whether through direct care (e.g., APRN) or as a care coordinator, nurses are essential to maximize the financial return to and through these organizations.

Patient Centered Medical Homes (PCMHs) focus on patients with chronic illnesses and accomplish cost savings through communication and coordination of care (Dunham-Taylor & Pincuk, 2015). PCMHs provide care across the continuum of health services and are rewarded for their number of patients (Burton, Berenson & Zuckerman, 2017). In this setting, a goal is to provide patient centered care that improves the capacity for self-management. This provides opportunity for clinical nurses and nurse practitioners to utilize transformational leadership skills to empower patients and the interdisciplinary team to create health management plans that are unique, quality driven, and patient focused.

Bundled payments enable consumers to make informed choices for care. Bundled Payments for Care Improvement (PBCI) reimburse lump sum payments for an individual episode of care. The PBCI payment system has transformed total hip and knee arthroplasty surgeries to become models for patient centered, team driven, and value-based care. (Schwartz, Bozic, & Etzioni, 2019). Bundled payments enable consumers to make informed choices for care. Healthcare price transparency is becoming a policy in many hospitals. Financial counselors or online tools can inform consumers about the cost of procedures at individual institutions (Boston-Fleischhauer, 2018).

Opportunities for Nurses to Impact Healthcare Cost

These principles have influenced nurses to become leaders in healthcare change.The Robert Wood Johnson Foundation (RWJF) and the IOM (2010) report, The Future of Nursing: Leading Change, Advancing Health, provided the blueprint for nurses to address the ACA changes. The four guiding principles included: 1) the need to achieve higher levels and education; 2) practice to the full extent of nurses’ educational level; 3) become full partners with physicians and other health professionals; and 4) develop effective workforce planning and policymaking (IOM, 2010). These principles have influenced nurses to become leaders in healthcare change.

The RWJF and the American Association for Retired Persons (AARP) supported the mobilization of nurses across the nation to organize the Campaign for Action (Campaign, 2019). Within the Campaign for Action, each of the 50 states and Washington, D.C. have organized individual Action Coalitions of volunteer nurses partnered with businesses and organizations to advocate for healthier communities and address recommendations of the report. Members of each Action Coalition campaign for policy changes needed in their state to impact nursing practice, access to health, and quality care. Table 1 is a summary of the collective efforts of states’ Action Coalition’s work. The Campaign for Action also provides funding for grants and awards, research, and training (Campaign, 2019).

Table 1. State Action Coalition Successes

[View table]

Increasing the level of education for practicing nurses addresses the ACA requirement for improved quality. The National Advisory Council on Nurse Education and Practice (NACNEP) (2010) found that a 10% increase in nurses holding Baccalaureate of Science in Nursing (BSN) degrees resulted in a 4% decrease in mortality. At the entry level, Associate degree and Diploma in Nursing programs still exist. However, states such as New York and New Jersey have passed the “BSN in 10” law, requiring all licensed registered nurses (RNs) to earn a BSN within 10 years of licensure (Trossman, 2008; Nelson, 2017, December 30). Hospitals with the American Nurses Credentialing Center (ANCC) Magnet Recognition are required to strive for an 80% BSN-prepared workforce by 2020. Since 2010, the percentage of BSN-prepared nurses has increased to 5 to 10% nationwide reaching 55 to 60%. (Mararac, 2017). Baccalaureate-prepared nurses are formally educated in critical thinking skills and provide quality care that focuses on prevention and community populations. These nurses develop skills to engage in health policy initiatives that contribute to a stronger healthcare delivery system through patient advocacy.

Increasing the level of education for practicing nurses addresses the ACA requirement for improved quality. At the Master’s level of nursing education, the clinical nurse leader (CNL) role was developed to address changing healthcare delivery systems. The CNL has expertise in care coordination; outcomes measurement; care transitions; interprofessional communication and team leadership; implementation of evidence-based practice; risk assessment; and quality improvement (American Association of Colleges of Nursing [AACN], 2019a). These areas of expertise are all critical to the implementation of the ACA. In 2010, less than one percent of nurses held a doctorate level degree (IOM, 2010). Today, in part related to the AACN drive to require the Doctor of Nursing Practice (DNP) degree for all advanced practice nurses, there are 6,090 DNP-prepared nurses (AACN, 2019b). The DNP-prepared nurse holds expertise in translational research, providing evidence-based care, quality improvement, and systematic leadership.

Performance-based care places value on nursing care and demonstrates the important role of nurses as part of the healthcare team.Removing barriers to practice for APRNs has enabled these nurses to become full partners with physicians and other health professionals in most states. Pappas & Welton (2015) suggested developing performance-based nursing care to align with value-based healthcare. Performance-based nursing care places value on nursing care and provides price transparency for nursing care provided, as opposed to DRG lump sum charges that bury the cost of nursing care. Kavanagh, Cimiott, Abusalem, & Coty (2012) recommended a nursing sensitive value-based purchasing (NSVBP) program that applies the National Database of Nursing Quality Indicators^® (NDNQI^®), along with other data (such as electronic medical records data and time spent in a patient room providing care), to align with patient safety and quality outcomes to develop financial incentives and decrease cost of care. Scientific review of this data could develop new evidence-based policies for care and improve patient outcomes. Performance-based care demonstrates the important role of nurses as part of the healthcare team.

Performance-based care places value on nursing care and demonstrates the important role of nurses as part of the healthcare team.The fourth principle included in the 2010 IOM report was developing effective workforce planning and policymaking. While this initiative may start at the bedside, understanding and critical review of data is the role of the doctorally-prepared nurse. PhD and DNP prepared nurses work together to inform and change practice. Nurses holding PhD degrees formulate clinical and theoretical questions, followed by scientific examinations. The outcomes of scientific research can then be tested in practice as translational research. The DNP-prepared nurse systematically applies scientific findings in practice and gathers outcome data to inform policy. Examples of this work include new evidence-based care bundles, clinical pathways, and models of care. The nurse attorney, prepared with a Juris Doctorate, acts at the local, state, and national level to inform policy makers, lawmakers, and administrators regarding the support of legislation needed to improve healthcare systems and patient outcomes.

Nurse Impact on Healthcare Quality

As full partners with physicians, nurses provide unique disciplinary expertise to assist financial stakeholders...Regulations subsequent to the ACA link quality to reimbursement. Increasing levels of nursing education and removing barriers to full scope of nursing practice based on education advances quality initiatives across the healthcare delivery system. One goal of the ACA is to promote state control of insurance markets (Luther & Hart, 2014). Such regulation promotes state control of insurance markets by directing reimbursement. These regulations require insurers to submit annual reports to the secretary of Health and Human Services (HHS) to assure that benefits under their plans meet the following four criteria: 1) improvement of health outcomes through activities such as quality reporting, case management, care coordination, and chronic disease management; 2) implementation of activities to prevent hospital readmission; 3) implementation of activities to improve patient safety and reduce medical errors; and 4) implementation of wellness and health promotion (NAIC, 2011). The financial impact of these regulations includes monetary penalties for low quality at the provider level. As full partners with physicians, nurses provide unique disciplinary expertise to assist financial stakeholders to develop programmatic and patient-centric innovation that escalates value through increasing quality.

Current Quality Initiatives
Financial links to quality are now regulated through CMS and operationalized through transformational healthcare teams that utilize contemporary, provider-quality reporting. Reimbursement is reduced when Medicare Access and Chip Reauthorization Act (MACRA), Merit Based Incentive Payment Systems (MIPS) and Hospital-Acquired Condition Reduction Program (HACRP) outcomes fail to meet quality metrics established for hospitals and providers. The ACA has been credited with improving quality by limiting reimbursement in response to adverse outcomes such as CAUTIs, CLABSIs and pressure ulcers; however, the actions were in place as a result of CMS initiatives as early as 2008 (Lee et al., 2012).

The cost of hospital acquired infections remains high. The cost of hospital acquired infections remains high. A CAUTI is associated with anywhere from $7,670.00 to $10, 197.00 in inpatient and outpatient costs to Medicare (Hollenbeak & Schilling, 2018). A CLABSI is associated with $100,980 and a mortality rate of 12-25% (Health Research, 2017). Interestingly, the initiative to link reimbursement reductions for these adverse outcomes has not resulted in reduced incidence (Lee et al., 2012). The combination of the impact on patient outcomes and cost continue to drive nurses and nurse administrators to improve outcomes through evidence based practice. In this capacity, nurses are empowered to become full partners with physician colleagues and provide physicians with the support they need to advance the practice of medicine.

Nurses have historically led team based care Quality of care has also been impacted by the move to population management. The patient care team on the nursing unit is a clinical, nurse-managed team that is highly skilled, supported by nurse-led rapid response teams, nurse-led utilization review teams and nurse-friendly financial teams. Population management requires an integrated team approach. Nurses have historically led team based care (Luther & Hart, 2014). The ACA shifted the focus of healthcare, quality, and program development from a patient centered, disease-specific approach to a health management approach with an emphasis on primary and preventive care (Ariosto et al., 2018).

While many nurses understand changes within their practice areas, they may not have had the opportunity to appreciate collective power across practice boundaries. Nurses play a key role in providing components of health reform as leaders in care management, care coordination, and informatics (Luther & Hart, 2014). Population management represents a paradigm shift in healthcare from care within individual organizations (sometimes called siloed care) to coordinated care across the patient’s health trajectory (Ariosto et al., 2018). In this environment, APRNs, case managers, physicians, administrators, pharmacists, physical therapists, psychologists, nutritionists, and social workers form an interactive multidisciplinary team that manages the life of an individual, as opposed to reacting to the disease state needs of a patient (Salmond & Echevarria, 2018). While many nurses understand changes within their practice areas, they may not have had the opportunity to appreciate collective power across practice boundaries. Increased communication between practitioner levels, specialty practices, and care environments is essential to create a strong business case for the impact of the power of nurses to stabilize and de-escalate healthcare spending.

Nurses led the evolution of case management based on needs of populations they cared for in the hospital (NACNEP, 2010). Once organizers of interdisciplinary team rounds in hospital settings, nurses now find themselves in roles as APRNs directing patient navigation through health screenings, wellness checks, and preventive care. When nurses responded to health payment reform during the transition from cost based to DRG based reimbursement, they responded strategically through development of case management roles and processes to organize and lead interdisciplinary rounds; coordinate discharges via enhanced discharge planning activities; and offer leadership in utilization review. Nurses engaged physicians, pharmacists, and social work colleagues to identify post-acute care environments that offered lower cost discharge opportunities beyond high cost, short term, acute care hospitals when possible. When this was not feasible, providers considered venues that remained cost-based, such as long term acute care hospitals and sub-acute centers to care for chronically critically ill patients.

Opportunity for Nurses to Impact Quality
There has never been a time quite as compelling as the present to inspire nurses to earn DNP and PhD degrees. The shift to population health provides nurses with the opportunity to practice in the full scope of their license in traditional and advanced practice roles. There has never been a time quite as compelling as the present to inspire nurses to earn DNP and PhD degrees. There is more need than ever for nurses to analyze the evidence base and conduct scientific research to support interdisciplinary practice to improve value, through programs that enhance quality outcomes and emphasize prevention and wellness. Reimbursement incentives have not been successful to improve quality. Research has shown that independent healthcare teams have identified and worked to reduce negative outcomes (Hollenbeak & Schilling, 2018).

While nurses must continue to address safety, they must also use education and trust to advance efforts for prevention and wellness for all populations, across all socio-economic groups. Through development of population health-based initiatives in health information technology (HIT), research, education, and policy, nurses can leverage initiatives to support the transformation of healthcare from an expensive, disease-based model to a cost effective, quality focused health management system (Ariosto et al., 2018).

The population health model brings nurses to the table as key stakeholders in managing care across the continuum and among all socioeconomic groups The population health model brings nurses to the table as key stakeholders in managing care across the continuum and among all socioeconomic groups (Salmond & Echevarria, 2017). For nurses to make the greatest possible impact, there must be continued financial and educational support for research. Additionally, nurses must work collaboratively across disciplines to heighten the impact of HIT and increase use of big data in research. When these strategies complement daily patient centered care, continued quality improvement and cost reductions will follow. As quality improves and cost reduction ensues, access to care will grow due to more resources to support programmatic developments in the care of vulnerable populations.

Quality developments have led to the introduction of bundled payments, which requires the organization of care across the continuum via case management (Steaban, 2016). Care coordinators set goals and prioritize care with patients and families, coaching and educating patients and coordinating and evaluating care provided by others (Lamb, 2013). Steaban (2016) postulated that through transformational partnerships with patients, nurses can maximize their effectiveness by matching patient and family goals to those of the healthcare team, to achieve health and illness management.

Nurses bring to the table their intellectual capital and position as trusted patient advocates to build partnerships with policymakers to innovate economical solutions for identified needs of families. Duncan, Thorne, Van Neste-Kenny, and Tate (2012) noted that involvement of nurses in policy advocacy is changing as a result of the IOM report study. Nurses are now empowered to extend their ability to improve quality beyond the bedside. Stronger impact has been shown by nurses who establish policy teams and legislative action committees to impact change across populations and into communities (Smith & Cleveland, 2018). In these forums, nurses have the opportunity to translate their daily bedside impact into opportunities for growth across health systems, specialties, and states.

Nurse Impact on Access to Care

The impact of nurses providing access to care across all populations is profound and long standing...Nurses have powerful influence over increasing care to communities through policy making and board room contributions. Actions of nurses in these positions have improved the health of communities by increasing access. The impact of nurses providing access to care across all populations is profound and long standing, with nurses leading initiatives to care for those in vulnerable and underserved populations. Nurses consistently advocate for and provide lifesaving and life sustaining care for vulnerable and fragile populations (Kreider, French, Aysola, Saloner, Noonan & Rubin, 2016; Shi, Nellans & Shi, 2015).

The ACA provides financial support and workforce education to expand and enhance these efforts. Prior to enactment of the ACA major provisions, as many as 46.5 million non-elderly Americans were without health insurance (Kaiser Family Foundation, 2018). To achieve the objective of increased access for all Americans, the following strategies were included in the law: 1) creation of the Health Insurance Marketplace; 2) expansion of health coverage through coverage through qualified health plans; 3) identification of minimum coverage components for insurance plans; 4) elimination of the option to deny coverage to individuals with pre-existing conditions; 5) extension of coverage to adult children, allowing them to stay on the parents’ health insurance until age 26; 6) requirement that all citizens purchase health insurance and providing subsidies for individual who need additional assistance to purchase insurance; and 7) elimination of lifetime coverage caps. (Public Law 111-148, 2010; Collins & Saylor, 2018a; Kreider et al., 2016; Shi et al.,2015).

The ability to access healthcare services is closely tied to employment, education, income and health insurance (Griffith, Evans & Bor, 2017). A key provision in the ACA is creation of the Health Insurance Marketplace, through which individuals who are uninsured could select a plan to fit their budget and healthcare needs (Shi et al., 2015). The ACA requires insurers to provide a specified minimum coverage that includes preventive care at no additional cost to the individual and allows more expensive comprehensive plans that exceed minimum coverage requirements (NAIC, 2011)

Current Status on Access to Care
States that have expanded Medicaid have reduced disparities in access to care...Despite efforts to broaden access to healthcare through the expansion of insurance coverage, gaps in coverage remain and there is the potential that further gaps may open due to the fiscal unsustainability of our health system. The Supreme Court rendered as unconstitutional a penalty on states that did not expand Medicaid programs to cover adults with incomes that were 33 percent above the poverty level by 2014 (Blake, 2012). This left a chasm that remains today. Currently, 28 million people remain uninsured and 30 million remain underinsured in the United States (Karpf, 2017). States that have expanded Medicaid have reduced disparities in access to care among the unemployed by 11%, and those with low annual incomes by 15% (Griffith et al., 2017).

Research conducted since the implementation of the ACA has shown reductions in uninsured persons; delay of necessary care; foregoing of necessary care; and increase in probability of a physician visit between 2011 and 2014 in low income non-elderly adults (Chen, Vargas-Bustamante & Ortega, 2016) and 19-25 year olds (Kotagal, Carle, Kessler, & Flum 2014). The financial strain of healthcare costs and disparities in care have lessened for some adults with low- and middle-income levels (McKenna et al., 2018).

Among states that have expanded Medicaid coverage since the implementation of the ACA, studies have shown that children remain vulnerable; there remains difficulty with access to specialty care regardless of the type of insurance coverage (Kreider et al., 2016). Children insured by Medicaid and plans not related to employment have less access to primary care providers (Alcala, Roby, Grande, McKenna & Ortega, 2018). School nurses have been instrumental in offering access to care for children through several ACA provisions: reimbursement for school health services and activities related to community-based prevention; and health education and counseling programs (e.g., immunizations, integrated behavioral health screening, suicide prevention activities, and substance use programs) (Maughan & Mazyck, 2014).

One concern that arose from the increased access to care provided by the ACA was that patients newly added to the system, who have not previously had regular healthcare, were sicker with more comorbid conditions and less health literacy (Omolola, Preston & Gonzales, 2015). This concern posed an expanded role for nurses. As previously noted, recent emphasis has highlighted the need for nurses to practice to the full extent of their education and licensure (American Association of Nurse Practitioners [AANP], 2018; Public Law 111-148, 2010; CMS, 2012; Federal Trade Commission [FTC], 2014; IOM, 2010; National Council of State Boards of Nursing [NCSBN], 2008). Historically, most states have limited the practice of APRNs to a role that involved physician collaboration or supervision. The emphasis to extend nursing practice, led by the IOM and ACA, has fueled efforts to increase the number of states that grant full practice authority to APRNs. To date, 22 states have removed language that limits APRN practice (AANP, 2018). A summary of efforts to expand nursing’s role is captured in Table 2.

Table 2. Policy Provisions Supporting Expanded Nursing Roles to Improve Access to Care

Agency	Provision
Affordable Care Act (ACA)	Health insurers are prohibited from limiting access and payment to “any health care provider who is acting within the scope of that provider's license or certification under applicable state law” (42 U.S.C., n.d.).
Center to Champion Nursing in America	Worked to fostered development state-level groups call “action coalitions” to implement recommendations from the IOM’s Future of Nursing report (RWJF, 2012).
Centers for Medicare and Medicaid Services (CMS)	Broadened language to include “other practitioners” as authorized caregivers “to perform all functions within their scope of practice” (CMS, 2012).
Federal Trade Commission (FTC)	Worked to remove barriers to APRN full practice through the production of documents and the provision of testimony in several states, citing concerns that “physician supervision requirements” violate trade principles by allowing one group to restrict the practice of another group of health professions (FTC, 2014).
National Council of State Boards of Nursing (NCSBN)	Published the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education in 2008 with the goal of implementation by 2015 (NCSBN, 2008).
National Governors Association (NGA)	Recommended states change their nurse practice acts to expand APRN scope of practice to increase access to care and to increase APRN involvement in primary care (Schiff, 2012).
Veterans Health Administration (VHA)	In response to the IOM Future of Nursing report, the VHA removed restrictions on APRN practice, permitting independent practice throughout the system (U.S. Dept. Veterans Affairs, 2016).

Opportunities for Nurses to Impact Access to Care
In addition to expanding scope of practice for APRNs, the ACA placed increased emphasis on primary and geriatric care to provide support to underserved populations and decrease disparities. Primary care providers are charged to help patients navigate the health system and remain healthy (Carver & Jessie, 2011). In states where nurses practice with full authority, nurse practitioners reduce the cost by 11%-29% and improve quality and access through provision of care in routine settings, retail clinics, and vulnerable communities (Perloff, Desroches & Buerhaus, 2015; Naylor & Kurtzman, 2010).

Nurses at every level of practice have assisted in the implementation of medical homes. The medical home provides a cohesive structure through which patients can access primary care with increased equity and decreased cost (Omolola et al., 2015; Tillett, 2011). APRNs are essential team members of the interdisciplinary primary care setting to decrease cost, increase quality, and improve access (Carver & Jessie, 2011). Use of telemedicine as an option to reach underserved populations has expanded the role of the nurse to include leading healthcare informatics and electronic medical record teams and developing e-health literacy across the lifespan (Collins & Saylor, 2018a; Ariosto et al., 2018; NACNEP, 2016; Omolola et al., 2015).

Nurses at every level of practice have assisted in the implementation of medical homes. To attract and retain enough providers to care for the increased numbers of patients who use healthcare services, nurses have the responsibility to take advantage of ACA provisions that provide for nursing education. Examples of these provisions include expanding support for undergraduate, graduate, and doctoral level nursing programs. Title VIII of the Public Health Services Act is 42 U.S.C. 296 et seq. was expanded through the ACA, removing caps for nursing doctoral program loans, allowing the Secretary of Health and Human Services to increase funding to nursing students, allocating funds to the Workforce Diversity Grant program to increase diversity in nursing, and providing grants for geriatric nursing traineeship programs (Nursing Community, 2011).

Opportunities for Nurses to Lead Change

Nurses serving on governing boards of health-related organizations have both the opportunity and the obligation to impact healthcare cost, quality, and access.The 2010 IOM report identified nurse involvement in healthcare decision making as a key component to create lasting change throughout healthcare reform efforts. This recommendation led to formation of a coalition to increase the number of nurses who serve on governing boards, with the intention of “improving health of communities and the nation through the service of nurses on boards and other bodies” (Nurses on Boards Coalition, 2019, pg. 1). Nurses serving on governing boards of health-related organizations have both the opportunity and the obligation to impact healthcare cost, quality, and access.

The direction for organizations to provide cost effective, quality care that is accessible to all stakeholders is enhanced by a governing board that is diverse in composition, with members who possess extensive knowledge of healthcare. Nurses are qualified to lead through board governance and are equipped to guide organizations through transitions. Key areas of expertise for nurses include quality, safety, and patient-centered care (Hassmiller, 2011; IOM, 2010; Patton, Zalon, & Ludwick, 2015; Prybil, 2009); patient and population advocacy; problem-solving innovation; and outcome attainment through interdisciplinary collaboration (Hassmiller, 2012; Patton et al., 2015). The combination of education and experiences affords a deep understanding to nurses about the evolving complexities of healthcare and positions them for the decision-making necessary in board governance (Sundean, Polifroni, & Libal, 2018). Further, there are a wealth of qualified nurses to serve in governance roles (Prybil, Dreher, & Curran, 2014).

Nurses are powerful change agents beyond the board room. As stakeholders in the health of the communities where they live and work, nurses make their voices heard about issues of concern. The impact far surpasses just an economic benefit. Here, nurses help communities respond and prevent threats that endanger the health, safety, and collapse of economic infrastructures. Examples of this are seen in the response of nurses to human trafficking, labor trafficking, and food insecurity. In these situations, nurses utilize their knowledge to re-position communities to care for populations they manage through formation and utilization of legislative action and policy teams; this reduces healthcare costs by keeping communities healthy (Smith & Cleveland, 2018).

Policy teams are not unique to population management or hospital based care. Nurse educators have been linked through AACN to their government relations teams (AACN, 2019c). The Office of Government Affairs for universities with nursing programs is linked directly to AACN. This linkage provides support that directs the agenda to advance nursing education by decreasing costs and supporting opportunities to encourage advanced degrees.

Conclusion

What is clear is that nurses will continue to transform the provision of care in the United States... Whether the ACA remains the healthcare law of the United States is a question of political opinion, stakeholder debate, and legislative action. What is clear is that nurses will continue to transform the provision of care in the United States by leading cost reduction, quality enhancement, and removal of barriers to access through advancing roles as policy leaders, board members, and legislative action team members. As nurses have extended their reach and impact beyond the bedside to include transformative relationships, they are translating practice into key policy initiatives that impact both organizations and communities. The time is ripe for nurses to harness the power of a unique disciplinary perspective and enduring patient trust to advocate for the advancement of policy and continuation of quality research, evidence-based initiatives, and patient centered innovation.

Authors

Kimberly Cleveland, JD, MSN, RN, C-MBC
Email: kthoma43@kent.edu

Kimberly Cleveland is a lecturer in the Nursing and Health Care Management Concentration and Coordinator of Undergraduate and Graduate Health Care Policy at Kent State University College of Nursing, in Kent, OH. She practices law as a solo practitioner, concentrating in healthcare, professional licensure, and choice of entity. Kim is licensed to practice law in the state of Ohio and the United States Supreme Court and is a PhD student at Kent State University. Nurse-Attorney Cleveland is an international and national speaker and consultant on health reform, health law, nursing leadership, and health policy. She is a co-investigator in funded research examining the role of nurses on governing boards. She serves in a number of volunteer roles within nursing organizations including The American Association of Nurse Attorneys, Nurses on Boards Coalition, National League for Nursing, and Sigma Theta Tau International.

Tracey Motter, DNP, RN
Email: Tmotter2@kent.edu

Tracey Motter is Associate Dean of Undergraduate Programs at Kent State University College of Nursing, in Kent, OH. She earned a BSN from Duquesne University, a MSN from Gannon University, and a DNP from Kent State University. She has received numerous teaching awards at the college, university, and national level and has received national workforce development funding to increase diversity in nursing. Her area of interest for research is in nurses’ self-care and resiliency, transition to practice, and preparing nurses to be leaders in providing quality cost-effective healthcare.

Yvonne Smith, PhD, APRN-CNS
Email: ysmith@kent.edu

Yvonne Smith is an Associate Professor and Concentration Coordinator for Nursing and Health Care Management (NHCM) at Kent State University College of Nursing, in Kent, OH, with extensive experience in nursing education, accreditation and regulation. In her current position, she teaches management and health policy courses in the graduate nursing program at Kent State University. She conducts research on nurse roles in academic and healthcare institutions and is the primary investigator in funded research examining the role of nurses serving on governing boards. Dr. Smith has served in a number of leadership roles that influence organizational, state, and national policy, including Assistant Dean at Kent State and President of the Ohio Board of Nursing. Active in a number of professional nursing associations, she has held volunteer leadership positions in state and national organizations and serves as a site evaluator for the Commission on Collegiate Nursing Education accreditation.

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