QUESTION: Discuss a barrier to health care delivery resulting from state or federal policy or law. What changes might you recommend to the policy/law and what positive or negative impact might you anticipate on patient care?
The implementation of the Affordable Care Act (ACA) was a huge benefit to the American population; however, while there were many benefits that came out of it, barriers continue to exist. The passage of the ACA enabled people with pre-existing conditions to purchase health coverage for a reasonable amount of money, and it allowed those who were ineligible due to pre-existing conditions to purchase insurance (Harvard, 2017). For middle-class Americans, being able to purchase a plan or receive a health plan from work enabled them to keep their children on their plan until the age of 26 for lower medical premiums (Harvard, 2017). Medicaid benefits were also greatly expanded under this program, but these benefits vary depending on where you live. For example, Medicaid coverage was expanded in most states; however, twelve states elected not to expand coverage (Alio et al., 2022; Harvard, 2017). Some of these states do not allow for Medicaid benefits unless you are well below the poverty line; Texas does not allow for Medicaid coverage unless a single parent earns less than $6,000 annually, for those with no children, you do not qualify for Medicaid unless you are disabled (Harvard, 2017). This illustrates the point that healthcare can be inequitable depending on where you live and shows how many disparities exist due to racial stigmatization of Medicaid since their health systems are highly politicized and do not advocate for health equity (Alio et al., 2022; Harvard, 2017). Additionally, Medicaid reimburses providers at a lower rate than Medicare, which reduces the number of physicians who take the coverage (Alio et al., 2022). This adds to continued health inequities in poor and minority populations, thus continuing a cycle of health disparities based on structural racism Alio et al., 2022).
As a doctoral leader, I would advocate for increased reimbursement for Medicaid recipients so that providers would not have to choose between Medicare and Medicaid. Increased reimbursements or incentives to take on Medicaid recipients would allow for minorities and those with lower socioeconomic means to be treated as equally as everyone despite their geographical location. An additional intervention would be to advocate for medical centers to adopt the Street Nurse Program so nurses could go into the community and treat those who live in homelessness. The Street Nurse Program in California helps those living with housing and food insecurities and gives access to basic healthcare needs by sending a nurse to homeless encampments to tend to basic medical care (American Organization for Nursing Leadership, 2021). This program aligns with my worldview to ensure that health access is equitable for all humans despite the ability to pay for services.
Alio, A. P., Wharton, M. J., & Fiscella, K. (2022). Structural Racism and Inequities in Access to Medicaid-Funded Quality Cancer Care in the United States. JAMA Network Open, 5(7), e2222220-e2222220.
American Organization for Nursing Leadership. (Host). (2021, May). Street nurse program delivering care to meet patient [Audio podcast episode]. In Today in Nursing leadership. SoundCloud.
Harvard University. (2017, October 6). It depends what state you’re in: Policies and politics of the US health care system – Part 1 [Video]. YouTube.
There are many barriers to healthcare delivery resulting from state and federal laws. One such barrier is the lack of Medicaid expansion in some states. Although the Affordable Care Act was enacted to increase the coverage for healthcare insurance for all Americans, the decision by the Supreme Court in 2012 gave the option to states to opt out of the Medicaid expansion(Singer & Rozier, 2020). As a result of this decision, many states chose not to expand Medicaid coverage, leaving millions of people without healthcare coverage. Many low-income Americans and immigrants cannot access health care due to affordability issues. This issue is giving rise to poor health outcomes and increasing healthcare costs by leading to chronic disease and adverse events, which could be preventable with proper primary care. Lack of Medicaid expansion can lead to a vicious cycle of poverty. A recent study(Baicker et al., 2023) discussed some strategies to achieve universal health coverage in the country. These strategies include determining how much insurance and healthcare access society wants based on the health benefits generated by a service. It also should consist of payment models for the type of services, and the authors gave examples of Medicare Advantage Plans and social insurance in the Netherlands and Switzerland. Then, the authors talked about cost-sharing options. As advanced practice registered nurses, Doctor of Nursing Practice (DNP) prepared nurses are uniquely positioned as leaders and educators to advocate for Medicaid expansion in all states. The learner can work with the national and locally accredited nursing bodies to prompt discussions on the strategies discussed in the study mentioned above. Another way the learner can recommend change to the policy is to make Medicaid expansion mandatory for all states. This would ensure everyone can access affordable health care regardless of income level or location. It would also reduce the number of uninsured individuals, reducing the burden on hospitals and healthcare providers currently caring for uninsured patients. During the pandemic, Medicaid expansion for all the states was discussed. In a report(Blumberg & Mann, 2020), the economic aspect of this issue was discussed in detail. This task is complex, but the learner can lobby, educate the public, develop innovative healthcare models, and conduct more research on this topic to make the officials aware. The potential positive impact of the mandatory Medicaid expansion is undoubtedly an improvement in patient care with easy access to primary care focusing the preventative care, reduced hospitalization, and ER visit rate.
Baicker, K., Chandra, A., & Shepard, M. (2023). A different framework to achieve universal coverage in the US. Journal of the American Medical Association, 4(2). https://doi.org/10.1001/jamahealthforum.2023.0187
Blumberg, L., & Mann, C. (2020, March). Medicaid expansion would have a larger impact than ever during the COVID-19 pandemic. urban.org. https://www.urban.org/sites/default/files/publication/101910/quickly-expanding-medicaid-eligibility-as-an-urgent-response-to-the-coronavirus-pandemic_3.pdf
Singer, P. M., & Rozier, M. D. (2020). Shifting threats and rhetoric: How republican governors framed Medicaid expansion. Health Economics, Policy, and Law, 15(4), 496–508. https://doi.org/10.1017/s174413312000002x
Identify a nurse who serves on a state, regional, or national board, within or outside of health care. Describe the membership and mission/vision of the board. Provide background on the nurse’s preparation and qualifications for sitting on the board. How does this particular nurse holding a seat benefit the board?
Nurses take on a variety of roles from home health to acute care, nursing leadership, research, advanced nursing practice, and beyond. The doctoral-prepared nurse can lead change from all positions, but when working as a board member they are utilizing their skills as a collaborator, which is what is vitally needed to help make healthcare safer for patients (DeNisco, 2021). Thus, another role that is of great value is that of a board member of a highly coveted and prestigious organization where they have the ability to make large systems changes at the global level. A nurse of this caliber is Catherine H. Ivory, Ph.D., RN-BC, RNC-OB, FAAN. She is the Senior Director of Nursing Research at Vanderbilt University Medical Center and sits on the National Advisory Council for the Agency for Healthcare Research and Quality (Agency for Healthcare Research and Quality (AHRQ, 2022). The Agency for Healthcare Research and Quality (AHRQ) is an agency that provides information, advice, and recommendations to Health and Human Services on research for our nation’s health (AHRQ, 2022). There is a 14-member advisory panel that is comprised of private-sector experts in their respective fields who work to promote quality and improvements to healthcare (AHRQ, 2022). Their mission is to “produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used” (AHRQ, 2022, AHRQ profile section). These experts are appointed by the Secretary of the Department of Health and Human Services to serve a 3-year term of office (AHRQ, 2022).
Dr. Ivory is an expert in her field of data standardization, particularly in the area of perinatal data; she is also a nurse informaticist and works in collaboration with stakeholders to improve quality, evidence-based practice, and translational research (AHRQ, 2022). She was excited to bring her ideas on quality measurement to her new position; she was an obstetric nurse for twenty years before completing her Ph.D. in 2011 (Batcheldor, 2021). She is one of two nurses on the fourteen-member panel that is mainly comprised of medical doctors; she brings her wealth of nursing expertise to help bridge the gap between research and practice (AHRQ, 2022). She is happy to serve on the panel as a nurse since the nurse is “the closest to patient care” and can “give the perspective of the patient from all settings” (Batcheldor, 2021, para. 6). Nurses are in a prime position to influence health care. The doctoral-prepared nurse has the education and clinical expertise to shed light on gaps in care and how change can be made to make healthcare more inclusive and equitable for all.
Agency for Healthcare Research and Quality (AHRQ). (2022). National Advisory Council for Healthcare Research and Quality: Overview. AHRQ. Retrieved on March 9, 2023, from https://www.ahrq.gov/cpi/about/nac.html
Agency for Healthcare Research and Quality. (2022). NAC member biography: Catherine H. Ivory. AHRQ. Retrieved on March 9, 2023, from https://www.ahrq.gov/cpi/about/organization/nac/ivory.html
Batcheldor, M. (2021, November 30). Ivory appointed to AHRQ’s National Advisory Council. VUMC Reporter. Retrieved on March 9, 2023, from https://news.vumc.org/2021/11/30/ivory-appointed-to-ahrqs-national-advisory-council/
DeNisco, S. M. (2021). Advanced Practice Nursing: Essential Knowledge for the Profession. (4th ed.). Jones & Bartlett.