PPACA -- THE IMPLEMENTATION STAGE

As our nation experiences the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act (PPACA), over the next five to ten years, it is important to appreciate that the bill was crafted primarily with consumers (i.e., patients) in mind and not clinicians.  Perhaps as legislative modifications are made, based upon practical experiences, we will eventually see the enactment of the Single Payer System which the liberals so vocally championed.  There are a multitude of questions to be answered.  For example, how will the provision which requires health insurance plans to utilize at least 80% to 85% of the premium dollars collected to pay medical bills or otherwise improve their customers' health, ultimately be interpreted?  Will this allow insurance companies to pay clinicians for upgrading their office computers or attending continuing education (CE) courses?  The nonpartisan Congressional Budget Office (CBO) estimates that PPACA will reduce the federal deficit by $143 billion over the first ten years of enactment, ensure that 94% of Americans have health insurance, and effectively bend the ever-escalating cost curve.  Does this suggest that with 76% of Medicare spending currently being for patients with five or more chronic diseases, that we will see a special, national focus upon this growing population?  It is simply too early to predict with any sense of certainty.  Change is always unsettling and takes time, especially when important.

It is useful to view the enactment of PPACA within its historical context.  On May 22, 1964 President Lyndon Johnson laid out his vision for a Great Society at a Universityof Michigan commencement, which at that time was the most attended non-football event in campus history.  "I have come today from the turmoil of your Capitol to the tranquility of your campus to speak about the future of your country.  The purpose of protecting the life of our Nation and preserving the liberty of our citizens is to pursue the happiness of our people.  Our success in that pursuit is the test of our success as a Nation.  For a century we labored to settle and to subdue a continent.  For half a century we called upon unbounded invention and untiring industry to create an order of plenty for all of our people.  The challenge of the next half century is whether we have the wisdom to use that wealth to enrich and elevate our national life, and to advance the quality of our American civilization.…  Will you join in the battle to build the Great Society, to prove that our material progress is only the foundation on which we build a richer life of mind and spirit?  There are those timid souls who say this battle cannot be won; that we are condemned to a soulless wealth.  I do not agree.  We have the power to shape the civilization that we want.  But we need your will, your labor, your hearts, if we are to build that kind of society.  Those who came to this land sought to build more than just a new country.  They sought a new world."  On July 30, 1965 the President signed P.L. 89-97, the Social Security Amendments of 1965, and thus made Medicare [and Medicaid] the law of the land.

During his address before his first Joint Session of Congress, President Obama held out a similar vision and challenge.  "We will rebuild, we will recover, and the United States of America will emerge stronger than ever….  The costs of health care eats up more and more of our savings each year, yet we keep delaying reform….  Now is the time to jumpstart job creation, re-start lending, and invest in areas like energy, health care, and education that will grow our economy, even as we make hard choices to bring our deficits down.…  (T)his is America.  We don't do what's easy.  We do what is necessary to move this country forward….  (W)e can no longer afford to put health care reform on hold….  I suffer no illusions that this will be an easy process.  It will be hard.  But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of health care has weighed down our economy and the conscience of our Nation long enough.  So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year."  Compelling visions provide the context within which day-by-day experiences shape specific implementation strategies.

Six months after enactment of PPACA, the Chairmen of the two Senate Committees which were most involved in crafting the legislation stated:  Finance -- "Americans have reason to celebrate.  The new law put Americaon the road to a more sustainable consumer-friendly health care system.  The new law putAmerica on the road to a healthcare system in which all Americans have access to quality, affordable health insurance.  And the new law put America on the road to a health care system in which patients and their doctors – not insurance companies – control patient care.  These transformative changes will not happen overnight….  Today, with this 6-month mark, we pass a key milestone on our road to providing quality, affordable health care to all Americans.  This milestone is justone of many along the road.  But this milestone is one that signals an end to the insurance companies' worst abuses."

Health, Education, Labor, and Pensions (HELP) -- "On September 23, the law's six-month anniversary, six major reforms kicked in.  Now the law: * Bans insurance companies from dropping patients' coverage….  * Bans denial of coverage for children with pre-existing conditions….  * Cracks down on benefit payment limits.  Insurance companies are prohibited from imposing lifetime dollar limits on essential benefits….  * Provides for appeal of insurance company decisions….  * Guarantees free preventive care….  * Extends coverage for young adults.  Young adults are now allowed to stay on the parents' plan until 26….  [And, mental health parity is finally the law of the land.]  As many predicted, the law is increasingly popular as Americans get better acquainted with its broad range of benefits and consumer protections….  Mark my words: Americans will not allow their hard-earned benefits and protections to be taken away.  We will stay the course, defending the strong reforms in this new law and creating a reformed insurance and health care system that works not just for the healthy and the wealthy but for all Americans."  President Obama's vision will ultimately curtail the ever-escalating costs of health care; enhance the availability of high quality Primary Care; make Wellness and Preventive Care a national priority, as well as eliminating racial and geographical Health Disparities; and empower Educated Consumers to take responsibility fortheir health care, utilizing the most up-to-date advances in the communications and technology fields (i.e., Health Information Technology, Telehealth, and the utilization of data-based Gold Standards of care).  The next decade will be very "interesting," for consumers and practitioners alike – truly uncharted waters.

The health care environment of the 21^st century in which psychology will practice will be increasingly interdisciplinary in nature.  California nurse-psychologist Ann Carson, reflecting upon the Nurse Managed Health Clinic provision in PPACA: "This is an amazing document and gives me hope for the future of nursing and health care.  In many ways, a return to the earlier practice of nursing within the public health realm would be a huge step forward.  I was taught prevention (primary prevention) in my nursing program in the late 1960s.  The rest of the health care world, especially medicine, seems a bit delayed in recognizing the value."

In December, 2009 President Obama issued a Memorandum for the Secretary of Health and Human Services, calling for a Medicare demonstration to test Medical Homes in federally qualified health centers.  "My Administration is committed to building a high-quality, efficient health care system and improving access to health care for all Americans.  Health centers are a vital part of the health care delivery system.  For more than 40 years, health centers have served populations with limited access to health care, treating all patients regardless of ability to pay….  There are over 1,100 health centers across the country, delivering care at over 7,500 sites.  These centers served more than 17 million patients in 2008 and are estimated to serve more than 20 million in 2010….  Health centers use interdisciplinary teams to treat the 'whole patient' and focus on chronic disease management to reduce the use of costlier providers of care, such as emergency rooms and hospitals.  Federally qualified health centers provide an excellent environment to demonstrate the further improvements to health care that may be offered by the medical homes approach.  In general, this approach emphasizes the patient's relationship with a primary care provider who coordinates the patient's care and serves as the patient's principal point of contact for care….  (They) also emphasize activities related to quality improvement… and coordination….  Therefore, I direct you to implement a Medicare Federally Qualified Health Center Advanced Primary Care Practice demonstration."

We fully expect that those colleagues who possess psychopharmacological skills will be at a distinct advantage in the ever-evolving healthcare system.  Accordingly, we were pleased to learn from Steve Tulkin that this September, the Postdoctoral Master of Science Program in Clinical Psychopharmacology at the California School of Professional Psychology at Alliant International Universitybegan its fourth National Cohort with close to 60 students.  Students attend classes live over the Internet, and can ask questions and participate in class discussions utilizing this technology.  Psychologists in 23 states (fromHawaii to New York) are participating in the class, and one psychologist is participating live from South Africa.  He spoke briefly during the first meeting of the class to thank his U.S. colleagues, and express his hope thatSouth Africa will enact prescriptive authority legislation in the next couple of years.  Aloha,

Pat DeLeon, former APA President – National Register – October, 2010

AN EXCITING JOURNEY – AN INCREASING NEED FOR VISION

            With the enactment of President Obama's landmark health care reform legislation, the Patient Protection and Affordable Care Act [PPACA] [P.L. 111-148], nursing, as well as the rest of our nation's health care system, entered an era of exciting and totally unprecedented opportunity.  One of my fondest memories of that cold Christmas-eve morning was seeing Tine and our then-DoD Nurse Detailee, Jacqueline Rychnovsky, heading off to watch the historical Senate passage of the comprehensive bill.  Included at Senator Inouye's request and Jacqueline's perseverance was the new Nurse Managed Health Clinic provision which the AMA opposed.  This Fall, the Senate passed resolutions celebrating the 25^th Anniversary of the National Institute of Nursing Research (NINR) and designating the first week of October as "National Nurse-Managed Health Clinic Week."  Nursing has come a long way.

            One of the hallmarks of a maturing profession is its commitment to effectively addressing society's pressing needs.  Michelle Obama has generated a concerted focus on Childhood Obesity.  The White House Task Force on Childhood Obesity -- "The Childhood obesity epidemic in America is a national health crisis."  One in every three children ages 2-15 is overweight or obese.  Obesity is estimated to cause 112,000 deaths per year and one-third of all children born in 2000 are expected to develop diabetes during their lifetime.  The current generation may even be on track to have a shorter lifespan than their parents.  The Task Force proposed 70 policy recommendations for developing a national plan of action: * creating a healthy start on life for our children, from pregnancy through early childhood; * empowering parents and caregivers to make healthy choices for their families; * serving healthier food in schools; * ensuring access to healthy, affordable food; and, * increasing opportunities for physical activity.  Not surprisingly, their vision is highly consistent with PPACA's emphasis upon prevention, wellness, and encouraging healthy lifestyles.  The envisioned family-oriented services reflect the essence of nursing practice.

            The Task Force urged that developers of local school wellness policies be encouraged to include strong physical activity components, on par with nutrition components.  Further, that social skill development should be actively encouraged and there should be an age- and developmentally- appropriate focus.  The business community should be encouraged to consider which resources and physical assets (e.g., fields and gyms) can be used to increase students' access to outdoor and indoor recreational venues; while the entertainment and technology companies should be encouraged to develop new approaches for using technology to engage children in physical activity.  These are all excellent suggestions for making a difference in the lives of our nation's families.

The Task Force pointed out that obese adults have an increased risk for many diseases, including type 2 diabetes, heart disease, some forms of arthritis, and several cancers.  Overweight and obese children are more likely to become obese adults.  Obesity is a highly stigmatizing condition and in addition to the physical health consequences, severely obese children report a lower health-related quality of life (a measure of their physical, emotional, educational, and social well-being).  Childhood obesity is also associated with some psychiatric disorders, including depression and binge-eating disorders, which may both contribute to, and be adversely impacted by obesity.  U.S. Women's Olympic Soccer Team mental skills coach, Colleen Hacker reports that one in four high school girls reports that she does not like herself; 53 percent of 13-year old girls are unhappy with their bodies, while 78 percent of 12 grade girls are unhappy with their bodies; and, one in three adolescent girls will experience depression, anxiety, or eating disordered behavior.  Among girls, physical inactivity is associated with withdrawn, depressed symptoms; somatic complaints, social and attention problems, and rule-breaking behaviors.  While one in two boys participate in high school sports, only one in three high school girls participate.  Women of color are underrepresented in 20 of the top 25 participation sports.

            The Institute of Medicine (IOM) has recently called for developing a New Conceptual Framework to help obesity prevention researchers determine useful areas of study.  "The real world is a complex system, and the many influences on the energy-balance equation are all interacting simultaneously.  A systems perspective helps decision makers and researchers think broadly about this whole picture rather than merely studying the component parts in isolation.  Such a perspective can help to frame, explain, and resolve complex problems such as obesity.  It can lead to a better understanding of interactions, and highlights the importance of taking into account the context in which public health problems occur and how that context may affect the implementation and impact of interventions….  The United Kingdom Government Office of Science undertook an extensive evidence review that resulted in the characterization of obesity as a complex system involving seven major subsystems: individual psychology, biology, activity, food consumption, food production, activity environment, and societal influences.  This map was then used to assess links and interactions among influences; simulate and consider possible future scenarios; and ultimately justify a comprehensive, cross-government, national action plan on obesity."  "There is increasing recognition that overweight and obesity are not just problems of individuals, but also society wide problems that have serious health consequences and costs and affect some population groups more than others.  Acting on this recognition will require multifaceted, population-based changes in the social and environmental factors that influence energy intake and expenditure."

            We would rhetorically ask: Where is nursing's vision and collective voice in this evolving national agenda?  A careful review of the White House Task Force report does not find any express mention of the potential contributions of our nation's Schools of Nursing or their students or graduates.  And yet patient-centered, family-centered care is the hallmark of nursing care.  In its 25 years of outstanding accomplishments, the National Institute of Nursing Research (NINR) has clearly demonstrated that nursing research, and especially patient-centered research, makes a significant difference in the lives of our nation's citizens.  As healthcare continues to transform and the focus of care transitions from a disease and illness perspective to a health promotion and disease prevention strategy, Nurse Practitioners will play an increasingly important role in the provision of primary care.  Over 200 Nurse-Managed Health Clinics are providing high quality care to vulnerable populations in medically underserved rural, suburban, and urban communities throughout the country.  The challenge for Nurse-Managed Health Clinics will be to implement this knowledge and equally importantly, to ensure that those who shape our nation's health policies come to appreciate nursing's contributions.  Therefore Nurse Practitioners must continue to lobby for federal and state recognition of the central role the profession can play in a revamped health system.  Aloha,

 

Lt. Col. Corina Barrow, DoD Nurse Detailee

Natalie Bridgeman, Native Hawaiian Nurse Fellow

Pat DeLeon, former American Psychological Association President

 

National Nursing Centers Consortium (NNCC) – September, 2010