Healthcare System and Policy in the

United StatesShalee Belnap, RN, BSN

Affordable Care Act of 2010• The primary intent of the Affordable Care Act of 2010 was to “extend

insurance coverage to approximately 30 million uninsured Americans through private insurance regulation, expansion of public insurance programs, and creation of health insurance marketplaces to foster competition in the private health insurance market” (Mason, Gardner, Outlaw, O’Grady, 2016, p. 172).

• With this expansion of healthcare coverage, the consumer cost of insurance coverage has increased; therefore, an emphasis has been given on health promotion and disease prevention to assist in decreasing some of these costs (Fielding, Teutsch, & Koh, 2012).

Impact of Affordable Care Act on Nursing

• With the substantial increase in access to healthcare, there is an increased need for primary care providers. This has caused a growing demand for mid-level providers, such as nurse practitioners.

• According to Mason, Gardner, Outlaw, and O’Grady (2016), “evidence supports that APRNs and NPs deliver high-quality health care and improved health outcomes at a lower cost than the traditional medical model” (p. 191-192).

Two Divisions of Healthcare Policy

Private Sector• Insurance provided through the

patient’s employer• State-sponsored healthcare

exchanges• Patient is financially responsible

for monthly premiums, co-payments, and deductibles

Public Sector• Medicare• Medicaid

Private Insurance Sector(Mason, Gardner, Outlaw, & O’Grady, 2016)

PPO• “Preferred Provider

Organizations”• Open-ended access to

providers• Fee-for-service

reimbursement• No referrals required for

specialty visits

HMO• “Health Maintenance

Organizations”• Provider is a manager of the

patient’s health care • Spending is controlled, as well as

quality and accessibility• The primary care provider is

typically the gatekeeper

Private Sector: Employer Insurance

• Employers with over 50 employees must provide health insurance benefits to their employees

• If a person’s employer provides health insurance benefits, that person will not be eligible to receive discounts on a plan through the healthcare exchange

• (Mason, Gardner, Outlaw, & O’Grady, 2016)

Private Sector: Healthcare Exchange(Nevada Health Link, 2016)

• Enroll through nevadahealthlink.com• Open enrollment dates: 11/1/16-1/31/17• Discounts may be available based on financial eligibility

• Consumers are ineligible for discounts if their employer offers health care benefits

Public Sector: Medicare(Social Security Administration, 2016)

• Who qualifies:• Age 65 or older• Younger than 65 with certain disabilities, permanent kidney failure, or amyotrophic

lateral sclerosis• Helps with the cost of health care but doesn’t cover all medical expenses• Four parts:

• Part A – hospital insurance• Part B – medical insurance (services from doctors and other healthcare providers)• Part C – Medicare Advantage plans• Part D – Medicare prescription drug coverage

Public Sector: Medicaid(Nevada Health Link, 2016)

• Who is eligible?• Adults with household income up to 133 percent of poverty (138 percent with the 5 percent

income disregard). • Pregnant women with household income up to 160 percent of poverty. • Children, depending on age, with household income up to 133 percent or 160 percent of

poverty; all children are eligible for CHIP with income up to 200 percent of poverty

• Will often back-pay a few months from the application date to assist with incurred medical expenses.

• How to apply?• Nevadahealthlink.com• healthCare.gov

Emergency Medical Treatment and Labor Act

(American College of Emergency Physicians, 2014)

• What is EMTALA?• Requires Medicare-participating hospitals with emergency departments to

screen and treat the emergency medical conditions of patients in a non-discriminatory manner to anyone, regardless of their ability to pay, insurance status, national origin, race, creed or color.

• What is considered an “emergency?”• "a condition manifesting itself by acute symptoms of sufficient severity (including

severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs."

…EMTALA continued(American College of Emergency Physicians, 2014)

• Who pays for EMTALA-related medical care?• It is federally-regulated, so ultimately we all do; however,

hospitals and emergency physicians shoulder the majority of the financial burden.

• The burden of uncompensated care continues to grow and is leading to the closure of many emergency departments and decreasing the care available to the underinsured and uninsured.

References• American College of Emergency Physicians. (2014). EMTALA. Retrieved from:

https://www.acep.org/news-media-top-banner/emtala/• Healthcare.gov. (2016). Health insurance. Retrieved from:

https://www.healthcare.gov/glossary/health-insurance/• Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (2016). Policy and

politics in nursing and health care (7th ed). St. Louis, MO: Elsevier Inc.• Nevada Health Link (2016). What is Medicaid. Retrieved from:

https://www.nevadahealthlink.com/individuals-families/medicaidnevada-check-up/• Social Security Administration. (2016). Medicare. Retrieved from:

https://www.ssa.gov/pubs/EN-05-10043.pdf