Don’t go short cut and mess it up. Address each question separately like you did last week.  You end one covering every point and doing a very good job.

The article attached has information that will help create a good work.

You can get article to question 1a. Please cite all work thoroughly. No rejection please. 

1a What is the National Health Insurance? 

B: Evaluate selected healthcare policy models and frameworks

1C: Is Medicare effective? 

1D:What about the VA Health System? How do sociopolitical factors influence these systems? 

1E:What can you do as a DNP nurse to formalize support to advance health care policies or agendas?

What is a Health Insurance Exchange? Use this part to develop great introduction

Section 1311 of the ACA requires each state to establish a health insurance exchange by January 1, 2014. The fundamental purpose of a health insurance exchange is to create an online marketplace for the sale and purchase of health insurance for customers (consumers). The exchange is required to serve two markets: the individual market and the small group market. The exchanges are structured to benefit customers by providing choice, transparency, and convenience, in which one chooses among competing health insurer providers (both public and private).

Marketplace competition is how everything is purchased, from books to shoes to food. Everything, that is, except health insurance. The health insurance exchanges were designed using this business model and current understanding of the economic drivers of health care. The benefits of using the marketplace model are obvious to anyone who has ever shopped at a Costco (Klein, 2009). The products are clearly priced, standardized for ease of comparison, and written in clear language to assess quality. Buying in bulk can lead to cost savings. 197Health insurance exchanges are created to provide this same type of information and transactional opportunity. Essentially, the exchanges are designed to increase access for uninsured or underinsured Americans to quality and affordable health insurance by expanding the size of the insurance coverage pool. (The Henry J. Kaiser Foundation, 2013b)

Customers are also protected by ACA regulations that ensure insurance companies (issuers) that choose to sell their products (plans) through an exchange are not deceptive. Issuers are required to comply with other consumer protections, such as offering insurance to every qualified applicant and meeting the private market reform requirements in the ACA. However, exchanges are not issuers (insurance companies); rather, exchanges contract with the insurance companies who will provide insurance products available for purchase through exchanges (Fernandez & Mach, 2013).

Exchange Purchasers

Individual Purchasers

The health insurance exchange is a marketplace that offers an individual the ability to compare health insurance plans. Each state was to create a market for the individual consumer to purchase health insurance, although states also had the options of partnering with the federal government to create an exchange or having the state’s residents use a federal exchange. Individuals are required to have health insurance or face a fine (tax) imposed by the federal government. Dependent on an individual’s income, he/she may qualify for a reduction in the overall cost of the health plan premium, known as federal subsidies. This is a way to reduce the overall out-of-pocket cost of the consumer and help to make insurance more affordable. Individuals may also qualify for Medicaid. Qualified health plans (QHPs) sold on the insurance exchanges cannot be priced differently outside of the insurance exchange (Peterson & Fernandez, 2010), but an insurance company can offer other plans off the exchange with different pricing.

Table 20-1 depicts scenarios of how individuals and those up to a family of six can potentially qualify for tax subsidies, Medicaid, and cost-sharing reductions (CSRs), which are additional out-of-pocket reductions.

Health Insurance Exchanges

Expanding Access to Health Care

Coral T. Andrews, Deborah B. Gardner 

“Follow the path of the unsafe, independent thinker. Expose your ideas to the dangers of controversy. Speak your mind and fear less the label of ‘crackpot’ than the stigma of conformity. And on issues that seem important to you, stand up and be counted at any cost.”

Thomas J. Watson

The health insurance exchange has been described “as arguably the single most important element of health care reform. It is the bridge between the current health care system we have and the system we want” (Klein, 2009, para. 3). Before the Affordable Care Act (ACA) went into effect, health insurance provided little security. Instead, it provoked apprehension and fear. As many as 129 million insured Americans, nearly one in two people, could be discriminated against because of preexisting conditions such as heart disease, diabetes, or cancer, or for that matter even pregnancy (Hilzenrath, 2009U.S. Department of Health and Human Services [HHS], 2011). For other Americans, many knew that if they were diagnosed at some point with a serious illness it could leave them unable to access affordable coverage. This often resulted in people being trapped in ill-suited jobs or even dropped from their coverage. Vice President Biden stated in a recent speech about health care insurance before the ACA “… that every family was one job loss or one illness away from seeing the worst of the insurance system” (as cited in Simas, 2014). With the implementation of the ACA (Public Law [PL] 111-148, as amended) insurance access is changing. No longer are individuals with preexisting issues uninsurable. If you lose coverage or lose a job that had coverage, there will be a way to access care. Now there is a new way for families to have access to affordable health insurance.

This chapter outlines the required functions of exchanges and differentiates exchange types, the coverage offered, and implementation challenges. The roles that nurses can play as the exchanges evolve are presented and an assessment of the impact of the health insurance exchanges after the first year is discussed.

What is a Health Insurance Exchange?

Section 1311 of the ACA requires each state to establish a health insurance exchange by January 1, 2014. The fundamental purpose of a health insurance exchange is to create an online marketplace for the sale and purchase of health insurance for customers (consumers). The exchange is required to serve two markets: the individual market and the small group market. The exchanges are structured to benefit customers by providing choice, transparency, and convenience, in which one chooses among competing health insurer providers (both public and private).

Marketplace competition is how everything is purchased, from books to shoes to food. Everything, that is, except health insurance. The health insurance exchanges were designed using this business model and current understanding of the economic drivers of health care. The benefits of using the marketplace model are obvious to anyone who has ever shopped at a Costco (Klein, 2009). The products are clearly priced, standardized for ease of comparison, and written in clear language to assess quality. Buying in bulk can lead to cost savings. 197Health insurance exchanges are created to provide this same type of information and transactional opportunity. Essentially, the exchanges are designed to increase access for uninsured or underinsured Americans to quality and affordable health insurance by expanding the size of the insurance coverage pool. (The Henry J. Kaiser Foundation, 2013b)

Customers are also protected by ACA regulations that ensure insurance companies (issuers) that choose to sell their products (plans) through an exchange are not deceptive. Issuers are required to comply with other consumer protections, such as offering insurance to every qualified applicant and meeting the private market reform requirements in the ACA. However, exchanges are not issuers (insurance companies); rather, exchanges contract with the insurance companies who will provide insurance products available for purchase through exchanges (Fernandez & Mach, 2013).

Exchange Purchasers

Individual Purchasers

The health insurance exchange is a marketplace that offers an individual the ability to compare health insurance plans. Each state was to create a market for the individual consumer to purchase health insurance, although states also had the options of partnering with the federal government to create an exchange or having the state’s residents use a federal exchange. Individuals are required to have health insurance or face a fine (tax) imposed by the federal government. Dependent on an individual’s income, he/she may qualify for a reduction in the overall cost of the health plan premium, known as federal subsidies. This is a way to reduce the overall out-of-pocket cost of the consumer and help to make insurance more affordable. Individuals may also qualify for Medicaid. Qualified health plans (QHPs) sold on the insurance exchanges cannot be priced differently outside of the insurance exchange (Peterson & Fernandez, 2010), but an insurance company can offer other plans off the exchange with different pricing.

Table 20-1 depicts scenarios of how individuals and those up to a family of six can potentially qualify for tax subsidies, Medicaid, and cost-sharing reductions (CSRs), which are additional out-of-pocket reductions.

TABLE 20-1

Quick Check Chart: Do I qualify to save on health insurance coverage?








Private Marketplace Health Plans

You may qualify for lower premiums   on a marketplace insurance plan if your yearly income is between …
See next row if your income is at the lower end of this range.







You may qualify for lower premiums   AND lower out-of-pocket costs for Marketplace insurance if your yearly income   is between …







Medicaid Coverage

If your state is expanding   Medicaid in 2014: You may qualify for Medicaid coverage if your yearly income   is below …







If your state isn’t expanding   Medicaid: You may not qualify for any Marketplace savings programs if your   yearly income is below …







From (2014). Income levels that qualify for lower health coverage costs. Retrieved from

Individuals and small businesses can also choose to continue any insurance coverage they already have. Plans that existed before the ACA are grandfathered and considered coverage that meets the terms of the law (, n.d.).

Small Business Purchasers

Currently, small businesses with 50 employees or less can shop for coverage for their employees in a different market. These exchanges are called small business health options programs (SHOPs). Starting in 2016, employers with up to 100 employees will be eligible to participate in the exchanges (Small Business Association, 2013). Moreover, all insurance companies participating in exchanges must offer plans that provide a core package of Essential Health Benefits. For some states, this may be equal to typical employer plans in the state.

Small businesses that purchase coverage through the insurance exchanges may also qualify for tax credits. The small business tax credit helps small businesses afford the cost of health care coverage for their employees and is specifically targeted for those businesses with low- and moderate-income workers. The credit is designed to encourage small employers to offer health insurance coverage for the first time or maintain coverage they already have. This makes health insurance more affordable for small employers who lack buying power in the market to negotiate price in the same way that a large employer can.

Before the ACA went into effect, small businesses paid on average 18% more than big businesses for health insurance. By pooling risks across small groups, larger pools can be created like large businesses to be cost-effective (Small Business Association, 2013).

Other Health Insurance Options

Although the fundamental purpose of the exchanges is to facilitate the offer and purchase of health insurance, nothing in the law prohibits qualified 199individuals, qualified employers, and insurance carriers from participating in the health insurance market outside of exchanges. Moreover, the ACA explicitly states that enrollment in exchanges is voluntary and no individual may be compelled to enroll in exchange coverage (Fernandez & Mach, 2013). Government plans, including federal, state, and local health insurance plans for employees, retirees, veterans, and other groups such as children (Children’s Health Insurance Program [CHIP]), older adults (Medicare), and low-income households (Medicaid), continue to offer coverage to their participants (, n.d.).

Federal or State Exchanges

It is entirely up to each state to build their own exchange to meet the needs of its citizens or to have the federal government do it. Exchanges may be established either by the state itself as a state-based exchange (SBE) or by the Secretary of the U.S. Department of Health and Human Services (HHS) as a federally facilitated exchange (FFE). An FFE is operated solely by the federal government, or it may be operated by the federal government in conjunction with the state, as a partnership exchange. Fourteen states plus Washington, DC are running their own exchanges (both individual and small business [SHOP] markets). There are three states that only run SHOP markets and the marketplace for individuals is federally run. In 2014, 36 states had either state-federal partnerships or federally facilitated marketplaces. These decisions are highly politicized and will be changing and evolving in the years to come (National Conference of State Legislatures, 2014). No matter what type of exchange is established, all are subject to federal and state oversight. The ACA gives various federal agencies, primarily the HHS, responsibilities relating to the general operation of exchanges. Federal agencies are generally responsible for developing regulations, creating criteria and systems, and awarding grants to states to help them create and implement exchanges. All exchanges are required to carry out many of the same functions and adhere to many of the same standards (Fernandez & Mach, 2013). The primary functions relate to determining eligibility and enrolling individuals in appropriate plans, plan management, consumer assistance and accountability, and financial management.


States had to declare their intentions to establish their own exchange no later than December 14, 2012 (Centers for Medicare and Medicaid Services [CMS], 2012). States intent on setting up their exchanges had to demonstrate their capabilities specific to basic functions set forth in the proposed rule released July 11, 2011 including enrollee support services, oversight of health plans offered through the exchange (QHPs), operation of websites, and risk management. However, there are other areas of program design in which a state has significant flexibility to customize its exchange to best meet the needs of its residents (Center for Budget and Policy Priorities, 2013).

Development of the Exchanges

State Options

An SBE had the capacity to incorporate a brand design that uniquely fit its state’s culture. Federal exchanges did not offer that same flexibility but did afford states an option to access an insurance marketplace without building it themselves. Some states had existing state laws that needed to be considered when making a choice about which model would be best for their population and their market. To pursue an SBE, a state was required to establish a statute (pass into law) and include in that law the accompanying governance structure that would oversee the marketplace (such as a board of directors). The state statute clarified the business structure, the governance structure, and the oversight. Exchanges, in their implementation, had to work with the federal government, state government, and legislatures. This required a high degree of collaboration.

The percentage of uninsured is variable from one state’s market to the next. Because of this, an analysis of the benefits and risks of Medicaid expansion (as a policy decision and financial decision) 200had to be assessed. Strategic considerations contributed information to aid in making such policy decisions. For example: What change is the state seeking to effect by implementing the marketplace and expanding Medicaid? Will it increase access? Increase cost?

Understanding how the population is sorted into different groups by income was an important consideration in devising strategies to expand coverage. To address affordability, SBEs could implement a policy decision to actively purchase and negotiate with issuers or not negotiate directly but rather serve as a clearinghouse to display plans that met the qualifications established by the regulators. Each has merit. Medicaid expansion is just one of many variables taken into consideration as the insurance marketplace is conceptualized and sustained. Depending on the political climate at the state level and market dominance by issuers, the ability to advance any of the above policies could be enabled or disabled (The Henry J. Kaiser Family Foundation, 2013a).

Establishing State Exchanges

Once the key policy decisions were sorted out, funding was sought through the federal grant application process. The federal government made planning grants available to states that chose to convene and develop a plan to establish a health insurance exchange. SBEs had to complete and submit a blueprint application to the Secretary of the HHS. The blueprint served as a roadmap with timelines for building the exchange. Blueprints were due by November 2012. One notable ACA expectation was that SBEs would be self-sustaining by January 2015. There is flexibility in how states chose to generate revenue necessary to be self-sustaining, but many states did not want to take on this revenue challenge. The largest revenue source thus far, for federal and state exchanges, is being garnered from administrative fees on issuers who participate in the marketplace and leverage it in the sale of their products (Dash et al., 2013).

Once blueprints were completed, insurance exchanges received a certification by the federal government to start the build phase. The implementation phase began in October 2013. It is important to note that SBEs were phased in at different times. Early state innovators informed planning efforts. An initiative to identify and create early state innovators (incubators) was funded through federal grants to design and implement online health insurance exchanges. The participating states developed cutting edge and cost-effective technology components, intellectual property, and best practices for implementing insurance exchanges. These models served as a framework for adoption by other states. The knowledge gained from this initiative informed the statutory development (The Center for Consumer Information and Insurance Oversight, 2011).

The Federal Exchange Rollout: ACA Setback

At this time the federal health insurance exchange website has overcome its technical problems and is functioning well with enrollment numbers surpassing expectations. Unfortunately, when went live, there were so many problems plaguing the site that Congress held hearings demanding answers regarding its failure to launch (May 2013). A technical debacle, this event was a setback in the implementation of the ACA. The public became angry and fearful regarding personal health insurance access and government competence in leading health care reform. These fears were exacerbated as health policies for individual or small groups were being cancelled for millions of Americans around the same time.

Toward the end of 2013, as federal and state regulators were developing the marketplace to ensure ACA-compliant health coverage was available, the nation’s health insurers focused on cancelling insurance policies that did not meet ACA standards. The cancellation notices came as a surprise to many Americans who relied on President Obama’s repeated promise that “if you like your health plan, you can keep it.” In retrospect, the Obama administration failed to explain the strict conditions required to keep your health plan. As this reality became apparent, a subsequent 201challenge arose when the federal marketplace failed to be accessible during its first 2 months of operation.

Because individuals would soon be required to have insurance, simultaneously their policies were being cancelled. Citizens in states without state-operated exchanges had no way to obtain insurance through the nonfunctioning marketplace website in time to avoid the 2014 penalties. Congressional leaders from both parties demanded resolution from regulators. This prompted President Obama to implement a “transitional policy” allowing insurers to renew previously cancelled policies through 2014 (McGarey, 2013).

New York’s Success Story

The establishment and rollout of state health insurance exchanges have also been exceedingly complex and politically charged. There have been successes and failures as states that chose to develop their own exchanges met with many challenges. The state of New York is a success story. The state health care exchange surpassed its own expectations, with the state’s enrollment efforts as one of the most effective in the nation. The New York health department reported that as of April 2014, 960,000 New Yorkers had signed up for health insurance through the state’s exchange, and 70% had been uninsured the year before (Goldberg, 2014).

New York’s success, in sharp contrast to the initial rollout of the national exchange, is attributed to the following factors: the state’s exchange had few technical issues and ran smoothly after the first week; Governor Andrew Cuomo (Democratic governor) was a supporter of the law; an aggressive and highly visible advertising campaign was created that saturated the public airwaves and subways with enrollment reminders; and finally a majority of state residents supported the law in the first place (Goldberg, 2014). The New York Action Coalition that was formed in 2011 to implement in the state the recommendations of the Institute of Medicine’s report on The Future of Nursing played a role in educating New Yorkers about the state exchanges, as did nurses in other parts of the country. Other state-run marketplaces have also prospered, including California’s, Connecticut’s, and Kentucky’s (Goldstein, 2014).

The Oregon Story

The Cover Oregon exchange, once touted as a model for other states, is now described as “one of the worst in the country” (Viebeck, 2014a). The Washington Post reported that the website was so dysfunctional that “no resident has been able to sign up for coverage online since it opened early last fall” (Goldstein, 2014). How did this happen? The state received $304 million in federal grants, including $48 million for being one of the early innovator states. About $250 million was spent trying to get its website working but to no avail. Choosing between spending another $80 million in an effort to get the website functioning or about $5 million to have the federal government and take the lead, Cover Oregon’s board made the decision to do the latter (Tennant, 2014).

An assessment of this failure was conducted (Cover Oregon Website Implementation Assessment, 2014). There were two themes identified as causes for the failed rollout: lack of communication and unrealistic optimism:

The lack of a single point of authority slowed the decision-making process and contributed to inconsistent communication, and collaboration across agencies was limited at best. In addition, communication with oversight authorities was inconsistent and at times confusing … Although there are numerous sources of documented communication regarding project status, scope issues, and concerns about system readiness, there does not appear to be a formal acceptance by the Cover Oregon leadership of issues significant enough to affect the success of the October 1 launch until August 2013. (Cover Oregon Website Implementation Assessment, 2014, p. 2, p. 4)

Oregon is not the only state with technical troubles in the insurance marketplace, as Maryland and Massachusetts exchanges were faltering in 2014 and looking to partner with the federal government as well. Hawaii and Minnesota also experienced 202technical problems on the initial launch of their exchanges (Goldstein, 2014).

Exchange Features


To achieve the overall ACA goals, there are several mechanisms included in the design of insurance exchanges that drive the intended outcomes of the law. The mechanisms include mandates, subsidies, guaranteed issue (requirement that insurance companies cover all applicants without discrimination for a preexisting condition), minimum benefits standards, and variable levels of cost-sharing.

The quality and affordability objective of the ACA is reflected in the marketplace design. The ACA ensures that health plans offer, in the individual and small group markets, the 10 identified minimum or essential health benefits (EHBs). The 10 categories are: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habi­litative services and devices; laboratory services; preventive and wellness services and chronic dis­ease management; and pediatric services, including pediatric oral and vision care. States did have some flexibility of adding to these benefits based on their population health priorities. Funding for additional benefits had to be reconciled at the state level. Consumers now have a standard benchmark by which plans are regulated (The Center for Consumer Information and Insurance Oversight, 2013).

Marketplace Insurance Categories

There are five categories or metal level plans that must be offered through the health insurance marketplaces (Table 20-2). Each plan still includes the 10 essential health benefits but there is variable cost-share (the amount that the consumer pays vs. health plan) for each level. CSRs are also available for some consumers (based on their income).

TABLE 20-2

Marketplace Insurance Categories

Metal (Coverage) Levels

Consumer Payment Levels

Bronze Health Plan: pays 60% on average

You pay about 40%

Silver: health plan pays 70% on   average

You pay about 30%

Gold: health plan pays 80% on average

You pay about 20%

Platinum: health plan pays 90% on   average

You pay about 10%

Catastrophic: coverage plan pays less than   60% of the total average

Only available to people under 30   years old or have a hardship exemption


Role of Medicaid

Medicaid expansion was a key provision of the law. Along with the state health exchanges, another pathway for providing a continuum of affordable coverage to significantly reduce the number of uninsured is through Medicaid. In June 2012, the Supreme Court declared Medicaid expansion could not be mandated by the federal government; rather’ it had to be offered as a choice for states. An analysis by the Urban Institute (Holahan et al., 2012) projected the impact of the ACA Medicaid expansion would vary across states depending on current coverage levels and number of uninsured. They anticipated that states implementing Medicaid expansion along with other provisions of the ACA could significantly reduce their number of uninsured. They also found that in looking at factors that reduce costs, states as a whole were likely to see net savings from the Medicaid expansion. However, this analysis provided little persuasion. As a result of each state’s decision, a significant number of consumers who could qualify for Medicaid are not currently able to access this benefit (see Chapter 40).

Nurses’ Roles with Exchanges

Successful implementation of the state and federal insurance exchanges is dependent on accurate 203messaging by trusted professionals. Nursing remains the most trusted of the health professions. As such, this is an opportunity to help in educating the public on the purpose and function of the exchange being used by the state. Additionally, nurses need to look for opportunities to influence service coverage within the exchanges, including requirements for plans to cover critical nursing services. As health care exchanges are implemented and improved, nurses need to use their influence at the bedside and in the boardroom.

Consumer Education

Consumer outreach and education is a critical and challenging component of the health insurance exchange. Empowering consumers to make choices about their own health insurance coverage options is aided when they have access to information and resources that clearly explain their options. It is every nurse’s responsibility to refer uninsured patients to the state or federal exchange for coverage, at the very least, and even better if nurses can articulate the basics, including that people may qualify for subsidies that can result in a very low per-month payment.

In addition to providing information and enrollment online, all exchanges are required to have a toll-free call center and in-person options that addresses the needs of consumers requiring assistance. Promoting health literacy is an area where nurses are particularly well positioned to contribute given they are educators, coordinators, and advocates. Nurses know that patient education needs to be adapted to different age, language (written and oral), and delivery preferences. The exchanges must provide the information to applicants and enrollees in plain language, written at a third grade level, and in an accessible and timely manner for individuals living with disabilities at no cost to the individual. Each exchange also provides navigators. These are usually community experts who can explain consumer eligibility, enrollment processes, and plan benefits (Brennaman, 2012).

The open enrollment periods of the health insurance marketplaces were focused on consumer education, in-person assistance, community education, and outreach events into health care organizations. Social media has presented itself as a viable marketing channel for all ages but in particular those between the ages of 18 and 29 years who are less likely to perceive the need for health insurance. As noted earlier, the technology systems used for the health insurance exchanges is designed to create a user-friendly experience for the consumer.

The insurance exchange is an integrated system that leverages a “no wrong door” model to allow consumers and small businesses to shop and compare via one portal. Before health insurance exchanges, consumers would have to go to multiple places to search for information about health insurance options, prices, Medicaid entitlement, and so on. A streamlined marketplace supports a one-stop shopping experience for a small business or family. Families who have children, for example, who qualify for Medicaid or CHIP can be serviced through one portal ( State Medicaid and CHIP Policies, 2014).

Likewise, small business employers can assess whether or not they qualify for tax credits, and the administrative burdens previously resulting in multiple invoices from different insurance subscribers are eased somewhat by aggregated billing through the insurance exchange. Employers receive one bill for their employees’ coverage. Easing administrative costs supports small business viability.

While technology is critical, it is important to remember that business drives technology. The core business of the health insurance exchange is its ability to make the marketplace transparent for consumers through outreach and education efforts.

State Requirements Include Aprns in Exchange Plans

The ACA has provided an opportunity for advanced practice registered nurses (APRNs) to address long-standing barriers to practice, including reim­bursement by third party payers. More states—in 2014, Minnesota, Connecticut, and Nevada—have passed legislation that supports full scope of practice for APRNs (American Association of Colleges of Nursing, 2014). In Oregon, insurers are now 204required to reimburse nurse practitioners in independent practices at the same rate as physicians, and Rhode Island was successful in removing their certified registered nurse anesthetist supervision requirement (Brassard, 2014). Much of this progress has come about in part by the success of the state and federal health insurance exchanges in extending coverage to millions of people who had been uninsured.

The high degree of autonomy provided to the states by the ACA in regulating their insurance markets creates many more governance tables for APRNs to be at. It is imperative that APRNs hold seats at these health exchange governance tables to bring nursing expertise to these decision-making bodies. This will require state and national nursing organizations to deploy their political capital to strategically place well-prepared APRN leaders to serve on these boards and commissions. This would ensure that the public has full access to a wide range of providers and promote interdisciplinary practices.

Assessing the Impact of the Exchanges and Future Projections

As the ACA’s first individual market open enrollment period (OEP) has ended, the assessment of its impact is being closely watched. Enrollment numbers in the exchanges have been debated and there has been a lot of concern about whether those who signed up on the exchange would actually follow through in paying their premiums. A recent McKinsey survey report (Bhardwaj et al., 2014) shows that 83% of uninsured individuals have paid up. For previously insured individuals, the percentage of payers is 89%. Although this is progress for the health law, the survey also indicates that 74% of enrollees were previously insured.

Another closely watched aspect has been the ACA’s impact on health care costs. Per capita health care costs have been rising at just under 3% a year since 2010, but that is less than half the average annual growth in the preceding 8 years. Some economists credit the ACA for a bit of the decline (Farley, 2014). A report by CMS (2014) estimated that the premium rates for approximately 11 million people will increase and approximately 6 million people are expected to experience a premium rate reduction in 2015. This analysis included both individual and small employer groups. A primary cause of insurance premium rate hikes has been attributed to the requirement for insurers to cover high-risk consumers (, n.d.). The fact is that insurance companies can no longer deny coverage to Americans with preexisting conditions or charge higher rates based on health status or gender. Other analysts (Batley, 2014) attribute the rate increases to four factors: commercial underwriting restrictions, the age bands that do not allow insurers to vary premiums between young and old beneficiaries, the new excise taxes being levied on insurance plans, and new benefit designs. In 2015, health insurance premiums are expected to vary substantially by region, state, and carrier. Areas of the country with older, sicker, or smaller popu­lations are likely to be hit hardest, whereas others may not see substantial increases at all (Viebeck, 2014b).

It will be several years before the success of the health insurance exchanges can be fully evaluated for their effectiveness in improving market competition (providing consumers with a diversity of choices and hopefully lower prices). However, a recent study by the Kaiser Family Foundation (Cox, et al., 2014) found that California and New York have significantly more competitive exchange markets compared with their individual markets in 2012. The study also found that Connecticut and Washington, DC states were very successful in enrolling more consumers and appear to have less competition than in their 2012 individual markets. Results from the remaining states show either similar levels of competition as pre-ACA markets or mixed signs. Another interesting trend noted was that although competition may not have increased in some states, enrollment across participating plans was significantly redistributed, suggesting a more dynamic market than indicated by statistics alone and the potential for greater price competition in the future (Cox et al., 2014).

If, over time, the exchanges prove to be effective and open to everyone, then workers and employers 205alike might well decide to use them. Recent projections from S&P Capital IQ, a financial research firm, are that 90% of American workers who now receive health insurance through their employers will be shifted to government exchanges by 2020 (as cited by Irwin, 2014). This reflects a very large and fast impact of the insurance exchanges on the current health care system. The S&P researchers estimate that big American companies could save approximately $700 billion between 2016 and 2025. It is envisioned that employers would provide their workers with a stipend to pay for health insurance on the exchanges rather than sponsor a plan themselves. The report concludes that the ACA will make a profound change in how employers offer health benefits and in how the average American employee purchases health insurance (Irwin, 2014).


In conclusion, the only way that health care reform will truly give a more efficient, more effective, more affordable health care system is if it begins to fundamentally change the inefficient, ineffective, unaffordable system currently in place. The strength of the health insurance exchanges is key to that transition. How the exchanges are governed will dictate how well the exchanges are patient-centered. Nurses must be involved in health exchange governance. It is also critical that nurses keep an eye on their respective state’s insurance exchange progress. There are sources that can assist with this monitoring, including the consumer advocacy group,, and the Kaiser Family Foundation.

Discussion Questions

1. What barriers and opportunities do you believe impacted the implementation of the state health insurance exchanges?

2. What type of health insurance exchange does your state have? What were the factors that led to this choice?

3. How well is it meeting the needs of your state’s citizens?


American Association of Colleges of Nursing [AACN]. Connecticut and Minnesota pass legislation to recognize APRNs as full practice providers. [AACN Policy Brief. Retrieved from]; 2014.

Batley M. Health premiums skyrocketing under Obamacare. [Newsmax. Retrieved from]; 2014.

Bhardwaj A, Coe E, Cordina J, Saha R. Individual market: Insights into consumer behavior at the end of open enrollment. [Mc­Kinsey Center for US Health System Reform. Retrieved from]; 2014.

Brassard A. Scope of practice wins in Iowa, Nevada, Oregon and Rhode Island. [The American Nurse. Retrieved from]; 2014.

Brennaman L. State health insurance exchanges: The critical role of nurses and nursing. [American Nurses Association Issue Brief. Retrieved from]; 2012.

Center for Budget and Policy Priorities. State policy decisions in exchange implementation. [Retrieved from]; 2013.

Center for Consumer Information and Insurance Oversight. States leading the way on implementation: HHS awards early innovator grants to seven states. [Retrieved from]; 2011.

Center for Consumer Information and Insurance Oversight. Essential health benefits standards: Ensuring quality, affordable coverage. [Centers for Medicare and Medicaid Services. Retrieved from]’s/ehb-2-20-2013.html; 2013.

Centers for Medicare and Medicaid Services [CMS]. Blueprint for approval of affordable state-based and state partnership insurance exchanges. [Retrieved from]; 2012.

Centers for Medicare and Medicaid Services [CMS]. Report to Congress on the impact on premiums for in­­divi­duals and families with employer-sponsored health insurance from the guaranteed issue, guaranteed re­newal, and fair health insurance premiums provisions of the Affordable Care Act. [Retrieved from]; 2014.

Cover Oregon Website Implementation Assessment. First data. [Retrieved from]; 2014.

Cox C, Ma R, Claxton G, Levitt L. Sizing up exchange market competition. [Updated: May 1, 2014. The Henry J. Kaiser Family Foundation. Retrieved from]; 2014.

Dash S, Lucia K, Keith K, Monahan C. Implementing the Affordable Care Act: Key decisions for state based exchanges. [The Commonwealth Fund. Retrieved from]; 2013.

Farley R. ACA impact on per capita cost of health care. [FACTCHECK.ORG. Retrieved from]; 2014.

Fernandez B, Mach AL. Health insurance exchanges under the Patient Protection and Affordable Care Act (ACA). [Congressional Research Service 7-5700 R42663. Retrieved from]; 2013.


Goldberg D. Why New York worked. [Retrieved from]; 2014.

Goldstein A. Obama administration prepares to take over Oregon’s broken health insurance exchange. [Washington Post. Retrieved from]; 2014. (n.d.). Health insurance marketplace. Retrieved from

The Henry J. Kaiser Family Foundation. State decisions for creating health insurance marketplaces. [Retrieved from]; 2013.

The Henry J. Kaiser Family Foundation. The youtoons get ready for Obamacare: Health insurance changes coming your way under the Affordable Care Act. [Retrieved from]; 2013.

Hilzenrath DS. Papers show insurers limited coverage for acne, pregnancy. [Washington Post. Retrieved from]; 2009.

Holahan J, Buettgens M, Carroll C, Dorn S. The cost and coverage implications of the ACA Medicaid expansion: National and state-by-state analysis. [The Urban Institute. Kaiser Commission on Medicaid and the Uninsured. Retrieved from]; 2012.

Irwin N. Envisioning the end of employer-provided health plans. [The New York Times. Retrieved from]; 2014.

Klein E. Health insurance exchanges: An overlooked key to reform’s success. [Washington Post. Retrieved from]; 2009.

May A. What went wrong with—and what now. [Retrieved from]; 2013.

McGarey S. Market transitional policy—The latest setback in the implementation of ACA. [Retrieved from]; 2013. State Medicaid and CHIP Policies. State Medicaid and CHIP Policies for 2014. [Retrieved from]; 2014.

National Conference of State Legislatures. Healthcare reform—Affordable Care Act legislative database. [Retrieved from]; 2014. (n.d.). Obamacare insurance premiums: How Obamacare impacts insurance premium rates. Retrieved from

Peterson C, Fernandez B. PPACA requirements for offering health insurance inside versus outside an exchange. [Congressional Research Service. Retrieved from]; 2010.

Simas D. Health coverage before the ACA, and why all Americans are better off now. [The White House Blog. Retrieved from]; 2014.

Small Business Association. Affordable Care Act 101: What the health care law means for small businesses. [Retrieved from]; 2013.

Tennant M. After huge website crash, Oregon asks feds to run Obamacare exchange. [New American. Retrieved from]; 2014.

U.S. Department of Health and Human Services Report. At risk: Pre-existing conditions could affect 1 in 2 Americans. [Retrieved from]; 2011.

Viebeck E. Oregon to abandon O-Care exchange. [The Hill. Retrieved from]; 2014.

Viebeck E. O-Care premiums to skyrocket. [The Hill. Retrieved from]; 2014.

Online Resources

Federal Insurance Marketplace.

National Academy for State Health Policy.

The Commonwealth Fund.


Health Care Reform

The ACA has had a significant impact on care to developing families, in general, and the ability of these innovators to bring these models to scale.

Primary Care and Prevention

The ACA contains many provisions that directly target primary care, including increasing reimbursement rates, investing in the primary care workforce, and expanding the reach of Federally Qualified Health Centers (Abrams et al., 2011). Maternity and newborn care is listed as 1 of 10 essential health benefits (Association of Maternal and Child Health Programs, 2013). There are specific provisions addressing prevention in pregnancy, such as the mandated coverage of tobacco cessation services for pregnant women. Some provisions, such as requiring that women receive insurance coverage for all U.S. Food and Drug Administration-approved methods of birth control without cost-sharing, have been challenged in the courts (see Chapter 53for a discussion of some of these legal challenges).

Fostering Innovation

The Center for Medicare and Medicaid Innovation (CMMI), or The Innovation Center, was established by the ACA for the purpose of testing “innovative payment and service delivery models.” The goal is to advance best practices that will preserve or improve the quality of care, while reducing costs.

In 2012, the U.S. Department of Health and Human Services (HHS) Secretary Sebelius announced (in an event at the Developing Families Center) the Strong Start Initiative, a public campaign to reduce early elective deliveries and a grant program that would test the effectiveness of “enhanced prenatal care approaches” to reduce preterm births among Medicaid beneficiaries. The CMMI chose three evidence-based approaches: Centering/group visits, birth centers, and Maternity Care Homes (these are sites that assume responsibility for coordinating quality, evidence-based, woman-centered perinatal care and social services). The Strong Start Initiative has highlighted prenatal care as a significant issue with the HHS and brought increased recognition of problems facing MCH. Across the United States, key MCH advocates (some of whom had never sat at the table together) came together to submit proposals. In some states where those proposals were not chosen for funding, advocates have continued to work together with birth centers and Centering is on the radar as never before. For those sites that were funded, data collection is under way, including an evaluation that includes both outcomes and evaluation.

Payment Reform

The ACA contains many provisions that are an attempt to change the existing perverse payment incentives that drive the provision of more intervention. For example, despite the cost savings, the scale-up of birth centers has been hampered by lack of payment for the facility services. The ACA included a provision that would mandate Medicaid payment for facility services. Unfortunately, many states have not yet implemented that provision (Stapleton, Osborne, & Illuzzi, 2013). And yet it is estimated that if 10% of U.S. births occurred in birth centers, the potential savings in facility service payments alone compared with hospital facility service payments could reach $800 million per year.

Barriers to Sustaining, Spreading, and Scaling-Up Models

There are many forces that can drive innovation or stifle it. There is a growing emphasis on the need to 304provide innovators with the tools and support to scale up proven innovation (Agency for Healthcare Research and Quality, n.d.).


The health care industry is made up of many stakeholders, with competing (and sometimes unclear) interests. Although the landscape is changing, nurses have not always been strong players. In particular, nurse midwives, who have been the innovators behind both Centering and the birth center movement, have not always been in a powerful position to effect change. One clear advantage for Centering has been that it is an interdisciplinary model that has enjoyed uptake from physicians (both obstetricians and family physicians) as evidenced by an editorial in an obstetric journal where two physicians conclude, “We believe it is time to start thinking of group prenatal care as the default model for prenatal care” (Garreto & Bernstein, 2014). But the women and families served by these models can be strong advocates and persuade policymakers to support policies that remove the barriers to sustaining these MCH services.

Scope of Practice

Lifting barriers to practice is a necessary step for scaling up nurse-led innovations that use certified nurse midwives, clinical nurse specialists, and nurse practitioners. See Chapters 54 and 66for more on scope of practice.


Any innovative model that relies on a new and/or separate funding stream is at risk. Birth centers and Centering are innovations that have been able to grow in part because they are within the existing payment system. Because a midwife, physician, or nurse practitioner credentialed to provide prenatal care is performing the routine prenatal assessment in the group space, it is billed as any other prenatal visit. Likewise, credentialed providers can bill for services provided in a birth center, although they have faced a greater challenge contracting with payers. In addition, a birth center requires a significant capital investment. Centering also requires an initial investment in system redesign, training, and, often, redesign of space.


The fact that the ACA provision mandating adequate payment to birth centers has not yet been fully implemented is evidence of how difficult it is to effect change. There are other barriers to birth center facility services payment by both commercial and Medicaid payers, including lack of recognition of and contracting with nurse midwives by Medicaid and commercial managed care organizations, and inadequate reimbursement by many state Medicaid agencies.


The regulatory process can aid or hinder inno­vation. For example, in the case of payment for birth centers, many states have not yet completed the regulatory process that implements the new payment mandate.


Not since the creation of the Children’s Bureau in 1912 has there been such attention to MCH care and openness to reform. Although significant barriers exist, nurses are becoming increasingly effective advocates for change by building collaborative relationships with key allies and stakeholders, applying new science, engaging families, and having a clear message for the media, all key components of effective advocacy for developing families.


#2A;. We all know how to be patient advocates but not everyone understands how to be nursing advocates. As you are formulating your response and reflecting this week, how can obtaining your DNP help you affect public policy?

2B; Give an example of how a nurse can affect public policy in various appointed positions. What aspects of professional identity (leadership role) formation would you anticipate acquiring for such positions? 

Community Health Centers Demonstrate the Advocacy Process for Innovation

In 2013, 1200 community health centers (CHCs) served more than 22 million people at 9000 clinical sites all over the United States (National Association of Community Health Centers [NACHC], 2013). These programs provide medical, dental, mental health and substance abuse services, nutrition counseling, outreach, transportation, and other social services to uninsured patients as well as those with Medicaid, Medicare, Children’s Health Insurance Program (CHIP), and even private health insurance. CHCs also include programs serving migrant workers and the homeless.

CHCs are located in areas designated by the federal government as medically underserved and provide care without regard to insurance status or ability to pay. They are primarily funded by a mix of public insurance and federal grants. About half of the patients receiving primary health care at CHCs live in rural areas, 72% have incomes at or below the federal poverty level, three quarters are either uninsured or covered by Medicaid, and most are members of racial and ethnic minorities (NACHC, 2013). Patients served by CHCs are sicker than patients seen by other providers and tend to have higher levels of chronic illness, yet independent federal government evaluations find that these patients receive high-quality care (NACHC, 2011).

CHCs are unique health service institutions in several important ways. First, they are a community-oriented, culturally sensitive model of health care services integrated with social and educational services. Second, they are governed by consumer boards that, by federal law, must have a majority of members who are patients at the health center. Third, they are safety net providers, caring for people who do not have health insurance. Fourth, the 2010 enactment of the Patient Protection and the Affordable Care Act and its accompanying legislation, the Health Care and Education Affordability Reconciliation Act (referred to as the ACA or health reform in this chapter), gave CHCs the opportunity to play a critical role on the front lines of health reform: helping uninsured individuals enroll in new health coverage options, while meeting the health service needs of the newly insured.

These health care institutions were first funded as neighborhood health centers as part of the War on Poverty in 1965, one aspect of President Lyndon B. Johnson’s Great Society Program. They were created by activist physicians and federal government officials, “policy entrepreneurs” who believed that disparities in health status were intimately linked to social, economic, and political inequalities. Health centers were to treat whole communities, not just individuals, and to provide jobs as well as health services. Although these programs were products of the policy environment of the 1960s, they survived the end of the War on Poverty and 287subsequent political challenges during the more conservative Nixon and Reagan administrations. Not only did they overcome these challenges but they also became institutionalized as part of the federally funded health care system. In fact, health centers were the only domestic social program (other than abstinence-only health education) that was expanded during President George W. Bush’s tenure in office.

The policy history of the CHC program explains how a program providing care to communities with very few political resources, and therefore little political influence, was able to survive and grow in an era in which less and less attention was paid to problems such as poverty and inequality. This occurred because supporters within federal executive agencies and Congress nurtured the program during its first decade until an effective national advocacy organization was built. This national organization, its state partners, and local health centers then successfully created broad support for health centers that is bipartisan and exists across ideological boundaries. The story of the survival of the CHC program is a story about the creation of a policy network supportive of CHCs. The story of its expansion is a tale of skilled policy advocates who have been able to frame the argument for health center funding in a way that fits within a political environment vastly different from the one in which it was born.

The Creation of the Neighborhood Health Center Program

The first neighborhood health centers were funded in 1965 as demonstration programs by the Community Action Program established by the Economic Opportunity Act (EOA) of 1964. The goal of this legislation was to eliminate the causes of poverty in the United States. Health was not initially one of the areas in which programs were to be established, but early on it became clear that participants in the educational and training programs that were established, such as Head Start and the Jobs Corps, suffered from lack of access to health care. The very first health programs were created by two medical educators, Dr. H. Jack Geiger and Dr. Count Gibson, of Tufts University Medical School (Sardell, 1988).

The model of the two centers that they established, one in a Boston housing project and one in a poor rural area of Mississippi, was based on a public health/social medicine approach. It combined comprehensive health services, community development, and the training and employment of community residents. Health center staff in Mississippi found that children in the community had recurring episodes of malnutrition and dysentery. In response they organized residents who decided to construct wells and establish a farm cooperative to feed themselves and their children. Other health centers funded under this program, which was authorized by an amendment to the EOA by Senator Edward Kennedy (D-MA), also provided community development and employment opportunities as well as health care services. For example, a neighborhood health center in Brooklyn, NY gave preference in hiring to local residents, and health center staff facilitated the creation of a community organization to rehabilitate housing in the area.

By the end of 1971, 100 neighborhood health centers had been funded under Kennedy’s 1966 amendment. The original neighborhood health center model contained four elements: social medicine, community-based care, community economic development, and community participation. From a social medicine perspective, health status is shaped by the physical and social environment, and treatment includes intervention in that environment. Health care was to be community based by offering services to all of the residents of a specific geographic catchment area (rather than to those who fit within certain disease or health insurance categories) and by employing community residents to serve as a bridge between patients and professional staff. These workers, often called family health workers, made home visits and provided health education and advocacy services along with health care. The recruitment, training, and employment of these workers was also an example of the way in which neighborhood health centers were venues for community economic development. Finally, maximum feasible participation of the poor was 288required of all programs funded under the EOA. As we discuss later, when health centers received a separate federal program authorization in 1975 community governance became a central component that defined the program (Sardell, 1988).

Policy innovation in the United States most often requires that one or more individuals “invest their resources—time, energy, reputation, and sometimes money” in advocating for a new policy idea. John Kingdon calls these advocates “policy entrepreneurs” (Kingdon, 1995). Policy advocacy is most successful when entrepreneurs in and outside of government work together to support a new policy or program. This is what happened in the case of the creation of the neighborhood health center program. Activist physicians and federal Office of Economic Opportunity (OEO) officials worked together to create a policy that would increase health care access to low-income populations and to provide services that were different from those offered by mainstream medical institutions. In addition, Senator Edward M. Kennedy (D-MA) acted as an advocate for the program within Congress, deflecting opposition to both antipoverty programs and to socialized medicine.

When President Nixon took office the political environment changed; Nixon was not supportive of the social programs initiated by the Johnson administration. Yet during the Nixon administration, sympathetic federal agency officials protected the program until its advocates outside of government grew stronger (Sardell, 1988).

Program Survival and Institutionalization

Beginning in 1968 the public health service (PHS) within the U.S. Department of Health, Education, and Welfare (DHEW) also provided funding for the establishment of about 50 comprehensive health centers in low-income areas. The involvement of the PHS in primary health services had been historically limited to the funding of categorical disease programs. However, the 1960s was a period in which socially concerned health professionals, administrators, and social scientists joined the agency as an alternative to serving in the military during the Vietnam War. Some of these individuals became policy entrepreneurs within the PHS for comprehensive health service programs for underserved populations. They were supported in their efforts by top DHEW officials appointed by President Johnson.

Although the Nixon administration did not support the neighborhood health center program, there were civil servants in the PHS, as well as the OEO, who acted to protect it. As the OEO was phased out, decisions as to the timing of the transfers of individual programs to the PHS were made in ways that would protect more politically vulnerable programs, such as those in the South. In addition, agency officials awarded technical assistance grants to newly formed state health center associations and (in 1973) to the National Association of Neighborhood Health Centers, an organization created in 1970. Key congressional leaders such as Senator Kennedy and Congressman Paul Rogers (D-FL) also supported the health center program during the presidencies of Richard Nixon and Gerald Ford.

In 1972, the DHEW announced that it planned to phase out federal grants to health centers on the assumption that they would be funded through Medicaid. However in 1974 and 1975 Congress, in opposition to the Nixon and Ford administrations, enacted legislation that specifically described community health centers and authorized grant funding for them. The legislation was vetoed by both presidents, but in 1975 Congress overrode President Ford’s veto. The creation of the program took place within the wider context of intense conflict between presidents who aimed to reduce the role of the federal government in social policy and a liberal democratic Congress that wanted to preserve the social programs of the Great Society. This congressional action was a critical point in the history of the program because it now had its own legislative authority that defined its characteristics.

A CHC has to have a governing board with a consumer majority. This board establishes general policies for the center, has fiduciary responsibility, and appoints its executive director. A majority of board members have to be consumers who use its services. When enacted, this was the most rigorous 289community participation provision in any health service program up to that time. This legislative provision, reaffirmed many times, has meant that community-based primary care programs that do not have this governing board structure, such as those run by hospitals, cannot receive federal grants as CHCs. This provision has also enabled advocates to frame CHCs as embodying local control, an aspect of the program that has appealed to Republicans as well as Democrats.

The Ford administration (1974 to 1977) attempted to reduce CHC program funding and to end categorical grant programs in health. Within that political environment, federal program officials initiated changes that helped to expand congressional support. New program monitoring systems were established that provided measurable performance criteria for the health centers so that congressional concern with efficiency was addressed. In addition, rural health initiatives and smaller-scale, basic medical programs were funded. More centers could be funded because they required fewer resources than the large urban cen­ters. And rural, white congressional districts could potentially become a part of the health center constituency. These changes were part of the institutionalization of the health center program (Sardell, 1988). Over time, the cost-effectiveness of CHCs has been one of the major arguments made for increasing support for this model of care. Further, since the 1980s, members of Congress from rural districts and states have been important health center champions.

At the same time federal agency officials were making programmatic decisions that would ultimately strengthen congressional support for CHCs, the National Association of Community Health Centers began to educate members of Congress about the value of CHCs. A policy analyst was hired, a weekly newsletter on policy events was published, and the association initiated an annual policy and issues forum in Washington, DC, which brought together health center consumers and staff to learn about policy issues and the policy process. In 1976, a Department of Policy Analysis was created. During the following decades, membership in the NACHC grew, as did the organizational infrastructure. Today, this organization is one of the most effective advocacy organizations in Washington, DC.

Continuing Policy Advocacy

During the next 2 decades, under both Republican and Democratic presidents, the health center community strengthened its advocacy efforts and Congress continued to increase funding for the program. While Jimmy Carter was President (1977 to 1981), the rural health initiative concept of smaller centers was extended to urban areas and the focus on management efficiency continued. President Ronald Reagan’s attempt to end the CHC program as a separate federal grant program was rejected by Congress in 1981. An important shift in the source of health center funding occurred during the 1990s as a result of legislation initiated by the staff of Senator John Chafee (R-RI) and the NACHC to deal with the problem of low Medicaid and Medicare reimbursement rates for services delivered at CHCs. Under the Federally Qualified Health Center (FQHC) Program, which became part of Medicaid in 1989 and Medicare in 1990, CHCs and look-alikes (clinics that did not get federal grant monies under the CHC program but had the characteristics of CHCs) would have special Medicaid and Medicare reimbursement rates that were closer to actual costs than regular per-visit rates paid by Medicaid in many states. As a result, health centers were able to collect higher reimbursements for Medicaid and Medicare patients and Medicaid replaced federal grants as the major source of revenue for health centers. From 1990 to 1998, the proportion of health center revenues from federal grants substantially decreased from 41% to 26%.

The Expansion of Community Health Centers Under a Conservative President

Republican George W. Bush was elected president in 2000 as a conservative, yet he embraced CHCs, a program created by a liberal Democratic president 290in the 1960s. In 2001, in his first year in office, Bush proposed a 5-year initiative to expand health center sites to serve 6.1 million new patients. Congress supported funding for this initiative and throughout his two terms in office President Bush acted to fulfill his promise to expand the CHC program. Each time that Congress did not approve his full request for health center funding, the President would add the missing funds to his request for the following year (Hawkins, 2009). While the Bush administration was promoting the expansion of health centers, it was slashing spending for a wide variety of domestic programs including food stamps, home energy assistance, training grants for health professions, veterans’ benefits, and Medicaid (Pear, 2005). In addition, during the effort to reauthorize the CHC program during 2007 and 2008, the Bush administration quietly helped to gain support from Republican members of Congress in spite of conservative opposition to the expansion of social programs at the federal level (Hawkins, 2009). What explains the support that CHCs, programs serving ethnic minorities and the poor, had from President Bush?

First are the data-based policy arguments that show that health centers provide access to high-quality health care for underserved populations in a cost-effective way and are central in efforts to reduce ethnic and racial disparities in health status (NACHC, 2011). Second is the expansion of the policy network to include conservative members of Congress, so that now that network includes an ideologically diverse set of policymakers. In addition to the liberal Democrats and moderate Republicans who were program supporters in its formative years, health center champions in Congress during Bush’s first term in office included powerful Republican conservatives such as Senators Orrin Hatch of Utah (R), Christopher “Kit” Bond of Missouri (R), and Representative Henry Bonilla (R) of Texas. In fact, Senator Bond and Congressman Bonilla educated George W. Bush on the value of the health center model during his first campaign for the presidency (Hawkins, 2005). Third, it is the long experience and high levels of skill of the officials and staff of the CHC advocacy community that has successfully wedded policy arguments with grassroots political activity. Primary care associations at the state and regional levels, together with the NACHC, have successfully met a series of policy challenges to the program’s continued existence and growth and have helped to create the very broad support enjoyed by the CHC program almost 50 years after its creation.

Community Health Centers in the Era of Obamacare

The 2008 election of a Democratic President who began his professional life as a community organizer (and was endorsed during the Democratic Presidential primary by Senator Edward M. Kennedy, the long-time champion of CHCs) suggested that the CHC program would continue to enjoy Presidential support.

The American Recovery and Reinvestment Act (ARRA) of 2009, federal legislation designed to respond to the steep recession in the American economy, included an almost $2 billion investment in CHCs for both new sites and the expansion of existing sites (Bureau of Primary Health Care, 2010). The CHC program was the only direct health services program to receive money under the ARRA.

When Congress was beginning to consider this legislation, two CHC champions, Congressman David Obey (D-WI), Chair of the House Appropriations Committee, and Senator Tom Harkin (D-IA), Chair of the Senate Appropriations Subcommittee for Labor-Health and Human Services, Education, and Related Agencies programs, included funding for CHCs in the House and Senate bills. Health centers presented data to members of Congress about the many newly unemployed workers seeking care at CHCs, the cost savings achieved when disparities in access to care were reduced and chronic disease was effectively managed, and the fact that health centers were themselves engines of job creation and community economic development.

The $2 billion authorized for CHCs in the ARRA was more than that recommended by either the House ($1.5 billion) or the Senate ($1.87 billion.) Usually, when the Senate and House negotiate 291on final legislation, the amount of funding for a program is a compromise. But in the case of funding for CHC expansion in the Recovery Act, those negotiating the final bill, Democratic party leaders from both Houses, Representatives from the Obama administration, and a small group of Republicans supporting the stimulus package, agreed to actually raise the amount (Hawkins, 2009). Clearly, sup­port for CHCs came from both parties and from members of Congress across the liberal/conservative ideological spectrum, from Socialist Bernie Sanders to Conservative Orrin Hatch.

CHC advocates were very active in the process of formulating health care reform legislation during 2009, arguing that expanding health insurance alone is not sufficient to create access to high-quality preventive and primary health care. Senator Bernard Sanders (I-VT) and the House Majority Whip James Clyburn (D-SC) were key congressional champions for including funding for health centers in the health reform bills (Hawkins, 2009McDonough, 2011, pp. 204-205). The health reform legislation enacted in March 2010 emphasizes public health initiatives and preventive and primary health services as means to improve health outcomes, reduce health care disparities, and save money. The legislation continues federal support for expansion of the numbers of CHCs and the services that they provide. Eleven billion dollars in new funding is authorized for the CHC program over a period of 5 years, beginning in fiscal year 2011, both to serve an additional 20 million patients and to increase medical, dental, and mental health services. While most of the funds will be spent on providing services, $1.5 billion of the authorization is for new construction and renovation of existing facilities.

Other provisions of the new health reform legislation also affect the operations of health centers. Federal eligibility for Medicaid is expanded (to all those with an annual income less than 133% of the federal poverty level) and that will provide health insurance coverage to 16 million more people, some of whom were previously treated as self-pay patients at CHCs, and some of whom probably did not seek primary care. However, the national impact of expanding Medicaid is now uncertain. The 2012 U.S. Supreme Court decision in National Federation of Independent Business v Sebelius meant that the Medicaid expansion is essentially optional for states (Kaiser Family Foundation, 2012). By the end of 2013, only 25 states and the District of Columbia moved ahead with implementing the expansion (Ku et al., 2013). More states may decide to opt in at a later date.

The legislation also seeks to protect the financial viability of health centers within the new health insurance system. In addition to the $11 billion to establish the Health Center Trust Fund mentioned previously, $1.5 billion in new funding from 2011 to 2015 is authorized for the National Health Service Corps (NHSC), which provides educational scholarships and loans to primary care providers who agree to serve in provider shortage areas. Funding expansions for the NHSC is expected to improve CHC recruitment efforts (Kaiser Family Foundation, 2013). In addition, new grant programs are established for the development of teaching and residency programs at CHC sites (NACHC, 2010).

Another ACA provision that benefits CHCs is the increased reimbursement rates for Medicaid primary care services to the same levels as Medicare payments in 2013 and 2014 (Health Care Education and Reconciliation Act, 2010). Combined with the Medicaid eligibility expansion, the enhanced Medicaid rate should potentially increase Medicaid revenue at CHCs (Ku et al., 2013). The ACA has also given CHCs the opportunity to broaden their safety net role through new federal funding for outreach and enrollment assistance for CHC patients who are newly eligible for Medicaid or subsidized private health insurance. In May of 2013, the Health Resources and Services Administration announced that over 1000 CHCs across the United States were granted $150 million to educate their patients about the new health insurance options available under health reform and to assist any eligible patient with enrolling in these programs (U.S. Department of Health and Human Services, Human Resources and Services Administration, 2013).

In spite of new federal funding and the Medicaid expansion, challenges to the sustainability of CHCs remain. Funding for CHCs remains as critical as ever, because millions of people are expected to 292remain uninsured after the ACA is implemented, particularly in states that ultimately decide not to expand Medicaid. A recent analysis projects that if only half the United States ultimately takes up the Medicaid expansion, more than 30 million people will remain uninsured (Nardin et al., 2013). In addition, through the newly created insurance marketplaces under the ACA, many CHC patients will be newly enrolled in private health insurance, known as qualified health plans (QHPs). CHCs must have the capacity, knowledge, and experience to successfully navigate the complexities of private health insurance, such as ensuring they are included in provider networks, negotiating reasonable reimbursement rates, and understanding the out-of-pocket cost-sharing rules among the different levels of QHP coverage.

The result of 5 decades of advocacy by health care activists, federal officials, members of Congress, and organized health center patients and staff has been the recognition and support of CHCs as critically important parts of the U.S. health care delivery infrastructure. A social medicine model originally funded as a poverty program is now viewed as a cost-effective way to focus on the social, economic, and environmental variables that influence the health status of all Americans.

Discussion Questions

1. What does the creation of the CHC program tell us about the conditions necessary for policy innovation?

2. Who were the policy entrepreneurs supportive of the institutionalization and continuation of the federal CHC program at key junctures in its history?

3. Research the policy history of a CHC or FQHC program in your local community or region. Who were/are the individuals/institutions acting as policy entrepreneurs supportive of this program?


Bureau of Primary Health Care. The Health Center Program: Recovery Act Grants. [Retrieved from]  www.; 2010.

Hawkins, D. R., Jr. (2005). Phone interview with Daniel R. Hawkins, Jr., Senior Vice President, Public Policy and Research, National Association of Community Health Centers.

Hawkins, D. R., Jr. (2009). Phone interview with Daniel R. Hawkins, Jr., Vice President for Federal, State, and Public Affairs, National Association of Community Health Centers.

Health Care Education and Reconciliation Act. Pubic Law No. 111-152, 124 Stat. 1052. Sec. 1202. [Retrieved from]; 2010.

Kaiser Family Foundation. A guide to the Supreme Court’s Affordable Care Act decision. Kaiser Family Foundation: Washington, DC; 2012 [Retrieved from]

Kaiser Family Foundation. Community health centers in an era of health reform: An overview and key challenges to health center growth. Kaiser Family Foundation: Washington, DC; 2013 [Retrieved from]

Kingdon J. Agendas, alternatives, and public policies. 2nd ed. HarperCollins: New York; 1995.

Ku L, Zur J, Jones E, Shin P, Rosenbaum S. How Medicaid expansions and future community health center funding will shape capacity to meet the nation’s primary care needs. The George Washington University School of Public Health and Health Services: Washington, DC; 2013 [Retrieved from]

McDonough JE. Inside national health reform. University of California Press and Milbank Memorial Fund: Berkeley, CA; 2011.

Nardin R, Zallman L, McCormick D, Woolhandler S, Himmelstein D. The uninsured after implemen­tation of the Affordable Care Act: A demographic and geographic analysis. Health Affairs Blog. [Retrieved from]; 2013.

National Association of Community Health Centers. Community health centers and health reform. [Retrieved from]; 2010.

National Association of Community Health Centers. Community health centers: The local prescription for better quality and lower costs. [Retrieved from]; 2011.

National Association of Community Health Centers. America’s health centers fact sheet. [Retrieved from]’s_Health_Centers2013.pdf; 2013.

Pear R. Domestic programs subject to Bush’s knife: Aid for food and heating. New York Times. 2005;A22.

Sardell A. The U.S. experiment in social medicine: The community health center program, 1965–1986. The University of Pittsburgh Press: Pittsburgh, PA; 1988.

U.S. Department of Health and Human Services, Health Resources and Services Administration. Health center outreach and enrollment assistance fiscal year 2013; HRSA-13-279, CFDA# 93.527. [Retrieved from]; 2013

Role of Professional Nursing Associations

Historically, nursing organizations have played a critical role in developing and advancing policies on human rights issues. The International Council of Nurses’ (ICN) Code of Ethics for Nurses position statement, Nurses and Human Rights, requires nurses to safeguard and promote human rights (ICN, 2006a2006b). This statement as well as other ICN advocacy and lobbying position statements cover a wide range of health issues where nurses must act to enforce human rights and to promote and protect health as a fundamental human right and a social goal (ICN, 2010).

In 2008, the New York State Nurses Association (NYSNA) invited me to deliver an address entitled Nurses Working to Stop Human Trafficking at their annual convention. The NYSNA board’s response was immediate. They drafted and submitted an action proposal on human trafficking to the American Nurses Association (ANA), which was passed by the ANA House of Delegates in 2008. The resolution states that it will advocate legislation to reduce the incidence of human trafficking and will work to ensure that nurses know how to identify and assist victims. This is a commendable action by the ANA to educate nurses nationally and support stronger enforcement of the federal laws (American Nurses Association [ANA], 2008).

Investigate to see whether your state nurses’ association and specialty nursing association has a position statement on nurses’ role in human trafficking. You can be the person who takes the lead on this initiative if nothing exists to date. A good place to start would be to identify one or two state nurses’ associations that have already developed a policy and ask for guidance from them on strategy and language for your state nurses’ association.

Advocating for State Legislation and Policy on Human Trafficking

Nurses can become part of a national network of health providers and advocacy groups challenging the lack of services available to victims of human trafficking by advocating for the allocation of resources on both the federal level and state level to address this void. They can also use their influence and leadership to advocate for better enforcement of existing antitrafficking laws in their state.

In 2000, the federal law Victims of Trafficking and Violence Protection Act (TVPA) was enacted, making human trafficking a federal crime. The TVPA includes a provision that each state could 682pass their own legislation to strengthen the work of the federal government and coordinate a partnership with local and federal law enforcement. The Federal Bureau of Investigation (FBI) and agents of Immigration and Customs Enforcement (ICE), a division under Homeland Security, are the main federal agencies involved in investigating human trafficking cases. Because states are enacting legislation and strengthening laws to prosecute traffickers and training law enforcement, we have an increase in investigating human trafficking. To date, not every one of the 50 states has done so. The website of the Center for Women Policy Studies (2014), an advocacy organization, provides an interactive map to learn about individual states and their statutes on human trafficking. If your state has legislation and an interagency antitrafficking task force working on a comprehensive plan to provide services for persons who have been trafficked, ask if there is a nurse on the task force. Once identified, ask how you can help. If there is no nurse on the task force, work toward getting a nurse appointed, or nominate yourself. If your state is one of the remaining states without antitrafficking laws, identify local and national advocacy organizations working toward this goal and work with them to pass this legislation. Contact and engage your state nurses’ association to lobby to pass these comprehensive laws.

Advancing Policy Through Media and Technology

The media, both traditional media and digital media, is the single most powerful tool to educate, effect social change, and influence policies. Like most Americans, nurses’ knowledge about human trafficking has been shaped by the media. A study by researchers Johnston, Friedman, and Scaefer (2012) evaluated print and broadcast media reports on human trafficking beginning in 2008 through 2012. They found that stories on the crime of sex trafficking dominated the coverage, while stories of survivors or the impact on public policy were less common. Dramatization of human trafficking appears more frequently in story lines on popular crime series on television and in movie plots in theaters. The news media have been the primary source of national policy and legislative issues about human trafficking.

Coverage of the issue about the health of the victims and the public health implications of human trafficking has been missing. A recent study on the dominant issues covered in the media on the issue of sex trafficking reported that only 1% of the news coverage addressed the issue of public health. When nurses become educated on the health implications of human trafficking they can become resources for the media’s coverage on trafficking and shape the public’s understanding of human trafficking beyond the issue that it is a crime. When the public is aware of the indicators of human trafficking and whom to contact if they see such indi­cators, victims can more readily be identified and helped.

Technologies are now being used for antitrafficking efforts. The Global Human Trafficking Hotline Network shares and analyzes data from hotlines to find and help victims and identify trafficking locations. One of them, the National Human Trafficking Resource Center (NHTRC) in the United States, answers calls from anywhere in the country and has started accepting text messages. Texting can be a safer form of connect­ing with victims and those seeking to report suspected human trafficking activities. When a text is received, a live, trained specialist receives the text and responds immediately. Texting provides secrecy that phone lines cannot provide if the person reporting feels threatened by others near them (Polaris Project, 2014).


General Accounting Office [GAO]. Human rights: U.S. government’s efforts to address alleged abuse of household workers by foreign diplomats with immunity could be strengthened. [Retrieved from]; 2008.

General Assembly of the United Nations. Universal declaration of human rights. [Retrieved from]; 1948.

Hynes P, Raymond JG. Put in harm’s way: The neglected health consequences of sex trafficking in the United States. Stillman J, Bhattacharjee A. Policing the national body: Sex, race and criminalization. South End Press: Cambridge, MA; 2002.

International Council of Nurses [ICN]. ICN code of ethics for nurses. [Retrieved from]; 2006.

International Council of Nurses [ICN]. Nurses and human rights. [Retrieved from] ments/C06_Nurse_Retention_Migration.pdf; 2006.

International Council of Nurses [ICN]. About ICN. [Retrieved from]; 2010.

International Organization on Migration. Caring for trafficked persons. International Organization for Migration: Geneva, Switzerland; 2009 [Retrieved from]

Johnston A, Friedman B, Shafer A. News framing of the problem of sex trafficking: Whose problem? What remedy? Feminist Media Studies. 2012 [Retrieved from]

Polaris Project. Tools for service providers and law enforcement. [Retrieved from]; 2014.

United Nations [UN]. Protocol to prevent, suppress, and punish trafficking in persons, especially women and children, supplementing the United Nations Convention Against Transnational Organized Crime. [Retrieved from] 2/convention_%20traff_eng.pdf; 2000.

United Nations Office on Drugs and Crime [UNODC]. Global report on trafficking in persons. [Retrieved from]; 2009.

U.S. Department Homeland Security. Blue campaign. [Retrieved from]; 2013.

U.S. Department of State. Trafficking in persons report. [Retrieved from]; 2013.

U.S. Department of State. Federal strategic action plan on services for victims of human trafficking in the United States 2013–2017. [Retrieved from]; 2013.

Victims of Trafficking and Violence Protection Act [TVPA] of 2000, 22 U.S.C. § 7102(8).

Zimmerman C, Hossain M, Yun K, Gajdadziev V, Guzun N. The health of trafficked women: A survey of women entering post trafficking services in Europe. American Journal of Public Health. 2008;98(1):55–59.

Medical Homes and Primary Care

Susan Apold

“Change will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change that we seek.”

President Barack Obama

Chronic conditions are the leading cause of death in the world and have replaced specific acute episodic disease as the number one cause of mortality and morbidity in the United States (Centers for Disease Control and Prevention [CDC], 2014). Almost half of all adults in the United States are living with at least one chronic condition (Robert Wood Johnson Foundation, 1996) and one in four Americans is living with multiple chronic disease (Ralph et al., 2013). This tectonic shift has evolved over the past century as a result of an aging population; advances in public health; increasing knowledge of genetics; and improvements in pharmacology, research, and technology.

This changing epidemiology of the nation and its impact on the cost of health care became one of the major drivers of health care reform in the United States and resulted in the passage of the Affordable Care Act (ACA) on March 23, 2010. This historic legislation brought the most sweeping changes to the U.S. health care system since the passage of amendments to the Social Security Act in 1965 (which created Medicare and Medicaid). The ACA supports initiatives from the public and private sectors that seek to improve quality of care and support a reimbursement model that compensates for quality, not quantity, of care. It is widely believed that a shift in focus from a fee-for-service model of care, where revenue is generated on the number of patients seen and the number of procedures and diagnostic tests ordered, to payment for comprehensive patient-centered care evaluated by outcomes will result in lower cost and higher quality. Comprehensive patient-centered care is the focus of the profession of nursing.

The Experience of Chronic Care in the United States

Chronic illness is a condition that continues indefinitely, limits activity, and requires ongoing actions and responses from patients and caregivers (Larsen, 2009Robert Wood Johnson Foundation, Partnership for Solutions, 2002). It is a relatively new phenomenon. In the early 1900s, the leading causes of mortality in the United States were tuberculosis, pneumonia, and gastritis/enteritis. The average life expectancy then was 47 years (National Center for Health Statistics, 1909). Health care was an oxymoron as diagnosis and treatment of disease were the only tools in the health care armamentarium. With only a rudimentary comprehension of the major causes of mortality and without antibiotics, insulin, and imaging ability, the sick were identified late in their illness (or not at all) and either got better or died. The system developed to handle disease was based on face-to-face encounters with physicians who provided a service in exchange for a fee. That fee-for-service system with an emphasis on illness management remains central to health care policy today.

A century later, life expectancy is 78.9 years (Social Security Online Actuarial Tables, 2010); the first baby boomers are Medicare-eligible; and in 2014 the youngest baby boomers turned 50, a continuing challenge to the nation’s ability to effectively 276and efficiently manage the growing prevalence of chronic illness (Anderson, 2005). Treatment of chronic disease accounts for more than 75% of the nation’s health care budget. The financial impact on the U.S. economy of treatment and lost productivity caused by chronic illness is more than $1.3 trillion per year, with projections of an increase to $5.7 trillion by 2050 (Bloom et al., 2011). Increases in health care spending have not translated into improvements in health care quality. In a fee-for-service episodic care model, research shows that care is fragmented and illness-based; patients frequently do not get the care that they want or need (Coleman et al., 2009Mattke, Seid, & Ma, 2007). Fee-for-service models of care do not provide for the management of chronic illness. Payment for services is based upon face-to-face encounters with health care providers for acute and episodic illness, and much needed aspects of care management, such as coordinating services between and among providers, managing multiple providers across chronic illness problems, or transitioning from one type of care and care provider to another, are not reimbursed and therefore not done. Neither federal entitlement programs nor private insurances have traditionally provided coverage for prevention or care management.

Medical Homes

One initiative which blends comprehensive care with quality and reimbursement is the Patient-Centered Medical Home (PCMH). The concept of a medical home was first advanced by the American Academy of Pediatrics (AAP) in 1967 as a place where all medical information about a patient would be located (Sia et al., 2004). The National Committee for Quality Assurance (NCQA), which has the largest PCMH program, defines a medical home as “…a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety” (NCQA, 2014). The PCMH is built on the Chronic Care Model (CCM) proposed by Gerteis and colleagues (2003), which requires a whole-person orientation and a relationship between patient and provider which is regular, accessible, and mutual. The eight dimensions of patient-centered care can be found in Table 31-1. The American College of Physicians (ACP) expanded the PCMH model to include reimbursement incentives for the management and coordination of care (Barr & Ginsburg, 2006). Reimbursement in this model would support system-based versus volume-based care, that is, payment based on a process of care delivery that assures positive outcomes rather than the volume of patients seen by a given provider. Furthermore, reimbursement would acknowledge the value of providing coordinated care in a system that incorporates the elements of the CCM. In addition, the ACP model requires that a medical home must be team-based and led by a physician.

TABLE 31-1

Dimensions of Patient-Centered Care

1. Respect for patients’ values, preferences, and   expressed needs

2. Information and education

3. Access to care

4. Emotional support to relieve fear and anxiety

5. Involvement of family and friends

6. Continuity and secure transition between health   care settings

7. Physical comfort

8. Coordination of care

From Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T.L. (2003). Through the patient’s eyes: Understanding and promoting patient-centered care. San Francisco, CA: Jossey-Bass.

In 2006, led by IBM and major national medi­cal associations (American College of Physicians, American Academy of Family Physicians, American Osteopathic Association, AAP), the Patient-Centered Primary Care Collaborative (PCPCC) was established to promote the widespread implementation of the medical home concept as a major force in the provision of health care. In 2007, the aforementioned medical societies developed the Joint Principles of the Patient-Centered Medical Home. These principles included such concepts as whole-person orientation to care, care coordination, voluntary focus on quality and safety, enhanced access to care, and payment which recognizes the value added to care. In addition, the principles included 277the necessity that a PCMH has, at its core, a physician-patient relationship and that the PCMH occurs within a physician-led practice setting. The PCPCC has evolved in their definition of a PCMH and has adapted their definition from the Agency for Healthcare Research and Quality (AHRQ). The current position of the PCPCC is that a PCMH is an approach to care that is “patient-centered, comprehensive, coordinated, accessible, and committed to quality and safety” (PCPCC, 2013). The requirement of the PCPCC that the model be implemented in a physician-led team remains a principle in this group’s definition.

In 2008, the NCQA, the Utilization Review Accreditation Commission (URAC), The Joint Commission, and the Accreditation Association for Ambulatory Health Care implemented medical home accreditation programs.

Since its introduction the PCMH concept has proliferated and studies are under way to evaluate the effect this model has on the Institute for Healthcare Improvement’s (IHI) Triple Aim: improving the patient care experience, improving the health of populations, and reducing the per capita cost of health care. The National Academy for State Health Policy reports that more than 47 states have adopted policies to advance the PCMH initiative. The NCQA reports that 10% (approximately 7000) of primary care practices are credentialed as PCMHs (NCQA, 2014). Quality data, reported annually by the Milbank Memorial Fund, indicate that PCMHs “demonstrate improvements in the areas of cost, utilization, population health, prevention, access to care, and patient satisfaction” (Nielsen et al., 2014). This report highlights 20 studies of PCMHs in 2012 to 2013. Although the data represent early results and have not been subjected to a peer-review model, they do indicate that primary care practices engaged in this model demonstrate consistent positive outcomes on a variety of measures, specifically:

• Decreases in cost of care

• Reductions in the use of unnecessary or avoidable services

• Improvements in population health and access to care

• Increases in patient satisfaction

• Decreases in income-based disparities

The Role of Nursing in Medical Homes

The concept of a medical home is a natural fit with nursing. Nursing has always held the core values inherent in patient-centered care: an orientation to the whole person; consideration of the patient’s emotional, social, and edu­cational needs; and coordination of care across multiple community and health care agencies are fundamental nursing skills. The American Nurses Association’s definition of nursing provides the best evidence that the profession of nursing has both opportunities and responsibilities as a driv­ing force in health care reform, chronic care policy, and implementation of new models of care delivery:

“Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” (American Nurses Association, 2003, p. 3)

The natural fit between the nursing profession and the concepts underpinning the chronic care model led the advanced practice nursing community to lobby for a name change from medical home to health home. A health home reframes the con­text of care from pathology (medicine) to health and supports the Institute of Medicine (1996) focus on the process of care and not on any one type of provider. However, legislation requiring the implementation of demonstration projects designed to test this method of health care delivery (Tax Relief and Health Care Act [S.1796], 2006) codified the term medical home in federal statute. Curiously, the ACA refers to medical homes in relation to Medicare and health homes in relation to Medicaid.

An additional point of controversy for the nursing community was the PCPCC premise that a PCMH be led by a physician and exist only within physician-led practices. Because of that principle, PCMH credentialing organizations were unable to certify practices led by nurses whose practices 278otherwise met the criteria for a medical home. Leaders within nurse practitioner (NP) associations and nurse-managed health centers engaged in a variety of strategies to influence policy on the implementation of the medical home model and the appropriate health care provider leadership of medical homes. The message to patients and other stakeholders was clear: Nurses and NPs have the capacity to serve as both leaders and participants in PCMH models of care delivery.

Organizational and grassroots strategies to influence policy on NPs and PCMHs were somewhat successful. NPs influenced members of the Senate Finance Committee to recognize NPs as leaders of medical home demonstration projects. Support for a technical amendment to the S.1796 emerged from Senators Bingaman (D-NM), Harkin (D-IA), Murkowski (R-AK), and Collins (R-ME), who read a colloquy on the Senate floor that spoke of the inclusion of NPs as leaders of medical homes (Congressional Record, 2008).

In July 2008, the ACP worked with NP representatives to discuss the ACP’s policy on NPs. As a result of this meeting, the ACP published a policy monograph that recognizes the role of NPs in primary care and advocates for testing NP-led medical homes (ACP, 2009). After subsequent conversations, the PCPCC adopted the AHRQ’s defi­nition of a PCMH, which uses provider-neutral language. Because of PCPCC’s adoption of this language, the NCQA updated the criteria for consideration for practices to be certified as PCMHs to include NPs, physician’s assistants, and a variety of providers who practice primary care. A number of NP practices and nurse-managed health centers have met the criteria put forth by the NCQA and have been certified as medical homes, making them eligible for reimbursement subsidies for care management and coordination.

Nonetheless, organized medicine remains dedicated to a definition of a medical home that includes physicians as the leaders, and major physician organizations hold fast to the original Joint Principles adopted by the PCPCC in 2007, specifically requiring that a medical home must include a “personal physician in a physician-directed team-based medical practice” (American Academy of Family Physicians, AAP, ACP, and American Osteopathic Association, 2011).

Patient-Centered Medical Homes: the Future

Preliminary data speak to the emerging success of this model of care. Any care model which seeks to understand patients and their health as a whole within the context of their lives places the patient at the center of care, precisely where they should be. Patient-centered versus illness-centered approaches to health make intuitive sense and are central to the science of nursing. The future of PCMHs depends on a variety of factors. Practices must have economic support for the transformation from traditional fee-for-service models to true outcome-based patient-centered units. In addition to economic support for all health care providers, those who provide both direct and indirect care must undergo training in true nonhierarchical interprofessional teamwork. With the patient at the center of this system, all members of the health care team must be available and able to take leadership roles that best meet patient needs. This will require education, training, and patience for the change process.

The nursing profession continues to play a pivotal role in the development of successful PCMHs. Nursing education focuses on patient centeredness, team building, team membership, and managing change and conflict. These are principles found in nursing curricula from baccalaureate through doctoral education. Nurses need to encourage providers to adopt the principles of PCMHs and develop their own practices within that model. Finally, professional nurses have an obligation to be informed about best practice models, funding sources, and legislation and policy around new models of health care delivery.

The ACA identifies NPs as lead providers in medical home demonstration projects and allows for provider-neutral language in the definition of health homes. The PCPCC has revised its de­finition of a medical home to include patient-centered, comprehensive, and coordinated care that is accessible and committed to quality and safety. 279The NCQA provides for recognition of medical homes led by NPs. Additional work is necessary to eliminate barriers to NP practice to maximize the NP workforce in the pursuit of access to safe, affordable care within the health home model.

Discussion Questions

1. In 2006, organized medicine developed Joint Principles for a Patient-Centered Medical Home. The first two principles mandated physician practices and physician-led teams as a condition of PCMHs. Do these principles hinder the advancement of PCMHs? How should organized nursing respond, if at all, to these principles?

2. Select a PCMH accrediting body (NCQA, URAC, The Joint Commission, and the Accreditation Association for Ambulatory Health Care). Review the criteria for certification of PCMHs. Identify the strategies that medical practices would implement to transform from a tra­ditional fee-for-service model to a PCMH model. What role can nursing play in this transformation?

3. Critique nursing’s strategy on influencing PCMH policy. What lessons can be learned from the strategies that were implemented? What additional strategies might have been employed?


American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association. Guidelines for patient-centered medical home recognition and accreditation programs. [Retrieved from]; 2011.

American College of Physicians. Nurse practitioners in primary care. Policy monograph. American College of Phy­sicians: Washington, DC; 2009 [Retrieved from]

American Nurses Association. Nursing’s social policy statement. 2nd ed. American Nurses Association: Silver Springs, MD; 2003.

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