The Affordable Care Act (ACA) focused the American Healthcare System on improving healthcare for all. The law sought to reduce healthcare costs, improve access to healthcare, and improve the quality of healthcare (Cleveland, et al., 2019; Collins & Saylor 2018; Penson, 2015). Since 2010, when the law was enacted, nurses have continued to innovate, advocate, and lead patient focused change in health delivery systems (Cleveland, et al., 2019). Meanwhile, the globe has faced over two years of unprecedented challenges. The COVID-19 pandemic has changed financial, educational, and social norms. War has broken out in eastern Europe challenging liberty and democracy with far-reaching social considerations. Soaring energy prices have challenged the ability to provide food, affordable heating and cooling, and affordable transportation for many people around the world. The power of nurses to bring forth equitable solutions that align with the provisions of policy, law, and regulation outlined in the ACA are needed now more than ever. This article discusses how nurses can leverage their collective power and align efforts with the tenets of the ACA to provide direction and leadership for US healthcare despite unprecedented global challenges.

The ACA and Access to Care

Nurses exercise their power by critically evaluating the impact of policy and advocating for the needs of their community when revision is needed.Nurses exercise their power by critically evaluating the impact of policy and advocating for the needs of their community when revision is needed (Patton et al., 2019). Nothing tests the impact of policy or law more than how it withstands unexpected and unprecedented challenges. In evaluating the impact of the ACA, the Centers for Medicare and Medicaid (CMS) are accountable for reporting statistics. CMS reported a 21% increase in insured consumers during the 2022 re-enrollment process. Over 14.5 million consumers signed up for healthcare benefits in 2022 (CMS, 2022). That increase in insured consumers came in the wake of the COVID-19 pandemic and was aided by the enhanced subsidies of The American Rescue Plan Act (ARPA) 2021 (Keith, 2022). In this instance, the ACA access outcomes were supported through additional ARPA legislation that supported the U.S. economy during the pandemic. Further study and analysis of these results will need to occur to evaluate whether the positive impact on patient access is sustainable. One clear immediate and actionable opportunity for nurses with interest in policy is to inform their elected officials of their experiences and perspectives with the ACA and the ARPA in providing people with affordable access to care.

Equity and the ACA

The ACA was intended to provide for equity in the delivery of healthcare (Grogan, 2017). The COVID-19 pandemic revealed that while much had been accomplished in advancing healthcare, much remained to be done in providing for equity if population health goals were to be achieved (National Academies of Science, Engineering and Medicine [NASEM], 2021). The report acknowledged nursing’s unique disciplinary preparation, culture of compassion, and professional commitment to justice as quintessential to creating equity. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report emboldened the ACA’s focus on health equity and advocated for the removal of remaining barriers to health. This report calls on nurses to use their power to lead beyond the hospital environment to build equity at all levels of the community including schools, organizations, and institutions. The report goes on to embrace that this includes the well-being of an adequate number of nurses to meet the needs of the population (NASEM, 2021).

Providing for equity remains a focus of the 2023 notice of benefit and payment parameters rule pertaining to coverage under the ACA. The proposed 2023 payment notice would require insurers that use the HealthCare.gov to have: 1) standardized designs for deductibles, drug formularies and deductible-free services and would set time-and-distance standards; 2) maintain appointment wait-time standards to judge the adequacy of the provider network in a plan to ensure patients have timely access to various types of providers and facilities; and, 3) to require Marketplace plans to increase the proportion of essential community providers such as federally qualified health centers, Indian healthcare providers, community health centers, and family planning clinics that have a long history of serving members of racial and ethnic groups and underserved communities. (Keith, 2022).

Health and Human Services provided additional guidance on ACA related issues in January of 2022 that will become effective in 2023. Among these were: 1) payment for breastfeeding services and supplies, contraceptives, screening for HIV, counseling for sexually transmitted infections, and obesity prevention; 2) depression and suicide screening for children; 3) changes in behavioral, social, and emotional screening; 4) increased risk assessment for cardiac arrest and death; 5) LGBTQ nondiscrimination protections and, 5) hepatitis B risk assessments (Keith, 2022). These provisions empower nurses, and the health systems they work with, the support necessary to be reimbursed in the provision of equitable care.

The ACA and Healthcare Cost

...nurses need to remain focused and knowledgeable regarding the economics, politics, and business challenges occurring around their practice...The National Health Expenditure Report (NHE) presents health spending and enrollment for the next decade. The 2021-2030 report projected a decrease in spending despite an increase in demand for hospital care in 2021. The report found an expected average growth in healthcare spending of 5.1% between 2021-2030 and an increased Gross Domestic Product (GDP) of 5.1% in the same period. As such, CMS projects that the health share of the GDP is expected to be 19.6% in 2030. The healthcare share of the GDP in 2020 was 19.7% (CMS, 2022). The assumptions suggested by these metrics include that the overall economy will grow in the U.S. thereby keeping the health share of the GDP low. If the economy does not prosper (as can happen in times of global turmoil), this assumption becomes invalid. The result would challenge whether the ACA or other attendant legislation, like the ARPA, has been successful in decreasing healthcare costs. This determination will need to be discerned on an ongoing basis. As such, nurses need to remain focused and knowledgeable regarding the economics, politics, and business challenges occurring around their practice and be vigilant of the value of each program where they are directly involved.

The ACA and Quality and Safety

The new provisions announced through the ACA call for implementation by nurse leaders. The Institute for Healthcare Improvement (IHI) added equity as one of the 5 factors necessary for healthcare improvement when it published The Quintuple Aim for Healthcare Improvement (Nundy et al., 2022). As such, equity was added to improved patient experience of care, improved health of populations, reduced per capita cost of healthcare and clinician burnout in describing the approach necessary to optimize health system performance. The framework revision followed in line with The Future of Nursing 2020-2030 Charting a Path to Achieve Health Equity.

The American Organization of Nursing Leaders (AONL) has developed Nurse Executive Competencies to clarify the role and guide actions of nurse leaders. Nurse leaders support and lead staff, and guide organizations through strategic plans that build resilience by providing for training, support, and compassion (Wymer et al., 2021). Most importantly, the nurse leader is essential to leading safety, quality, and service of an organization. Nurse leaders collaborate and lead teams that promote safety within their organizations through assured adequate human workforce, use of information technology, and collaboration with technology partners in the industry. One example is using technology and remote monitoring by nurses to improve patient safety (Quigley et al., 2021) during the pandemic. Injury and harm due to falls were avoided through surveillance by a competent and trained workforce, along with appropriate patient communication (Quigley et al., 2021). The study provided insight into RNs rapid action using Patient-Engaged Video Surveillance to meet the needs of patients and healthcare workforce when experiencing the unknown (Quigley et al., 2021).

Care delivery models that enhance quality and service outcomes are essential for quality outcomes. Value based purchasing and public reporting indicate there is a need for continued innovation in care delivery; many hospitals during the pandemic developed and evaluated team-based models to prioritize care. This involves utilizing the RN as a leader and support for LPN and nursing assistant roles. Monitoring patient outcomes such as falls, central line associated bloodstream infections (CLABSI), catheters associated urinary tract (CAUTI) infections, hospital acquired pressure ulcers, and patient experience are examples of current research for monitoring expected outcomes. Here, the critical component to success is the RN successfully leading the team of caregivers through appropriate delegation, communication, and trust among healthcare providers.

Another example of nursing leadership that advances quality and cost is the nurse leaders’ collaboration with human resource leaders to address different models of adequate supply and demand to care for patients across the continuum. The academic service model of collaboration is an example that is increasing because of the known shortage of the nursing industry hindering admission of students into nursing programs. Hospitals are partnering to offer scholarships and loan repayment programs along with offering support for schools through nursing staff as faculty because they recognize the need to eliminate the barriers to becoming a nurse (Noguchi, 2021). These collaborations between health systems and academic centers are focusing on quality through outcomes from clinical research (Albert et al., 2019). Through research and monitoring processes and outcomes, changes in models of patient care delivery can be made to improve both nurse and patient satisfaction and improve clinical outcomes

Strategies to Impact Healthcare Policy, Access, and Equity

Promoting Nurses on Boards
Nurses belong everywhere important decisions are made because every nurse can be a leader. Nurses have been serving on boards in communities where they live and work for years. Many of the early board roles originated from needs that were discovered in working with underserved populations (Harper and Benson, 2021). As such, these opportunities were an excellent mechanism to provide a voice for equity. Over time, the contributions of nurses serving on all types of boards gained recognition and value, rising to a strategic level of visibility and importance (Harper & Benson, 2021).

Nurses are charged to impact a highly regulated environment by advocating for legislation and policy revisions that consider a variety of stakeholders, while remaining steadfast in promoting equity. Board service is one way that nurses can impact the health of their community. Nurses in board seats can leverage their unique disciplinary knowledge to create resources provided within the ACA and assess the value of services provided.

Nurses want their voices heard, and they are eager to serve on boards, commissions, and appointments to improve health in communities across our country and beyond.The importance of including nurse perspectives in all settings, including the boardroom, is gaining popularity. Nurses want their voices heard, and they are eager to serve on boards, commissions, and appointments to improve health in communities across our country and beyond. As of December 31, 2021, nurses filled 10,353 board seats as self-reported through the Nurses on Boards Coalition (NOBC) database (NOBC, 2022). Sundean et al. (2022), demonstrated, “nurses bring expert healthcare knowledge, expertise, and wisdom along with the values of caring and collaboration to impact board decision, which may, in turn, influence governance effectiveness and organizational performance” (p. 111).

Since 2014, The Nurses on Boards Coalition (NOBC) has been helping nurses serve in board leadership roles. NOBC was created in response to the 2010 Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, which recommended increasing the number of nurse leaders in pivotal decision-making roles on boards and commissions that work to improve the health of everyone in America. The Campaign for Action, an initiative of AARP Foundation, AARP, and the Robert Wood Johnson Foundation initially brought the groups together as part of their collaborative effort to implement the recommendations of the IOM report through the Future of Nursing: Campaign for Action (NOBC, 2022).

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity articulates the Committee’s vision of the achievement of health equity in the United States built on strengthened nursing capacity, diversity, and expertise. The report calls nurses to, “inform and implement policies that will ultimately affect the greatest numbers of people in the most profound ways” (NASEM, 2021, p. xvi). Nurses are strongly positioned to advocate for equity through continuity of programmatic community and health system changes that align with the ACA.

Aligning Nursing Education with Workforce Demand
As healthcare demands and delivery continue to change, the methods and pedagogy in nursing education are challenged to develop curriculums that align with the nursing workforce demand and to increase the diversity among its members. Today's nursing graduates must be prepared to address the social determinants of health (SDOH), promote health equity, and increase the focus on population health (NASEM, 2021). There are three current nursing education accrediting authorities in the United States; the Commission for Nursing Education and Accreditation (CCNE), accrediting BSN, MSN and DNP programs and the Accreditation and the Commission for Education in Nursing (ACEN) and the National League for Nursing Commission for Nursing Education (NLN CNEA), accrediting LPN, diploma BSN, MSN and DNP programs.

The 10 domains and competencies of CCNE's American Association of Colleges of Nursing (AACN) Essentials [for BSN, MSN, Doctoral] Education reflect the uniqueness of nursing practice while aligning with other healthcare professionals providing a common language in the expectations of practice. Within each domain, competency and sub-competencies, educational concepts are weaved to provide the nursing student a core component of knowledge. Clinical judgment, communication, compassionate care, diversity equity and inclusion, and SDOH make up the concept's students learn to apply to their nursing practice. The Essential domains, competencies, and core components of knowledge prepare students to practice across a variety of settings focused on wellness and prevention, disease management, hospice and palliative care and population health (AACN, 2022).

The proposed CCNE standards (AACN Essentials) focus on competency-based education directed at two levels, entry to practice and advanced practice (AACN, 2022). The BSN and entry to practice MSN are included in level one. Level two consists of education for advanced practice nurses, management and administration nursing, and the DNP degree. The AACN Essentials include 10 domains with both competencies and sub-competencies that each level of education must achieve (AACN, 2022). A higher level of competency application is expected for advanced degrees. This competency-based approach to nursing education addresses the knowledge, skills and abilities nurses need to practice safe quality patient centered care. The CCNE's recent proposed updates to the Essentials are leading the charge in nursing education to strengthen nursing curriculum to address quality, safety, diversity, and inclusion and the SDOH (AACN, 2022).

Academic Practice Partnerships
To achieve the goals of the Affordable Care Act and the Future of Nursing Committee, the American Association of Colleges of Nursing (AACN) recommends developing Academic Practice Partnerships (AACN, 2022). Academic Practice Partnerships are collaborative relationships between academia and practice with mutual goals to educate practice ready graduates. Within the Academic Practice Partnership, knowledge and role modeling is shared by practicing nurses, educators, and researchers. Some examples include the development of nurse residency programs, creative clinical experiences, joint funding, research endeavors, new faculty experiences and shared workforce data.

Providing culturally sensitive care continues to be a recommendation of the Future of Nursing Committee (NASEM, 2021). The first step to increasing the diversity of the nursing workforce is to increase the diversity of nursing's student body. The National Council of State Boards (NCSBN) (AACN, 2019) 2017 survey reported only 19.2% of the nursing workforce as ethnically diverse and only 9.1% of the workforce is male. One approach to increasing the diversity in nursing education is to apply a Holistic review as the admission standard (ANA, 2022). The holistic review or holistic admission process is comprised of an admission policy that aligns with the academic programs mission and goals and considers more than grade point average and performance on standardized tests. Some examples of other factors that are included may be essays about overcoming a personal challenge, volunteer activities, shadowing in the healthcare community and personal goals. According to the National Institute on Minority and Health Disparities (Urban Universities for Health, 2014) 67% of health professions schools now use a holistic admission process that has increased the diversity of their students admitted by an average of 72%. (Urban Universities for Health, 2014).

Supporting the Health and Well-being of Nurses
Building and sustaining the health and well-being of nurses is critical to quality and safety for patients.Building and sustaining the health and well-being of nurses is critical to quality and safety for patients. Before the pandemic, the American Nurses Association (ANA) Health Risk Appraisal (2017) reported that 82% of nurses surveyed had experienced a "significant" amount of stress, about half reported being bullied, and nearly 30% of the had an average BMI in the overweight category (NLN, 2016). The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity prioritizes the health and well-being of all nurses by implementing a commitment to systematic changes that support evidence-based interventions. Achieving this priority was extremely challenging during COVID-19. During these unprecedented times, nurses reported high levels of stress, depression, anxiety, insomnia, and compassion fatigue and moral distress (Munro et al., 2022; Hofmeyer et al., 2020; Hossain et al., 2021). The increased stress, workload, emotional and physical burden of caring for COVID patients, and lack of available support and self-care has resulted in nurses leaving acute care positions, becoming travel nurses, or leaving the profession all together. The reduced numbers and health of the nursing workforce undoubtedly impact the safety and quality of patient care.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity recommends the implementation of NASEM's Systems Model of Burnout and Wellbeing to address the health and wellbeing for nurses (NASEM, 2021). This model includes a three-level approach to wellness; (1) the external environment and includes the healthcare industry, laws, regulations, and standards, (2) healthcare organization's leadership, management, and approach to governance, and (3) the individuals involved in the frontline delivery of care. First level approaches include the Dr. Lorna Breen Healthcare Provider Protection Act, passed in February 2022, to provide grant funding for education and training in mental well-being for health profession students, residents, or healthcare professionals (American Hospital Association, 2022). Funding covers education, peer-support and mental and behavioral health treatments and research.

Nursing organizations are also a level one approach to the health and wellbeing of nurses. In response to the American Nurses Association's (ANA) Health Risk Appraisal (2017) findings and nurses’ responses to pandemic care, the ANA drafted an interpretative statement from the ANA's Nurses Code of Ethics: Provision 5: Self-Care and COVID-19 (2020). The ANA underscores the moral obligation for employers and nurse leaders to provide opportunities and support for the self-care of the nursing workforce and a safe work environment. The work of professional organizations give voice to the demands of nursing that ultimately impacts patient care.

Employee wellness programs are second level approaches at the organizational level. According to the Center for Disease Control and Prevention (2020), 83% of US hospitals offer wellness programs, 63% offer health screenings and 31% have health coaches. The success of these programs is largely related to participation. While many benefit packages include financial incentives for participating in a wellness program, nurses, especially during COVID-19, have lower participation than other professions (Ogilby, 2022). In a recent study, critical care nurses were offered self-care programs. One site required all nurses to attend the self-care program and reimbursed them for their time. After the program, 77% of the nurses reported the program "met their needs to restore" and 87% would recommend the program to other nurses (Ogilby, 2022). A similar self-care program offered at a second site included voluntary participation and only one nurse completed the full program (Ogilby, 2022). While nurses are knowledgeable of the benefits of self-care and wellness, work-life balance must be a priority for nurse managers to support their staff and maintain the nursing workforce.

Nurses working on the frontline delivery of care are directly impacted by the workplace environment, actions, and interaction of the healthcare team and patient care technologies. During the height of COVID-19, unsafe work assignments, long hours, and inadequate supplies of PPE were routine. Provision 5 of the ANA's Code of Nurse Ethics (2020) addresses unsafe assignments and work environments and calls on nurses to use their collective voices to lobby for change. Working in persistently stressful situations can lead to actions of incivility and bullying. Incivility in the clinical environment can compromise nurse's self-confidence and clinical decision making resulting in medical errors that harm patients and the results of bullying can result in poor patient satisfaction (Clark, 2019). Nurse leader Dr. Cynthia Clark (2019) provides training to improve the workplace environment by educating nurses on navigating, preventing, and stopping workplace incivility and bullying at all levels.

Conclusion

When the ACA became law, great steps were taken to reduce healthcare expense, improve access to care, and provide for equity in healthcare. Over the 12 years that followed, nurses experienced unprecedented challenges and changes in healthcare. Nursing practice and education continue to develop to meet these challenges. Nurses have responded by innovating models of care delivery, researching patient and nurse responses to changes and innovation, and leading others in recognizing the importance of addressing the social determinants of health. The profound impact of nurses is felt beyond hospitals and clinics. Nurses are influencing decision making in community planning, classrooms, and across the continuum of care. The future of healthcare is being determined by nurses who remain courageous, bold, and responsive to the policy, legal, and regulatory requirements that surround caring for patients, educating the next generation, and caring for each other. Nurses belong everywhere important decisions are made because they are uniquely prepared to solve complex problems amid complicated circumstances. As such, nurses must remain influential in charting the path to efficient and effective health reform.

Authors

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

Kimberly Cleveland is an associate lecturer in the Nursing and Health Care Management Concentration, Coordinator of Undergraduate and Graduate Health Care Policy, and Co-Coordinator of the Undergraduate Nursing Honors Program at Kent State University College of Nursing. She practices law as a solo practitioner, concentrating in healthcare issues, professional licensure, and choice of business entity. Kim is licensed to practice law in the state of Ohio and the United States Supreme Court and is a PhD candidate in the College of Education Health and Human Services at Kent State University. Nurse-Attorney Cleveland is an international and national speaker and consultant on health reform, health law, nursing leadership and health policy. She is co-principal investigator in funded research examining anxiety and resilience in nursing students during the COVID-19 pandemic. She is a co-investigator in funded research examining the role of nurses on governing boards. Kim is the board chair for the Nurses on Boards Coalition where she represents the American Association of Nurse Attorneys. She also is a committee member for the National League for Nursing public policy committee.

Tracey Motter, DNP, MSN, RN
Email: tmotter2@kent.edu

Tracey Motter is the Associate Dean at Kent State University College of Nursing in Kent, OH. During her tenure at Kent State, she has received numerous teaching awards at the college, university, and national level and has received national workforce development funding to increase diversity in nursing. Dr. Motter is also a co-investigator in funded research on interdisciplinary end of life care. Her area of interest for research is in nurses’ self-care and resiliency, transition to practice, and preparing nurses to be leaders in providing quality cost-effective healthcare. She is a member of Sigma Theta Tau and the American Nurses Association.

Pamela Rudsill, DNP, RN, MSN, NEA-BC, FAAN, FAONL
Email: pam_rudisill@chs.net
ORCID ID: 0000-0002-3573-937X

Pamela Rudisill is Senior Vice President and Chief Nursing Officer at Community Health Systems (CHS). In her role, she supports nurses with quality, safety, patient experience, and nursing workforce resources as they deliver patient care across more than 80 affiliated hospitals in 16 states. Pam serves as the board emeritus for NOBC. Her other memberships include the AONL, where she served a term as president in 2010; American Academy of Nursing being inducted as a Fellow in 2011. She has published extensively in nursing literature and has spoken at national healthcare seminars throughout the United States. Pamela has earned certification as a Board Certified Nursing Administrator Advanced (NEA-BC) through ANCC. Pamela received her Doctorate in Nursing Practice from Duke University. In 2019 Pamela was an inductee as a Fellow in the inaugural class of the American Organization for Nursing Leadership (FAONL).

Laurie Benson, BSN
Email: laurie@nursesonboardscoalition.org

Laurie Benson serves as the Executive Director, Nurses on Boards Coalition, whose mission is to improve health in communities through the service of nurses on all types of boards. She is a successful Co-Founder and former CEO of a technology systems integrator. She has served on both public and private corporate boards in the technology, finance, insurance, engineering, commercial real estate, manufacturing, and services industries as well as numerous non-profit boards focused on entrepreneurship, transforming healthcare, and honoring and advancing nurses and the profession of nursing.