Haas, Sheila A

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Opportunities for the Uninsured to Access Affordable Health Insurance and Care

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Loyola University ChicagoLoyola eCommonsSchool of Nursing: Faculty Publications and OtherWorks Faculty Publications2013Opportunities for the Uninsured to AccessAffordable Health Insurance and CareSheila A. HaasLoyola University Chicago, shaas@luc.eduThis Article is brought to you for free and open access by the Faculty Publications at Loyola eCommons. It has been accepted for inclusion in School ofNursing: Faculty Publications and Other Works by an authorized administrator of Loyola eCommons. For more information, please contactecommons@luc.edu.This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.© American Academy of Ambulatory Care Nursing, 2013.Recommended CitationHaas, S. "Opportunities for the Uninsured to Access Affordable Health Insurance and Care." ViewPoint, November/December 2013.12 ViewPoint   NOVEMBER/DECEMBER 2013Opportunities for theUninsured to AccessAffordable Health Insurance and CareThere continues to be marked confusion about the sta-tus of the Affordable Care Act (ACA) that was passed in2010. The Republicans in the U.S. Congress have tried torepeal the ACA more than 40 times, and their efforts havebeen unsuccessful. Staunch conservatives have ramped uppressure on Republicans in Congress and the Senate tomake efforts to repeal the ACA before its major provisionsgo into effect in 2014. The results of so many ACA repealsound bites have many Americans thinking the ACA hasbeen repealed, and consequently, some may not have beenusing or seeking benefits, such as private insurance throughstate insurance exchanges. Some say conservatives arehighly concerned that the ACA will be successful providinghealth care access and in cutting costs, thereby creating sat-isfaction with the ACA among voters. This could be a majorissue in the 2016 presidential campaign. The ObamaAdministration has begun to do public service announce-ments and Webcasts to enhance Americans’ understandingof what the benefits of the ACA are and how they canobtain them. Many are concerned that these efforts are toolittle and coming too late in the game. Ambulatory care nurses and other providers in ambula-tory care settings need to be conversant on both ACA ben-efits and how to access and use the state-based insuranceexchanges. Private foundations, such as the Kaiser FamilyFoundation (KFF), have designed their Web sites for ease ofuse and provide many up-to-date issue briefs, slide sets,videos, and analyses that will be summarized in this col-umn. The KFF document “An Early Look at Premiums andInsurer Participation in Health Insurance Marketplaces,2014” (Cox, Claxton, Levitt, & Khosla, 2013) providesinsurance information and tables that spell out actual costsand cost savings for persons with low incomes.The ACA provisions provide the opportunity for individ-uals and families to purchase private insurance coveragethrough new state-based exchanges, also called“Marketplaces,” which opened in October 2013 and offercoverage beginning January 1, 2014. Some states haveopted not to set up their own exchanges, and in thesestates, the federal government will either run the exchangeor work in partnership with the state to create an exchange.“Regardless of whether an exchange is state-run or federal-ly facilitated, enrollees with family incomes from one to fourtimes the federal poverty level (about $24,000 to $94,000for a family of four) may qualify for tax credits that willlower the cost of coverage through reduced premiums, andin some cases, also be eligible for subsidies to reduce theirout-of-pocket costs” (Cox et al., 2013, p. 1). The KFF reportlooks at insurer participation and exchange premiums –both before and after tax credits – for enrollees in 17 statesplus the District of Columbia that have released data onrates or the rate filings submitted by insurers (Cox et al.,2013). Of those presented, 11 states operate their ownexchanges, and seven have a federally facilitated exchange. In January 2014, the ACA will provide three major ben-efits: private insurance at affordable prices, a ban on annu-al limits for coverage, and coverage for those with pre-exist-ing conditions. Plans offered in the state exchanges, as wellas insurance coverage sold to individual and small business-es outside the exchanges, must meet several new regulato-ry requirements (Fernandez/Congressional ResearchService, 2011). The ACA provisions state that insurers mustcover a minimum set of services called “essential healthbenefits.” At a minimum, essential health benefits “mustinclude ambulatory patient services, emergency services,hospitalization, maternity and newborn care, mentalhealth, and substance use disorder services (includingbehavioral health treatment), prescription drugs, rehabilita-tive and habilitative services and devices, laboratory servic-es, preventive and wellness and chronic disease manage-ment, and pediatric services (including oral and visioncare)” (Fernandez/Congressional Research Service, 2011, p.2). Further, insurance carriers must organize plan offeringsinto five levels of patient cost sharing (catastrophic, bronze,silver, gold, and platinum, ranging from least to most pro-tective). Insurers will only be able to vary premiums by age(to a limited extent), tobacco status, geographic region,and family size (Cox et al., 2013).The KFF (Cox et al., 2013) explains considerations thatimpact cost of an insurance premium and offers examples oftypical premiums. Bronze plans cover 60% of health carecosts when averaged across all enrollees, have the most costsharing, and therefore, represent the lowest level of cover-age available through exchanges. Consequently, bronzeplans typically have the lowest premiums; they vary signifi-cantly across geographical areas and by age but are also sig-nificantly reduced by subsidies for low-income populations.Catastrophic plans will be sold on the state exchanges, butwill only be available to people who are under 30 years ofage or would have to spend more than 8% of their house-hold income on a bronze plan (Cox et al., 2013).What impact will state insurance exchanges have onpremiums for individuals and families who do not qualityfor subsidies? A recent New York Times article highlights,“State insurance regulators say they have approved rates for2014 that are at least 50% lower on average than thosecurrently available in New York. Beginning in October, indi-viduals in New York City who now pay $1,000 a month ormore for coverage will be able to shop for health insurancefor as little as $308 monthly. With federal subsidies, the costwill be even lower” (Rabin & Abelson, 2013).View health care reform resources online at:www.aaacn.org/health-care-reformcontinued on page 1414 ViewPoint   NOVEMBER/DECEMBER 2013Charlene Morris, MSN/ED, RN,is the Coordinator for SupplementalStaffing at Virginia CommonwealthUniversity Health Systems inRichmond, Virginia, and supportsover 70 ambulatory care practices.She trains and supervises staff toensure that competent and skillednurses provide excellent care topatients and families in their variouscomplex clinics.As a new AAACN member thisyear, Charlene has realized that the strength of AAACN is itsknack for developing leaders while maintaining ongoingsupport of their delivery care model in ambulatory care.AAACN and its leaders strongly embrace nurse empower-ment and autonomy through its values. She is scheduled totake the ambulatory care certification exam shortly, and hasbeen reviewing the Core Curriculum for Ambulatory CareNursing and the Scope and Standards of Practice forProfessional Ambulatory Care Nursing – these have beenresources for practice and her upcoming certification.According to Charlene, what she likes most aboutworking in ambulatory care is “living the important transi-tions of cultural diversity and partnerships between thenurses, family, community, and health care providers toensure that the best and most accessible care is provided.”Her job satisfaction is stimulated by the positive feed-back from patients, families, and research that provides evi-dence-based support to bring about change and betteroutcomes. This positive feedback also enhances staff satis-faction with their peers and colleagues.Charlene’s biggest challenge as a nurse is staffing herorganization’s complex, high-volume clinics. She is respon-sible for finding the right staff mix to achieve effective out-comes while supporting their multidisciplinary teams.Selecting the proper staff mix requires assurance of compe-tency and training. She is also challenged to create the beststaffing plan that helps to reduce nurse burn out and dissat-isfaction in the workplace.On a personal note, Charlene enjoys spending timewith her 16-year-old son, family, and community. Sheenjoys reading, watching her son play basketball, and par-ticipating in community outreach. Her future plans are tobegin teaching in spring 2014 as a nursing instructor at acommunity college. Teaching full-time and working as alegal nurse consultant is her ultimate goal as she continuesto grow and learn in her current leadership role.Deborah A. Smith, DNP, RN, is an Associate Professor, GeorgiaRegents University (formerly Georgia Health SciencesUniversity), College of Nursing, Augusta, GA, and Editor of the“Member Spotlight” column. She can be contacted atdsmith5@gru.eduCharlene MorrisThere are several other resources available on Web sites.The U.S. Department of Health and Human Services(DHHS) (2013) offers on its Web site the opportunity toclick on a state to learn about current insurance statisticsand benefits available. KFF (n.d.) offers a subsidy calculatorthat can assist patients with determining what level of sub-sidy they may qualify for when purchasing health insuranceat a state insurance exchange. The National Association ofInsurance Commissioners (2010) offers on its Web site anexcellent set of frequently asked questions (FAQs) by con-sumers and employers with very concise answers. This FAQsite can be used as a resource to inform providers and beshared with patients and families. Ambulatory care nursesare only too aware of the need for reasonably priced healthinsurance for patients and families. The United States final-ly has an Act, the ACA, that offers the opportunity for accessto health insurance and health care, but we must do muchmore to spread the word and assist patients and familieswith this new opportunity. Sheila Haas, PhD, RN, FAAN, is a Professor, Niehoff School ofNursing, Loyola University of Chicago, Chicago, IL. She can becontacted at shaas@luc.eduReferencesCox, C., Claxton, G., Levitt, L., & Khosla, A. (2013). An early lookat premiums and insurer participation in health insurance mar-ketplaces. Retrieved from http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-participation-in-marketplaces.pdfFernandez/Congressional Research Service. (2011, January 3).Grandfathered health plans under the Patient Protection andAffordable Care Act (PPACA). Retrieved from http://assets.opencrs.com/rpts/R41166_20110103.pdfKaiser Family Foundation (KFF). (n.d.). Subsidy calculator: Premiumassistance for coverage in exchanges. Retrieved fromhttp://kff.org/interactive/subsidy-calculatorNational Association of Insurance Commissioners. (2010). Healthcare reform frequently asked questions (FAQ). Retrieved fromhttp://www.naic.org/index_health_reform_faq.htmRabin, R.C., & Abelson, R. (2013, July 16). Health plan cost forNew Yorkers set to fall 50%. New York Times. Retrieved fromhttp://www.nytimes.com/2013/07/17/health/health-plan-cost-for-new-yorkers-set-to-fall-50.htmlU.S. Department of Health and Human Services (DHHS). (2013).How the health care law is making a difference for the people ofIllinois. Retrieved from http://www.hhs.gov/healthcare/facts/bystate/il.htmlHealth Care Reformcontinued from page 12Core Curriculum forAmbulatoryCare NursingThird EditionCandia Baker Laughlin, MS, RN-BCEditorAvailable now!The Core Curriculum for AmbulatoryCare Nursing (3rd ed.) is for sale inthe AAACN online store. Memberssave $20 and can earn over 30 FREEcontact hours! See www.aaacn.org/core for details.

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