Running head: THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 1
The Affordable Care Act: Funding for Primary Care Training and Implications for Practice
Jonathan D. Brouse
THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 2
The Affordable Care Act: Funding for Primary Care Training and Implications for Practice
Introduction: The U.S. Primary Care Provider Shortage
Fundamentally, for the United States (U.S.) to build, implement, and sustain a high-
performing health care system envisioned by the Affordable Care Act (ACA), existing
provisions to bolster primary care provider supply must be fully funded and evaluated (Schwartz,
2011). Since its inception, the ACA has expanded health care access to millions in America,
thereby generating significant downstream impact upon demand of primary care physicians,
physician assistants (PAs) and nurse practitioners (NPs) alike (Allen et al., 2013). Nationally, an
expected shortage of 91,500 physicians is projected to occur by 2020 (Allen et al., 2013).
Meanwhile, Aiken (2011) noted that nursing programs have dismissed tens of thousands of
qualified applicants on account faculty shortage juxtaposed with budgetary constraints. Without
a dramatic increase to the US primary care workforce, cost containment, improved quality, and
enhanced provider access will not be achieved (Schwartz, 2011).
Although US Congressional efforts to dismantle or defund the ACA place the health
reform law at risk, the insidious threat of a primary care bottleneck exists (Schwartz, 2011).
Presently, the U.S. Health care delivery is plagued by a confluence of systemic challenges facing
the core of its primary care capabilities (Naylor & Kurtzman, 2010). Continued pressures
mounting from gaps in quality outcomes to increasing patient acuity, compounds concerns
regarding workforce adequacy in addition to resultant lags of quality (Naylor & Kurtzman,
2010). Likewise, health care consumption will be spurred by the impending “silver tsunami” of
80 million Americans retiring over the next two decades as expanded coverage is set to newly
integrate 32 million Americans (Schwartz, 2011). Finally, Naylor & Kurtzman (2010) note,
“Questions regarding the value of the primary care system, as evidenced by the performance on
THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 3
numerous economic indicators, health outcomes, and multiple dimensions of patients’
experience, have been raised, especially in comparison to other developed countries” (p. 295).
Disregarding ACA provisions, it is expected that the primary care demand will increase
by 29% starting in 2005 and leading up to 2025 (Schwartz, 2011). Since 2011, 80 million baby
boomers joined the Medicare-eligible ranks, while this “silver tsunami” increasingly adds 10,000
per day through the year 2029 (Schwartz, 2011). Since 2002, medical schools have expanded
efforts to meet the projected need and have grown class sizes by 18%; yet, the shortfall continues
(Allen et al., 2013). Further, Naylor & Kurtzman (2010) underscores the point that, “gaps in
quality care accompanied by workforce shortage that threaten the provision of services” (p. 894).
Hence, the primary care shortage is likely to experience a perplexing bottleneck to realizing a
successful and optimal ACA implementation, resulting in millions of Americans disillusioned by
the unmet promise of system access despite coverage (Schwartz, 2011). Even with expanded
provisions to the 3P’s of primary care policy (pipeline, practice, and payment reform) within the
ACA, present funding and efficacious implementation remains susceptible unless greater strides
to rebuild the primary provider workforce occurs (Naylor & Kurtzman, 2010).
Affordable Care Act Provisions for Expanding Primary Healthcare Providers
On March 23, 2010, President Obama signed the historic legislation known as the Patient
Protection and Affordable Care Act (ACA), which represented the most profound transformation
of the U.S. healthcare system since the inception of Medicare and Medicaid (Manchikanti et al.,
2011). According to Allen et al., (2013), the ACA presents a new element to the pursuit of
expanding primary care provider supply. In meeting the envisioned goals of maximizing
efficiency, quality, and cost-containment, many hospitals throughout the U.S. are strategically
aligning into integrated health systems; yet, this alignment process entails assimilating physician
THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 4
practices, which results in fewer independent physician practices and hospitals (Allen et al.,
2013). To that end, “some plan to become or align with accountable care organizations
(ACOs)—the defining organizational structure under the ACA, designed to reduce cost while
improving quality, safety, and efficiency” (p. 1862).
The ACA: Attending to the Primary Care Provider Shortage - Implications for Nursing
Granted the urgency to dramatically bolster the primary care workforce overall, greater
pecuniary support is required to expand the pipeline of primary care providers, including
advanced-practice registered nurses (APRNs) (Naylor & Kurtzman, 2010). To help ensure
sufficient primary care access as new coverage expands to millions of Americans, the ACA
provides significant investments that further expand the role of APRNs and PA’s alike (Paradise,
Dark, & Bitler, 2011). On September 27, 2010, the U.S. Department of Health and Human
Services (HHS) indicated that initial grant awards provisions
On the surface, the education of nurses may seem less pressing than ensuring care for
millions of Americans in a manner that is efficacious, safe, and affordable for all (Aiken, 2011).
However, Aiken (2011) cautioned that, “if we don’t alter the historical patterns of nursing
education, the country’s nursing resources will be crippled for the foreseeable future” (p. 196).
In underscoring the urgency of the faculty shortage, Aiken (2010) added, “Within the next 10
years, half of nursing-school faculty members will reach retirement age; the anticipated attrition
represents a crisis in the making, with potentially far-reaching consequences for the
replenishment of the nurse workforce, which is itself on the verge of losing some 500,000 nurses
to retirement” (p. 196). Fortunately, the ACA has begun to address the nurse faculty bottleneck
that precluded optimal enrollment of qualified students from entering into practitioner roles.
According to Naylor and Kurtzman (2010), the ACA provides relief in that, “it expands
THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 5
eligibility criteria so that faculty at nursing schools qualify for loan repayment and scholarship
programs, and it establishes a federally funded student loan repayment program for nurses with
outstanding debt who pursue careers in nursing education” (p. 897).
Transforming health care for the advanced practice registered nurse (APRN) through the
political process begins with a focused approach upon emphasizing nursing education and
engaging the public in recognizing that nursing care provides an indelible component to quality
care outcomes (Tilden, 2010). Several important implications concerning the role of the
advanced practice nurse in shaping health care policy stem from the 2010 Institute of Medicine
(IOM) Report, The Future of Nursing, which calls for greater emphasis upon improved
curriculum to health policy education. According to the IOM report, a key lesson provided from
the past 2 decades is the degree to which “health systems and policy shape the health both of
populations and individual patients,” (Tilden, 2010, p. 559). Yet, few nursing students fully
appreciate the gravitas of health policy in its ability to not only affect nursing practice, yet, in the
end, direct patient outcomes (Tilden, 2010). Since nursing education curricula often exposes
students to little more than a token policy course, the resultant naiveté of nurse graduates
abounds, as with the perception that “nurses generally view themselves as being shaped by, not
shaping policy” (Tilden, 2010, p. 559).
When compared to the preeminent presence of medicine in driving legislative reform, it
has been well documented that nurses themselves often opt to a back seat policy approach
(Tilden, 2010). Later Tilden (2010) indicates that missed stakeholder opportunities to shape
policy are alarmingly common to the nursing profession. Nowhere is this more prominently
evidenced than within the Centers for Medicare and Medicaid Services (CMS) stipulation that
withholds reimbursement for “never events” (e.g., pressure ulcers, injuries, surgical site
THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 6
infections, and catheter-related infections). Despite these conditions being preventable by means
of nursing intervention, the profession has yet to convince an American public or Congress, of its
vital importance to both the protection from and prevention of such health risks (Tilden, 2010).
In rectifying the “outgrowth of the inattention” facing nursing curricula to the matter of
health policy and the nursing profession, it is necessary to visit the recommendations placed
forth by the Health People Curriculum Task Force (Association for Prevention Treatment and
Research [APTR], 2014). This panel consisting of multi-disciplinary health specialties including
medicine, PAs, nursing, pharmacy, and representative educational associations contributed four
following domains quintessential to health policy curricula and instruction:
1. “Organization of clinical and public health systems (concerning the pieces of the
system; concerning clinical care to public health structures)”
2. “Health Services financing (underlying determinants of cost and options for payment
and cost containment; comparison to health systems of other countries)”
3. “Health workforce (understanding the roles and responsibilities of other health
4. “Health policy process (introduction to the impact of policy on health and clinical
care, the process involved in developing policies, and opportunities to participate in
those processes, whether within a local institution or state or federal legislation)”
(Allan et al., 2004).
As emphasized in the preceding points, adequate health policy curricula is needed at every level
of nursing education. Yet, at the graduate level, APN students “need to be actively involved in
political processes that affect the care they will deliver in the future” and therefore, educational
experiences should suffuse a hands-on approach along with explicative learning experiences
THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 7
(Tilden, 2010, p. 561). To that end, an example curriculum objective for APN students includes
expecting students to demonstrate the link between evidence and policy (i.e., discerning the role
APNs perform in illuminating practice issues and garnering attention of policy creators).
Finally, interprofessional groups can collaboratively engage students together in directing policy
projects (Tilden, 2010).
Pros and Cons of the ACA Legislative Provisions in Addressing Primary Care Shortage
Commentary - Scope of Problem and Fulfilling the Promise of Improved Primary Care
First and foremost, sustaining meaningful efforts to drive ACA’s patient-directed goals of
effective, accessible, quality-outcomes based care rests upon ensuring an expanded pipeline to
primary care practitioners (Jacobson & Jazowski, 2011). Doing so relies in part upon channeling
public funding for nurse education in order to steer change in healthcare delivery according to
the IOM’s recommendations (i.e., streamlining efficient pathways to obtain further advanced
education after initial licensure) as this will lead to greater potential for optimal outcomes
(Institute of Medicine [IOM], 2011).
Furthermore, a combination of financial resources via public and policy-driven initiatives
Great strides to nursing education are required, from inclusion of greater health policy
curricula to producing graduates with requisite nursing acumen to practice safely and effectively.
While there will be inherent challenges to adapting entrenched paradigms to nursing curriculum
and instruction, it is possible to create inroads to existing models of nursing education (APTR,
2014). By structuring content around knowledge, related competencies including policy-related
THE AFFORDABLE CARE ACT: FUNDING FOR PRIMARY CARE 8
learning opportunities, students can master requisite legislative techniques to play important
policy stakeholders in order to influence both practice and ultimately, patient care outcomes
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