The Affordable Care Act and Its Future Paradigm


The present paper is devoted to the discussion of healthcare policy development, implementation, and its relation to healthcare professionals and uses the example of the Affordable Care Act. Access to affordable healthcare has been an ongoing problem for the United States health system, and the coverage options were expected to improve as a result of the Patient Protection and Affordable Care Act of 2011 (ACHE, 2016). Initially, the Act coverage was expected to extend the Medicaid to thirty-two million of uninsured people. However, the decision by the Supreme Court has reduced the number of newly covered individuals by stating that the Medicaid is a state option. Healthcare reform has now reduced the number of those uninsured and defined mandated benefits (see fig. 1).

The percentage of uninsured population in the US, 2006-2014.
Figure 1. The percentage of uninsured population in the US, 2006-2014.

Based on the US Census Bureau (2016) data. The year of the Affordable Care Act implementation (2010) is highlighted.

The problem at this point is that access to affordable care is exacerbated by the limited community-based resources that provide preventative services, primary care access, and ongoing care for patients with chronic conditions (Orentlicher, 2014). With more people with coverage, expectations of what is covered and what is not are not clearly defined. Lack of medical education and experience may lead to expectations that are not reasonable or possible medically. As discussed in Orentlicher (2014), outcomes may lead families and patients to have unreasonable expectations and false hopes of what the system can offer. The future paradigm of The Affordable Care Act intends to address the remaining issues to extend affordable medical help to all (Hood, 2012).

The following paper will identify the main aspects of the issue of unaffordable healthcare based on the latest evidence from scholarly sources and provide position statement to support the proposed policy solution to the existing problem. Apart from that, it will consider various aspects of policy development and implementation while paying special attention to ethical considerations and the role of organizations and healthcare professionals.

Health Care Issues

Healthcare policy is a complex phenomenon that is being realized at the international, national, local, and institutional levels. The World Health Organization (WHO) is probably the most important organization for the first level; it can provide suggestions, advice, and create policies that national healthcare policy may include or not. Unfortunately, the WHO policy cannot have the status of legislation in a particular country (World Health Organization, 2016), while the national policy is often regulated by the law (for example, the Affordable Care Act).

In the US, the relationships between the federal and state laws are supposed to be regulated by the Constitution, and the federal preemption of state legislation is a possibility, but an unwanted one (National Governors Association, 2015). National (federal and state) laws (as well as recommendations and policy requirements) are supposed to be adhered to by local institutions, but most often the latter are allowed a certain degree of freedom in defining their policy as long as it does not conflict with the national one.

It is apparent that of the three levels, the national policy has the greatest influence on modern healthcare, but in effect, all the levels are of importance both for the development and the implementation of policy. For example, the universal insurance coverage is a controversial topic: there are numerous arguments that defend and criticize it (Bodenheimer & Grumbach 2012), and the experiences of various countries provide evidence suitable for either view (White, 2013).

The accumulation of international experience gives ground for international policies as well as national ones. At the same time, the criticisms of the healthcare professionals who have the first-hand experience of the changes that reforms bring to institutions provide the ground for the development of national policy, which can eventually affect the international one (Gardner, 2014). Thus, policy-making is interwoven with its implementation, and the coordination of the entities working at every of the levels allows handling complicated issues like the universal coverage idea.

In the US, the universal coverage is still not achieved, and it remained the last industrialized country in the world that refused to guarantee basic care for every citizen until 2010 (Bodenheimer & Grumbach 2012). However, the introduction of the Affordable Care Act is meant to bring this achievement closer.

Socio-Political and Economic Context of Policy-Making. Ethical Issues

The preparation of healthcare policies is always concerned with the analysis of the context and the consideration of ethical issues. In the case of the Affordable Care Act, it may be guided by these two aspects. The problem of unaffordable healthcare remains one of the most complicated ethical and legal issues in the U.S. healthcare system. Healthcare services in the USA are quite expensive compared to other countries around the globe, and according to the opinion stated by multiple specialists in the area, the prices are unjustifiably high (Sommers, Buchmueller, Decker, Carey, & Kronick, 2013).

The outcome is quite sad for millions of Americans, which can be seen from the following comment by ACHE (2016), “the U.S. Census Bureau report noted approximately 49 million Americans did not have healthcare coverage in 2011” (para. 1). In reality, this sad statistics means that millions of people go to the healthcare facility only when it is too late, and few chances to achieve the positive outcomes remain (Sommers et al., 2013).

Apart from that, it is apparent that the provisions of the Act are primarily aimed at the reduction of healthcare disparities, that is, the differences between the level of accessible health care and health among the population of various groups. It is a form of discrimination that, unfortunately, is part of the modern socio-economic context of the US. The indirect and direct consequences of healthcare disparity can lead to severe economic losses that have been estimated to the annual amount of $309 billion in the US (Kaiser Family Foundation, 2012, para. 2).

Apart from that, it is ethically problematic, especially for the healthcare professionals who are caught between the pledge to provide care to those who need it and the impossibility of providing it to those who need it the most (Bodenheimer & Grumbach, 2012).

The data from the US Census Bureau (2016) can be used to demonstrate the existing disparities. Fig. 2 presented below shows the most apparent disparity that can be found among the populations belonging to different races. However, other bases for healthcare disparities include gender, age, marital status, education, employment, and even geography. For instance, the population of the south of the US remains underinsured when compared to the northeast the US Census Bureau (2015).

The percentage of uninsured population in the US by race (including White, Black, Hispanic), 2013-2014.
Figure 2. The percentage of uninsured population in the US by race (including White, Black, Hispanic), 2013-2014. Based on the US Census Bureau (2016) data.

It should be pointed out, though, that apart from combating an ethical issue, the Act has also led to the development of one. The people who do not wish to participate in the national insurance program are no supposed to pay fines that have been rising steadily (U.S. Centers for Medicare & Medicaid Services, 2016). This part of the Act was called unconstitutional (as it can be interpreted as limiting the freedom of choice), but it was deemed necessary to ensure the funding of the reform (Faria, 2012).

This aspect appears to be an example of the government making some unethical choices in the process of policymaking. In this case, the US government chose the lesser evil of introducing another fine or tax to keep the reform running and to let it reduce the disparities that healthcare proceeds to exhibit.

Limitations and ongoing issues

Controversies in the legislative system make the problem of unaffordable care more complicated because despite the efforts of the government to cover around 32 million of uninsured people more with the provisions made by Affordable Care Act of 2011, the Supreme Court decision regarding assigning the state status for Medicaid has minimized the benefits of this historic decision made by Obama (Hood, 2012).

However, the scale of the problem of healthcare affordability is so large that even full implementation of Affordable Care Act of 2011 will not cover the existing gaps. Addressing my position as for this complex issue, I fully agree with the vision expressed by ACHE (2016) in the following statement, “no person should be denied necessary healthcare services because of an inability to pay or a lack of accessible services” (para. 5). In addition, I support the point of view stated by ACHE that healthcare executives have the key role in helping the vulnerable populations acquire the healthcare assistance they need.

Position Statement

The US government has made its position statement, and it consists in moving towards universal coverage. Similarly, the Universal Health Coverage Statement from the WHO declares the objective of over 500 leading health institutions around the globe to provide affordable and high-quality care for all (World Health Organization [WHO], 2014). This view is not only consistent with medical ethics principles (Bodenheimer & Grumbach, 2012), its significance is also supported by the experience of vaccination, which can lead to the eradication of diseases like smallpox (Henderson, 2011) and generally creates healthier population and safer environment (Andre et al., 2008; Davis & Walter, 2011).

Only high-quality care that is accessible for nearly everyone can yield such positive results, and the U.S. government is striving to share the vision of healthcare for all in the federal law regulating the health care affordability. Reflecting upon the situation in the U. S. healthcare, the definition of the Universal Health Coverage has much in common with the Affordable Healthcare Act objectives. However, evaluation of this act as well as other federal and state legislative norms regulating patients’ access to care along with the coverage issues demonstrates that the exalted objective of quality care for all is not yet realized in the U.S. Still, the situation definitely improved to a certain degree with the Affordable Healthcare Act of 2011 (Sommers et al., 2013).

Implementation Concerns

Unfortunately, the implementation of legislation is a complicated process, and the Affordable Care Act can be used to illustrate this fact. The success of the legislation is moderate because there are multiple issues still left. The remaining issues mostly relate to the vulnerable layers of the population without insurance coverage. Discrimination is among these issues, and the demonstration of racial disparities can be seen in fig. 2. Similarly, the 1990s vaccination in the US that was aimed at combating measles outbreaks covered about 50% of the population, but resulted in noticeable disparities by race (with differences amounting to 8% coverage) and income (11%) (Davis & Walter, 2011, p. 873).

Evaluation of facts demonstrates that our society still has the room to improve in this area, and, of course, the health care professionals have the weighty role in these changes because they need to become its leaders. An example of such successful health care agenda is the Vaccines for Children Program. Although its activities and the general governmental course for disparity reduction, in 2010, no more than 4% disparities existed between racial minorities and economically disadvantaged children (Davis & Walter, 2011, p. 873).

Also, the tendency to the reduction of the uninsured can be seen since the implementation of the Affordable Care Act (fig. 1), and it is apparent, that the year 2014 saw the greatest drop. Fig 2., however, can also be used to see that the changes implemented through the Affordable Care Act and its expansions do reduce the number of uninsured, and the reduction is greater for the disadvantaged (for example, 4.5% for Hispanic and 2% for white). This fact proves that the instruments selected by the government are working despite the implementation issues.

Some of the issues related to the implementation of the Act are of concern for the individual institutions and even healthcare professionals. In particular, the shortage of staff, which had been an issue before the implementation of the Act (Bodenheimer & Grumbach, 2012), is now even acuter. In general, the issues of efficiency, effective spending, funding, and understaffing at the local and organizational levels affect the implementation of the policy. As a result, it is apparent that organizations and individual healthcare providers can and should take the lead and contribute to the policy-making as well as the implementation of changes and the direct improvement of healthcare (Gardner, 2014).

It is true that the healthcare professionals do not have the legislative power to remove the disparities from the U.S. healthcare system. Nevertheless, they can make change by becoming the leaders of change and participating in the legislative process as consultants, initiators of change, and active citizens who are not indifferent to the nation’s future (Sommers et al., 2013). With respect to institutions, healthcare providers can and should be involved in quality improvement programs; they tend to create precedents of best practice, which can be used at various levels of healthcare policy (Tuan, 2014).

Finally, healthcare professionals need to maintain high standards in personal practice and promote the improvement of the quality of healthcare and quality of patients’ lives. For example, educating the patient and their family about care and treatment will continue to be shouldered by the nurses. Orentlicher (2014) has stated that nurses need to help patients clarify perceptions regarding quality of life, and discuss not only how life might be extended, but also how the quality of life may be affected by various options. To sum up, the role of healthcare professionals in achieving the vision of high-quality care for all is crucial.

The Issue Implications to Nursing Informatics

Finally, addressing the implications of the issue under consideration to nursing informatics, it should be noted that this area of nursing has its exalted objective to optimize the process of using patient information to assist the healthcare providers in achieving the optimal patient outcomes and provision of cost-effective care (Collen & Walker, 2015). The role of nursing informatics professionals in solving the issues related to affordable care for all is in increasing their professional potential to continue to minimize the spending and thus ensure better accessibility to care services by the economically-disadvantaged clients (Collen & Walker, 2015).

In addition, it has been suggested that the healthcare costs can be dramatically reduced, which will make it affordable to the representatives of the vulnerable social layers, in case patients are kept out of hospitals provided that the wide scope of care services can be offered to them in their very communities with the use of modern informational technologies (Collen & Walker, 2015). At that, physicians and sometimes even family nurse practitioners will not need to travel to the remote communities. For instance, follow up visits to the primary care providers to monitor the effectiveness of the proposed treatment regime and consult patients can be done with the use of distant communication technologies (Collen & Walker, 2015).

Finally, the quality, as well as efficiency and safety of healthcare and healthcare information exchange, appear to be able to benefit from the use of nursing informatics. For example, the Omaha System has been implemented in institutions all over the US has successfully fulfilled a number of aims. The latter included specifics ones (for example, the program has been used for the evaluation of home visiting programs and the engagement of senior patients in health promotion activities) as well as the goal of overall improvement of patient and community outcomes in a variety of settings and the improved flow of health information. These outcomes were proved by a bulk of studies, including recent research and the evaluations that were carried out at the time of the program’s origin several decades ago (Martin, Monsen, & Bowles, 2011).

Given the fact that funding and efficiency are among the key issues that modern healthcare experiences (Bodenheimer & Grumbach, 2012), nursing informatics adoption and development are of primary importance for the success of the Affordable Care Act.


The analysis of the Affordable Care Act provides an example of the development and implementation of healthcare policy in the socio-economic context of a particular country. In conclusion, it should be pointed out that the problem of unaffordable healthcare continues to be a burning issue for the American society that needs effective policy-making in order to provide more people with an opportunity to lead a quality life and engage in the health promotion activities.

The healthcare reform has reduced the number of uninsured citizens and defined mandated benefits. The problem at this point is that access to affordable care is exacerbated by the limited community resources that provide preventative services, primary care access, and care for patients with chronic conditions. Moreover, with more people covered, the expectations of what services are actually covered are not clearly defined.

It is the task for nursing professionals to work with the community populations they are assigned to work with to educate people regarding the provisions that the Affordable Care Act has made possible for them, and help them to benefit from the available resources to the highest possible extent. The healthcare professionals should not remain indifferent to the well-being of patients by active participation in the policy-making process with the purpose to eliminate the existing limitations. Therefore, the future paradigm of the Affordable Care Act is to ensure that there are no vulnerable population categories with little or no access to the timely and quality healthcare.


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