IntroductionHealthcare costs in the U.S. are higher than any other country in the world. This paper examines the numbers behind America’s massive healthcare expenditure from a macro perspective, in addition to highlighting the provisions within the Affordable Healthcare Act (ACA) aimed at containing these costs. A complex policy, the ACA is not without its challenges, however data reveal that the policy has gone far in terms of increasing healthcare access, affordability, and equity. As the ACA rapidly changes the healthcare landscape, this paper also analyzes the impact of legislation on nursing models of care and ratios.

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U.S. Healthcare Costs and ACA Provisions
The current cost of healthcare per person in the United States is $9,255, making the U.S. number one in health care expenditure globally (“CDC: Health Expenditures,” 2014). National health care costs ballooned to $2.9 trillion in 2013, with healthcare expenditure making up 17. 4 percent of the Gross Domestic Product, the CDC reports. Americans spend more than twice as much per capita on healthcare than five of the top developed countries. For example, the UK spends $3, 235 per capita on healthcare, Japan — $3, 713, Australia — $3, 866, France – $4, 124, and Canada — $4, 351 (“Per Capita Healthcare Costs — International Comparison,” 2015).
Of the total U.S. health expenditure in 2013, 32.1 percent was spent on hospital care, 5.3 percent on nursing home facilities, 20.1 percent on physician and clinical services, and 9.3 percent for prescription drugs.
The Affordable Care Act Provisions Designed to Contain Costs
Signed into law in 2010 by President Barack Obama, the Affordable Care Act (ACA) contains several provisions designed to contain the rising costs of healthcare in the U.S. According to the White House’s Economic Report of the President, provisions to control healthcare costs include: Expanding coverage, pay-for-performance programs, strengthened care coordination, and Medicare payment reforms (“Economic Report of the President: Chapter 5,” 2013).
The White House projects that the ACA will expand coverage to 27 million by 2022. Further, the pay-for-performance program, also known as the “The Hospital Value-Based Purchasing Program” gives more than 3,500 hospitals cash bonuses or penalties based on the level of care delivered, the White House reports (2013, p. 175). The ACA also works to strengthen coordination of care through the Comprehensive Primary Care (CPC) initiative and the roll-out of Medicare payment reform.
Will the ACA Increase Access, Equity and Affordability?
So far the ACA has made progress in expanding coverage and increasing equity, affordability, and social justice in vulnerable populations. As of March 31, 2015, 10.2 million Americans have acquired active coverage through the ACA’s Health Insurance Marketplace, and a total of 16. 4 million uninsured now have coverage (“The Affordable Care Act is Working,” 2015). Many of the newly insured are low-income and young people. In addition, 28 states and the District of Columbia have extended Medicaid and CHIP to 12.3 million people. With its Medicaid-payment reform, four million people have received care through more than 250 Accountable Care Organizations participating in the Medicare Shared Savings Program and other Medicaid/Medicare projects, The White House reports (2013, p. 177). Further, insurance costs $100 or less after tax credits for at least 80 percent of people in the Healthcare Marketplace. Other surveys show that fewer Americans are struggling to pay medical bills and expenses, (“The Affordable Care Act is Working,” 2015). Furthermore, ACA’s “Patient’s Bill of Rights” is making in impact in social justice by ensuring coverage no matter a patient’s health condition or financial standing. In an effort to protect patients, the bill bans the pre-existing condition exclusion for children under 19, extends coverage for children of insured parents, and prevents insurers from arbitrarily canceling coverage (“About the Law,” 2015).
Staffing Models and the Importance of Advocacy
As the ACA emphasizes cost control and quality care, advocacy for consumers and the nursing profession in the political process is even more critical. With 3.4 million registered nurses (RNs) in the U.S., nurses make up the largest single group of health care professionals (“Advocacy – Becoming More Effective,” 2016). Nurse advocacy in legislation is vital. Throughout the rapidly evolving healthcare landscape, nurses continues to be the great link of care between doctors and patients, and carry a brunt of the responsibility for improving outcomes. That’s why the American Nursing Association (ANA), a major advocate, actively monitors and takes action concerning more than 1,000 nurse-related pieces of legislation.
Currently, inpatient nursing care is based on four traditional models of care. They include:
Patient-focused care – RNs manage care with unlicensed assistive personnel  (UAP)
Functional and team care — RN leads a team of LVNs/UAPs  to perform tasks
Total patient care and primary nursing – An all-RN staff delivers direct care; RN manages care throughout the patient’s day
Shared governance – MD-RN collaboration; RNs and managers have shared decision-making (Seago, 2008)
Already, the ACA is having a big impact on nursing staffing plans and ratios. A key example of this is ACA’s Hospital Readmissions Reduction Program (HRRP)  which penalizes hospitals excessive 30-day readmissions for heart patients on Medicare. This directly impacts nurse staffing and ratios, as the demand on nurses to manage care increases. In fact hospitals that increase their nurse-to-patient ratio significantly lowers the readmission rate of Medicare heart patients, which then reduces the risk of being penalized — a new study by the University of Pennsylvania School of Nursing found (“Higher Nurse Staffing Levels Associated With Lower Odds of Readmission Penalties,” 2013). By increasing the nurse-to-patient ratio, hospitals are able to reduce the workload on each individual nurse, thereby helping nurses work more effectively. For every extra nurse-hour per patient-day, the hospital lowers the risk of being penalized under HRRP by 10 percent (“Higher Nurse Staffing Levels Associated With Lower Odds of Readmission Penalties,” 2013). The HRRP and other legislation are having a notable impact on nurse staffing and ratios.
Future Staffing Models
Increased regulation through the ACA will impact the ever- evolving staffing models for health care delivery. The law’s effort to control costs will require health care providers to improve its leadership and innovate within the models. Staffing models that allow RNs in particularly to better coordinate care, make decisions, and manage care throughout the patient’s day can only enhance delivery. In order for this to happen, a patient-centered, primary and total patient care model must replace the functional and team model.
With the U.S. facing massive costs and challenges in healthcare, the ACA promises to enhance efficiency and manageability for providers and patients overall. The effectiveness of the policy to contain costs and improve care will be determined by the evolving practices of health providers and insurers. Innovating nursing and related staffing models are critical to the success of the ACA legislation. Enhanced staffing models can help curtail the overutilization of resources in hospitals and doctor’s offices. Looking toward the future, nurses and healthcare consumers will require a new level of advocacy in the political process to best guide ACA’s implementation.

  • “About the Law.” 2015. U.S. Department of Health & Human Services. Retrieved January 27, 2016 from
  • “Advocacy – Becoming More Effective.” 2016. American Nursing Association. Retrieved January 29 from:
  • Seago, Jean Ann, Ph.D., RN. (2008). “Chapter 39. Nurse Staffing, Models of Care Delivery, and Interventions.” University of California, San Francisco School of Nursing. Retrieved January 28, 2016 from: