Experts estimate the Patient Protection and Affordable Care Act of 2010 (ACA) will extend health coverage to more than 30 million Americans and alter care-delivery models to focus on remaining healthy and managing illness before it becomes acute. How will the healthcare workforce treat these new patients and implement this new paradigm?
Title V of the ACA includes more than 40 provisions to support, increase and encourage innovation in the healthcare workforce. From student loans, training grants, and employee retention programs, to expansion of health centers and innovative pilot programs for both training and care delivery, the law casts a wide net to accomplish its intent of increasing the healthcare workforce's capacity to care for more patients in more proactive ways.
"There is a lot in [the ACA] that would help us boost our workforce, particularly in allied health professions," said Mollye M. Demosthenidy, JD, clinical assistant professor in the department of global health systems and development at the Tulane University School of Public Health and Tropical Medicine in New Orleans. "It was a major step and very important that they included those incentives for workforce development and training. Do we have the capacity to train the number of people we need to train? The law takes a forward-thinking approach."
Scholarships and Loan Repayment
One of the ACA's primary mechanisms for increasing the number of providers, especially in areas where need is high, is through additional funds to the National Health Service Corps (NHSC). This 40-year-old program, administered by the Health Resources and Services Administration (HRSA), offers providers financial, professional, and educational resources in exchange for working in traditionally underserved areas of the country.
The ACA and the American Recovery and Reinvestment Act (ARRA) have increased funding to the NHSC loan repayment program, which provides health professionals with up to $60'000 in exchange for two years of service in an underserved community. The health reform law also changed the way HRSA administers the program to offer higher awards and more flexibility, including the opportunity for providers to complete their service by working half-time and to obtain credit for teaching. Providers in the fields of medicine, dentistry, psychiatry, social work, marriage and family therapy and counseling, as well as nurse practitioners, physician assistants, dental hygienists and psychiatric nurse specialists are eligible.1
Further, the ACA created the NHSC Students to Service Loan Repayment Program. Medical students (MDs and DOs) in their last year of school can receive loan repayment assistance of up to $120,000 in exchange for committing to three years of full-time service in communities with limited access to care. The program has been appropriated $9.1 million in funding, according to the U.S. Department of Health and Human Services (HHS).2
The ACA also has increased funding for the NHSC scholarship program. Awardees receive tuition, required fees, and other education costs for up to four years of schooling in exchange for providing two to four years of service at an NHSC-approved site in a high-need area.3
Thanks to the ACA and ARRA, in addition to annual appropriations, the NHSC has awarded $900 million in scholarships and loan repayment assistance. As of 2011, nearly three times the number of providers - more than 10,000, up from 3,600 in 2008 - are receiving assistance through the NHSC to provide care in underserved areas.3
Separate from the NHSC, the Health Professions Opportunities Grants provide tuition and supportive services for those seeking training in health professions. These grants, created under the reform law, have so far provided more than $67 million for low-income individuals to attend training programs to enter the healthcare workforce as home care aides, certified nursing assistants, registered nurses, health information technicians, and other professionals.4
Prevention and Public Health Fund
Public health budgets have taken a serious hit during the recession, said Denise Link, PhD, WHNP-BC, CNE, FAAN, clinical associate professor in the College of Nursing and Health Innovation at Arizona State University. These budget cuts have led to reduced workforces, while individual and family financial strains have pushed more people to seek care from public health entities.
"The [public health workers] left behind are working themselves to death, and they traditionally work with a very underserved and vulnerable population," added Link, who is also program manager of NP Healthcare Grace, a nurse-managed clinic in downtown Phoenix that provides care to individuals who are uninsured and at or below poverty level. "There is funding for [public health in the ACA] - by supporting the public health infrastructure, those benefits are going to cut across everyone."
The health reform law created the Prevention and Public Health Fund to bankroll initiatives that target health promotion, disease prevention, early screening, and management of chronic conditions. In fiscal years 2010-2012, the fund has allocated more than $2 billion.5,6 That spending includes several programs aimed at expanding and developing the healthcare workforce, such as:
- 500 additional primary care residency slots
- training for more than 600 new physician assistants
- 10 new clinics run by nurse practitioners to provide care to the underserved and assist in clinical training of new NPs
- funds for states to develop their own innovative strategies to expand their primary care workforces by 10 to 25 percent7
- more than $40 million to support 37 Public Health Training Centers around the country (these centers, established at university schools of public health and other public and nonprofit institutions, provide education and training for practitioners in public health)6,8,9
- funding to nursing schools for stipends to increase full-time enrollment, with a goal of training 600 new nurse practitioners and nurse midwives by 2015
- a demonstration project to support states in developing a curriculum to train personal and home care aides, with a goal of training more than 5,000 aides by 20134
- $45 million in funding to bolster state health departments' epidemiology, laboratory, and health information systems, including hiring and training of staff.10
Community and School Health Centers
Federally qualified health centers, also called community health centers (CHCs), are a major tool in achieving the ACA's goal of moving toward a wellness model of service provision. As the largest network of primary care providers in the country, these entities serve low-income Americans with no or public insurance.
The ACA allocates $11 billion in funding for CHCs through 2015, with the goal of doubling the number of patients these facilities are able to serve to 40 million.11 CHCs have increased their employment by 15 percent - more than 25,000 new full-time positions - since 2009, according to HHS.12, 13
The reform law also provides $200 million over four years to improve and expand school-based health centers. These centers, typically partnerships between schools and community health organizations, enable children with acute or chronic illnesses to attend school, as well as provide health promotion and screening and prevention services. The funding is expected to help these centers nearly double the number of children they are able to serve, and to create new jobs for healthcare providers as well as jobs within the community to meet the resulting capital needs, including construction, renovation, and equipment.14
Outside of specific workforce initiatives, the reform law is expected to result in new roles for providers - and even new types of providers - that are only beginning to emerge.
"Acute care is going to be the delivery site of last resort," Link said. "Keeping people healthy; that's where the jobs are going to be."
A majority of the delivery system reform was in the form of demonstration projects, Demosthenidy explained. For example, earlier this year, HHS announced 107 Health Care Innovation awards, ranging from $1 million to $30 million per grant, to projects that are designed to deliver quality care while enhancing the healthcare workforce and saving money.15 Those that are successful in improving quality of care while reducing costs will likely be copied by both government and private providers.
One of the ways to keep costs down is to use less-expensive providers in more effective ways; the ACA emphasizes primary care delivery through providers such as NPs, PAs, and registered nurses. Link expects this trend to grow and include more lay people to "supplement the care and direction the licensed professionals can provide," she said.
Health informatics can also reduce costs, and is integral in collecting the data needed to analyze the effectiveness of interventions.
"There are plenty of opportunities for people interested in health IT," Demosthenidy added. "There will be extra payments for providers who adopt EHRs and technology, and later this decade you'll get payment penalties for people who haven't done it."
Another cost-containment strategy is to improve management of chronic conditions. Diseases such as heart disease, cancer, and diabetes are responsible for 7 out of 10 deaths and account for 75 percent of U.S. healthcare dollars.16 "We are coming to the conclusion that we have to help patients manage [those conditions] outside of the hospital," Link said.
Chronic disease management is a facet of the larger goal of health maintenance. To that end, nurses, case managers, rehab providers, and other professionals will start acting as care coordinators and health coaches.
"I stress to my students to start thinking of themselves as bookends in this process," Link said. "There is a provider at either end of this patient's journey, and in the middle they are out there on their own. My job, when I see them at those intervals, is to address how they are doing, to make sure they know how to take care of themselves until I see them again, and to know when to come back to me if they are not well."
Working Toward a Paradigm Shift
All of these initiatives, and the Affordable Care Act as a whole, work toward one overarching goal: making and keeping people healthier by providing high quality, cost-effective services that everyone can access. New models to deliver care - including provider teams, nurse-led community health centers, patient-centered medical homes, and Accountable Care Organizations - likely will continue even if the ACA is repealed.
It is "a delivery system oriented toward promoting health and preventing disease instead of treating it," Demosthenidy said.
Whether health reform can accomplish these goals has yet to be seen. A number of obstacles stand in the way, including the upcoming presidential elections and funding issues. The federal deficit and debt have impacted Congress' allocation of funds to implement elements of the ACA, including provisions of Title V.
For example, section 5101 creates the National Healthcare Workforce Commission, charged with identifying how the need for providers is being met; improving coordination of health entities at the federal, state and local level; and encouraging innovation in care delivery. The General Accounting Office appointed 15 members to the commission in 2010; however, the group has never met because no funds have been appropriated for its function.
Healthcare providers can play a role by advocating. "If you want this to be successful, the appropriations have to come, and we can't just argue for our own piece," Link said. "This is a priority. This needs to be funded."
Even providers who do not agree with the approach the ACA takes can be vocal about the problems in the system and ways to fix them that benefit both patients and providers. "Regardless of where you stand politically on this," Link added, "the fact of the matter is that the current situation that we have in terms of healthcare, both in delivery of services and how we pay for them, is not sustainable."
1. "Affordable Care Act bolsters the primary care workforce in medically underserved communities." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2010pres/11/20101122b.html.
2. "New health care law helps expand primary care physician workforce." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2012pres/02/20120213a.html.
3. "HHS announces record number of National Health Service Corps members." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2011pres/10/20111013a.html.
4. "HHS awards $320 million to expand primary care workforce." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2010pres/09/20100927e.html.
5. "Building Healthier Communities by Investing in Prevention." http://www.healthcare.gov/news/factsheets/2011/02/prevention02092011b.html.
6. "Prevention and Public Health Fund: FY 2012 Allocation of Funds." U.S. Department of Health and Human Services. http://www.hhs.gov/open/recordsandreports/prevention/index.html.
7. "Sebelius Announces New $250 Million Investment to Strengthen Primary Health Care Workforce." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2010pres/06/20100616a.html.
8. "HHS awards $16.8 million to train public health workforce." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2010pres/09/20100913a.html.
9. "HHS awards $40 million to boost public health infrastructure, prepare tomorrow's public health workforce." http://www.hhs.gov/news/press/2011pres/08/20110831a.html.
10. "The Affordable Care Act helps states prevent, fight infectious diseases." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2012pres/08/20120816a.html.
11. "Expanding Health Centers under Health Care Reform." National Association of Community Health Centers. http://www.nachc.com/client/HCR_New_Patients_Final.pdf.
12. "Health care law helps community health centers build, renovate facilities, serve more patients." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2012pres/05/20120501a.html.
13. "Health care law expands community health centers, serves more patients." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2012pres/06/20120620a.html.
14. "The Affordable Care Act and the School-Based Health Center Capital Program." http://www.healthcare.gov/news/factsheets/2011/12/health-centers12082011a.html.
15. "HHS announces 81 Health Care Innovation Awards." U.S. Department of Health and Human Services. http://www.hhs.gov/news/press/2012pres/06/20120615a.html.
16. "The Affordable Care Act's Prevention and Public Health Fund in Your State." http://www.hhs.gov/news/press/2012pres/06/20120615a.html.
Title V of the Patient Protection and Affordable Care Act: http://www.healthcare.gov/law/resources/authorities/title/v-healthcare-workforce.pdf.
Jill Glomstad is on staff at ADVANCE. Contact her at firstname.lastname@example.org.