coverage, with premium‐ and cost‐sharing credits available to individuals and families with income between 133% and 400% of the federal poverty level (FPL) (the poverty level was $18,310 for a family of three in 2009).
PPACA and HCERA created separate state Insurance Exchanges through which small businesses can purchase insurance coverage. They subsidized insurance premiums for people making up to 400% of the FPL ($88,000 for a family of four in 2010), so their maximum out‐of‐pocket payment for annual premiums will be from 2% to 9.8% of income, providing incentives for businesses to provide health care benefits, prohibiting denial of coverage and denial of claims based on pre‐existing conditions, prohibiting insurers from establishing annual coverage caps, and giving support for medical research. The costs of these provisions are offset by a variety of taxes, fees, and cost‐saving measures, such as new Medicare taxes for those in high‐income brackets, taxes on indoor tanning, cuts to the Medicare Advantage program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies. There is also a tax penalty for those who do not obtain health insurance, unless they are exempt due to low income or other reasons. The Congressional Budget Office estimated that the net effect of both Acts will be a reduction in the federal deficit by $143 billion over the first decade.
PPACA included fundamental changes to Medicare, expansion of the Medicaid program, and reforms to Part D, closing the Medicare donut hole by 2020. It includes initiatives to prevent fraud and abuse; includes more health information technology (IT); and promotes disease prevention programs across the health care system. HCERA makes a number of health‐related financing and revenue changes to the PPACA of 2010. HCERA is divided into two titles, one addressing health care reform and the other addressing student loan reform. It was anticipated that PPACA and HCERA would impact health care significantly, and it was estimated that the net effect of both PPACA and HCERA would be a reduction in the federal deficit by $143 billion over the first decade. A fast‐forward of changes since the ACA was enacted (Collins, Bhupal, & Doty, 2019). Today, 45% of U.S. adults aged 19–64 are inadequately insured (almost the same as in 2010)
Compared to 2010, many fewer adults are uninsured today.
Despite actions by the Trump administration and Congress to weaken the ACA, the adult uninsured rate was 12.4% in 2018.
More people who have coverage are underinsured now than in 2010.
History of Health Care
Florence Nightingale observed that noise, food, rest, light, fresh air, and cleanliness were instrumental in health and illness patterns. Thus, she maintained, the aim of nursing was to put the patient in the best condition for nature to act upon her or him (Nightingale, 1865/1970). Nightingale also discovered the link between adverse patient outcomes and a lack of cleanliness and hand washing. Yet generations after the insights of Nightingale were first set forth, sporadic adherence by health care providers to hand washing continues. Although significant progress has been made in preventing some health care‐associated infection types, there is much more work to be done. On any given day, about one in 31 hospital patients has at least one health care‐associated infection. Three percent of hospitalized patients in the 2015 survey had one or more HAIs. There were an estimated 687,000 HAIs in U.S. hospitals in 2015. About 72,000 hospital patients with HAIs died during their hospitalizations (CDC, 2018b).
One hundred years ago, illnesses such as tuberculosis or pneumonia required lengthy hospitalizations and were often catastrophic for individuals and families. Today, such illnesses are preventable and are often easily treated. Vaccination programs have been used extensively to prevent the spread of communicable diseases. Additionally, surgical interventions in hospitals (e.g., tonsillectomies, appendectomies, and reproductive procedures) have improved to treat otherwise debilitating or mortal conditions. Health care is delivered by professional nursing and medical practitioners who are science based and who use evidence‐based practice. Health care is primarily directed at preventing and treating chronic and behavioral diseases. Health care advances have extended life expectancy, with the consequence of more elderly people requiring more health care for chronic and complex health problems. The majority of clinical care is still provided in hospitals, but length of stay is much shorter, and a variety of innovative models of care are now used to provide cost‐effective care for people with acute, community, and long‐term clinical needs (Health Workforce Solutions LLC & Robert Wood Johnson Foundation, 2008).
Health care‐associated infections currently result in increased length of stay, mortality, and health care costs. In addition, a Centers for Disease Control and Prevention (CDC, 2018) report estimates that the overall annual direct medical costs of health care‐associated infections in U.S. hospitals ranges from $28.4 to $33.8 billion. These infections are most often attributed to invasive supportive measures such as endotracheal intubation and the placement of intravascular lines and urinary catheters. Several studies have noted that health care‐associated infections can be prevented through a number of multidisciplinary, evidence‐based interventions, reducing the incidence of infection by as much as 70% (Anderson et al., 2007; Harbarth, & Gastmeir, 2003; Muto et al., 2005).
Structuring Hospitals Around Nursing Care
Nightingale also described the importance of structuring hospitals around nursing care. The initial design of hospitals followed that advice by building large wards where nurses could easily monitor and observe their patients. Later, hospital design evolved to placing patient rooms surrounding centrally located nursing stations. Then, as today, the physical environment of hospitals can create stress for patients, their families, and clinical staff. Research is finding links between the physical environment and patient outcomes, patient safety, and patient and staff satisfaction (Hamilton, 2003). Studies show that such elements of hospital design as exposure to natural light, private rooms, and facilities that are staff friendly and have less noise contribute to improved patient outcomes (Ulrich, Quan, Zimring, Joseph, & Choudhary, 2004).
Although little is known about how to best design the hospital environment to facilitate clinical advances and care delivery, an estimated $200 billion will be expended for new hospital construction across the United States during the next 10 years (Institute of Medicine (IOM), 2004a). The Robert Wood Johnson Foundation (RWJF), the nation's largest philanthropy devoted exclusively to health and health care, has provided funding to the Center for Health Design, a nonprofit research organization, for the Designing the twenty‐first Century Hospital Project, which is the most extensive review of the evidence‐based approach to hospital design ever conducted. Launched in 2000, the Pebble Project is a joint research effort between the Center for Health Design and health care providers. The project engages health care providers that are building new health care facilities or renovating old ones using an evidence‐based design. The project uses the latest available evidence to inform design innovations and then measure the outcomes of the innovations through carefully designed research projects. The results are shared with the larger health care community to promote change. The Pebbles Project is an example of facility design to improve quality of care (The Center for Health Design, 2011).
Collecting Data
Nightingale also astutely recognized the importance of collecting and using data to assess the quality of health care. She employed coxcomb diagrams to present visual images of the number of preventable deaths during the Crimean war (Figure 2.1) and then later in London hospitals.
Source: Florence Nightingale (1820–1910). [Public domain].
Today, data is collected through patient records,