Beyond the Affordable Care Act

The United States has the opportunity to transform its health care system, and nurses can and should play a fundamental role in this transformation. Working on the front lines of patient care, public health nurses have a unique opportunity at this time to lead and contribute to the redesign of the health care system that focuses on care of the community with an emphasis on public health. Traditional nursing care delivery models that have been used to focus on disease management of patients while in the hospital need to be changed. Nurses need to know how to be part of the solution to achieve better outcomes. Nurse leaders should start thinking about ways of health promotion and disease prevention that will move beyond hospital walls to the community and stay within keeping of the Patient Protection and Affordable Care Act (PPACA).

Medical care and public health are typically considered two separate overlapping systems. The goal of the health care system is the improvement of patient outcome through the provision of medical services. In contrast, public health is the improvement of health outcomes in the population as a whole through health promotion and disease prevention (Kulbok et al., 2012). Health care services receive the bulk of funding and political support, while public health starves for funding. In order to improve the nation’s health, policy makers must shift their attention from two separate systems, health care and public health, to integrating the two systems into one single health system.

With the enactment of the PPACA in 2010, estimates suggest that thirty-two million Americans will have acquired health insurance coverage by 2018 (Williams et al., 2010). The primary goal of the PPACA was to improve access to health care services for all citizens through insurance system reform. However, improving access to health care services will not enhance the nation’s health. The PPACA neglected to put emphasis it needed on population health. Nurses, therefore, should take advantage of new opportunities to deliver care and play an integral role in leading population health, which was neglected by the PPACA. Understanding these new opportunities is just the first step.

Also, nurses need to know how they can be part of the solution to achieve better patient outcomes at a reasonable cost. Nurses should become involved in population health, whether it happens within our community, in our hospitals or in our homes. Nurses can take a leadership role and do more to prevent disease early and promote health and wellness among a more diverse population. Health care is changing and nurse leaders can be proactive in planning for change by improvement in community partnerships and initiatives. Nurses can do more to help improve coordination between medical care and public health.

Nurse leadership in the community will be more important than ever if we are to improve the health and well-being of the population. Nursing can no longer remain a profession that is concerned chiefly with illness and disease; instead, it should be more focused on health and wellness. Nurse leaders must address a wider picture of need. Nurses need to be leaders in health delivery and work across practice disciplines to empower the most vulnerable groups, harness the strengths of the community, and facilitate leadership in the community.


The purpose of my paper is to reflect on the PPACA’s potential to improve the overall health. Is health enhanced by offering health promotion and disease prevention services rather than by making health care services more accessible? Evidence indicates that health promotion and disease prevention do more to decrease morbidity and mortality than access to services (Graham, 2008). Literature will be explored as to the effective ways that nurse leaders in the community can use to improve health outcomes through prevention services and patient education in an effort to keep patients healthy.

Integrated Review of Literature

The primary objective of the health care system should be the improvement of the public health. To advance this goal, policy makers must concentrate on health promotion and disease prevention rather than health care services. Having access to health care services largely addresses the symptoms of diseases that have already manifested. An effective health care system must put emphasis on the public health in order to eliminate the underlying causes of disease, thereby avoiding unnecessary costs and morbidity.

The Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA) aims to improve the overall health. Hawks (2012) states that the PPACA improves the overall health by ensuring patients are not discriminated because of pre-existing conditions. The pre-existing conditions refer to an injury or illness that a particular patient may be facing before joining any health plan. The pre-existing conditions include type 2 diabetes, asthma, heart diseases, and high blood pressure. From September 2010, the PPACA ensured that children below the age of 19 years are granted access to the health plan of their parents. Due to this, private insurance companies will cover children with diabetes and cancer. This will give families the right to access medical care.

Researchers have also established that this act will improve the overall health care due to free prevention services that it has introduced (US Department of Health and Human Services, 2012). According to this Act, it is mandatory for insurers to cover preventive services such as diabetes, blood pressure screening, and cancer without deductibles or co-pay (Sherman, 2012). This Act will also preserve Medicare benefits. It will ensure that Medicare is strengthened through offering low cost prescription drugs. Patients with high prescription drug costs will be given discounts to ensure that they are able to afford the cost of such drugs. Free preventive services will also be offered to elderly patients.

The PPACA and Health Promotion and Disease Prevention

Prior to the passage of the PPACA, the existing federal law on prevention includes limited preventive medical services. There was no comprehensive prevention and wellness statute and no spending statute targeting prevention and wellness. In 2008, the importance of the role of the public health, prevention, and wellness was discussed.

The PPACA created a national approach to focus on prevention and the public health through the creation of the National Prevention, Health Promotion, and Public Health Council, a strategy and prevention fund to address the comprehensive prevention and wellness statute. The council provided leadership and coordination of public health activities at the federal level on these topics. The council had two important duties. First, the council had to create a National Prevention, Health Promotion, Public Health, and Integrative Health Care Strategy (Rigby, 2011). This strategy will focus on identifying effective means to improve the health status of Americans and reduce the incidence of preventable diseases and disabilities in the United States. The strategy will also build upon the existing program such as Healthy People 2020 (Healthy People, 2020). The goal of the strategy is to increase the number of healthy people in America. The strategy had four basic pillars: (1) recognize communities that support prevention and wellness, (2) connect prevention-focused health care and communities, (3) empower and educate individuals on healthy choices, and (4) eliminate disparities in underserved populations to improve quality of life for all Americans (HP, 2020).

Under the PPACA, the second important duty of the council is to make recommendations on how to confront the most pressing public health issues facing the United States and change the policy to achieve national wellness, health promotion, and public health goals.

Under the PPACA, the Prevention and Public Health fund was established to provide needed resources to make financial investments in the public health, prevention, and wellness initiatives. The ideas reflected in the councils, strategy, and funds were consistent with the recommendations of the Institute of Medicine (IOM) on how to improve the public health system in the 21st century. There is a noticeable movement toward health promotion and disease prevention in the PPACA. There is little mention of mandating the implementation of their finding, allocation of funds, and reforming a broader view of public health that includes, for example, social, environmental, and behavior determinants of health. In effecting change in policy, nurse leaders must act as educators for the policy development and healthcare decision-makers. Nurses should act as educators and informers, providing evidence-based data to support positions and issues.

The Importance of Public Health

The Institute of Medicine (IOM) defines public health as “what we as society do collectively to assure the conditions for people to be healthy” (Majette, 2011). Unfortunately, the United States spends trillions of dollars on health care each year; yet the incidence of chronic preventable diseases is escalating. The United States has the highest per capita and total health spending among industrialized nations; however, ranks are very low in preventable mortality and morbidity.

Experts agree that the public health system in the United States needs to be improved. The public health system is underfunded, and there is insufficient collaboration at the federal and state level. Other problems include a lack of transparent and easy to understand information about health, communities with lack of public health services, vulnerable and outdated information systems, and poorly trained public health workers.

Public health is important for several reasons. It focuses on prevention of disease rather than treatment of disease. Researchers argue that most chronic diseases could be prevented if the public was educated on ways of preventing them (Hardcastle et al., 2011). Diabetes has been increasing over the past several years since Americans are eating more junk food and sugar in their diet. Miller, Nobari, & Blanton (2011) support the argument by stating that public health would help Americans to learn the benefits of engaging in physical exercises and reducing sugar intake in order to eradicate preventable diseases such as diabetes, obesity, and heart disease. Public health addresses the whole population instead of focusing on health needs of people. If more nurses concentrate on public health, they will be able to learn about the diseases that affect the whole population so that they can formulate the required strategies for mitigating such diseases (McKinnon, 2009).

Institution of Medicine: Building a Healthier Nation

In 2002, the Robert Wood Johnson Foundation (RWJF) established a commission to make Americans healthier. As a group, they identified solutions beyond hospital walls for improving the nation’s health. The commission concluded that creating a healthy nation is a goal that can be obtained. Improving the nation’s health will take a national commitment to health and wellness for all Americans. Improving health must be incorporated into every aspect of society and daily life (Williams et al., 2010). This means that it is necessary to begin educating society early. In 2002, the IOM made six recommendations on how to improve the public health system and better protect the collective health of Americans:

(1)Adopt a population approach that considers multiple determinants of health; (2) strengthen the governmental public health infrastructure; (3) build partnerships that draw on the perspectives and resources of diverse communities and engage them in health actions; (4) develop systems of accountability to assure the quality and availability of public health services; (5) make evidence-based practices the foundation of decision-making and the measure of success; and (6) enhance communication within the public health system (IOM Report, 2002, p. 7)

In 2010, the IOM noted an improvement in the health of the United States population from 2002 to 2010 and, therefore, increased the focus on preventing disease and promoting health.

Public Health: Emphasis on Population Health

Population health refers to health outcomes of a particular group of individuals. It also considers the distribution of health outcomes among a certain group of people. Health promotion and disease prevention have a far greater impact on the health status than health care services. Inadequate access to medical interventions is not the primary cause of premature morbidity and mortality (Hardcastle et al., 2011). There are nine preventable conditions that are responsible for 50% of all deaths in the United States (Department of Health and Human Services, 2011).

Most diseases result from a combination of individual behavioral factors (for example, smoking, diet, physical activity, and sexual behavior); the environment in which people live and work (for example, pollution, toxic chemical exposure, and lack of healthy foods); and social determinants of health (for example, education, income, and housing). Evidence shows that preventable interventions targeting the root cause accounts for approximately 80 percent of the reduction in morbidity and mortality, whereas health care is responsible for less than 20 percent (Schroeder, 2007). If the public’s health is to improve, then the improvement is more likely to come from behavior change than enhancing traditional medical care. Nurses should be culturally sensitive to diverse populations and respect cultural influences on health behaviors.

Health care seeks to improve individual health outcomes, while the public health system focuses on identifying and preventing illness in the broader community. Public health’s central focus is on population. Population health has come to the forefront with the recent debate on health reform. The goal of population health is to improve the health of a defined population. It is an approach that aims to enhance the health of an entire population. Population health seeks to go beyond traditional medicine and address a range of factors, such as social, economic, environmental, and behavior factors. In 2011, Miller, Pollack, & Williams found that the socioeconomic status strongly affects health even when controlling access to health. The studies found that no amount of medical attention will help decrease the likelihood of someone getting diabetes without controlling health-affecting habits of the individual. In order to improve the health of a particular population, nurses should eradicate health inequalities among different population groups.

In terms of relative costs of public health and public health services, numerous studies have demonstrated the cost of effectiveness of public health strategies such as smoking cessation and weight programs. Evidence consistently shows a correlation between public health spending and improved mortality rates. Statistics have estimated that public health has contributed less than four percent to the decline in mortality since 1900 (Bureau of Labor Statistics, 2011). Because public health services have been deprived of much needed funds, there are still substantial gains that can be made from investments in health promotion and disease prevention.

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