Abstract
Numerous attempts to reform health care in the United States on the federal level have been made since the 1930s, but differences between each state represent a significant barrier to every previous federal health care reform. In 2010, the Affordable Care Act (ACA) was signed into law, but the current implementation and effects of the law are not the same across different states. The purpose of this paper is to compare and contrast the effects of the health care reform in California and Florida, as well as the positions of the two states. It was found that the insurance rates increased in both states as a result of the reform, but Florida did not expand Medicaid, which could explain why more people gained insurance as a result of the health care reform in California compared to Florida. Both states agree that their populations would benefit from extended insurance coverage, but both states also have additional concerns regarding the health care reform. The nursing practice in both states is not likely to be affected by the health care reform because of the restrictive state laws. Less than 2% of the population in California and Florida have nurse practitioners as their primary care providers, so the nurses are not likely to extend their roles and responsibilities in the health care systems of those states.
Keywords: California, Florida, health care reform, nursing practice
The United States has the most expensive health care system in the world, but compared to other industrialized countries, the country has the highest preventable mortality and hospitalization rates (Mason, Gardner, Outlaw, & O’Grady, 2015). The Affordable Care Act (ACA) was the latest federal reform aimed at improving the quality of care in the United States by improving insurance coverage, expanding health care access, reforming care payment systems, and improving coordination of care delivery. However, the implementation efficiency and effects of the reform on state levels depends on the characteristics of each state and its existing health care needs and care delivery capabilities. The purpose of this paper is to compare and contrast the effects of the health care reform in California and Florida, as well as the positions of the two states regarding the health care reform.
SECTION I: Health Insurance Characteristics
The U. S. Department of Health and Human Services (HHS) reported a nation-wide decrease in the number of uninsured individuals. The percentage of uninsured individuals decreased from 18.5% to 8.6% in California and from 21.3% to 13.3% in Florida between 2010 and 2015 (HHS, 2016a). The higher insurance coverage rates in both states are attributed to better employer and individual market coverage under the ACA (HHS, 2016b). For example, it is illegal to discriminate against individuals based on their pre-existing conditions, so those people are now more likely to gain health care coverage than they were before. Under the ACA, health insurance policies no longer have an annual or lifetime limit because that is now prohibited, so fewer people lose their coverage in both states. However, even though both states reported an increased insurance coverage rate between 2010 and 2015, more people gained coverage during that period in California compared to Florida (3.8 vs. 1.6 million; HHS, 2016a).
The difference between the two states is the fact that California has expanded Medicaid as of December 2016, whereas Florida has not done that. According to the HHS (2016b), the expansion of Medicaid in California accounts for a health care coverage 1,188,000 people now have. If Florida had expanded Medicaid under the ACA, an additional 750,000 people living in Florida would have had health care coverage by December 2016 (HHS, 2016b).
Based on the differences between the two states, it is possible to conclude that the health care reform on a federal level will have a different effect in different states. The extended insurance coverage rates will depend on which parts of the ACA each state adopts and the available infrastructure a state has to successfully deliver quality care to covered individuals. Therefore, it is possible to assume that the states which make the most out of the opportunities presented by the health care reform will also improve their population’s general health statistics.
SECTION II: General Health Statistics
According to the United Health Foundation (2016), California is ranked as the 16th healthiest state and has a much better overall health score compared to Florida, which is ranked as the 36th healthiest state. The overall score of 0.346 indicates that the population in California is healthier compared to the national average score, whereas the overall score of -0.307 indicates that the population in Florida is less healthy compared to the national average health score.
The difference between the two states in terms of health ranking could be explained by the fact that the population in California has a better health behavior score compared to Florida, so California has lower rates of obesity, higher levels of physical activity, and a lower percent of adults smoking compared to Florida. However, Florida has better community health and environmental conditions, so its air pollution and pertussis rates are lower compared to those in California. Both states are showing improvements in terms of premature deaths and preventable hospitalization, which is an important improvement considering the fact that the United States has the highest rate of preventable events in the world (Mason et al., 2015).
The overall health rank in California has been increasing since 2010, and it is now more than 10 ranks higher than it was before the health care reform. Florida is consistently below the national average in terms of population health, and even though some positive health behavior changes can be observed in the population (e.g., decreasing smoking rates), other outcomes indicate lack of positive health behaviors in the population (e.g., obesity). It is possible that different levels of health care reform adoption account for the differences in health rank observed between the two states. However, it is not possible to exclude other factors that could explain the differences between the health status of the populations in the two states, such as different rates of elderly people in the population or health care accessibility based on the number of facilities available and their proximity to the population.
SECTION III: Positions on Health Care Reform
California has a divided position regarding the health care reform. According to empirical projections, the effects of ACA on health care coverage and insurance costs for low-income families were considered to be beneficial (Long & Gruber, 2011). However, Berenson, Ginsburg, and Kemper (2010) argued that state policy makers should consider regulating insurance price caps in order to protect private payers from higher rates associated with certain models, such as the accountable care organizations. That recommendation was based on an upward trend in hospital prices for private-pay patients, which started in 1999 and was associated with the growing market power of providers caused by reforms in payment and organizational delivery models (Berenson et al., 2010).
The analysis of the health care system in Florida also indicates that extending health care coverage is necessary, but it was also asserted that extending insurance coverage will not solve the problems associated with primary care accessibility and low federal funding of the state’s (Rosenbaum, Shin, Finnegan, & Whittington, 2009). Although the rate of uninsured people in Florida has declined since the introduction, Florida’s health care system faces numerous other challenges, including the lack of health care funding and access to primary care.
It is evident that both states consider improved insurance coverage as important parts of the health care reform. However, both states also acknowledge that they have different problems in their health care systems, and those issues should be resolved to achieve the desired effects of the reform. For California, regulating the insurance marketplace prices is the primary priority for extending health care coverage, whereas Florida requires more state and federal funding to improve primary care access to its population. Although expanding health care access and reforming the payment system are also goals of the ACA health reform, the full implementation of the law is not expected until 2023 (Mason et al., 2015). Therefore, it is not yet clear how the health care reform will affect the two states once it is fully implemented.
SECTION IV: Health Care Reform and Nursing Practice
Two characteristics of the health care reform under ACA allow states to improve care delivery and coordination of primary care by improving equity for nursing services (Mason et al., 2015). First, advanced practice registered nurses can manage health centers to extend the primary care capacity available to the local community. Second, the Non-Discrimination in Health Care amendment prohibits health care plans from discriminating against services provided by a group or an individual health care practitioner, so the population should have better access to nurse practitioners under the ACA. However, state-level regulatory barriers can interfere with the adoption of those reforms. Nurse reimbursement under Medicaid will be regulated on a state level, and the scope of the nursing practice under a state license could prevent the expansion of primary care capacity if the nurses are not allowed to manage and deliver primary care to patients (Mason et al., 2015).
Kuo, Loresto, Rounds, and Goodwin (2013) predict that the health care reform will have a different effect on nursing practice in different states because each state has a different set of local regulations. According to their analysis of nursing practitioners in primary care, California and Florida both appear have restrictive nursing regulations because less than 2% of the population receives primary care from nurses in those states. To provide context for that statement, only nine other states have the same percent of population receiving primary care from nurse practitioners, whereas more than 4% of the population receives primary care from nurses in 21 states (Kuo et al., 2013).
Based on the review of the health care reform in the two states, it is possible to expect that the health care reform could have a stronger effect on nursing practitioners in Florida than on nursing practitioners in California. If Florida needs to extend its primary care capacity to improve its populations’ general health, the state will be more likely to improve the scope of practice for advanced practice registered nurses than California, which is already showing improvements in the overall health rank. However, the ACA does not mandate or influence the decisions of state policy makers, who develop policies that determine the nursing scope of practice in their respective states. Therefore, the expansion of primary care by increasing the scope of nursing practice may not be the future of the health care system in either of the two states.
References
Berenson, R. A., Ginsburg, P. B., & Kemper, N. (2010). Unchecked provider clout in California foreshadows challenges to health reform. Health Affairs. Advance online publication. doi:10.1377/hlthaff.2009.0715
Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E.T. (2015). Policy and politics in nursing and health care (7th ed.). St. Louis, MO: Elsevier Saunders.
Kuo, Y. F., Loresto, F. L., Rounds, L. R., & Goodwin, J. S. (2013). States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Affairs, 32(7), 1236-1243.
Long, P., & Gruber, J. (2011). Projecting the impact of the Affordable Care Act on California. Health Affairs, 30(1), 63-70.
Rosenbaum, S. J., Shin, P., Finnegan, B., & Whittington, R. (2009). Primary and preventive healthcare: A critical path to healthcare reform for florida: The role of Florida's FQHCs. Health Policy and Management Faculty Publications. Retrieved from http://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?article=1160&context=sphhs_policy_facpubs
U. S. Department of Health and Human Services [HHS]. (2016a, December). Compilation of state data on the Affordable Care Act [Data set]. Retrieved from https://aspe.hhs.gov/compilation-state-data-affordable-care-act
U. S. Department of Health and Human Services [HHS]. (2016b, December). State by state. Retrieved from https://www.hhs.gov/healthcare/facts-and-features/state-by-state/
United Health Foundation. (2016). America’s health rankings annual report: A call to action for individuals and their families. Retrieved from http://www.americashealthrankings.org/learn/reports/2016-annual-report
