U.S. Health System Reform, Children's Health Care and Nursing: An Integrative Policy Analysis

Purpose:  Conducting an integrative analysis of a health policy is an important skill for nurse leaders.  This presentation will review the process of health policy analysis and describe the analytic process used to examine the Patient Protection and Affordable Care Act of 2010 (ACA) and other health care reform legislation and the subsequent direct and indirect impact on the US child health system.  In addition, the speaker will make recommendations for future nursing research to inform nursing leadership, practice and advocacy regarding the delivery of health care services to children.

Background:  The major provisions of the Patient Protection and Affordable Care Act of 2010 (ACA) emphasized expanding health insurance coverage to previously uninsured populations, promoting new fixes for longstanding delivery system problems and broadening prevention and population health interventions, many of which benefit children.  Although the ACA improved insurance coverage for children and their families by covering comprehensive preventive services with no cost sharing, eliminating exclusion for pre-existing conditions, prohibiting lifetime dollar limits, extending dependent health benefits to age 26, and expanding coverage to many previously uninsured parents, the scope of change and its reverberation throughout a complex health system has raised serious questions about the ACA’s direct and indirect impacts on children’s health care, and its potential to affect the quality of children’s health care in ways that were not planned or expected.

The delivery of children’s health care is highly dispersed and includes outpatient clinics and physician offices, school-based health centers, early intervention programs for developmentally delayed infants and toddlers, and a host of other specialized programs.  While Medicaid is the largest payer for children’s healthcare in the U.S., a variety of other state-funded or state administered programs provide essential services for defined populations with special risks and needs.  This complex and fragmented set of child health care services is uniquely vulnerable to policy changes, including those embodied in the ACA and other health reform legislation.

Process:  Using a modified Bardach (2000) approach to policy analysis, specific provisions of the ACA and other legislation were examined for their effects on the delivery of child health services.  An integrative review using a comprehensive examination of the literature, as well as interviews with stakeholders (e.g., pediatric providers, clinics, hospitals, advocacy organizations, federal agencies) and exploration of contextual factors (e.g., state laws/regulations) informed analysis.

Outcomes: The ACA represents a major transition in health care financing and delivery and, as a result, there are unintended consequences for children’s access to care and subsequent health outcomes, especially among low income children, children of color, and children with special health care needs (CSHCN).  Child access to health services is influenced by Medicaid expansion to previously uninsured adults.  Children’s hospitals are impacted by the implementation of Accountable Care Organizations (ACOs) as well as current rules defining network adequacy for “qualified health plans” (QHP), which limit access to pediatric subspecialty care in some regions risking fragmentation of care.  And, the “essential health benefits” package of private plans sold in state marketplaces can fall short of meeting the unique needs of CSHCN, especially with regard to access to habilitative services.

Conclusions: The unique health care needs of children highlight the importance of monitoring the effect of the ACA and other health care reform efforts on the U.S. child health system.  Although children’s health care is relatively inexpensive, the unique needs and vulnerabilities of children, and the long-term consequence of poor child health outcomes make the stakes for society high. Therefore, researchers must track policy effects in real time to avoid unnecessary harm, take deliberate and strategic action to preserve critical child health services, and leverage opportunities presented by health care reform to improve the child health system. Nurses, as frontline health care providers, are in a prime position to survey the impacts and identify the challenges experienced by children and families in this evolving system.