Introduction
Medicaid expansion falls under the Affordable Care Act’s (ACA) overall effort to improve care quality and curb rising costs. Other benefits of Medicaid expansion include broadening care access in rural areas and for people with disabilities, plus reducing racial disparity in coverage rates. As reported by Ku and Brantley (2021), approximately 11 million adults enrolled for Medicaid by 2016. However, Medicaid expansion remains controversial as states continue to assess whether or not to pursue the expansion. ACA critics argue that Medicaid expansion would result in significant shortages in the healthcare workforce due to increased demand from newly insured individuals and reduced care quality. The ACA Medicaid expansion affects nurses’ role in the provision of care.
Medicaid Expansion
In an era of constant change, healthcare has become a global concern. While studies have detailed the benefits of Medicaid expansion from health outcomes to fiscal impacts, unanimity remains elusive (Levy et al., 2020; Searing & Ross, 2019). States like Mississippi, North Dakota, Texas, Tennessee, Florida, Kansas, and Alabama resist the expansion (Searing, & Ross, 2019). A cited concern of the expansion by these states and policymakers is its impact on the state budget. While Medicaid expansion allows states to cut spending on traditional Medicaid, they finance a share of the expansion, which increases state spending despite federal assistance. However, Rudowitz and Antonisse (2018) argue that Medicaid expansion helps a state to save. Advocates believe that the benefits of Medicaid expansion are far-reaching.
The stakeholders engaged in successful Medicaid expansion include the advocacy and patient community, healthcare providers, and legislation. Each of the stakeholders provides a viewpoint on Medicaid expansion in relation to each other. After the ACA, Medicaid provided low-cost healthcare coverage to several Americans, including the elderly, low-income earners, people with disabilities, families, and children, plus pregnant women. Sugar et al. (2021) highlights that the American Rescue Plan Act (ARP) encourages states to expand Medicaid to cover individuals aged up to 65 living at the federal poverty level. Furthermore, states that implement the expansion receive federal funding authorized under the ARP. Ideally, Medicaid expansion maximizes public health within a state’s resource constraints.
Factors Surrounding Medicaid Expansion
Socioeconomic
The ACA Medicaid expansion has the potential to mitigate income-based inequality regarding healthcare access. As Kino and Kawachi (2018) state, socioeconomic inequality in healthcare access is a prevalent issue in the United States compared to other developed countries. Among the fundamental economic functions of ACA expansion is the protection of financial assets against costly medical bills. Moreover, public insurance coverage provides financial benefits to previously uninsured individuals. Subsequently, greater financial security stimulates social behavior like political activism, volunteering, and community representation. Similarly, Medicaid expansion represents unprecedented importance to subpopulations of low-education, ethnic or racial minorities, low-income, people with disability, plus the formerly incarcerated. For instance, apart from racial injustice, the incarcerated are at a greater risk of substance abuse and mental illness (Beck, 2020). Thus, expanding Medicaid to the formerly incarcerated impacts individual families and the wide-reaching community.
Political
The ACA created a framework for expanding healthcare insurance and addressing issues in the private insurance market. While states have shaped the expansion agenda, it remains unlikely. Delegation of crucial aspects of Medicaid expansion to the states has resulted in substantial uncertainty on health insurance especially when political polarization adversely affects policy implementation. For instance, governors and state legislators of some Republican-controlled states have delayed initiatives to implement Medicaid expansion (Rocco et al., 2020). Plus, the criticism of ACA expansion discourages progressive coalitions and administrators in policy change. The ACA was to settle the political issue surrounding Medicaid expansion, which has proven otherwise.
Cultural
Racism and limitations on immigrants’ eligibility for health coverage have resulted in disparities in care access and health outcomes. Lee et al. (2021) provide substantive data on the prevalence of diabetes, obesity, and overall poor health among Hispanics and Blacks. Significant reduction in uninsured Americans occurred among non-elderly, Hispanics, and Blacks in ACA expansion states, which dropped from 9.8 to 3.2 percentage points (Chaudry et al., 2019). Furthermore, the COVID-19 pandemic made the underlying ethnic disparities in healthcare more visible. Compared to non-expansion states, expansion states addressed the crisis’ impact on people of color more effectively (Cross-Call, 2020). Thus, the ACA expansion has an equalizing effect in reducing cultural disparities in healthcare coverage. Nonetheless, factors outside Medicaid expansion prolong the disparities in healthcare outcomes.
Ethical
The ethical issue surrounding Medicaid expansion has gained great importance through the ACA that widened care coverage using market systems. Individuals previously unable to obtain healthcare insurance because of low income or pre-existing health conditions can now access coverage through Medicaid expansion and the reformed private insurance market (Levy et al., 2020). However, ethical conflict becomes apparent when financial and political factors place barriers between the access and cost of care. For example, while Medicaid expansion improves care access, individuals are limited in receiving care within their residential state since the health coverage varies widely. Therefore, providers, legislations, and society must align personal responsibility and incentives to effectively enable access, quality, and equitable healthcare.
Professional Health Organizations
The social, political, and professional contexts into which Medicaid expansion is introduced may further facilitate or prohibit implementation. Therefore, the expansion must contain professional and individualized strategies to ease implementation across states. The American Nurses Association (ANA), American Medical Association (AMA), and American Hospital Association (AHA) jointly emphasize evidence-based practices, information technology adaption in healthcare, health outcomes, and recognize the debate over ACA expansion. Talutis et al. (2019) highlight that AHA supports the coverage principles and the goal to expand financial assistance and options for more Americans. Likewise, AMA works with federal and state advocates to fund Medicaid expansion and improve provider participation with policies to support and streamline care programs.
Moreover, Medicaid expansion has uniquely advanced the healthcare system toward realizing ANA’s fundamental principles. ANA commits to advancing the nursing profession by advocating on healthcare issues affecting nurses and the public. The increasing demand for care services because of the expansion means an increase in the nursing workforce, subsequently affecting total nursing hours (Leszinsky & Candon, 2019). However, ACA Medicaid expansion fails to provide specific details on the effect of a demand shock on nursing hours and employment. Plus, even with the demand increase, healthcare organizations may delay wage increases to avoid attracting a low-quality nursing workforce. Nurses have a critical role in the debate, and ANA commits to expanding access to quality and affordable care while protecting nurses.
Conclusion
In summary, nurses are at the center of ACA Medicaid expansion. Nursing practice has experienced a significant transformation over the years as healthcare regulations also evolve. The expansion of Medicaid including a renewed focus on access and quality of care is coupled with an expected increase in nurse labor force compounded by a rise in the number of newly covered patients. Subsequently, shortages of nurses and decreased care quality present as major concerns of the expansion. Furthermore, the political, cultural, ethical, and socioeconomic issues on Medicaid expansion continue to heighten. Therefore, the ACA Medicaid expansion should provide specific details on the effect of a demand shock on nurses and healthcare organizations to prepare providers for comprehensive care.
References
Beck, A. (2020, February 20). Medicaid enrollment programs offer hope to formerly incarcerated individuals and savings for states. Health Affairs: Leading Publication of Health Policy Research & Insight. Web.
Chaudry, A., Jackson, A., & Glied, S. A. (2019). Did the affordable care act reduce racial and ethnic disparities in health insurance coverage. Web.
Cross-Call, J. (2020). Medicaid expansion has helped narrow racial disparities in health coverage and access to care. Center on Budget and Policy Priorities. Web.
Kino, S., & Kawachi, I. (2018). The impact of ACA Medicaid expansion on socioeconomic inequality in health care services utilization. Web.
Ku, L., & Brantley, E. (2021). The economic and employment effects of Medicaid expansion under the American rescue plan. Web.
Lee, H., Hodgkin, D., Johnson, M. P., & Porell, F. W. (2021). Medicaid expansion and racial and ethnic disparities in access to health care: Applying the national academy of medicine definition of health care disparities. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 58, 0046958021991293. Web.
Leszinsky, L., & Candon, M. (2019). Primary care appointments for Medicaid beneficiaries with advanced practitioners. The Annals of Family Medicine, 17(4), 363-366.
Levy, H., Ayanian, J. Z., Buchmueller, T. C., Grimes, D. R., & Ehrlich, G. (2020). Macroeconomic feedback effects of medicaid expansion: Evidence from Michigan. Journal of Health Politics, Policy and Law, 45(1), 5-48.
Rocco, P., Keller, A. C., & Kelly, A. S. (2020). State politics and the uneven fate of Medicaid expansion: An examination of mechanisms that affected Medicaid expansion, including electoral competition, ballot-box initiatives, interest-group coalitions, and entrepreneurial administrators. Health Affairs, 39(3), 494-501. Web.
Rudowitz, R., & Antonisse, L. (2018). Implications of the ACA Medicaid expansion: a look at the data and evidence. Henry J Kaiser Family Foundation.
Searing, A., & Ross, D. C. (2019). Medicaid expansion fills gaps in maternal health coverage leading to healthier mothers and babies. Washington, DC: Georgetown University Health Policy Institute Center for Children and Families.
Sugar, S., Peters, C., De Lew, N., & Sommers, B. D. (2021, June 10). Medicaid churning and continuity of care: Evidence and policy considerations before and after the COVID-19 pandemic. US Department of Health & Human Services.
Talutis, S. D., Chen, Q., Wang, N., & Rosen, A. K. (2019). Comparison of risk-standardized readmission rates of surgical patients at safety-net and non–safety-net hospitals using Agency for Healthcare Research and Quality and American Hospital Association data. JAMA Surgery, 154(5), 391-400.