Jul 19 2012
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Cautiously Optimistic about the Affordable Care Act - If Older Americans and Their Advocates Speak Out as It Is Implemented

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act.  Margaret P. Moss, PhD, JD, RN, FAAN, is associate professor, Yale School of Nursing and an alumna of the RWJF Health Policy Fellows program (2008 – 2009).

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As I reflect upon the monumental decision by the Supreme Court to uphold the Affordable Care Act, I can’t help but be awed by how the branches of government are alive and well and operating just as they were designed to work.  But as I filter what this decision will mean for the groups I am most closely tied with professionally and personally, I am struck at how the ‘system’—public and private—has largely let them down.

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My professional focus has been in aging, and in particular American Indian aging.  My profession is nursing, with a background in law.  I am optimistic that these groups, both patient and provider, will be lifted and solidified by the spirit of this law.  But I am cautious that the letter of the law must be handled with an eye toward impact, unintended consequences, short-term pilot and demonstration projects, and authorized but unfunded rules.

There can be no question that there are provisions in the Act that no-one would dispute are positive.  The most cited are: 1) no more pre-existing condition exclusions, 2) the ability to keep adult children under parents’ plans until after college age, and 3) widening the net for coverage to include those now uninsured. The opposing point being moot now with the Supreme Court’s decision, we must look forward and responsibly carry out the law before us.  Unfortunately, the devil, as they say, is in the details.

I am an enrolled member of the Three Affiliated Tribes of North Dakota. I also worked for years as a nurse at the Santa Fe Indian Hospital in New Mexico.  And I grew up in urban areas with a native brother and sister—another stayed in North Dakota. I have seen the early and preventable weakening and death of family members, friends and patients all around me in Indian Country—whether urban, rural or reservation.

All of these siblings died as young adults, and largely, from the top known mortality reasons in Indian Country including alcoholism/liver failure, motor vehicle accidents and infectious disease. My aunts and uncles on the reservation lived similarly shortened lives. The people I am citing here all had their care paid for and/or provided by the federal government.

American Indians have some of the poorest morbidity and mortality numbers in the country.  The Indian Health Care Improvement Act, which had a long history of not being reauthorized for years, was folded into the current health reform law.  What does this really mean for Indian health care? In my area, there are new provisions for eldercare.  Eldercare was never a solid part of the mission, funding, or programming in the Indian Health Service. The problem? It is authorized but as yet unfunded.

Older Americans are suffering from a system that largely is unprepared to care for them.  There is very little geriatric education given in any health professions schools.  Considering older people are more likely to access the system and providers, this is unacceptable. I cared for my mother at the end of her life in my home.  Before her move to my state, I accompanied her to her doctor who had cared for her for 30 years.  But the doctor still treated her as she had as a 50-year-old.  I intervened on my mother’s behalf.  The doctor seemed shocked to realize that the patient in front of her was depressed, anxious, had more pain than she told the doctor, had bladder spasms and needed a cane.

As a nurse for 23 years, I have seen people from all walks of life who are in great need of care, receiving care they cannot hope to pay for, or receiving care that does not meet their needs. Money and the ability to pay are not always at the root of the problems.  Targeted, appropriate, accessible and acceptable care are the keystones to care utilization, health optimization and quality.  These are the ‘things’ that must be carefully crafted within the regulations that will flow from the law, not just payment.

The law—although a thousand pages long—is not the law under which all these provisions for aging, for Indians and for nursing will operate.  The law now gets parsed into thousands more pages as the executive branch agencies roll out regulations at the state and federal levels. My optimism leaves here and my call for sustained diligence on the part of older Americans and their advocates, nurses, and American Indian entities kicks in.  This is where voice(s) must be heard.  Those who understand current circumstances, likelihoods, history, divergences from norms, and needs must add their voices to each and every regulation up for public comment.

The power of the law to make a real difference in America’s health exists but the power differentials around ageism, racism and professional hierarchies also exist.  I still hold back some caution as we move forward, with an optimistic eye toward the future health of America.

Learn more about the RWJF Health Policy Fellows program.

Tags: American Indian (incl. Alaska Native), Family and Social Support, Health & Health Care Policy, Health Policy Fellows, Nursing, Seniors (65+), Supreme Court Health Reform Ruling, Voices from the Field