With President Trump and congressional Republicans promising to repeal or replace parts or the entirety of the Affordable Care Act (ACA), emergency medicine stakeholders are making sure lawmakers know what provisions in the law must remain intact, and what new reforms are needed. They also are urging emergency medicine clinicians to stay informed on the issues, and to advocate for their interests.
- The American College of Emergency Physicians (ACEP) wants to ensure that emergency services remain essential covered benefits, and that freestanding EDs and other emerging healthcare delivery models are supported.
- Although ACEP calls on lawmakers to preserve Medicaid, Medicare, and the Children’s Health Insurance Program, the organization is less than satisfied with the insurance products offered on the ACA exchanges. The organization wants lawmakers to address both the affordability and transparency of coverage options.
- The Emergency Nurses Association calls for an expanded role for advanced practice registered nurses in both primary and emergency care, and it wants more action to improve access to mental healthcare services.
Healthcare is once again the subject of a political tug-of-war, with President Trump and congressional Republicans signaling plans to repeal and replace parts or all of the Affordable Care Act (ACA). On the other side are lawmakers and other ACA advocates who want the law’s provisions to remain intact.
With guns fully loaded on both sides of the issue, it’s unclear just how or even whether the law will be altered to a significant extent, but it is hard to underestimate the stakes for emergency medicine. Indeed, leaders of both the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) have outlined their legislative priorities. Leaders of both groups are urging their members to familiarize themselves with the intricacies of the law and get actively involved in promoting their interests.
ACEP President Rebecca Parker, MD, FACEP, stresses that it is vitally important that emergency services remain as a covered benefit under any insurance plan. “In the ACA, emergency services are one of the 10 essential services, and we believe it is crucial for that to continue,” she says.
Parker adds that the Prudent Layperson definition of an emergency needs to continue as well. “If someone thinks he is having an emergency, he should be able to seek emergency services without being worried about being denied [insurance coverage] on the back end,” she says. “We don’t want patients with chest pain worrying about whether that is covered. We want that to be a par-for-the-course service.”
Further, ACEP wants to make sure that any alteration or replacement of the ACA recognizes the importance of freestanding EDs as well as other emerging models of healthcare delivery. “Freestanding EDs are an innovative way to offer access to care in new places that may not be large enough yet to require a hospital, but do have a need for emergency or outpatient care,” Parker says.
Other examples of healthcare delivery innovation Parker would like to see supported in any new legislation include telemedicine solutions to deliver or coordinate care and the expanding use of paramedicine for follow-up or ongoing care to patients after discharge from the hospital. “We have some members in that space, and they are showing some remarkable improvements in care, including decreases in readmission rates,” Parker observes. “Those types of approaches are common sense and are good ways to improve care that our members are exploring.”
Parker is not a fan of any efforts to eliminate or repeal the Center for Medicare & Medicaid Innovation (CMMI) — at least in the near term. “We were one of seven specialty societies to receive a CMMI grant, and we have been pleased with the opportunity. The grant is $3 million over three years,” she says.
Parker explains that ACEP has used the CMMI funds to form the Emergency Quality Network, or E-Qual (), an entity that focuses on improvements in three areas: low-risk chest pain, sepsis, and radiology use. “Physicians sign up for the program, we provide them with education ... and they measure outcomes both before and after the education,” she says. “We have had a terrific response from our members, and it has been a way to not only improve quality of care but also show how we can contain costs as well.”
Preserve Access, Improve Affordability
House Republicans have already signaled that as part of their replacement plan for the ACA, they want to gradually undo the ACA’s expansion of Medicaid. Parker takes issue with this stance, noting that such a move would put coverage out of reach for many patients. “We will watch that very closely and advocate to keep Medicaid solvent,” she says. “We want to be sure our patients who receive Medicaid continue with that access to care. It is important to not only when we see them, but also after we see them. We want to make sure they are getting into primary care clinics where they are able to get follow-up and to get the medicines they need.”
While ACEP wants to ensure lawmakers preserve Medicaid, Medicare, and the Children’s Health Insurance Program, the organization is not satisfied with the insurance products offered on ACA exchanges. In particular, ACEP would like to see mandated improvements with respect to affordability and clarity. “The deductibles are very high and the networks are very narrow,” she says. “What we see from our patients is that they are confused by the insurance; there is not good transparency. The premiums are higher, the deductibles are higher, and they get caught in the middle when they are starting to get bills they did not anticipate.”
Parker says ACEP is concerned about what she terms “bad insurance products” that patients cannot afford and that don’t adequately cover emergency situations. “People think they are covered when they are actually not covered,” she says.
In the same vein, ACEP maintains that any expansion in the use of Health Savings Accounts, Health Reimbursement Accounts, Association Health Plans, or Individual Health Pools must provide what the organization terms meaningful benefits and coverage, including access to emergency care.
In addition, ACEP wants to make sure that patients with pre-existing conditions have access to coverage, that there are no lifetime coverage limits in insurance policies, and that children can remain on their parents’ insurance policies until age 26.
Deliver Liability Reform
The Independent Payment Advisory Board (IPAB) is one highly controversial feature of the ACA that was designed to help control costs. However, while it has never been funded, the ACEP is eager for this concept to be eliminated. “The American Medical Association is also against it as well as every other physician specialty,” Parker says. “It would be an entity that would not be supervised by Congress or any type of outside body, so we are completely against the IPAB and urge repeal. We think the current system works well and want to continue with it.”
Another issue ACEP wants to see lawmakers finally address is liability reform. “It is always a top priority for our members, and it is also important for our patients,” Parker explains. “We need specialists to take calls, and one of the issues that we often see is that specialists will drop calls if they feel they are in a high-risk environment, and emergency patients are just that; often, they are not known and they come in very ill, so we want to preserve that access for our patients.”
ACEP wants to see Emergency Medical Treatment and Labor Act (EMTALA)-related liability cases moved to the federal tort system for adjudication and review. “It provides support ... which is different from the costs and burdens that our local liability systems have,” Parker explains.
Parker adds that the current system in place to deal with medical liability cases focuses on the individual rather than improving care or finding systems of care that are better. “One-third of the money goes to attorneys, so the wrong people are getting paid if what we are trying to do is take care of the patient, make our system better, and provide better care,” she says. “It is a very personal thing to get sued, unfortunately, and it is not a good system that we have [to deal with these cases].”
Boost Mental Healthcare Resources
Parker applauds the recent passage of the 21st Century Cures Act, which President Obama signed into law before leaving office. Among other things, the legislation provides generous new funding for mental healthcare, but Parker notes that more solutions are needed. “We tell the story about our psychiatric holders — patients that we know need acute psychiatric services or need inpatient admission, but wait in our EDs for days and days,” she explains. “So funding more outpatient services, which have been cut back dramatically over the last 15 to 20 years, is crucial, along with looking at what our bed capacity is at some of our institutions.”
Parker adds that she hears about mental health-related issues from ACEP members in all regions of the country. “Everybody is short psychiatric beds,” she says. “And we also feel this issue connects together with the opioid crisis as well.”
There is always a combination of psychiatric illness with substance use, Parker notes. “Often times, patients cannot get the resources they need — maybe for depression, bipolar disorder, or another psychiatric condition,” she explains. “[These issues] go hand in hand, and that is what we see in our departments.”
ENA President Karen Wiley, MSN, RN, CEN, notes that her organization’s advocacy led to the inclusion of important mental health provisions in the 21st Century Cures Act, but she agrees with Parker that lawmakers must do much more. “According to ENA research, the average ED stay for mental health patients is 18 hours, compared to four hours for all other types of ED patients,” she says. “Access to mental healthcare treatment is severely lacking.”
Wiley notes that mental health patients often turn to the ED when their symptoms worsen or when they find themselves in a crisis, yet these patients would be served better in facilities with specialized expertise. Consequently, improving access to mental health resources is a top federal legislative priority of the ENA.
Expand the Role of APRNs
Beyond mental healthcare, the ENA has expressed many of the same concerns as ACEP regarding the importance of providing affordable insurance options and maintaining access to care, especially for vulnerable populations. The organization points out that the states that expanded Medicaid under the ACA saw a 31% drop in uninsured visits to the ED compared to the states that did not take advantage of expansion. Given the burdens that uncompensated care places on EDs and other healthcare providers, the ENA urges lawmakers to ensure that any changes to current policy avoid worsening these burdens.
The ENA also calls for an expanded role for advanced practice registered nurses (APRN) in both primary and emergency care. “There are several ways lawmakers could allow APRNs to practice to the full extent of their training,” Wiley explains. “Medicare could cover APRN services, as allowed by state law, to the same extent physician services are covered, [and] the Medicaid payment increase for primary care services under the ACA could be extended beyond physicians to include APRNs.”
In addition, Wiley notes that CMS could promote the use of APRNs in policies related to federal employee benefits and hospital conditions of participation in Medicare. At the state level, existing laws on nursing scope of practice could be changed to allow APRNs to fully use their skills and training. “The Veterans Administration [VA] took a big step when it finalized a rule in December that allows full practice authority to APRNs employed at VA facilities,” Wiley observes.
With their broad knowledge and expertise, APRNs with full practice authority could help address identified gaps in both primary and emergency care, Wiley offers. “In the ED, increasing demand for services and staffing challenges create an opportunity for APRNs,” she explains. “[They] can help address overcrowding, reduce patient waiting times, and improve patient satisfaction.”
Wiley adds that fully leveraging the skills of APRNs ultimately would lighten the strain on busy EDs. “With greater access to primary care, the number of patients who require emergency care may be reduced as patients engage in more preventive healthcare and better manage their chronic conditions, averting preventable healthcare emergencies,” she adds.
Further, to ensure a continued supply of well-educated nurses, the ENA wants to see reauthorization of nursing workforce development programs under Title VIII of the Public Health Service Act, as well as new support for workforce development, loan repayment, and tuition assistance programs.
Get Involved, Offer Expertise
To make sure that nursing concerns are appropriately addressed by lawmakers, Wiley states that providers must fully understand how proposals will affect their emergency setting and the care they provide. “Clinicians and administrators need to communicate with agencies and lawmakers about the impact of policy on their ability to provide high-quality patient care,” she explains. “They should contact state and federal lawmakers early and identify any overarching principles for improving the healthcare system, and pledge to work with lawmakers as the debate unfolds.”
Wiley adds that healthcare providers can offer their expertise as a resource to lawmakers as a way of building constructive relationships. “One way to offer expertise is to testify at legislative hearings, using personal experience in the ED,” she advises. “The ENA has already done this at the state level, testifying on bills that address the issue of criminal penalties for assaulting emergency nurses and other healthcare providers in EDs or hospitals.”
Other steps that clinicians can take include monitoring lawmaker websites and participating in town halls and other events that might be hosted locally, Wiley observes. “Write letters to the editor or op-eds in local newspapers, imploring fellow citizens and lawmakers to support responsible policies that improve the system for all,” she says.
Parker notes that from their vantage point on the front lines of healthcare, emergency physicians can bring important perspective to the debate over future healthcare reforms.
“We see everything because of the type of practice that we do, and we are the safety net, so I encourage our physicians to go out ... talk about the patients they see and about the opioid deaths, the crises, the families, and the work we are doing to make things better,” she says. “Emergency physicians have a unique voice, which is the patient’s voice.”