Hospitals will face a major dilemma if the current federal administration repeals the Affordable Care Act (ACA) without a suitable replacement. The ACA offers millions of Americans affordable health insurance, and hospitals have seen their revenues, and their quality of care, rise as those newly insured citizens access their services. If the ACA goes away, those health care patients and their accompanying insurance payments disappear, putting even more stress on today’s health care labor force. With profit decline comes employee decline, both in number and quality. This will first and foremost affect nursing staff, putting some out of work and others in-over-their-heads.
An Uncertain Health Care Future
Before enactment of the ACA, existing law required (and still requires) that health care facilities provide “stabilizing care” to any person who requests services, regardless of their ability to pay. Medicaid covered these costs. Without ACA coverage, many patients will be forced back to receiving only the substandard “stabilizing care,” and will not receive the services they need to regain their health.
In that circumstance, the medical facility will be forced to balance the volume of unsubsidized, stabilizing care offered against the revenues generated by paying patients, cost reductions, or staff workload increases. If they offer excessive unsubsidized care, they risk declining income levels, staff numbers and possible bankruptcy. If they provide too little, they risk losing their Medicaid/Medicare funding. In both cases, the facility, its staff, and America’s uninsured patients will suffer.
Unpaid Care Is Expensive for the Medical Office …
Every medical consultation generates a series of cost-creating actions, from those of the scheduling secretary to the attending medical professional, and all the way through to the deposits made by the final billing clerk. According to the American Hospital Association, hospitals provided $35.7 billion in uncompensated care to their patients in 2015 alone. When a hospital absorbs these losses, it is also forced to reduce the services it can afford to provide.
Consequently, it is not unheard of for doctors to reduce the size of their bills by limiting the services they provide or the number of recommendations they make, based on their perception of what the patient can afford. Other studies confirm that uninsured patients are checked into a hospital for shorter stays, and they are offered fewer interventions for their condition. For the health professionals, these painful decisions are in direct conflict with their oath to provide the best care possible for every patient.
… And Hard on the Staff
One group of hospital workers that will certainly absorb a significant percentage of additional work due to funding cuts are the nurses. Reduced funding often leads to reduced staff numbers; remaining staff end up working longer, harder shifts, with more responsibility and less break time. And nursing is already a challenging job, with a high demand for significant physical labor that also takes an emotional toll. In fact, between 2002 and 2012, nurses have reported the highest stress levels of all health care professionals.
Additionally, long hours may not allow nurses to get the sleep they need. Inefficient sleep has been associated with a deficit in performance, caused by cognitive problems, mood alterations, reduced motivation, increased safety risk, and physiological changes. These effects only get worse with total sleep deprivation, common among nurses who work consecutive shifts.
Additional Stress Factors
Research reveals that the changes in the nursing profession in particular and the health care system in general, contribute significantly to the problem:
Sophisticated technology offers immense benefits but adds additional layers of responsibility on already overloaded schedules;
Burnout is common, too. Protocols can change as resources ebb; nurses are compelled to follow evolving practices without the opportunity to add input regarding their patient’s care. A 2012 study published by the Canadian Federation of Nurses Unions found high levels of burnout correlated to lower ratings for quality of care.
Reduced staff numbers also drive nurses to work even when they are sick. Many choose to potentially infect their patients rather than leave their colleagues unsupported on shift.
The reality for America is that, before the ACA, unpaid hospital bills were often eventually born by other elements of the system, including taxpayers and patients who incurred higher medical care costs. Repealing it won’t save the country money, but instead will add extra stress to the system and further erode the health of millions of its citizens.
Five- and 10-year cancer survival rates were lower among American Indians and Alaskan Natives (AIANs) compared with non-Hispanic whites even when they had approximately equal access to health care, according to data presented at the American Association for Cancer Research conference on The Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved.
“Our preliminary analysis suggests that with presumed equal access to health care, five- and 10-year cancer survival among mostly urban-dwelling AIANs was lower than among non-Hispanic whites,” says Marc Emerson, MPH, a cancer research training award fellow in the Division of Cancer Control and Population Sciences at the National Cancer Institute in Bethesda, Maryland. “Our study focused on AIANs who live largely in urban areas, a population often hidden to researchers.
“The AIAN population experiences some of the greatest disparities in health and health outcomes, yet this remains an understudied area of research,” adds Emerson. “Future research should focus on factors other than health care access that may be driving disparity in the cancer outcomes observed.”
Emerson and colleagues found that the top four cancer diagnoses among AIANs and non-Hispanic whites were the same: prostate, breast, lung, and colorectal cancers. The fifth most common cancer type among AIANs was non-Hodgkin lymphoma, while it was melanoma for non-Hispanic whites.
The researchers also found that the five-year survival rates for AIANs and non-Hispanic whites were 52% and 58%, respectively, and the 10-year survival rates were 37% and 44%, respectively.
The most common comorbidities were the same for both races—chronic pulmonary disease, diabetes, and congestive heart disease—but the rates of these comorbidities were higher among AIANs compared with non-Hispanic whites. “In future analyses, we will examine the extent to which prevalence of comorbidities and other factors may account for the survival differences observed,” says Emerson.
The researchers collected data from Kaiser Permanente Northern California electronic health records for 1,022 AIANs and 139,725 non-Hispanic whites diagnosed with primary invasive cancer between 1997 and 2012. They used sociodemographic and health data of the study participants, including age at diagnosis, race, cancer site, type of treatment, comorbidities, and treatment follow-up time, for their study.
This study was funded by the National Cancer Institute.
About 30% of Hispanic Americans and 20% of African Americans don’t have a usual source of health care, but less than 16% of white Americans lack a source.
For women who have had an abnormal screening mammogram, the length of time before a follow-up test is conducted is twice as long in Asian American, Hispanic, and black women than it is in white women.
It’s no secret that there are racial and ethnic disparities in health care. These statistics, which come from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey, highlight a major concern in the field of medicine. Not all patients receive the same level of high quality treatment—or in some cases, receive treatment at all.
This concern is important within nursing schools, because they are tasked with making sure our country’s future nurses fully understand racial disparities and what can be done to address them, says Mary Green, PhD, MN, RN, interim chair of the Dillard University School of Nursing in New Orleans.
Schools must show the latest research and best practices to the next generation of nurses, and take them into communities so they can see firsthand the effects of health inequality, argues Green. “Nurses need to get the broadest experiences they can.”
Learning in the Community
Many nursing schools have mandatory community health courses that expose students to inequalities among groups of people. Nursing students learn about the statistical differences in health care outcomes, and along with that, many of these institutions require nursing students to meet the people behind the statistics.
For example, at the University of Alabama-Birmingham (UAB) School of Nursing, undergraduate students, along with faculty, go into communities in the greater Birmingham area that have historically had less access to health care, says Linda Moneyham, PhD, RN, FAAN, senior associate dean for academic affairs at UAB. There, nursing students learn how to master their clinical work while partnering with neighbor representatives who are interested in improving the community’s health, she adds.
“These tend to be communities that are lower income, have high minority populations, and have a lot of health needs,” she says. “In fact, Alabama is often the epicenter for some of the major health problems the country faces.”
Moneyham explains that Alabama ranks near the top for prevalence of heart disease, obesity, and HIV—and minorities are disproportionately affected. “We have to focus on these populations because they are the populations nursing students are going to be caring for,” says Moneyham.
At the University of Washington School of Nursing in Seattle, there is a similar approach. “We have for years had a required course on community health nursing that addresses health disparities and inequities,” says C. June Strickland, PhD, RN, associate professor, psychosocial and community health nursing, at the school. “It’s [often] the very first course that students take when they come into our program to study,” she says. “Essentially, it focuses on health disparities, equities, and social justice.”
“In addition, we have clinical sites in multicultural environments that include American Indian, African American, Latino, and Asian populations,” explains Strickland.
“When faculty members take students to those clinical sites, they get a cultural immersion and opportunity to understand some of the issues people are facing. For instance, with Native people, some of what we experience is the impact of colonialization that continues on in our community.”
The School of Nursing also attracts other students that plan to work in related fields, such as social work, public health, and psychology, says Strickland. “I teach a core course in assessment and that course also draws students from all over campus, because certainly these issues come up [in those disciplines].”
There are also graduate level courses that dig deeper into problems associated with inequalities. Deborah Ward, PhD, RN, FAAN, is associate dean for academics at the Betty Irene School of Nursing at the University of California-Davis in Sacramento. “We have a course in health status that all of our masters and PhD students take. That course looks at health status around the world, and it certainly looks at disparities in the US,” says Ward.
“We also have another course called Community Connection. Our masters students in the leadership program take this course where pairs of students work with community agencies,” she continues. Examples of these agencies include the Sacramento Unified School District and the local food bank’s parent-child program to provide support for parents with a variety of special needs. “Students come face to face with the issues that community agencies are working on, which includes the health effects of disparities of all kinds,” says Ward.
For example, one pair of students working with the county health department looked at soft drink vending machines in certain schools. School districts that are strapped for funds—and often in minority neighborhoods—can get money by having vending machines for soft drinks in their schools, Ward explains. “But on the other hand, if you have vending machines in schools that deliver sugary drinks, you’re contributing to the obesity epidemic that places students at all kinds of risk.”
Students who are obese are at great risk for many health problems, such as diabetes, says Ward. So the nursing students learned how school pupils in minority neighborhoods are exposed to factors that contribute to the obesity epidemic.
In this particular course, nursing students wanted to address the question of whether or not it was good for a cash-strapped school system to get immediate money from vending machines, or if it was better to ban the vending machines and have students ingest fewer sugary drinks.
“The students did a sophisticated analysis of the cost and benefits to the community in having soda machines in the school,” says Ward. “Armed with that kind of data, you can come back to your community as a nurse leader and demonstrate the long-term advantages of not having soda machines in a school.” The students learned how to work at system-level changes that are going to help communities make decisions about important health issues in their community, Ward adds.
Filling in Gaps
With upcoming changes in health care laws, there are going to be thousands of people from different communities who are going to be seeking health care services they might not have sought in the past, says Moneyham. In many areas, especially rural areas, nurse practitioners will be called on to help fill in the gap between patients requiring care and available physicians, Moneyham explains. Nursing schools are teaching their students that this is something that can directly help reduce the inequalities that have historically existed in those communities, she adds.
In addition, nursing students will be called on to share information about programs that help disadvantaged patients. For example, there are pharmaceutical companies that may supply medication for patients for minimal charge, particularly if the shelf life of the medicine is short. “Sometimes they’ll distribute those to poorer patients,” says Moneyham, and a nurse can be the link between that patient and the pharmaceutical company.
Avoiding Stereotypes
In order to give quality care to people who are from different cultures and ethnicities, all nurses, including minority nurses, need to learn to overcome misconceptions and even prejudices they may have about the patients they serve, says Moneyham. “For example, one stereotype is that if someone is overweight or they have health problems, they don’t care about themselves, and you can’t help those people because if they wanted to lose weight they could.”
But the nursing school helps students understand that there are often external affairs that affect a person’s health, and health professionals should understand what those factors are in order to effectively help a patient, she says. “We provide the experiences to nursing students to help them walk in the [patient’s] shoes, and try to understand their perspective about their weight problem and their challenges.”
The methods used when approaching people should be appropriate and respectful. If nurses don’t understand someone’s situation, any recommendation will likely not be effective, says Moneyham. She conducts focus groups with women who may be classified as obese, and she finds that many may not see themselves as overweight. Students learn that in these cases, giving lectures on losing weight likely won’t work. “What we need to focus on are things that help these women feel healthier, such as getting enough exercise or watching the types of food they eat,” she argues. “We have to work where the person is ready to work.”
Even then, minority nursing students should learn that individual actions are only a small piece of what impacts health, argues Vicki Hines-Martin, PhD, CNS, RN, FAAN, director of the office of health disparities and community engagement at the University of Louisville School of Nursing. In fact, students are often surprised to learn that social factors outside of a person’s control have a very large influence on their health. These “social determinants of health,” as outlined by the World Health Organization, identify that a person’s health status, access to care, and health outcomes are all influenced by things that are not specifically health-related, says Hines-Martin. Those determinants include economic status, education, and even access to transportation. “If you have people who have lower income, less education, and who live in communities that are less friendly to activity [and exercise], their health by definition is going to be less,” explains Hines-Martin.
“Increasingly, students at both the undergraduate and graduate levels are expected to think critically about the context from which a person comes. And as a result of that, faculty are changing where they do their work clinically, how they do their classroom teaching, and the examples they use to help a nursing student make better decisions about the populations they work with,” says Hines-Martin.
“Not only do we need to teach our nurses what they should be doing directly with the patient, we also need to put them into the context of where that patient comes from. Then we realistically adjust, adapt, or support that person’s ability to maintain whatever wellness they can,” she continues.
At Dillard, nursing students learn to address disparities and overcome their own prejudices by looking at case studies, says Green. She gives the following example of a case study:
Let’s say we have JM, who is a 47-year-old African American male who is currently homeless, jobless, and suffers from schizophrenia, uncontrolled diabetes, and hypertension. Because of the behavior attributed to his mental illness, he may be in and out of jail and perceived as a threat to the community. As nurses, what do we do?
Green explains that nursing students learn how to deal with urgent problems, such as the uncontrolled diabetes, as well as seek out other resources, such as helping to locate a case manager who could help JM access mental services that may be available.
These case studies are then followed up by actually visiting similar neighborhoods. “Going into the community gives a more accurate picture of the racial and ethnic disparities that exist,” says Green.
School Diversity
Understanding disparities can occur with one-on-one teaching, but diversity initiatives should also occur on an administrative, school-wide level, says Strickland. This means having a nursing school that reflects and celebrates racial and ethnic diversity in addition to teaching it. “It’s important to have systems and structures in place that support these behaviors.”
Strickland states that the University of Washington has a diversity council and an office of minority affairs that’s very active. “There is also a diversity council within our School of Nursing, and some of the activities have included working with faculty to design an evaluation so faculty can evaluate how effectively they’re addressing disparities and diversity in their course content,” she says. Strickland adds that the school recently voted to include diversity in their promotion and tenure documentation for faculty.
At UC-Davis, Ward says the first area where the school practices the goal of cultural inclusiveness is with its faculty and staff. “We like to think of what we’re doing as a multi-faceted approach,” she says. “This means cultural inclusiveness, teaching cultural approaches to care, and working with all of our communities to improve care and health.”
At the UAB School of Nursing, Moneyham says that more than 26% of students are minorities. “This is high compared to the national average,” she explains. “A lot of that has to do with where we sit in the Deep South region of the United States.” Moneyham adds that cultural diversity in nursing schools is good because nurses are able to accurately reflect the communities they serve.
When nursing schools cover minority populations and health care inequality effectively, they produce nurses who are more competent at addressing those inequalities. This in turn produces better nurses who are more likely to take a leadership role in helping eliminate disparities, says Hines-Martin. “It is a strategy of engaged scholarship, engaged teaching, and engaged research that has evolved.”
Margarette Burnette is a freelance writer based in Georgia.
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