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The Affordable Care Act (ACA) is a complex health reform package that was signed into law by President Obama on March 23, 2010, and amended by the Health Care and Education Reconciliation Act on March 30, 2010. The law consists of over 900 pages of statutory text that covers a wide range of topics. This section summarizes the parts of the ACA pertaining specifically to how the country’s health care system is reformed, as well as selected other highly relevant topics, such as health care delivery reform, workforce implications, provisions around the Centers for Medicare and Medicaid Services and Veterans Administration system exchanges, and some implications and provisions for states (1987- Gastmyer, 2013). The Role of Nursing Professionals in Healthcare Collectively, nursing is the largest professional healthcare provider group in the United States, and the profession that feels the deepest impact from the ACA. As the implementation of the ACA is still in its infancy, there is a thirst for insight into real world impacts from the providers who have experienced its implementation first-hand. Offered is the initial inquiry from a nursing student perspective to uncover some of these firsthand insights from nurses and nursing administrators involved with the ACA at various levels, from hospital administration to state level political involvement to direct patient care. Aimed at addressing these questions and expanding upon the impact of the ACA equitable nursing professionals turned to experts with experience ranging from direct patient care to legislative commentary (1987- Gastmyer, 2013). The question posed to three healthcare professionals with work experience in each of these direct ACS experiences. Political Climate Surrounding the ACA From its inception, the Affordable Care Act (ACA) has created significant division, both politically and between the public and healthcare workers. Individuals who disliked the ACA tended to be more politically conservative, while those who supported it more often identified politically as liberal. Political discord surrounding the ACA is currently significant, with recent polls indicating increasing levels of disapproval (Stidham Hall et al., 2015). Nurses may also be impacted by this discord, as they often hold significant involvement in advocacy for healthcare reforms. Current socio-political situations and nursing involvement indicate that there may be a strong influence of the socio-political climate on both nursing attitudes and activism surrounding the ACA. The goal of this study is to evaluate how the socio-political climate influenced nursing support and opposition of the ACA in an interview study conducted in 2020 and 2021. Public policy research has indicated that the socio-political climate in the U.S. has a profound effect on public health advocacy efforts (Hoornbeek et al., 2018). Specifically, health policy-related advocacy and lobbying is increased with the shifting of partisan control in government, especially if the party in control is viewed unfavorably by the interest groups. The primary goal of this study will be to determine if the data supports this hypothesis, with regard to the ACA and registered nurses, an advocacy group with a mission to provide healthcare to all. Evaluating support and opposition of the socio-political climate on a major healthcare reform creates unique implications for a profession aimed to directly provide healthcare to all. Using qualitative analysis, a secondary goal will be to expand upon how the socio-political climate began to shape nursing attitudes toward the ACA. Qualitative data provides rich context to understand the nuances in attitudes of various nursing demographics as it relates to the socio-political climate and its relation to perceptions of the ACA. Ultimately, addressing this issue will create a better understanding of the implications of such a wide-reaching socio-political movement on healthcare advocacy groups with a specific focus on nursing, an often-overlooked group in political science. Arguments for Keeping the ACA Proponents of the ACA offered a variety of arguments in favor of keeping the legislation. Although it was passed well over a decade ago, some of the arguments offered are the same ones put forth in 2010. Some of the arguments offered at that time are no longer relevant. In 2010, 50.7 million Americans were uninsured. That number has dropped. Many of these arguments have been reasserted over and over by many different individuals, organizations, and social and professional groups. Nevertheless, they are still very valid arguments. Increasing Number of Insured The greatest achievement of the ACA, first and foremost, has been to lower the number of uninsured Americans. The ACA did this through expanded eligibility for Medicaid, more affordable health insurance through the exchanges, and improved coverage. Not only did this give more access to care, but it also lowered the number of uncompensated hospital visits, helping to stabilize or even lower hospital costs and care for some routines procedures. Arguments for Repealing or Revising the ACA The indicates that “the AANP supports the Affordable Care Act,” a recent law that “greatly advances the goals of the NP profession by increasing available coverage options, assistance to purchase coverage and protections for those with pre-existing conditions.” Documents, literature, and opinions from nurse practitioner organizations regarding the ACA were collected for analysis to find opposition, dissent, or fears from this portion of the nursing profession. Individual journals, newsletters, and press releases were reviewed for the four professional organizations/Nurse Practitioner Associations: the Nurse Practitioner Association of New York State, the American Academy of Nurse Practitioners, the American Association of Nurse Practitioners, and the Nurse Practitioners in Women’s Health. Potentially revealing search terms were entered into each of these documents. Commonly, many articles noted support for the ACA but offered nothing further. Looking back through publications focused on the ACA’s passage, however, revealed concerns and fears regarding the bill, particularly regarding the lack of a public option. Many stressed their belief that a public option was important but tried to temper their disappointment with encouragement to seek more obvious victory or to “praise the good” (Hoornbeek et al., 2018). Most organizations outright endorsed the ACA. The literature in support of the ACA noted the shield against denial of pre-existing conditions, young adult coverage with parents insurance until 26, and the expansion of Medicaid. In states adopting the expansion, the Federal Matching Funds provided further incentive for states to adopt comparable plans. It is noted that such a plan is more or less inevitable as uninsured costs bomb. However, it is simply stated that “a million words of dissent won’t change the truth: The Affordable Care Act is buried beneath an avalanche of top-down bullshit”. Claim was made that a death spiral was inevitable with the ACA, asserting that law had left the Affordable Care Act in Kentucky “fiat-cation.” Rationale for Supporting the ACA A small sample of the candidates completed the 7-point, Likert-style question, which asked how supportive or opposed they were regarding the ACA. The modes for the classes, inhibitors, buffers, and neutral elements each fell within “supportive” on the original scale. This was most evident within the buffer elements as “very supportive” was chosen by 23 of the 86 responding candidates. More specifically, the increase of health insurance for those with pre-existing conditions was reported as supportive by just 1 candidate and the rest were reported as “very supportive” by 74 candidates. Similarly, the requirement for insurance companies to cover preventative care measures at no extra fee received the same distribution of responses. The modes for all of the elements from the 92-member class fell in the “supportive” range of the scale. Those issues which could be blocks or neutral items received the lowest modes within a neutral range of “neither supportive.” Rationale for Opposing the ACA Some nursing professionals believed they should publicly oppose the Affordable Care Act (ACA). This opposition did not come with the pathological, stereotypical or exaggerated passions that occasionally fueled a professional or public argument. Rather, the opposition carefully reasoned the matter and challenged much of the claims supporting the ACA while still agreeing with its abounding need, and only on the fact that the mechanism offered would inevitable lead to failure. Three primary reasons for that were as follows.Unlike the evidence-based practices many health care professionals relied on, the ACA was based on political choices, not medical choices. The ACA was meaningless if it did not put forth the actual reforms or provide the power to enforce new regulations. Budgets, taxes, limits, exemptions and penalties were rifts within the national discourse and stock positions for or against the ACA. Politically chosen values might yield a political result, but that result could only be questioned politically rather than clinically (J West, 2015). References 1987- Gastmyer, C. (2013). The Impact of the Patient Protection and Affordable Care Act on the Health Education Profession as Perceived by the Leaders of the Profession: An Exploratory Study. [PDF] Hoornbeek, J., Lanese, B., Albugmi, M., & Filla, J. (2018). Healthcare Reform Repeal Efforts in the United States in 2017: An Inquiry into Public Advocacy Efforts by Key Interest Groups. [PDF] J West, B. (2015). Opinions on the Affordable Care Act: The Role of Self-Interest. [PDF]

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