01/20/2017 |
With the looming “Repeal and Replace” of the Affordable care Act (Patient Protection and Affordable Care Act), all of us are anticipating either significant changes or slight modifications. In other words, no one knows what alterations are forthcoming nor when they can be expected. The political posturing seems to paint competing landscapes, sometimes austere and sometimes placid.
“People want certainty, and there isn’t any,” Vermont state Sen. Jane Kitchel, D-Caledonia, chair of the Senate Committee on Appropriations, told VermontWatchdog.org. “One day, [Trump] is talking about repealing the ACA, and then he says he wants to provide coverage for everyone. At this point, all we can do is track the situation closely.” In any case, we know one thing for sure; change is coming.
All stakeholders have their sights on Rep. Tom Price, President Trump’s HHS Secretary Nominee. Mr. Price authored a 2015 Health Reform Proposal and has been a fervent critic of the ACA. It is anticipated that at least some of the elements of Mr. Price’s proposal will make their way into the Replace portion of the Repeal and Replace strategy of the Republican held Congress.
According to the Kaiser Family Foundation, key elements of the Empowering Patients First Act (EPFA) (H.R. 2300) include:
The proposal removes the individual mandate, meaning there is no longer a requirement to have coverage. Instead, this plan adopts a different approach by rewarding purchasers of coverage. Fundamentally, the ACA is punitive for not having coverage while the EPFA rewards those who buy coverage.
As a business owner and a consumer, I have never understood the imaginary state lines confining commerce. Insurance sales are no exception and I doubt seriously that there are any real impacts by removing these academic boundaries. In fact, quite the contrary – if the notional company, American Health Insurance Company, wants to lower premiums and has efficiencies that none of its competitors have realized, then they should be able to sell in any state. Creating pricing competition and removing state’s self-imposed barriers, the market forces will yield a more robust market for purchasing coverage.
And this is simply a small peek into what may be coming.
Of course, this article promised to explore the impacts on travel nursing. As you’re probably aware, travel nursing and contingent clinical staffing altogether, has ridden a wave of increased use since the rollout of the ACA. AMN Healthcare’s revenue has grown 65% since 2011 which would lead our readers to associate the ACA with influencing the increased use of travel nurses and contingent clinical staffing. Diving deeper into the statistics, however, we can see that there may not be a relationship.
Between 2011 and 2015, hospitals actually saw fewer patient days, going from 18,896,876 patient days in 2011 to 18,321,570 in 2015. Live births decreased from 492,480 in 2011 to 478,847 in 2015. These statistics would seem to contradict the notion that the ACA has led to greater utility of acute care services.
The only increase in utilization has come from emergency services, which itself is not insignificant but could have a tighter relationship to the number of increased number of those insured. Even more interesting is the utilization of differing levels of Trauma Centers. As you will find with the comparisons below, use of Trauma Level I services had an unremarkable increase, while utilization of Trauma Levels II through Non Trauma Centers had an increase of 18.7%. The takeaway is that utilization of acute care services has increased exclusively in the Emergency Departments, but only among Trauma Level II through Non Trauma Center facilities.
2011
Trauma Center Hospitals
Number of Hospitals
ED Visits (w/ and w/o Admission)
% of Total ED Visits
Trauma Level I
14
1,019,634
7.18%
Trauma Level II
39
2,704,774
19.05%
Trauma Level III
13
542,537
3.82%
Trauma Level IV
10
203,064
1.43%
Non Trauma Center
410
9,728,164
68.52%
Totals
486
14,198,173
100%
2015
Trauma Center Hospitals
Number of Hospitals
ED Visits (w/ and w/o Admission)
% of Total ED Visits
Trauma Level I
15
980,829
8.12%
Trauma Level II
33
2,042,942
16.90%
Trauma Level III
11
341,856
2.83%
Trauma Level IV
9
145,807
1.21%
Non Trauma Center
419
8,574,382
70.95%
Totals
487
12,085,816
100.00%
Why the increase in use of travel nurses, then? While only anecdotal, the recession returned nurses to the workforce relieving a constraint on the supply of clinical labor. As the economy improves, these clinicians are not forced to work as they otherwise were in the uncertainty of a receding economy.
Turnover and the turbulence it brings could serve as the reasonable explanation. Surveys of newly licensed hospital-based nurses have shown that 43% leave their first jobs within 3 years of employment.[i] As Bernadette Kenny reports in "Forbes" magazine, any rate below 15 percent annually is considered healthy and no cause for alarm. As you can see, this could be the influence to greater utilization of travel nurses. Again anecdotally, but travel nurses could simply make up a national pool of nurses working within their first five years of nursing.
What will be the impact of the Repeal Affordable Care Act on travel nursing? As we all brace for the answer, the statistics would argue that there will be little to no impact. However, no one thought Donald Trump would prevail in the 2016 election either.
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[i] Brewer CS, Kovner CT, Greene W, Tukov-Shuser M, Djukic M. Predictors of actual turnover in a national sample of newly licensed registered nurses employed in hospitals. J Adv Nurs. 2012;68:521-538. Abstract
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