The Patient Protection and Affordable Care Act of 2010 (PL 111-148)

The Problem

There is a general consensus that at-risk families engender multiple costs for society (Children’s Bureau, 2008; Pew Center on the States, 2011). An array of publications describes home visiting interventions that target various at-risk populations for health, social, and economic reasons (Centers for Disease Control and Prevention [CDC], 2003; Duggan et al., 2000; Olds, Henderson, Tatelbaum, & Chamberlin, 1986; Stoltzfus & Lynch, 2009; Vasquez & Pitts, 2006). The Minnesota Department of Health (2003) described “at-risk” populations as persons who share similar characteristics that may have a detrimental effect on their health. The terms “high-risk” or “vulnerable” populations are frequently used synonymously with health and socially defined “at-risk” populations. Stanhope and Lancaster (2010) included individuals or groups of individuals who are at a heightened risk of experiencing poor health outcomes in their definition. Home visitation services to these high-risk families have the potential to modify risk factors and decrease the consequential societal burden (Karoly, Kilburn, & Cannon, 2005).

Home visitation work in this country focuses primarily on the public health perspective of preventive services for a maternal-child health (MCH) population, with a special emphasis on those at risk for adverse health and social consequences (Pew Center on the States, 2011; Thompson, Kropenske, Heinicke, Gomby, & Halfon, 2001). In comparison to the United States, European countries with a national health care infrastructure do not generally target only the at-risk MCH populations for home visit services. Based on a core philosophy that healthy mothers and children are indicators of a healthy society, they instead choose to provide universal nurse home visitation services for their MCH population (Kamerman & Kahn, 1993).

Over the past 30 years, Olds and colleagues have contributed to the body of home visitation research with extensive studies on a model of nurse home visitation services for a specifically identified at-risk population of low-income, first-time, early trimester pregnant women, the Nurse Family Partnership (NFP) program (NFP, 2010e). Although the work of Olds and colleagues dominates the home visitation literature, current home visitation services in the United States also target other subsets of the at-risk MCH population (Stoltzfus & Lynch, 2009). In a 2009 Congressional Research Service (CRS) Report on MCH home visitation, Stoltzfus and Lynch reviewed six national home visiting models and found that each one focused on different health and social needs of at-risk prenatal, postpartum, and early childhood populations.

Current statistics reporting problems associated with at-risk women and children are sobering. In 2009, the U.S. population consisted of 155 million women and girls, and 61.6 million of them were between the ages of 15 and 44, considered to be the childbearing years (Chandra, Martinez, Mosher, Abma, & Jones, 2005; Maternal and Child Health Bureau [MCHB], 2009b; U.S. Census Bureau, 2011). Of these women, 58.4% gave birth to a cumulative average of 2.3 children (Chandra et al., 2005). Lower socioeconomic status increases health and social risk factors in women and children (Kalil & Ryan, 2010). In 2009, 11% of the families in the United States were living in poverty, and 29.9% of single female-headed households were considered poor (National Poverty Center, 2009). Almost one fourth of the total U.S. household population consists of children, and of these, 21% were living in poverty in 2009 (Child Trends DataBank, 2010; Feeding America, 2010).

Another factor contributing to risk is the 15.5% of children exposed to domestic violence in the home (Family Violence Prevention Fund, 2010). Partner violence is now recognized as a risk factor for pregnant and postpartum women. Chang, Berg, Saltzman, and Herndon (2005) reported that homicide has increasingly become the most frequent cause of death in pregnant and postpartum women. Mandating child abuse reporting for children exposed to domestic violence situations is a recent policy attempt at mitigating this health and social risk factor in the MCH population (Children’s Bureau, 2009). Still other disturbing facts include a Child Protective Services (CPS) 2006 report indicating that there were 905,000 victims of child maltreatment, and 19% of the fatal episodes of maltreatment occurred in children less than 12 months of age (Division of Violence Prevention, 2008).

Statistics highlighting at-risk factors in childbearing women inevitably become intertwined with young children. Maternal depression, especially in the postpartum period, is increasingly recognized as placing women and their children at risk for health and social problems (Cheng, Fowles, & Walker, 2006). Civic and Holt (2000) found a significant association between maternal depression and behavioral issues in their children. The literature concerning MCH issues supports the U.S. national MCH goals and objectives of Healthy People 2020, directed toward improving the health of women and children (U.S. Department of Health and Human Services [USDHHS], 2009). Home visitation is one interventional strategy designed to decrease risk factors in women and children, thus improving their health and well-being, which ultimately benefits all of society. However, there is limited information comparing long-term health, social, and economic impacts of various home visitation programs. More important, access to these programs is limited with numerous at-risk mothers and children receiving few, if any, services.

The Stakeholders

The six national home visitation programs were obvious stakeholders in the passage of the PPACA. With promises of secure funding, which included 25% of the 1.5 billion dollar, 5-year budget allotted for funding of potential new effective models, home visitation organizations collaborated in the political lobbying process (CWLA, 2010b; Pew Center on the States, 2010; Redhead & Williams, 2010). In December, 2008, just 1 month into President Obama’s term of service, the National Home Visiting Coalition, comprising more than 700 local and national home visitation agencies, sent an action letter to the White House requesting support of early childhood home visiting services (Home Visiting Coalition, 2008).

President Obama is a strong supporter of MCH home visitation programs. While serving as U.S. Senator from Illinois, he gave a speech at Hampton University in which he clearly proclaimed a political platform in support of parents and their young children. He firmly believed that money spent on home visitation interventions to low-income families is cost-effective and ultimately decreases government spending on health and social programs (Stone & Page, 2009). Preserving and expanding MCH home visitation was a core essential of Obama’s campaign promises to address the needs of at-risk parents and children.

Elected members of the 111th Congress were the final decision makers in the move to include home visitation in health care reform, but as different versions of the health care reform bill were lobbied back and forth between the House and Senate, it became obvious that a bipartisan line was drawn. Republicans called for less government involvement and less spending, whereas Democrats supported President Obama’s health care reform agenda that included much-needed health and social programs. Reelection concerns undergirded Congressional debates and votes for or against health care reform bills. The ultimate inclusion of home visitation in the PPACA was a testament to the democratic majority in both the House and Senate (Capitol Net, 2009).

Antecedent Events

The final version of MCH home visitation in the PPACA evolved from prior unsuccessful legislative attempts to secure federal funding for home visitation services. While serving their senate terms in the 110th Congress, President Obama (D-IL) and Vice-President Biden (D-DE) joined other like-minded senators to cosponsor the Education Begins at Home Act (S. 667), a bill dedicated to funding home visitation programs and research (Civic Impulse LLC, 2010; National Human Services Assembly, 2007). During that same Congress, Danny Davis (D-IL), a fellow Democrat from President Obama’s home state of Illinois, introduced a partner home visitation bill H.R. 2343 in the House (Civic Impulse LLC, 2010). Unfortunately, with the closing of the 110th Congress, both bills died in their respective houses.

Stakeholder groups continued to follow the legislative journey of home visitation. Even before President-elect Obama’s January 2009 inauguration, action and support letters from across the country poured into Washington (NFP, 2009). Collaboration among the National Home Visiting Coalition, NFP, nursing, and other social organizations resulted in political action letters requesting support for evidence-based home visitation programs and research in the 2010 federal budget (Home Visiting Coalition, 2008; NFP, 2009). Senators Menendez (D-NJ) and Casey (D-PA), composed a Senate sign-on letter thanking President Obama for referencing the NFP in the FY-2010 budget (Menendez et al., 2009). Senate Representative Bennett (D-CO) from the home state of the NFP may have been instrumental in the choice of NFP as the home visitation exemplar, as described in the letter. This letter was copied to House committee leaders considered essential to the inclusion of home visitation in the PPACA.

During the last week of February 2009, President Obama released his first presidential budget proposal (Briceland-Betts, Sciamanna, Weidner, & Varner, 2009; CWLA, 2009b; Office of Management and Budget [OMB], 2010). True to his commitment to early childhood well-being, the proposal included a mandated 8.5 billion federal dollars over 10 years to fund evidence-based home visitation services for low-income families (CWLA, 2009b; OMB, 2010). The budget called for health and social outcomes yielding benefits in the areas of “child health and development, readiness for school, and parenting abilities to support children’s optimal cognitive, language, social-emotional, and physical development and reductions in child abuse and neglect” (OMB, 2010). This presidential budget proposal became the precursor to the Congressional debate surrounding home visitation as included in the 2010 PPACA.

As budget reconciliation took place in the House and Senate (H. Con. Res. 85 & S. Con. Res. 13), House representatives who championed home visitation sent letters of support to the Chairman and ranking members of the House Committee on Budget. Diana DeGette (R-CO), an advocate from NFP’s home state, together with Lois Capps (R-CA), made reference to the NFP model in their action letter (DeGette & Capps, 2009).

In June of 2009, the Early Support for Families Act (H.R. 2667) was introduced in the House and was scheduled to be heard before the House Ways and Means Subcommittee on Income Security and Family Support (Hearing for Proposals, 2009). Title IV of the amended 1935 Social Security Act was originally created to provide for the financial needs of dependent children, and H.R. 2667 intended to amend Title IV with a provision of federal dollars for statewide expansion of early childhood home visitation programs (CWLA, 2009a; Participatory Politics Foundation, n.d.; Ridenour, n.d.; Social Security Administration [SSA], 2010a). A companion stand-alone bill, the Evidence-Based Home Visiting Act of 2009 (S. 1267) was introduced in the Senate by Menendez (D-NJ). S. 1267 also proposed an amendment to the Social Security Act; however, this amendment was to Title V, of the 1981 Maternal and Child Health Services Block Grant (MCHB, 2009a; SSA, 2010b). Both bills were eventually absorbed into the final two health care reform acts of 2010, the PPACA and the Affordable Health Care for America Act (AHCAA).

The 2009 Hearing

Following the introduction of H.R. 2667, a hearing was scheduled for June 9, 2009, before the 111st Congress House Ways and Means Subcommittee on Income Security and Family Support (Hearing on Proposals, 2009). The proposal of billions of federal dollars directed toward home visitation services elicited intense deliberation among subcommittee members. The hearing included the testimony of public witnesses and written submissions, both pleading for members of Congress to pass H.R. 2667 (Hearing on Proposals, 2009). With the exception of submissions entered by the NFP, most of the statements were presented by nonmedical, nonnursing individuals and organizations. Chairman McDermott (D-WA) introduced the purpose of the hearing, which was to discuss home visitation work aimed at decreasing child abuse and improving children’s health and school readiness. The hearing concluded that evidence-based home visitation is an important public service, that nurses are the preferred home visitors, and that there is still a need to consider new innovative evidence-based programs.

Final Legislative Actions

Two events with the potential to affect the ultimate passage of the PPACA occurred in the late summer of 2009. One was the annual legislative summer recess, which gave congressional representatives and stakeholders time to strengthen their claims for or against home visitation. The other, more somber event was the death of Senator Edward Kennedy (D-MA), a well-known champion of health care reform. His death came as a great loss to all in favor of health care reform and was consequently a concern for the future of home visitation. Paul Kirk Jr. was temporarily appointed to fill the vacant Massachusetts Senate seat, with the understanding that he would uphold the health care reform goals of Senator Kennedy, thus temporarily blocking a Senate filibuster on health care reform bills during the 111th Congress (Associated Press, 2010).

At the conclusion of the legislative summer recess, the Senate Finance Committee released America’s Healthy Future Act of 2009 (S. 1796) for Senate discussion and vote. This bill would ultimately merge with the Affordable Health Choices Act (S. 1679) released in mid-July from the Senate Health, Education, Labor and Pensions Committee (HELP). The consolidated bill would continue to travel the legislative pathway and, together with the original House home visitation bill, H.R. 2667, its amended version would be assimilated into America’s Affordable Health Choices Act of 2009 (H.R. 3200). By mid-summer of 2009, the amended health care reform bill, H.R. 3200, was introduced in the House. The Ways and Means Committee reviewed this bill and, by October, reached consensus on recommending passage of an amended version of H.R. 3200 (House Committee on Ways and Means, 2010). Section 1904 of the bill called for a state grant program for maternal, infant, and early childhood home visiting programs and would ultimately be incorporated into Section 511 of the Social Security Act (SSA, 2010a). By the end of November, H.R. 3200’s marked version, the AHCAA (H.R. 3962) passed in the House and Senate assisted by the process of budget reconciliation (Committee on Energy and Commerce, 2010). This version would include the amendment left out of the PPACA, an amendment to Section 1905 of the Social Security Act allowing for Medicaid reimbursement of nurse home visits (Pew Center on the States, 2010). With President Obama’s signature, H.R. 3962 became Public Law 111-192, three months after the historic passage of the PPACA (H.R. 3590, 2009-2010).

Concurrently, the House was busy working on health care reform. House chairman Rangel (D-NY) sponsored H.R. 3590 (H.R. 3590, 2009-2010). His bill, initially called the Service Members Home Ownership Tax Act of 2009, would subsequently be rewritten to include the final House health care reform bill, the PPACA. This bill, which did not include Medicaid reimbursement for nurse home visitation services, was thought to be a relatively conservative form of health care reform and, thus, had a high probability of successful passage through the Senate with minimal roadblocks. House and Senate Democrats planned to use budget reconciliation as a means to include the agenda reform items left out of the PPACA. With a favorable Democratic majority in the House and Senate, the PPACA final congressional passage occurred on December 24, 2009, and became Public Law 111-148 on March 23, 2010.

Benefits

The discussion of who benefits and who does not from a mandated federal provision for home visitation looms over every debate on the topic. Some would argue that the PPACA is more needless government involvement in the lives of its citizens, whereas strong advocates of the bill claim that all of society benefits (Beck, 2009; Burke, 2009; Cawthorne & Arons, 2010; Estrada, 2010; Norris, 2009; Sprinkle, 2009b; Sullivan, 2009). For example, a 1998 and subsequent 2005 RAND study looking at the cost benefits of the NFP program reported that the government could expect a return of US $5.70 for every dollar infused into the NFP home visiting program (Karoly et al., 2005). Projected savings include decreased use of government aid programs for the poor, savings in health and education dollars, and safer communities through decreased involvement in the criminal justice system.

Legislative Compromises

As is to be expected, the concluding version of the PPACA incorporated numerous compromises. Much of the debate centered on the issue of home visitation models that had research-based outcomes supported by randomized controlled trials. The strength of the NFP lies in its program model based on 30 years of randomized controlled studies, which over time has grown to include supportive longitudinal data. Unlike many smaller programs, which may not have had the funding to support a government liaison department, NFP’s Federal Policy and Government Affairs department assured a voice in Washington and probably had a strong influence on the final bill (NFP, 2010c, 2010f). A concession was made to include programs documenting rigorous quasi-experimental research-based outcomes and to permit states to use 25% of federal dollars in support of research for “promising” new programs (H.R. 3590, 2010). Regrettably, there was no mention of qualitative research, which was a lost opportunity to incorporate participants’ voices and home visitation experiences in the final bill.

Another concession in the PPACA was the generalization of the target population. If the bill had supported only programs with a strong history of gold-standard nurse-involved quantitative research such as the NFP, many MCH populations would have been excluded. The NFP only enrolls low-income, first-time mothers, early in pregnancy. With average caseloads of 25 families per nurse, this translates to an annual average of 21,500 out of a potential 650,000 families receiving nurse home visitation services (NFP, 2010d; Sprinkle, 2009a). This is just a fraction of the 4.3 million infants born each year; even more disheartening would be the 154,508 women in 2007 (7.1% of births) who received late or no prenatal care, who would have been unable to benefit from these services and were probably most in need of them (Annie E. Casey Foundation, n.d.; Martin et al., 2009, p. 4). Fortunately, the final bill was broad enough to include other dimensions of MCH services related to child health and development such as child abuse, domestic violence, and school readiness.

A third accommodation in the bill addressed the qualifications of the home visitors. Again, using the NFP model as the gold standard would require the strict use of baccalaureate-prepared registered nurses. Nurses are long considered trusted home visitors with invaluable health education (ANA, 2009b). There was considerable discussion regarding not only the cost of hiring additional home visitation nurses but also how the current reported nursing shortage would affect hiring new staff to expand home visitation programs. The final wording encompasses “well-trained and competent staff” (H.R. 3590, 2010), which leaves open the option for hiring paraprofessionals if the use of home visiting model can yield beneficial participant outcomes in designated benchmark areas.

Public health nurses (PHNs) have long been considered strong advocates for prevention and health promotion services to at-risk populations. Considering their background in public health melded with nursing and the social sciences, the NFP would agree that PHNs are the ideal home visitor candidates. Utilizing Clark’s Population Health Nursing model, the legislated home visitation outcomes arise from six determinants of health: the “biological, psychological, environmental, sociocultural, behavioral, and health systems” (Clark, in press). Taking this foundational knowledge into account, public health nurses assess and provide nursing interventions to MCH clients during a home visit. The ultimate goal for these families is improved health and well-being; for the PHN, it is improved population health; and for government, it is a decreased use of resources by at-risk populations.

By and large, the compromises achieved strengthen, rather than detract from, the effectiveness of the bill. For example, expansion of the types of fundable programs increases the potential for multiple positive effects of home visitation services and also increases the potential numbers of clients served. Similarly, expansion of the target population beyond first-trimester first-time pregnant women permits more of the at-risk population to benefit from services. Expansion of the definition of preferred service providers beyond baccalaureate-prepared public health nurses could have both positive and negative repercussions. Use of PHNs to oversee and coordinate care by other levels and types of providers might be more cost-effective than use of PHNs alone. In the total absence of PHN involvement, however, clients would be left to receive services from providers who do not have knowledge of the full scope of health issues, concerns, and strategies for their resolution.

Nursing Implications

Once again, legislation has been formulated that so desperately needs the input of nurses (Gaffney, 2011). Public health nursing’s holistic view of caring for women and young children in the social context of their families and communities is critical to the success of home visitation programs. Public health nurses often are privileged to know the intimate details of the lives of at-risk women and children that place them in a unique position to advocate for the most effective home visitation approach.

More than 100 years ago, Lillian Wald distinguished public health nursing as a nursing specialty focused on bringing nursing into the homes and communities of at-risk populations (Jewish Women’s Archive [JWA], 2010). Wald tirelessly advocated on behalf of vulnerable populations in the political and health care arenas. In order for home visitation funding to pass through Congress, it became clear that there was a need to blend health and social services into one bill. “Social workers, educators, child development specialists, or other well-trained and competent staff . . .” (H.R. 3590, 2010), though capable of providing admirable services, cannot singlehandedly address the complex health needs of at-risk families. Nor can PHNs achieve intended home visitation outcomes independently. They must be willing and able to work in concert with other professional and nonprofessional staff to achieve program outcomes.

Implications of the PPACA for the nursing profession lie in three areas: workforce preparation, promotion of evidence-based practice, and education for leadership. If PHNs are to provide services or oversee home visitation services provided by others, there will be a need for far more nurses prepared in this specialty area. This will entail support for educational funding and programs to prepare nurses with the required public health background and skills. In addition, there is a need for PHNs to have a stronger grounding in the use of evidence-based practice and in the research skills needed to create that evidence base. Finally, PHNs will need additional preparation for leadership and coordination of the efforts of health visitation teams.

Salmon (2009) expressed praise for the recent involvement of today’s PHNs in the political process of health care reform; at the same time, she exhorted PHNs to continue to push forward in an effort to familiarize our legislators with avant garde PHN services provided to the most defenseless members of our society.