The coming year, 2014, will be a significant time for health care policy in the United States. We will implement the Affordable Care Act (ACA), the most important event in U.S. health policy since the passage of Medicare in 1965, and before that Social Security in 1935. While some condemned this legislation for not achieving universal single payer coverage, and others as a costly mistake, the reality is that the ACA will allow 28 million working Americans to purchase affordable health insurance and therefore their expanded access to health care services. The ACA will also extend dependent coverage to age 26, prevent insurance denials because of preexisting conditions, and cover preventive services and immunizations.

While there is justifiable excitement about the ACA, it is important to remember that the relationship between health insurance, and by extension, access to health services, and improved population health as measured by morbidity and mortality statistics remains unclear. Certainly, health insurance coverage increases the quantity of health services used (Freeman, Kadiyala, Bell, & Martin, 2008). But not all health care results in improvement in overall patient outcomes. To provide just one example, rates of cesarean sections have been steadily increasing over time and now account for 32% of all births in the United States, each costing $10,000 to $20,000 more than vaginal births (Childbirth Connection, 2013). However, birth outcomes, including infant and maternal death rates in the United States are worse than those in countries like the Netherlands where cesareans account for only 14% of all live births.

Some researchers do not see evidence of the ACA being able to have a positive impact on overall health outcomes. Levy and Meltzer (2008) reviewed the methods and results of studies examining the impact of health insurance and suggest that the methods used in many of these studies provide results that are not generalizable to the overall population. They state that the evidence is not there to assert that increased access to health insurance will improve overall health outcomes. However, they did acknowledge the existence of several studies in specific vulnerable populations, including infants, children, and people with HIV infection that did demonstrate improved health outcomes as the result of health insurance coverage. These researchers also note that positive effects were found for specific health conditions such as control of hypertension. On the other hand, Wilper et al. (2009) came to a different, positive conclusion about the relationship between health insurance and health outcomes. In their examination of evidence from the Third National Health and Nutrition Examination Survey (NHANES), they found that those without health insurance were 1.4 times more likely to die than those with insurance coverage. These results echo those of a 1993 NHANES analysis (Franks, Clancy, & Gold, 1993).

Thinking about the different results of these studies and about the lack of access to health care services for many people in the United States leads me to several conclusions. First, when having insurance provides access to necessary health care, especially for people with chronic conditions such as HIV or hypertension, it clearly improves an individual's health. Currently, many people find it difficult or impossible to access basic health care, and many others delay seeking help because of the cost. Use of emergency rooms for routine or nonurgent care is expensive to hospitals and leaves patients with very costly bills. Under the ACA, many these people will now be able to receive the same prevention, early detection and treatment that is available for those with health insurance.

A second conclusion is that the ACA will move the United States closer to being a more equitable society. We will come closer to achieving the human rights goal of health care for all—a less publicized but important reason to celebrate the ACA legislative victory. These two conclusions have important synergy. The United States spends too much money on high-tech, low-yield (and often dangerous) medical care, for example screening middle-aged men with prostate specific antigen or initiating routine mammograms for women at age 40. The solution is not to continue this for a portion of the population while denying another part of the population access to any care. The solution is to ensure that all people have access to necessary, beneficial, high-quality care and that unnecessary or harmful care is provided to no one.

A third important consideration, tied to the second, is that the ACA will be an important tool to help diminish the shameful health inequities pervasive in U.S. society. There are innumerable examples of these inequities that are familiar to readers of this journal. They include the fact that African Americans are diagnosed with AIDS at nine times the rate of Whites, are more likely to use the emergency department as their regular place of care than Whites, and are more likely to develop and die from cancer than any other racial or ethnic group (CDC, 2011). Hispanics and American Indians/Alaskan Natives have diabetes mortality rates 50% and 75% higher than Whites. These disparities reflect both presentation at a later stage of disease and a lack of primary and secondary prevention. Because this does not have to be the case, these disparities are inequities. To the extent that ACA can improve access to primary care services by providing currently uninsured people with health insurance coverage, it can be expected to decrease some of these inequities and improve the overall picture of health in this country.

A final, critical issue is to note what the ACA will not do: address the social determinants of health. It will have no impact on the growing disparity in wealth and income in the United States. It will not be able to change limited educational attainment or functional illiteracy, both critical social factors in achieving health equity. It will have no impact on poor neighborhood conditions that are so strongly correlated with high levels of violence, substance use, poor schools and high unemployment rates. These are areas in which public health and public health nursing has a major role. In the work of state and local health departments, through evidence-based interventions like the Family Nurse Partnership, with research methods such as community-based participatory research, and in educational programs around the world, the implementation and dissemination of the work of public health nurses is an ongoing, critical part of addressing these social determinants. Whether focusing on diminishing interpersonal violence, preventing substance abuse, addressing the impact of secondhand smoke, assessing vaccination coverage, or ensuring the health of refugees, to mention just a few areas covered in recent issues of the journal, public health nurses are a powerful group in all of our communities.

As the new Editor of Public Health Nursing, it is my goal to continue the excellent work of the previous Editors, Sarah Abrams and Judith Hays. I welcome the opportunity for our journal to contribute to the practice of public health nurses around the world and to seek out manuscripts that address the social, physical and economic environments that contribute to the health inequities found among the vulnerable populations. I invite new authors to contact me and new reviewers to consider becoming part of our editorial team. Along with our editorial board, I pledge to make the review process transparent, constructive and efficient. I look forward to this challenging role and to being in contact with our readers around the world.


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