Implications for Ambulatory Care Nurses of the ACA 'Individual Mandate' Provision and Possible Supreme Court Decisions

Individual Mandate provision of the Affordable Care Act (ACA), now a law since 2010, is an issue with the ACA that has been brought to the Supreme Court. The ACA Individual Mandate, simply stated, requires that all Americans have health insurance or pay a fine. It is one of the best-known and least popular components of the ACA (Henry J. Kaiser Family Foundation [HJKFF], 2012b). Arguments regarding the Mandate were presented to the Supreme Court in March, and a ruling is expected in June 2012. The Republican primaries and candidate rhetoric have added to the angst and confusion among the public regarding the Individual Mandate and have apparently slowed progression in the establishment of State Health Insurance Exchanges because 26 states are involved in lawsuits being brought to the Supreme Court. What do ambulatory nurses need to know about these issues? What, if any, effect will the Supreme Court ruling have on coverage of patients, ambulatory care nurses and their families, and patients?

Unfortunately, although the public is aware of the Individual Mandate as an issue, they do not have sufficient facts to make an informed decision about the implications of the Individual Mandate. The Urban Institute did a study titled, The Individual Mandate in Perspective, using the Urban Institute’s Health Insurance Policy Simulation Model (HIPSM) to estimate the number and share of Americans potentially subject to the mandate, identify their insurance status absent the ACA, and simulate eligibility for Medicaid and exchangebased premium and cost-sharing subsidies (Blumberg, Buettgens, & Feder, 2012). They found if the ACA mandate were in effect today, "94 % of the total population would not face a requirement to newly purchase insurance or pay a fine" (Blumberg et al., 2012, p. 1). Bringing this 6% into the insurance market would have a positive effect on health care insurance throughout the United States because it would lower premiums and create a more stable insurance market. Only 3% of the 6% mandated to purchase insurance would not be eligible for financial assistance to purchase insurance (Blumberg et al., 2012).

The Kaiser Family Foundation found in the polling data that the opinions of the public with regard to the Individual Mandate were affected by how they perceived the mandate would affect them. They were unaware that if they have employer, private or government health care coverage, such as Medicare or Medicaid, it would not apply to them. Unfortunately, however, this is not the message they are hearing. They are currently subject to sound bites about "big government" controlling health care and health care decisions.

The other message not being heard by the public or health care professionals is what will happen to health care if the entire ACA law is struck down by the Supreme Court. The American Nurses Association (ANA) Analysis of the Supreme Court of the United States – Oral Arguments on the ACA Topic: The "Individual Mandate" (March 29, 2012) provides implications of decisions on constitutionality, severability, and the consequences of the ACA law being struck down. The very popular ACA consumer protections already enacted include coverage of children up to age 26 under a parent’s plan, tax breaks for small employers, prohibition of lifetime insurance limits, prohibition on pre-existing conditions exclusion for children, and the discount on prescriptions for seniors on Medicare (ANA, 2012). The focus and funding for primary care, wellness, health promotion, and disease prevention will presumably also fall by the wayside.

State-based health insurance exchanges are a key component of the ACA. They will help facilitate expanded access to private health insurance for individuals and employees of small businesses (HJKFF, 2012a). Exchanges are required to be fully operational in every state by January 1, 2014, and readiness will be evaluated by the U.S. Department of Health and Human Services (DHHS) one year prior to this date. However, we only have 13 states with established exchanges and three with plans to establish. The ACA provides states with options regarding the structure of their exchanges, how they contract with qualified health plans, and financing of the exchanges (HJKFF, 2012a). The ACA requires that states create seamless, user-friendly interface that allows for eligibility determinations and enrollment. For example, it can be established within an existing or new state agency, as an independent public entity, or as a non-profit (HJKFF, 2012a). Given requirements specified for State Health Insurance exchanges, significant work remains for the states that are moving slowly on this component, and the Supreme Court decisions in June play a large role in how their trajectory will play out.

This brief overview provides some clarification regarding the facts about the individual mandate required in the ACA, as well as the implications of a Supreme Court decision to strike it down. Knowing who could be impacted by the individual mandate and that it affects only a small percent of the population, ambulatory care nurses can provide reassurance to patients and their families when they fall in the 94% insured. Further, they can give direction to the other 6% regarding possibilities of financial aid for purchase of insurance through state insurance exchanges.

This overview also discusses the impact that Individual Mandate has had on slowing the process of establishment of ACA Health Insurance Exchanges. Depending on state of residence, ambulatory nurses need to know the status of their state planning or enactment of insurance exchanges so they can answer patient questions and those of their family. They can use this understanding as we near January 1, 2014 to help patients know where to look for insurance coverage through state insurance exchanges.

American Nurses Association (ANA). (2012). Health care reform. Retrieved from

Blumberg, L.J., Buettgens, M., & Feder, J. (2012). The Individual Mandate in perspective. Retrieved from UploadedPDF/412533-the-individual-mandate.pdf

Henry J. Kaiser Family Foundation (HJKFF), The. (2012a). Establishing health insurance exchanges: An overview of state efforts. Focus on health care reform. Retrieved from upload/8213-2.pdf

Henry J. Kaiser Foundation (HJKFF), The. (2012b). Public opinion on health care Issues. Kaiser Health tracking poll. Retrieved from

Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at