On Monday, the U.S. Supreme Court will begin hearing arguments regarding the constitutionality of the Affordable Care Act and it’s linchpin provision: the mandate that all adults secure health insurance policy. The Court may uphold the law in its entirety, strike down certain provisions, or repeal it entirely.  

Passed in 2010, the Patient Protection and Affordable Care Act (ACA) aims to overhaul nearly every facet of the U.S. clinical health-care delivery system. In addition to securing health insurance coverage for 32 million previously uninsured Americans, the law places unprecedented emphasis on creating patient-centered medical teams through the development of personalized prevention plan services, pay-for-performance outcomes-based reimbursements, and financial incentives for clinicians to serve rural and low-income areas. These changes are expected to dramatically expand clinical roles for nurse practitioners and physician assistants.1-3

Should the law be struck down entirely, the future roles of midlevel clinicians in the changing health-care system will be somewhat less clear and will likely depend more on how individual states legislate and regulate scopes of practice.

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But one thing that will not change is the underlying set of demographic and economic realities prompting the expanded roles of midlevel health-care providers in clinical practice. These include a looming MD primary care shortage (particularly in rural and low-income areas), climbing medical education and health-care delivery costs, increasingly complex and inherently multidisciplinary best practices for chronic disease managment, and growing emphasis on patient education and disease prevention to control costs. 1,2

In the coming decade, half of nursing school faculty members – and a half-million nurses – are expected to retire.4 Despite sharp increases in demand for NPs, the graduation rate remains steady at around 8,000 a year.4,5 Many believe that NPs are a viable solution to the primary care provider shortage, as up to 12 NPs can be trained for the cost of educating a single MD.2,6 Yet, nursing schools reject tens of thousands of qualified applicants each year due to budget constraints.4

Furthermore, current estimates suggest that as baby boomers reach the age of eligibility for Medicare, that program could run out of money as early as 2017.7 ACA mandated state-run insurance exchanges for low-income or high-risk patients are currently being implemented even in states whose governors have called for the ACA to be struck down, such as New Mexico, and will likely survive even if the law repealed.8

Cost-control experiments mandated by the ACA, such as bundled care, medical homes and Accountable Care Organizations (ACOs), will likely continue to gain popularity, albeit movement toward these alternative reimbursement frameworks may not progress as quickly as it would under an intact ACA.2 Although cost-control needs and clinician shortages make the expansion of NP and PA roles all but inevitable, some researchers suggest that the ACA provides important scaffolding for a smoother and more uniform movement toward that future.

For example, the ACA expanded Title VIII of the Public Health Service Act and ACA Section 5202 introduced new federal funding and loan repayment assistance for nursing education. The law also provides incentives for nurses to specialize in public health and disease prevention, and to take jobs in community health centers and underserved rural and low-income inner-city areas.11,12

The ACA’s primary care workforce provisions explicitly seek to incentivize growth in the number of NPs and PAs available to perform clinical care. Section 5207 and 5208 increase funding for midlevel clinicians in underserved areas and encourage development and operation of more Nurse-Managed Health Centers nationwide.11,12 For PAs, ACA section 4301 establishes medical school and PA training program grants to expand accredited PA education programs and help pay for PA program faculties.12

Furthermore, ACA Section 3022 establishes Accountable Care Organizations (ACOs) that encourage interdisciplinary practices intended to coordinate care for Medicare patients based on performance and patient-outcome benchmarks, and includes NPs and Pas in the definition of “ACO professionals.”12 Section 3502 authorizes the U.S. Department of Health and Human Services to establish state grants for interdisciplinary community-based “health teams” to support coordinated patient-centered care in medical homes.12

These sections of the ACA and many others constitute a road map for a new health-care delivery system in which midlevel clinicians take the lead in addressing longstanding and expensive gaps in care and offer clinicians central roles in emerging healthcare delivery systems. But regardless of whether the law is repealed, NPs and PAs are poised to take increasing responsibility for clinical care in domains once limited to physicians in the near future.

Bryant Furlow is a freelance medical writer and investigative health-care journalist based in Albuquerque, New Mexico.


1. Horton R. Editorial: primary-care reform in the USA: a perfect opportunity? Lancet. 2010;375:1579.

2. Fairman JA, Rowe JW, Hassmiller S et al. “Broadening the scope of nursing practice.” N  Engl J Med. 2011;364(3):193-196.

3. DiSantostefano J. “Annual wellness visit for Medicare beneficiaries.” J Nurse Practit. 2011;7(5):421-422.

4. Aiken LH. “Nurses for the future.” N Engl J Med. 2011;364(3):196-198.

6. Sargan M, Hooker RS, Cooper RA. “Gaps in the supply of physicians, advanced practice nurses, and physician assistants.” J Am Coll Surg. 2011;212(6):991-999.

7. Starck PL. “The cost of doing business in nursing education.” J Prof Nurs. 2005;21:183-190.

8. U.S. Social Security Administration. Status of the Social Security and Medicare Programs.

9. Jennings T. “State moves forward on health insurance exchange: $24 million from feds to fund contract for computer framework.” Santa Fe New Mexican. March 6, 2012.

10. Laurant M, Reeves D, Hermens R et al. “Substitution of doctors by nurses in primary care.” Cochrane Database Syst Rev. 2005;2:CD001271.

11.Hansen-Turton T, Bailey DN, Torres N et al. “Nurse-managed health centers.” AJN. 2010;110(9):23-26.

12. American Nurses Association. “Health care reform: key provisions related to nursing.”

All online documents accessed March 23, 2012.