Abstract
The health care system in the United States is being overhauled by major legislation, the Patient Protection and Affordable Care Act (ACA). This study’s goal was to provide insight into the perceived impact and changes that could occur within the health education profession as a result of this health care reform legislation. Seven leaders of the health education profession participated in this qualitative research study. Six semistructured, exploratory interviews were conducted, and one participant provided written responses to the interview questions. A thematic analysis of the content of the interviews yielded five themes: (a) a fragmented sick-care system, (b) ACA becomes law: the participants’ reactions, (c) ACA becomes law: the profession’s reactions, (d) impact on the profession, and (e) health education in 2020. This article describes the fourth theme, the impact of the ACA on the health education profession. Leaders of the health education profession believed that the ACA creates a more favorable environment for health education practice. The positive elements of this legislation, however, will need to be protected, strengthened, and verified, through the work of health education professionals. As more mandates within the law are enacted over time, the impact on the profession, more than likely, will shift.
The significance of the Patient Protection and Affordable Care Act (ACA; Pub. L. 111-148), particularly on the field of health education, remains uncertain. According to Gable (2011), “The [ACA] has the potential to produce extensive public health benefits across the United States population by improving the health care and services and reducing cost” (p. 341). Additionally, Rosenbaum (2011) refers to the ACA as “a watershed in U.S. public health policy” (p. 130). Does the ACA continue what has been labeled as “the dominance of health care over public health”? (Hardcastle, Record, Jacobson, & Gostin, 2011, p. 317), or does the legislation, with its emphasis on the availability of prevention or health center funding, present important opportunities for expanded health promotion (Rosenbaum, 2011)? Exploring the perceptions of leading health educators regarding the impact of this health care law on the health education profession is, therefore, timely and critical.
The objective of this research was to investigate the perception of leading health educators regarding the ACA’s impact on the health education profession. The implications of this research could mean a more unified and systematic approach on behalf of the profession to seize emergent opportunities and recognize potential obstacles.
ACA and Health Education
On March 23, 2010, the ACA was signed into law by President Barack Obama. The 906-page document, organized into 10 titles, maps the direction for change regarding the health care system of the United States. By year 2018, every provision within the ACA will be in full effect, mostly being implemented by 2014. This extensive legislation is designed to expand the quality, efficiency, and availability of health care services and expand preventive health initiatives (Affordable Care Act, 2010).
As defined by the Bureau of Labor Statistics, U.S. Department of Labor (2010), health educators
provide and manage health education programs that help individuals, families, and their communities maximize and maintain healthy lifestyles. Collect and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies, and environments.
The health education profession, made up of health educators, is “dedicated to excellence in the practice of promoting individual, family, organizational, and community health” (Coalition of National Health Education Organizations, 1999). This study examines the perceptions of leading health educators regarding the impact of ACA on the health education profession.
Method
Participants
Purposive sampling (Erlandson, Harris, Skipper, & Allen, 1993) was utilized to select leading health educators, defined in this study as a person elected to a leadership role in a national health education professional organization or recognized by other health educators as a leader in the profession. In total, 18 leaders were invited to the study; 7 participated. Five participants were interviewed by phone, 1 by Skype, and 1 by e-mail. At the time of the interviews, 5 participants were serving in leadership positions for the following health education professional organizations: American Association for Health Education, American School Health Association, Eta Sigma Gamma, National Commission for Health Education Credentialing, Inc., and Society for Public Health Education (SOPHE). One participant recently retired although still played an active and influential role in the profession. Last 1 participant, a past president for the American Academy of Health Behavior, was recognized as a leader in the profession. These five males and two females contributed from 5 to 40+ years each to the profession.
Data Collection
Interviews were conducted August, September, and October of 2011. The study was approved by the research ethics board at Texas A&M University, and all participants provided their consent. At the start of each interview, participants were informed of the study, the information sheet, and the use of a digital audio recorder and handwritten notes to document responses.
During the interviews, researchers utilized interview protocol questions. Established before the first interview, the protocol questions were designed to elicit information from participants about their thoughts prior to and after the bill passed into law (e.g., Tell me about when you first started hearing about the ACA), perceptions of the health education profession’s reaction (e.g., How do you perceive the health education profession reacting to the ACA), and predicted future implications for the profession as a result of the law (e.g., How will the ACA affect the future of the health education profession). Additional open-ended questions and probes were drafted and utilized throughout the interviews to gain more insight from participants, and unstructured questions emerged throughout the dialogue (Patton, 2002).
Data Analysis
An inductive data analysis was conducted (Lincoln & Guba, 1985). Immediately following interviews, audio recordings were transcribed and unitized. Transcription was accomplished by listening to the audio recordings in small segments, transcribing the information into an MS Word document, and confirming the accuracy of the transcription before proceeding. To verify that the transcriptions were accurately transcribed, an outside person reviewed audio recordings and transcriptions. To maintain participant confidentiality, quotes contributed by participants were identified numerically, such as “Participant 1.” Approximately 281 minutes of recording were transcribed.
After transcription, researchers unitized the information. There were 802 units of data in this study “that [served] as the basis for defining categories” (Linoln & Guba, 1985, p. 344). Each unit of data was coded with the source (transcription page number), type of respondent (I = Interviewee), episode (interview number), and unit number. The units were then printed and cut to stand alone. Finally, each unit was read and grouped, according to content, with other like units using emergent categorization (Erlandson et al., 1993). Prior to finalizing, the study’s report was distributed to participants, allowing for the opportunity to review responses.
Findings
One and a half years after becoming law, most participants believed the health education profession had yet to experience a substantial impact from the ACA. “I’d be pretty blunt to say at this point that it’s had very minimal impact in terms of health education” (Participant 1). At the time, according to participants, the employment rate of health educators was stagnant; there was minimal influence on health education professional organization boards’ functionality and decision making; and health education preparatory programs had done little, if anything, in anticipation of the law’s enactment. Participants perceived the law’s time frame for implementation and threats to the constitutionality as explanations for the absent affect on the profession.
On the contrary, some participants perceived the law had some favorable impact on the profession by “[shedding] light on the importance of the public health workforce and . . . health education in general” (Participant 3). As an example, one participant mentioned that the value of public health and health education was emphasized with the appointment of the American Cancer Society’s CEO, Dr. John Seffrin, a professional health educator, to The Advisory Group 1 for the National Prevention Council (Council). Participant 3 said, “Some of our scholars in the field of health education [are] being appointed by the President to advise these groups that are going to be making these decisions regarding health reform and national prevention programs.” In the same time frame of the study, Surgeon General Regina Benjamin commented about the Council’s National Prevention Strategy as “the first time we’ve ever had this sort of commitment from high level government, focused on prevention and wellness” (Robert Wood Johnson Foundation, 2011). The Council described itself as an “unprecedented opportunity to shift the nation from a focus on sickness and disease to one based on prevention and wellness” (National Prevention Council, 2011). Participants collectively mentioned that the inclusion of the Prevention and Public Health Fund (The Fund) emphasized the importance of prevention. Participant 5 stated, “Because of the prevention component to this, everybody realizes that the clinical side of this is not enough to reduce the cost of health care. To improve the health status of populations, we need public health educators.”
Finally, the ACA had driven the health education profession deeper into third-party reimbursement discussions. The following questions were raised during conversations: Is there enough support written within the law for health educators to make the case for third-party reimbursement? Could becoming a credentialed field propel the profession toward reimbursement? What would reimbursement look like if the profession were to attain it? What eligibility criteria would need to be met in order to receive reimbursement? How could this affect the health education profession? This panel of experts believed that the ACA provided an opportunity for the health education profession to seek third-party reimbursement. 2
Looking Forward
Although participants stated that the ACA had minimal impact on the health education profession since enactment, they forecasted future opportunities, as well as challenges, for the profession.
Opportunities
“The opportunity for health educators . . . is enormous” (Participant 5). Five areas of opportunity were identified by participants: funding, patient education in health care settings, worksite health promotion, training, and total health care teams.
Participants forecasted increased public health promotion and prevention funds in the ACA, such as public health workforce training, community transformation, and school-based health center grants, as sources of support for health educators. According to Rosenbaum (2011), opportunities like these “are vital to communities throughout the country, and public health agency responsiveness and assistance to local community coalitions will be key. At the same time, these aspects of the Act perhaps represent relatively familiar public health practice turf” (p. 134). If mandated funds were to be delivered as intended, opportunities that currently did not exist, nor had ever existed, for health educators would become reality. The number of health education jobs would increase “by a predicted 18%,” 3 Participant 3 stated. Workforce training 4 would improve. The market for recruiting students into the profession would be boosted. A greater stream of evidence-based research centered on the functionality and improvement of the health care system would be born. And the capacity in which health educators’ work would expand.
Another opportunity, as well as a challenge, predicted by participants was a “major shift toward patient education as the focus as it did in the 1970s with the Medicare and Medicaid and the Regional and Comprehensive Health Planning and HMO Act [Health Maintenance Organization Act of 1973]” (Participant 6). “[Patient education] is going to be a substantial driver of what health educators are going to be asked to do” (Participant 6). This could drive health educators away from their public health roots and more toward individualized, patient education. Participant 6 described this potential departure from public health as the “unfortunate aspect” of the law, because “we don’t have enough health educators to cover both public health and patient education adequately.” Even though there are more health educators to fill the positions of both patient and public health education today than back in the 1970s, are health educators trained well enough to take on patient education responsibilities?5,6
Businesses that hire health educators, such as Kaiser Permanente, HMOs, and health care systems were projected to be impacted by the ACA because they have the best opportunities for health educators “to apply the skills of health education with real people, in real time, in circumstances that have the necessary support surrounding them to make a difference” (Participant 6). Therefore, participants predicted that health educators working in these kinds of settings have great opportunities to make a difference at the individual, patient education level. Participant 6 stated, Some of our best evidence of what can or could work in hundreds of different circumstances of the ACA come from studies done in Kaiser Permanente and the Group Health Cooperative of Puget Sound and a few other HMOs around the country that have had a research unit to help evaluate the innovations that health educators brought.
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Evaluations emerging from health educators working in these settings could play a major role in providing crucial evidence of the ACA’s impact on the health care system.
The impact on employer groups was predicted by some participants to drive worksite health promotion programs. As stated by Rosenbaum (2011), the ACA “encourages employers to undertake workplace wellness activities that promote and incentivize actual health outcomes” (p. 132). Most employers, under the ACA, were required to offer health insurance to employees. To reduce the potentially heavy burden on employers by such coverage, health educators could, according to some participants, seize this opportunity to work in worksite settings. Participant 4 stressed that the phrase “cost containment” needs to be in the vocabulary of health educators in order to gain the attention of employers. Health educators could be recruited to lead company-wide worksite health promotion programs if financial payoffs are communicated.
Participants predicted that health education training will be influenced by the ACA. To become a key player in reforming the health care system, health education preparatory programs have to adapt to this forward-thinking health care approach. Courses should, according to these experts, be influenced in a direction that prepares health educators to perform and utilize some of the specific functions outlined in the ACA (e.g., Patient’s Bill of Rights, electronic health records) and understand the law’s impact on certain populations, such as employees, and Medicare and Medicaid groups in particular. Participant 4 stated, “Forward thinking institutions are already . . . preparing health educators to do some of the specific functions outlined in [the ACA].” He predicted more institutions will do the same in the future.
Finally, participants emphasized the attention to total health care teams within the ACA could serve as an opportunity for health educators. In an issue brief by SOPHE, the authors wrote, “In order to form a comprehensive health care system and improve health outcomes, health education specialists should be integrated into the process of treating the “whole person.” The brief goes on to say, “The ACA provides new opportunities for health education specialists to complete the health care team working to improve overall care coordination and health promotion activities” (Goodman et.al., 2013, pp. 6, 9). However, for that to occur, “[health educators] need to demonstrate a capacity to make as much of an impact on health as any other profession” (Participant 5).
Challenges
Opportunities for the health education profession were not predicted without challenges as well. Participants forecasted obstacles: negative characterization of prevention funds, needed clarification of the legislation and health education credentialing, training not for today but for tomorrow, and competition among nonhealth educators.
With the downturn of the economy, the focus of the nation was diverted toward job creation and reduction of government spending. During the 2011 Congressional balanced budget meeting, one item on the “chopping block” was The Fund. This fund was labeled a slush fund: “something that can be taken out to balance budgets,” described Participant 2. Rigby (2011) described the situation: “critics labeled the Prevention Fund a ‘health care slush fund,’ ‘a taxpayer-funded exercise in social engineering,’ and an effort ‘to advocate for bigger government in hopes that state intervention will influence individual behavior’” (p. 2151). With the state of the nation’s economy and politics, defunding or underfunding the public health and wellness services mandated in the ACA was forecasted by participants to be a real possibility.
The vague language of the ACA was predicted by participants to be a potential barrier to the profession. As described by Participant 5, “The language around prevention and the operational side of the law suggested that health educators [have] a potentially huge role to play.” The language could provide the opening the profession needs to make the case for reimbursement for services. Rather than being merely suggestive, however, the legislation needs to be more direct. Without the language being clear, “the health educator’s role will be minimized inappropriately so, but minimized nonetheless” (Participant 5).
Clarification of the Certified Health Education Specialist (CHES) certification could be necessary for third-party status. Participant 6 described, There will be some pressure, some draw, for us to try to get some kind of a further clarification for our certification . . . The question will be whether the CHES certification will justify health educators getting reimbursed for . . . whatever roles we may be called on to play as more people have coverage for such things.
This challenge was also noted by Goodman et al. (2013, p. 12): “The present fee-for-service system allows for the use of a health education specialist but the services provided by a health education specialist must be ordered by a physician and made part of a treatment plan (Auld, 2012).”
One challenge the profession continues to face, according to this panel, is training health educators for future practice. Technology and the science base for health education have advanced rapidly: “I am not certain that the training programs are training our students effectively to practice five years from now because of this dramatic change” (Participant 5). The health education professional preparation programs should embrace the new insights emerging from other fields of science and technology. As Participant 5 stated, I don’t know any health education program that is adapting theory to accommodate the sciences that are coming out of physics, nanotechnology, bioengineering or genomics—to accommodate those theories in such a way that we can understand the implications of those things.
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Participants predicted that health education professionals will be competing with nonhealth educators. According to some participants, the market for doing health education was predicted to increase but whether those positions are filled by trained, certified health educators was uncertain. This panel noted that historically, nonhealth educators had been assigned duties of a health educator for reasons such as cost reduction and third-party reimbursement status. Participant 1 stated that he was “hesitant to be extremely hopeful about how [the law] ends up playing itself out for the health education profession” because competition persisted throughout many settings. The challenge for health educators will be to effectively communicate the importance of hiring a trained health educator, not only to employers but also to other professionals. As SOPHE moves forward with its plan to advocate for the term health education specialist, such advocacy will no doubt confront this challenge predicted by the leaders of the profession (Goodman et al., 2013). Finally, the participants predicted that with the downturn of the economy, health education positions increasingly could be filled with baccalaureate-level trained health educators because master’s- or doctoral-level trained professionals were too expensive to hire.
Conclusion
There were constraints to this preliminary study. First, the impact perceived by participants could shift overtime as more provision take effect. Second, findings from the study are not to be generalized across the health education profession, including health education professionals. Third, the sample size of this study was small. Fourth, every variable influential to the impact of the ACA on the health education profession may not have been made known by the participants. Fifth, the data-collecting method was limited mostly to phone interviews. Finally, this study’s scope did not expand to other health care legislations, other nations, or other professions.
In this study, the panel of experts perceived the health education profession had not been significantly affected by the ACA. A few participants noted, however, that light had been shed on the importance of health education. In support of the panel’s position, Hardcastle et al. (2011) stated, “The federal government’s increased attention to prevention and promotion is a significant step in improving health outcomes” (p. 321).
Though minimal thus far, participants predicted an impact on the profession in the future. They forecasted new funding opportunities, a call for more patient educators and health educators functioning in health care settings, an increase in worksite health promotion programs, improved health education preparatory programs, and a shift toward total health care teams. Additionally, the Council’s National Prevention Strategy reinforced the position of participants regarding the role, and future, of the health educator in prevention (U.S. Department of Health and Human Services, Office of Surgeon General, 2011).
The consensus of the participants was that the future for health education looks promising, but participants identified challenges, such as The Fund being labeled a slush fund. Hardcastle et al. (2011) expanded by describing it as “politically fragile, as recent attempts to divert funding to other programs have occurred” (p. 321). However, “because policymakers have deprived public health of stable and adequate funding, there are still substantial gains to be made from investments in health promotion and disease prevention” (Hardcastle et.al., 2011, p. 318). Participants also indicated that challenges exist with clarifying the language within the legislation to make the case for third-party reimbursement of health educators, training health educators not for today but for tomorrow, and competing with nonhealth educators to do health education work.
Our conclusion from this limited study is that the health education profession needs to take full advantage of every opportunity presented in this major piece of legislation. A new and improved health care system can include health education. To assure this, individual and professional action is now necessary. It is clear the ACA is not the be-all and end-all of health care reform. It is, however, the law of the land, and as the participants of this research clearly stated, the beneficial parts of this legislation need to be protected, strengthened, and verified. Furthermore, action needs to be taken to assure that future health care reform includes health education. As the provisions within the ACA go into effect over the course of the coming years, the impact the law has on the profession will shift. Therefore, similar studies, qualitative and quantitative, should be conducted on a regular basis.