Patient Protection and Affordable Care Act: The Role of the School Nurse

The Patient Protection and Affordable Care Act: The Role of the School Nurse

Position Statement

printable version


It is the position of the National Association of School Nurses (NASN) that the registered professional school nurse (hereinafter referred to as school nurse) serves a vital role in the delivery of health care to our nation's students within the healthcare system reshaped by the Patient Protection and Affordable Care Act of 2010, commonly known as the Affordable Care Act (ACA). This law presents an opportunity to transform the healthcare system through three primary goals: expanding access, improving quality and reducing cost (U. S. Government Printing Office, 2010). School nurses stand at the forefront of this system change and continue to provide evidence-based, quality interventions and preventive care that, according to recent studies, actually save healthcare dollars (Wang et al., 2014). NASN supports the concept that school nursing services receive the same financial parity as other healthcare providers to improve overall health outcomes, including insurance reimbursement for services provided to students.


Throughout the early twentieth century, American industrialists and organized labor recognized that worker illness led to lost productivity (Owen, 2009). Presidents Roosevelt, Truman, Eisenhower and Kennedy supported a national medical insurance plan financed via social security payroll taxes (Owen, 2009). In 1965, President Lyndon B. Johnson signed legislation authorizing Medicare and Medicaid, the first national medical insurance plan (Owen, 2009). Created in 1997, the Children’s Health Insurance Program (CHIP) provides affordable healthcare coverage to low-income children not eligible for Medicaid (U.S. Government Accounting Office, 2013). In 2010, President Barack Obama signed comprehensive health reform into law. The ACA aims to expand coverage, improve the healthcare delivery system and control healthcare costs (U. S. Government Printing Office, 2010).

This law also requires health insurance providers to provide “minimum essential benefits” to all Americans, regardless of their health status, age, gender or other pre-existing conditions for any plan offered through an employer or on the health insurance exchange. These benefits include the following:

  • Ambulatory services;

  • Emergency services;

  • Hospitalization;

  • Maternity and newborn care;

  • Mental health and substance use disorders services, including behavioral health treatment;

  • Prescription drugs;

  • Rehabilitative and habilitative services and devices;

  • Laboratory services;

  • Preventive and wellness services and chronic disease management; and

  • Pediatric services, including oral and vision care (Bagley & Levy, 2014).

Additionally, the ACA reauthorized CHIP through 2015 (Foxhall, 2014). Beginning in 2016, states that cannot afford to sustain CHIP coverage are required to ensure that CHIP-eligible children be covered either by Medicaid or a health plan available from the health insurance exchange. Under the ACA, states have the option to receive a federal match to expand Medicaid to children and families with household incomes at or below 138 percent of the federal poverty level (Hahn & Sheingold, 2013). In states that do not accept Medicaid expansion, families with incomes below 100 percent of the federal poverty level and who are not currently eligible for Medicaid will not have access to health insurance (Hahn & Sheingold, 2013). Americans whose household incomes range from 100 to 400 percent of the federal poverty level will have the option to purchase a health plan on the health insurance exchange and may qualify for federal tax subsidies to help offset the cost of premiums. Research demonstrates that mortality rates decrease when Medicaid coverage is expanded; thus a state’s failure to expand Medicaid eligibility has the potential to significantly impact overall community and individual health (Hahn & Sheingold, 2013).


NASN supports access to quality health care for all children, including the essential health benefits provided by the ACA. Research studies estimate that 25 percent of children and adolescents in the United States have chronic health conditions (Halfon & Newacheck, 2010) and that more than 7 percent, or 1 out of every 14 children, are without health insurance (Martinez & Cohen, 2013, U.S. Department of Health and Human Services, 2012). Rates of uninsured (9.3 percent) and under insured (34.3 percent) are higher for children with special healthcare needs (Child and Adolescent Health Measurement Initiative [CAHMI] 2012).

School nurses are healthcare professionals with the skills and expertise to assist students and their families in accessing health insurance, to provide vital health services to students and to coordinate care with other healthcare providers. Inclusion of the school nurse as the leader of the school health team ensures that health is prioritized in the school environment and that school health services are a part of the larger continuum of health care across all settings. School nursing interventions that promote healthy lifestyles choices as the norm have a lasting impact to influence overall student health (Frieden, 2010). Recent studies show that every dollar invested in school nursing saves $2.20 overall (Wang et al., 2014). Furthermore, by working to the fullest extent of their education and training (IOM, 2011), school nurses have the knowledge and skill to:

  • Promote population health and the prevention of chronic diseases;

  • Coordinate health care among students, families and healthcare providers;

    • Reduce the number of emergency room visits;

    • Provide transitional care to prevent re-hospitalization;

    • Serve as the liaison between families of children with chronic disease and their primary healthcare providers;

  • Provide critical primary (e.g., health education, immunizations), secondary (e.g., health screenings) and tertiary (e.g., chronic disease management) care to students;

  • Assist in efforts to enroll families for insurance coverage;

  • Advocate for and enable improved overall health care for students;

  • Advocate for meaningful use of the abundance of school nursing data and promote full utilization of electronic health records;

  • Assess student health conditions and provide appropriate care in the educational setting; and

  • Assess, plan and implement programs to impact school community health outcomes.


School nurses keep students healthy in the communities in which the students live, learn and play. NASN actively supports the position that school nursing services receive the same financial parity as other healthcare providers to improve overall health outcomes, including insurance reimbursement for services provided to students. School nurses serve a vital role in implementing the provisions of the ACA and stand ready to collaborate with students, families, and licensed healthcare providers to improve healthcare access and insurance coverage.


Bagley, N., & Levy, H. (2014). Essential health benefits and the Affordable Care Act: Law and process. Journal of Health Politics, Policy & Law, 39(2), 441-465. doi:10.1215/03616878-2416325

Child and Adolescent Health Measurement Initiative. (2012). National survey of children with special health care needs, 2009-2010. Retrieved from 

Foxhall, K. (2014). Expect changes to CHIP as ACA ramps up. Contemporary Pediatrics, 31(2), 14. Retrieved from

Frieden, T. (2010). A framework for public health action: The Health Impact Pyramid. American Journal of Public Health, 100(4), 590-595. doi: 10.2105/AJPH.2009.185652

Hahn, J.A., & Sheingold, B.H. (2013). Medicaid expansion: The dynamic health care policy landscape. Nursing Economics, 31(6), 267-297. Retrieved from:

Halfon, N., & Newacheck, P. (2010). Evolving notions of childhood chronic illness. Journal of The American Medical Association, 303(7), 665-666. doi:10.1001/jama.2010.130

Institute of Medicine.  (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

Martinez, M. E. & Cohen, R. A. (2013). Health insurance coverage: Early release of estimates from the National Health Interview Survey, January – June 2013. National Center for Health Statistics. Retrieved from

Owen, C. (2009). Consumer-driven health care: Answer to global competition or threat to social justice? Social Work, 54(4), 307-315. doi:10.1093/sw/54.4.307

U. S. Department of Health and Human Services.  (2012). Summary health statistics for the U.S. population: National Health Interview Survey, 2012.  Retrieved from

U. S. Government Accounting Office. (2013). Children’s health insurance: Information on coverage of services, costs to consumers, and access to care in CHIP and others sources of insurance. GAO-14-40: Published Nov. 2013. Retrieved from

United States Government Printing Office. (2010). The Patient Protection and Affordable Care Act. Retrieved from

Wang, L. Y., Vernon-Smiley, M., Gapinski, M., Desisto, M., Maughan, E., & Sheetz, A. (2014). Cost-benefit study of school nursing services.  Journal of American Medical Association. Retrieved from doi:10.1001/jamapediatrics.2013.5441

Acknowledgement of Authors:
Laurie G. Combe, MN, BSN, RN
Susan Sharpe, MBA, BSN, RN
Cynthia Jo Feeser, BSN, RN, NCSN
Lynnette Ondeck, MEd, BSN, NCSN
Nina Fekaris, MS, BSN, RN, NCSN

Adopted: January 2015
This document replaces the Position Statement Health Care Reform (Adopted June 2006, Revised June 2010).


Suggested citation: National Association of School Nurses. (2015). The Patient Protection and Affordable Care Act: The role of the school nurse (Position Statement). Silver Spring, MD: Author.


All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.