Affordable Care Act and Its Effect on Medicaid/Medicare: An Ethical Care Analysis Stephanie Springer Auburn University/ Auburn

Montgomery

Running Head: An Ethical Case Analysis

Abstract The Affordable Care Act has caused many healthcare workers to question the future of healthcare delivery. It is predicted that while the act will bring an increase in the quality of care, there will not be enough providers to serve a fast growing insured population. This paper will look at the Affordable Care Act, ways to prepare for its implementation and what it means from a leadership perspective by looking at North Carolinas current Medicaid coverage rates for different populations such as pregnant women, young children, disabled and the elderly. It will also discuss the current lack of coverage for childless non-disabled and non-elderly adults and the use of the North Carolina Health Choice Program This paper does not provide an opinion for or against the act but rather an insight into the predictions for the future of healthcare at a local and national level.

Running Head: An Ethical Case Analysis

Affordable Care Act and Its Effect on Medicaid/Medicare: An Ethical Care Analysis The United States Government issues public policies to address concerns made verbal by the public. One of the biggest problems faced by todays society is the number of people without health insurance or health providers. As the presidential election nears one of the biggest debates is over healthcare coverage. President Obamas administration issued a public policy identifying the issue and then a social program to solve it. A social program is defined as a public policy made visible (Milstead, 2012). In the instance of this policy the Affordable Care Act of 2010 was created. This paper will discuss the meaning of the Affordable Care Act, the current states of Centers for Medicaid and Medicare services (CMS) in relation to North Carolina and how this will impact the future of advanced nurses and leaders within healthcare organizations. Affordable Care Act The Affordable Care Act (ACA) passed in 2010 and set to become implemented in 2014 has many different goals. The overall goal is to reduce the number of non-elderly or non-disabled uninsured people under the age of sixty-five (which includes all those not eligible for Medicare) by 32 million Americans before 2019 (Davis & Somers, 2011). The different provisions of this act are meant to benefit this group of Americans. These individuals would fall 133% below the national poverty level (Davis & Somers, 2011). Presently each state holds its own Medicaid program while Medicare is governed nationally. With the new act, the state will continue to hold the Medicaid program now which services pregnant women, families with young children and those who qualify for dual eligibility but the federal government will step in and help allocate funds for childless young adults.
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Running Head: An Ethical Case Analysis

On a private side, each person will be required to hold some kind of health insurance whether through employment or purchased privately or federally. Those who do not hold insurance with be assessed a penalty of up to $695 per person (Davis & Somers, 2011). Each establishment that has greater than fifty employees will be required to provide some health insurance for employees or pay a fine of $2000 per employee each year (Davis & Somers, 2011). Insurance companies will also not be allowed to base the amount of coverage and the price of insurance on gender, age or preexisting conditions. This act will bring much more coverage for many people but has been controversial in todays society. Questions have risen as to where the funding for these programs is coming from if the national budget is already so strained? Doctors have questioned how this affects their reimbursement and how to accommodate the amount of patients who will now need care through primary and emergency settings. Others have welcomed the change but wonder what these individuals who are still not covered will do for the next four years. This paper will now look at the present and in particular the current Medicaid allotment in North Carolina. Ethical Case of Coverage for All According to the case study found on pages 202-204 of Health Policy and Politics, the authors discuss the current status of Medicaid allocation in North Carolina. Currently the North Carolina Department of Health and Human Services (DHHS) oversees the distribution of Medicaid funds. According to the case analysis the current poverty line is $30,429 for a family of four. In 2009, majority of funds were allocated for children under the age of six at 200 percent. After a child has reached the age of six years their coverage drops from 200 percent to 100 percent till the age of eighteen provided from Medicaid. At the age of eighteen if a person does

Running Head: An Ethical Case Analysis

not have any children and is not disabled or pregnant, there are no funds allocated for this age of uninsured population (Milstead, 2012). The DHHR of North Carolina reports that currently 1.5 million people are covered by the states Medicaid program (Cansler, 2010). It is estimated that the enrollment will grow thirty to fifty percent more by 2014. The DHHR is trying to revise its committees to accommodate the growing masses and provide a quicker process to implement insurance coverage as it becomes mandatory. What allows discrimination in the allocation of funds for Medicaid? Many could argue that it is too exclusive and others could argue that the distribution of funds could be weighted differently to provide some coverage for all. The current methodology is approached as a utilitarianism view in providing for the greater good or greater amount of people. Money is given to those who are pregnant or with small children to provide more funds to the greatest amount of people in a family. This however does not explain the allocation to the elderly or the disabled. Looking at the current distribution plan, it seems that money is dispersed to those who physically or mentally may not be able to provide for themselves. People between the ages of 1865 years of age with no disability or dependents are seen to be able to provide to todays society through occupations. In reality these occupations may or may not provide insurance coverage. Looking ahead to the changes predicted after the ACA is implemented in 2014, childless adults will qualify for Medicaid if their income is less than 138% of the poverty line (Milstead, 2012). 138% of the current poverty line would be $41992.02. In 2014, Medicaid will increase its coverage for children six to eighteen years of age but the North Carolina Health choice will still cover the deficit for health insurance.
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The North Carolina Health Choice (NHC) program also helps children of families who do not qualify for Medicaid but are still considered low income. It was initiated in 1998 by the DHHR of North Carolina (NCDHHS, 2012). The program is either free or at a reduced cost to the public depending on an individuals situation. The NHC covers services from routine examinations for health, dental, and vision to surgical services and prescription coverage within their provider service. NHC is not an entitlement program meaning that the government is not required to give money to the program so that all people who meet the requirements of the program are provided the service. The program has a cap on enrollment growth each year of six percent (NCDHHS, 2012). If funds are not available to support any growth, no new enrollments will be made during that fiscal year (NCDHHS, 2012). This means that kids who may be eligible for NHC but not for Medicaid remain uninsured if the program is frozen for new enrollments. The Impact of ACA on Primary Care at a National and Local Level The creation of the ACA has many primary providers and administrators wondering how to cover the shortage of providers available. Under the act an estimated thirty two million more U.S. citizens will be insured and encouraged to pursue a primary healthcare provider. Presently, there is already a shortage of primary care providers. The Association of American Medical Colleges (AAMC) projects that by 2025, there will be a deficit of greater than 124,000 physicians across all specialties with the largest deficit in primary care (Jacobson & Jazowski, 2011). One solution is to promote the use of advanced nurses in primary care. Recent studies have shown that the use of non-physician providers such as nurse practitioners and physician
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assistants have provided care comparable to that of a physician (Jacobson and Jazowski, 2011). These studies have also further demonstrated that nurse led care has shown to improve physical assessments, communication and patient satisfaction (Jacobson & Jazowski, 2011). Family and primary care nurse practitioners will be an asset to a practice. The scope of practices within each state for APN will have to be examined as in some rural areas many practitioners may have to practice on their own to meet the increasing demand from the public health. Depending on the state, a nurse practitioner can fall into three categories direct physician supervision, independent practice or physician collaboration (Jacobson & Jazowski, 2011). In the State of Alabama, nurse practitioners can have physician collaboration where a physician must be there to review a certain amount of charts. One suggestion made by Jacobson and Jazowski is that primary care could be transformed into a bi-level system (2011). Nurse practitioners could run a community health center and refer patients to primary care physicians when the patients plan of care becomes out of the scope of practice. This turns primary physicians more into a specialty. With a decreasing rate of internal and pediatric physician it may become a specialty to set up an appointment. Leading a New Era in Healthcare While the idea of ACA is very controversial and many healthcare workers have stressed a deep concern over the ACA, it will be implemented in 2014. The best plan for a leader during the upcoming years is to be proactive in preparing for the transition. Keep employees informed at what changes could be expected such as a possible increase in patient loads. By 2020 the nursing shortage is projected to reach 300,000 (Cleary & Wilmoth, 2011).

Running Head: An Ethical Case Analysis

Managers within an inpatient organization will have to put more focus on quality, reduction on patient readmissions, and reduction in hospital acquired infections. The ACA will enforce that reimbursement to hospitals be based upon these above mentioned areas (Cleary & Wilmoth, 2011). While many nurses already lead committees focusing on this, the implementation will be more important than ever before. The act also focuses on transitional care. Social workers and nurses will work together to provide close monitoring and assistance for chronically ill patients transitioning from an inpatient setting to home (Cleary & Wilmoth, 2011). In order to exemplify the leadership needed during a time of change one must display emotional intelligence. The five major components of emotional intelligence include selfawareness, self-regulation, motivation, empathy, and social skill (OGrady & Malloch, 2011). An example of a good leadership style as an APN is transformational leadership. Transformational leadership works better with long term goals and redesigns a current process to make the current goal more challenging. Transformational leadership focuses more on the mission. It looks to improve something in the process and not necessarily at the end goal. Since the process of implementation will take many years, transformational allows focus to stay on the mission and improvising it to work with the uniqueness of each healthcare organization big or small. Leading during this transition is not just about managers preparing their department for the change but about individuals showing leadership in their own practice. While the act is very controversial, there are some very important areas that are brought to light by the act that should always be enforced. The act focuses on health prevention and education on chronic illness. As an advanced practice nurse, one must focus on these areas regardless of the act. Prevention and education are key in public health self-management.
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ACA will bring many changes at an individual organizational level and at a national healthcare level. Private insurance premiums are expected to rise. The cost of placing this program will be costly to an already strained national budget. Reimbursement for physicians could suffer and cause a decrease in those entering medical school and increase in established physicians leaving the field. The biggest challenge faced both at a small rural level to a national level is finding enough providers to cover a big influx of insured patients particularly in primary care. As listed above, one solution is to embrace the expansion of autonomy of advanced practice nurses. Whether one believes in the act or opposes it, healthcare facilities nationwide must be prepared.

Running Head: An Ethical Case Analysis

References Cansler, D. (2010). Meeting the challenges of a changing state. Policy and Practice, p.6. Cleary, B., & Wilmoth, Peggy (2011). The Affordable Care Actwhat it means for nursing. Tar Heel Nurse, 73(2), pg 8-9, 12. Davis, C.S., & Somers, S. (2011). National health care reform and the publics health. Journal of Law, Medicine, and Ethics, 39, pp 65-68. Doi: 10.1111/j.1748-720X.2011.00569.x Jacobson, P.D., Jazowski, S.A., (2011). Physcians, Affordable Care Act, and primary care: disruptive change or business as usual? Journal of General Internal Medicine, 26(8), pp. 934937. Milstead, J. (2011). Health policy and politics: A nurse's guide (4th ed.). Burlington, MA: Jones & Bartlett Learning North Carolina Department of Health and Human Services. (2012). Basic Medicaid and NC Health Choice billing guide. Retrieved from http://www.ncdhhs.gov/dma/basicmed/NCHC.pdf Porter-OGrady, T. & Malloch, K. (2011). Quantum leadership: Advancing innovation, transforming health care. (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.

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