The Affordable Care Act (ACA) 2010 is one of the most radical healthcare moves in legislation of United States after Medicare and Medicaid. The main goals of ACA were to decrease the number of uninsured and provide cost-effective high-quality care to all in US. According to Kaiser Family Foundation, the potential plan of ACA was to expand coverage to 47 million nonelderly uninsured in the nation, which included 1.6 million uninsured North Carolinians (2014). The purpose of this paper is to review the effect of ACA on the North Carolina uninsured population, the influence of the economy of care provided care and the ethical implications. Impact of ACA on North Carolina Population
North Carolina has the highest index of the uninsured population approximately 1.6 million. Being uninsured has a profound impact on the health and well-being of the people. The ACA had a significant impact on the different population categories of North Carolina. According to The Affordable Care Act 2014, Medicaid will cover most low-income people if Federal Poverty Level (FPL) is no greater than 138 percent (Milsted, 2013). The people that have more impact are the children six to eighteen, working parents, nonworking parents, and childless adult. Prior to Affordable Care Act, Medicaid was limited to a specific group of low-income individuals, such as children less than six, pregnant women, elderly and disabled. Childless adult who was homeless or unemployed did not qualify for Medicaid. The Medicaid also did not enroll undocumented immigrants and lawful immigrants that resided lesser than five years in United States (Milstead, 2013).
Medicaid expansion became optional with Supreme Court rule 2012, and North
Carolina chooses not to expand Medicaid and put their most vulnerable in jeopardy (Kaiser Family Foundation, 2014). Consequently, the newly eligible uninsured adults in North Carolina will remain without coverage. The reason for this was, ACA envisaged that Medicaid would expand and provide coverage for people below 138% FPL and thus did not provide Marketplace subside for these low-income people. Therefore, the people that did not qualify for Medicaid nor subsides fell into a “coverage gap” which was estimated as 318,710 or 28 percentage of all uninsured nonelderly adults (Angster & Colleluori, 2014). This brought up ethical dilemma. The people in the coverage gap are facing barriers to health services and financial consequences. The Safety net of clinics and hospitals that had been traditionally serving these populations are still stretch in the state to provide care for the uninsured. Financial Impact of ACA on North Carolina
The biggest challenge that US health care is facing is the rapid escalation of health care costs. The United States spends more when compared to other developed centuries in the world. The United States spends 17.7 percent of gross domestic product (GDP) in health, and in terms of per- capita cost, US spend $ 8,247 in 2010 (Silberman, 2013). The ACA has put forward many provisions to reduce the health care cost. Some have immediate results, and some may take time to bend the cost curve. The Patient-Centered Medical Home (PCMH) is a model of care that aims to deliver comprehensive care which includes preventive, acute and chronic care to children, adolescents, and adult (Kovner & Knickman, 2011). North Carolina was the first state to get a demonstration grant for the Medicaid and Medicare innovation, and this was used for test PCMH model in seven rural counties. Bundle payments, Accountable Care Organization (ACO), Medicare diagnosis-related group (DRG), and Value-Based Purchasing (VBP) program are all aimed at reducing healthcare spending in the long term by the ACA. (Silberman, 2013).
The Federal government will be paying the state “ most of the costs for covering the new eligible: 100 % of the Medicaid costs for newly eligible clients for the first three fiscal years 2014 to 2016, and declining to 90% in 2020” (North Carolina Institute of Medicine, 2014, p. 2). The Affordable Care act also funded North Carolina for Prevention and Public heath Trust for promoting prevention, wellness, and public health, “ACA granted $750 million in FY 2011 increasing to dollar two billion in FY 2015 and each year thereafter” (Silberman, 2013, p 28). According to Middle Class Tax Relief and Job creation Act 2012, “the cut $6.25 billion over 9 years”, the fund instead of reach dollar two billion in 2015, it will reach it only in 2022 and the funds will remain at one billion until 2018 (Silberman, 2013, p 28). Effect of ACA on Cost, Quality, and Access to Treatment
According to the North Carolina Institute of Medicine(NCIOM), the Health Benefit Exchange (HBE) created by States or federal government provides standardized information on quality, cost, and network providers, which helps people and small business to select the health plan of choice (2013). Since North Carolina did not meet the deadlines for HBE for 2014, the state created partnership arrangement with North Carolina Department of Insurance for consumer assistance and plan management (Silberman, 2013).
The ACA provides cost effective and high quality health coverage through the Health Insurance Market (exchanges). There are different health plans and eligibility factors; to determine what savings and benefits the people can quality. The ACA provides people with income 100% and 400% of FPL to be eligible for the premium tax credits for purchasing marketplace insurance (Kaiser Family Foundation, 2014). The tax credits are based on income, cost of insurance and are only for people that are not eligible for other coverages. People with income greater than 400% FPL can purchase unsubsidized insurance from marketplace (Kaiser Family Foundation 2014).
Agency for Health Research and Quality ranked North Carolina performance score for overall health care quality as “average” when compared to other states. (Silberman, 2013). To improve the quality of care ACA helped the state to accelerate their effort. ACA recommended the secretary of US Department of Health and Human service to define “quality”, and healthcare institution should give a report on quality care measures adopted by them. To improve quality ACA also changed the reimbursement policies. The way health care providers were paid was based on quality and outcome of care provided. Increasing incentives and rewards was also emphasized by ACA to improve the quality of care in North Carolina (Silberman, 2013). PCMH model funded through ACA will improve the quality, effectiveness and efficiency of care delivered, which meets patients unique need and preferences. (Kovner & Knickman, 2011). Ethical Implication of ACA on the Organization and the Patient
Health care reforms bring controversial ethical issues to the population as well as to the legislators. There is a critical need for reforms in healthcare to reshape the healthcare delivery system in United States. However, it is always challenging to meet all demands of the people. According to Sorrell (2011), there are be four essential goals that shaped our health care system. First, there is always a want for high-quality care with great benefits. Second, the peoples needed the freedom of choice of “who, when, and where” for their health (Sorrell, 2011, para.4). Third, the health care should be affordable and fourth the people wanted fellow citizen to share the benefits of the health care (Sorrell, 2011).
When people are not treated with equal moral concerns, social injustice occurs. As in North Carolina, it is unfair that the populations that are in the “coverage gap” who are the poorest of the poor are denied of health care. Here, if North Carolina has opt-in to expand Medicaid, which would have extended coverage to an estimated 1.6 million uninsured people in the state (Kaiser Family Foundation, 2014). According to American College of Physicians (ACP), being uninsured poses a hazard to once health, chronic disease, and morbidity and mortality is high in the uninsured group (2014). Lack of health insurance also effects the people and the community financially, 60 percent of all bankruptcies are related to cost of medical care expenses due lack of insurance (ACP, 2014) Summary
Expanding of Medicaid is the North Carolina is one of the solutions to decrease the uninsured population. The Affordable Care Act gives funding to states that opt-in; it would improve not only the health care system but also the economy of the state as a whole in the future. Ethically it is not fair to deny treatment to any patient. With the new health care reform and newer evidence-based researches we can develop better Healthcare Models to contain this rising cost and provide universal health care to all. Affordable Care Act has to work against the obstacles, and it is still unfolding (ACP, 2014). It will take time, “ to know the real impacts of Affordable Care Act reform experiment is a success, a failure or a little of both” (ACP, 2014, p.305). But once thing for sure, Affordable Care Act have decreased the number of uninsured in United States.
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