Ethical Challenges in the Era If Health Care Reform

morals, Law, and Policy Vicki D. Lachman Ethical Challenges in the Era Of wellness reverence Reform n truth, the unify States is at the beginning of a long overdue and a much motivatinged wellness c be reform. We have seen the dismal statistics ab tabu our game terms wellness distribute agreement and some of the less than stellar outcomes (e. g. , infant fatality rate) (Callahan, 2011 World Health Organization WHO, 2011)). The purpose of this article is non to kvetch about the current health give feel for system, but instead to focus on existing reform efforts The Patient Protection and he inexpensive Care hazard (ACA), the respectable justifications for its creation, and ethical challenges it brings. I Key Features of the Law ACA offers new ways for consumers and providers to hold damages companies accountable. The just about important parts of the law are features described in the following discussion. Because of space limitation, I allow highlight some elem ents of the law that are enacted through 2014 and clearly impact nursing. These selected features include policy choices, insurance costs, rights and aegis, and spate age 65 and older. restitution ChoicesThe intention of the law is to expand health bearing coverage to most U. S. citizens and permanent residents by requiring most people to have or purchase health insurance (HealthCare. gov, 2012a). Citizens exit have a choice of private insurance, employer-paid insurance, Medicaid, Medi treat, or state-based insurance exchanges. Affordable redress Exchanges. Individuals and small businesses can purchase coverage through these exchanges, with premium and cost-sharing credits available to individuals and families with income between 133%-400% of the federal poverty guideline (in 2011, the overty guideline was $18,530 for a family of three) (Werhane & Tieman, 2011). Businesses with 50 or more employees need to make coverage available, and businesses with less than 25 employees de part qualify for tax credits to offset their cost (Kaiser Family Foundation, 2011). Consumer Operated and Oriented design (CO-OP). The ACA produces a new kind of non-profit health insurer, called a Consumer Operated and Oriented Plan (CO-OP). CO-OPs are meant to offer consumer-friendly, affordable health insurance options to individuals and small businesses. By January 1, 2014, individuals will be able to buy a CO-OPVicki D. Lachman, PhD, APRN, MBE, FAAN, is Clinical Professor, and Director, Innovation and Intra/Entrepreneurship in Advanced Practice nursing, Drexel University, College of Nursing and Health Professions, Philadelphia, PA. 248 health plan through the Affordable insurance policy Exchanges. Pre-existing condition insurance plan. All covered benefits are available to individuals, even to treat a pre-existing condition. This program offers temporary protection for people with pre-existing conditions until 2014, when insurance companies can no longer deny individuals cov erage based on their health status.Young adult coverage. Individuals can add or keep their children on their health insurance policy until they reach age 26. The law makes it easier and more affordable for young adults to get health insurance coverage. Insurance Costs ACA holds insurance companies accountable. It also helps individuals keep their costs down. Value for individuals premium dollar. ACA requires insurers selling policies to individuals or small groups to spend at least 80% of premiums on direct medical care and efforts to improve the quality of care. Unfortunately, this does not apply to self-insured plans.Lifetime and yearly limits. ACA restricts and phases out the annual dollar limits a health plan can place on most of its benefits. Furthermore, ACA eliminates these limits completely in 2014. Rate review. Insurance companies must now justify proposed rate increases for health insurance. Insurance companies cannot raise rates by 10% or more without first explaining the reasons to the state or federal rate review program. Rights and Protections The ACA puts consumers in charge of their health care, not insurance companies. The following rights and consumer protections are available. Preventive care.Individuals may not have to pay a copayment, co-insurance, or deductible to receive recommended preventive health services, such as screenings (e. g. , mammograms and colonoscopies), vaccinations (e. g. measles, polio, or meningitis), and counseling (e. g. , smoking cessation, weight loss, salubrious eating). Doctor choice and ER access. Individuals can choose any available fighting(a) primary care provider and they can access out-of-network emergency rooms without prior approval. ACA prohibits health plans from requiring a referral from a primary care provider originally women can seek coverage for obstetrical or ynecological (OBGYN) care. People 65 and older. ACA offers eligible elders a range of preventive services with no cost-sharing. ACA also p rovides discounts on drugs when older adults are in the coverage gap known as the donut hole. July-August 2012 Vol. 21/No. 4 Ethical Challenges in the Era of Health Care Reform TABLE 1. Views of Liberal Egalitarians vs. Libertarians and Free-Market Advocates Liberal Egalitarians Libertarians and Free-Market Advocates Health care is a fundamental good and access to this good Role of government is contain to protecting the freedom of all allows us to become full members of society. ersons to choose their own goals and means to pursue them. This right to health care must be exercised by removing all People have a right to non-interference. barriers to access. Justice, equality, and community are values. Freedom and soulal office are values. Health care is a right. Health care is a commodity. Single-payer system is the solution. Decentralized market mechanisms with personal payment are the solution. Preventive services. The list is significant and begins with an annual wellness vis it. other(a) important preventive services include b hotshot mass measurement cervical cancer creening, including Pap smear tests and pelvic exams colorectal, prostate, and diabetes screening influenza, pneumonia, and hepatitis B immunizations and many other services. There are other services and features in the ACA that could be discussed, but we will now move to discuss the ethical justifications for the ACA. The controversy it has created in the eyes of individuals with a free-market or libertarian view will be compared to those with a liberalegalitarian outlook. Ethical Justifications for the ACA Since 1986, the Emergency Treatment and Labor Act has prohibited hospitals from refusing acute care to any ndividual who could not afford to pay (CMS. gov, 2012). Consequently, $100 billion of care annually is costshifted onto unhurrieds who can pay, almost all whom are insured. This shift raises the average annual health insurance premium roughly $1,000 for every insured family (Crow ley, 2009, p. 10). This lack of distributive justice for the insured is one reason why insurance is being mandated in ACA. It is equally unfair to mandate that all citizens have insurance if insurance is not affordable, as this could cause significant harm to individuals and families already attempt financially.Therefore, the ethical principles of beneficence and nonmaleficence are supported by the features of Affordable Insurance Exchanges and the development of Consumer Operated and Oriented Plans. Ethical reasoning for health care reform has relied in the main on distributive justice as justification for change, specifically due to lack of access to care for the underinsured and uninsured (Lachman, 2009). According to the U. S. Census Bureau, 46. 3 one thousand million people in the United States were uninsured in 2008 (ProCon. org, 2012). The United States is the tho developed nation in the world hat does not guarantee health coverage. Table 1 offers a comparison of views o f persons who support distributive justice, see health care as a right, and therefore want a single-payer system with those individuals who want to continue the free-market system. To single-payer advocates, the primary goal of health policy is ensuring that everyone can obtain some minimal level July-August 2012 Vol. 21/No. 4 of health care (Sade, 2007, p. 1429). Making access to health care widely available permits individuals to be fully functioning members of society and the moral ommunity (a group of people bony together by a common interest in living according to a particular moral philosophy). On the other hand, Americans who are libertarians and free-market advocates for the most part look beyond the natural (genetic) and social (upbringing) lottery that places some at a disadvantage and instead look to the individuals free will and personal responsibility for actions (Callahan, 2011 Pariser, 2012 Trotter, 2011). They believe health care is one of the many options from wh ich to choose to improve their lot in life. Their belief in personal responsibility can make them unsympathetic o people with unhealthy lifestyles for whom they would ultimately have to spend their insurance dollars. They also resent having to fund treatments they personally would not choose (e. g. , transplants, mechanical ventilation for person in persistent vegetative state). Though many wealthy individuals support health care reform out of benevolence, they do fear the loss of freedom which is central to their value system. However, two additional factors drive change for health care reform significant cost and quality conundrums. In 2007, health care expenditures totaled $2. 2 trillion, 16. 2% of the U.S. economy. Health care employs more than 14 million people and is the largest industry in the United States. Of the 193 WHO member states, the United States is ranked first in per capita health care expenditures ($6,719) (ProCon. org, 2012). The present health care system is n ot giving the gain for the dollars played out. This cost problem is a reason that ACA has a focus on physicians counseling individuals on end-of-life options. It found that about 30 percent of Medicare dollars are spent during the last year of life, and half of that is spent during the last 60 days. In 2009 dollars, Dr.Gordon calculated, that amounts to $70 billion a year, much of it spent on futile care that prolongs suffering (Brody, 2009, para 20). Unfortunately, politics initially got in the way in 2009 with the death panel jargon and this counseling was dropped from ACA however, this end-of-life options counseling was incorporated into 2011 Medicare reimbursement for health care providers (HealthCare. gov, 2012b). 249 Ethics, Law, and Policy WHO (2011) statistics also indicate the money spent is not putting us at the top of the list in quality outcomes. The infant mortality rate for the United States in 2009 was even deaths per 1,000 live births, ranking the United States 43rd among WHO nations. Rates for Sweden, Spain, Italy, Germany, France, Czech Republic, Slovenia, and Iceland are all half of the United States rate. persona is a focus of ACA in the preventive realm and with quality measurement. Two essential principles of the ACA are that 1. Provider reimbursement for health services is based, in part, on the relation back quality and patient experience of the care provided. 2. Information about that comparative quality and patient experience will be publicly accessible. Quality and patient satisfaction will be rewarded by ata from hospital comparison required by the Hospital Consumer Assessment of Healthcare Providers and Systems for Medicare patients. The implications of Value-Based Purchasing (VBP) regulations for hospitals are clear FY2013 implementation at 1% of base DRG payments, rising to 2% by FY2017 (Acton, 2012, para 2). Hospitals will have to earn it back by achieving and maintaining high quality and positivist patient experiences. Th is consequential focus in the patient care experience supports the autonomous choice of the patient for hospitals and physicians. Ethical Challenges of ACA Legal ChallengeBefore discussing three key ethical challenges health care providers will face, the legal challenge before the ultimate lawcourt needs to be addressed. This challenge determined if the ACA indispensableness to purchase health insurance violates Article 1, Section 8, Clause 3 of the U. S. Constitution Congress shall have the Power To lay and collect Taxes, Duties, Imposts, and Excises, to pay the Debts and provide for the common refutal and the general Welfare of the United States but all Duties, Imposts and Excises shall be uniform throughout the United States (Werhane & Tieman, 2011, p. 83)The argument against this mandate is that the government has never required people to buy any good or service as a condition of lawful residence in the United States. However, every working person is required to pay into Soc ial Security and Medicare. The counter argument is that these are government-mandated and governmentrun programs. This argument ultimately could support a Supreme Court decision of provided a government-run singlepayer system, an action libertarians and free-market advocates oppose. Second, there are requirements for car insurance for drivers, and flood insurance for persons ho live within authorized distance from a practicable flood plain. Because all people will need health care at some point in their lives, the argument could be made that insurance should be a requirement so as not to burden the moral community with the costs of those who do pay for insurance (Hamel & Nairn, 2011). 250 On June 28, 2012, the U. S. Supreme Court endorsed most of the Patient Protection and Affordable Care Act, including the contentious individual mandate that requires most Americans to obtain health insurance. In a 5-4 decision, the greet said the federal government has he power to fine Americans who do not acquire insurance because it is considered a tax (Jaslow, 2012). Electronic medical examination Records The requirement for electronic records could generate a significant ethical challenge for privacy and confidentiality. Unfortunately, the $20 billion for health information technology from the American Recovery and Reinvestment Act (ARRA) did little to change the current HIPPA privacy paradigm (Crowley, 2009). Furthermore, it is likely patients will carry their personal health records in their own electronic devices or commend them through the Internet.A transformation in rural health care is likely through telehealth and telehomecare. These innovations will bring expertise to patients to facilitate the best choice in their treatment decisions. The challenge will be to assure informed consent and confidentiality in this expanded digital age. Chronic Disease Management Individuals with chronic infirmity benefit significantly from palliative care services, not just at end-of-life care but throughout the indisposition progression. The ACA focus on chronic disease management is best exemplified by this phrase An integrated care approach to managing illness hich includes screenings, check-ups, monitoring and coordinating treatment, and patient education (HealthCare. gov, 2012b, para 1). Feministic ethics, with its focus on managing the particulars of any persons situation, celebrates this personalized service to individuals who must manage illnesses often for many years. In her book, Caring A Feminine Approach to Ethics and Moral Education, Nell Noddings (2003) get byd that a morality based on rules is inadequate. She contended this approach loses the richness of the moral dilemmas people face, and nly situational and contextual knowledge of the individual can help interrupt the moral quandaries of life. Shaping Health Care Policy According to the Code of Ethics for Nurses, provision 9 (American Nurses Association ANA, 2001), nurses have an obli gation to work one by one as citizens or collectively through political action to bring about social change (p. 25). This responsibility to shape social (health care) policy calls for nurses to vowelise concerns about the meaning of the rejection of the individual mandate for society. The libertarians and free-market advocates reinforce a caricature of American individualism and weaken a sense of responsibility for oneself and fellow citizensIt neglects one side of the equation, forgetting that we are not only individuals with the freedom to choose, but also members of society called to uphold a common good. (Hamel & Nairn, 2011, p. 94) continued on page 245 July-August 2012 Vol. 21/No. 4 Ethics, Law, and Policy REFERENCES continued from page 250 Therefore, nurses and nursing associations have the ethical challenge to stand firm for patients and ensure the long-term sustainability of our health care system.Nurses need to advocate for the people without a voice those discriminate d against because of health status and lack of insurance. Conclusion ACA has provided a forum for debate about not only health care insurance, mechanisms to maintain financial stability of its systems, and strategies to ensure access to millions of people, but also has contributed to defining American societys values. It is easy to argue against the individual mandate impingement on choice and freedom. 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