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Running head: ETHICAL CASE ANALYSIS

Patient Protection and Affordable Care Act: An Ethical Case Analysis Beth Anne Kelley & Cassie Schmidt Auburn University/ Auburn University Montgomery

ETHICAL CASE ANALYSIS Abstract

The Patient Protection Affordable Care Act (PPACA) has promised great changes in the future of healthcare. Along with these changes can come many ethical dilemmas. This paper provides an Ethical Case Analysis on the issue of rationing and also discusses how the PPACA has affected economics on micro and macro system levels. An overview of different leadership styles is provided, proposing that a quantum leader has the necessary skills to manage a healthcare organization while dealing with the changes of the PPACA.

Ethical Case Analysis

Patient Protection and Affordable Care Act: An Ethical Case Analysis Many Americans have concern and questions about The Patient Protection and Affordable Care Act (PPACA) that was passed by the United States government on March 23, 2010. The Affordable Care Act (ACA) is a federal law that will transform how, where, and by whom health care is provided (Milstead, 2013, p. 7). Many Americans across the U.S. are not as familiar with the basics of the ACA much less with the ethical issues surrounding the act that could possibly involve their own health. According to the United States Department of Health and Human Services, 2013 the Affordable Care Act puts consumers back in charge of their health care. Some benefits of the new health care reform that deals with coverage, cost, and care include ending pre-existing conditions for children, extending young adults coverage through their parents, ending lifetime limits on coverage, preventive care concerns, and more choices of physicians (U.S. Department of Health and Human Services, 2013). With an increase in Americans who are insured, there is a major concern for the demand of services by primary care providers. Ethical issues can easily arise regarding the ACA with topics of healthcare rationing, leadership views, and economics. Ethical Case Study The Patient Protection Affordable Care Act promised great changes in healthcare system. Coupled with the rapidly aging baby boomers generation, this change may lead to an increased demand for services without an accompanying supply of providers. Do you think rationing as defined in the literature will be part of the post-PPACA future? How can you justify rationing in a universal healthcare environment?

Ethical Case Analysis

Ethical Case Summary Many Americans are opposed to the ACA because they feel that health insurance is more of a privilege instead of a right. Before the ACA was passed, many Americans had a right to decide when and what types of health insurance to choose and some feel that one should not be forced to pay for everyone to have equal health insurance. Before the passing of the ACA, many insurance plans were being provided by employers and Medicaid/Medicare services but there were still thousands of Americans who were not eligible for insurance or simply not interested in paying the costs. This issue can be considered ethical depending on moral values and beliefs when dealing with universal healthcare for everyone. Another ethical concern with universal healthcare is the topic of rationing. With an overflow of more insured people, resources can become scarce and this is a concern for many Americans. According to Goodman, 2011 there are two arguments about rationing. The first is in order to avoid financial ruin there is a need to ration health care and the second is that ration will be the ruin of health care (Goodman, 2011). Many people have different views about whether or not the ACA will lead to rationing and some argue that health care rationing has been taking place even before the ACA. Prices, fixed budget, intrinsic capacity, health opportunity and health improvement maximization are all types of rationing that have been taking place in the United States (2011). Whether this issue is ethically right or wrong, rationing has and probably always will be a problem of health care. Goodman argues that it is unrealistic that the insurance expansion resulting from health care reform will, by itself, lead to all patients receiving the care they want and need (2011, p. 65). On the other hand, one article states that the ACA seeks to

Ethical Case Analysis reduce the rationing of care by eliminating insurance limitations on pre-existing conditions, mandating coverage of annual physical exams and other preventive services, and defining essential health benefits that will set a floor rather than a ceiling on care (Cohen, 2012, p. 96). Ethical Case Synthesis Solutions to ethical issues are very hard to uncover and sometimes impossible. In health care, there are many forms of ethical dilemmas that many people experience and are either satisfied or dissatisfied with the outcome. Ethics on the ACA is a controversial subject and Americans need to realize that whichever type of health care reform they have to abide by now or in the future there may always be problems such as rationing that they will be facing. If rationing does occur as the ACA unfolds, then Americans must learn to accept equitable rationing as a fair and just way to distribute scarce resources (Cohen, 2012, p. 96). With issues such as rationing, it is definitely a challenge for the U. S. to find the best way to provide affordable, equal, and ethically sound health care to all Americans. Leadership Implications Summary

Leaders must be prepared for restructuring health care organizations to meet the evolving changes in health care. In order to manage systems within large or small healthcare organizations it takes a leader of many qualities. There are many styles of leadership and depending on the environment and approach of the leader, one can manage and lead a health care team effectively. A quantum leadership style engages all members of an organization and seeks to improve an organizations performance by exposing limitations (Porter-OGrady & Malloch, 2011). With benefits and limitations of the ACA, a quantum leader would embrace and handle changes in healthcare successfully. Transactional leaders are known to offer rewards for compliance and

Ethical Case Analysis

punishment for disobedience (Giltinane, 2013). An authority figure or a person who is in control are great examples of a transactional leader. Depending on an organizations staff response to positive and negative reinforcement, this type of leadership could benefit with organizational change due to ACA. Transformational leaders inspire others with their vision and work together with their team to identify common values (Giltinane, 2013). They are often viewed as great mentors or role models. This type of leadership is excellent for embracing change within a team to succeed. Shared leadership involves active listening while in healthy dialogue (PorterOGrady & Malloch, 2011). Listening is very important for healthcare organization changes due to the ACA. It is important for leaders and staff to listen to each other in order to understand the specifics of the healthcare change. A servant leader has a desire to serve others making care and concern priorities for leading a team (Waterman, 2011). Although some changes from the ACA may not be the most appealing to staff, the servant leader would go above and beyond to help them enjoy their jobs. Lastly, an emotional leader must be competent in emotional intelligence. Emotional intelligence involves the ability to perceive accurately, appraise and express emotion (Feather, 2009). There has to be much emotion behind the doors of organizations with such changes under the ACA. A leader that does not understand how to deal with emotions of themselves or others would not benefit a healthcare organization. Leadership Implications Synthesis Any leadership style can impact the success of a healthcare organization. The leader must be prepared for change and willing to learn and experiment. After reviewing all leadership styles, the quantum leader seems like it would be most beneficial in a health care organization dealing with ethical cases and health care changes. Quantum leaders believe in teamwork and listening to others opinions in order to get complete tasks. This type of leadership would enable health care

Ethical Case Analysis organizations to focus on a problem, work through it and move on to the next issue. With the

challenging aspects of the ACA, a good leader must stay attuned to their followers as well as the demanding needs of the health care organization as a whole. Economic Analysis Healthcare economics refers to the science of allocating resources, and in an environment of scarce resources, it is neither a moral science nor an immoral science (Milstead, 2013, p. 192). In other words, healthcare economics is not the arena to argue ethics. However, a major issue raised by ACA, rationing, has sparked ethical debates. In examining the economic impact or implications of rationing, ethics will be ignored. In the current and proposed Medicare policies, 90 percent of Medicare funds are used for 10 percent of the beneficiaries and most Medicare dollars are expended in the final events of a persons life (Milstead, 2013, p. 193). This phenomenon will only worsen with the increased demand for services place on the healthcare system by the rapidly aging baby boomers generation. A point presented by proponents of rationing is that these resources and funds could be better utilized in areas to better the population such as health promotion or health research. Rationing proposes to curb spending by limiting medical care demands by determining a decent minimum that everyone is entitled to. Schneiderman defines that decent minimum as a level of medical care that enables a person to acquire an education, seek or hold a job, or raise a family (2011, p. 8). From an economic standpoint, there are definite costs saving benefits to this proposal. However, most healthcare consumers are unable to accept this, instead believing that unlimited availability of useful medical care [is] perceived as a right in American society (Paris, 2011, p. 17).

Ethical Case Analysis

The battle then becomes gaining the participation of the public as patient cost controllers who no longer partakes in adverse selection or moral hazard. As defined by Milstead (2013), these two practices drive up costs for insurance companies and penalize other consumers. Healthcare economists and policy makers can combat these and maximize profits by educating patients and healthcare consumers of these effects. Macro System Application The way of offsetting these rising costs and increased demand is thought to be a mix of the 3 Psgrowth in Population, Productivity, and Participation to produce higher economic growth (Sammut, 2012, p. 18). The healthcare market nationwide can benefit by this maximization of efficiency. An article by David Alan Klein (2011) offers this solution: Efforts to reduce demand for expensive medical resources, coupled with increased investment in research focused on preventing and actually curing (rather than just treating) illness, is likely to yield more stable long-term benefits than reorganizing systems that continue to rely on scarce resources. (p. 20). The healthcare crisis, therefore, is not simply a problem for one particular area of healthcare with a simple solution. To develop sustainable healthcare, a macro system of nurses, physicians, patients, healthcare researchers, insurers, and payers must work together as a healthcare market. Micro System Application Rationing healthcare is already a staple in many micro systems such as public hospital systems. Costs are being managed and resources are being allocated via blunt expenditure controlsfrontline budget caps and bed cuts (Sammut, 2012, p. 21). Unfortunately, many of

Ethical Case Analysis

these cost controls and rationing result in decreased patient satisfaction and increased wait times due to bed cuts. A better alternative to rationing in a micro system includes access as a greater choice and competition at the provider level will reduce the cost of services and achieve better value for money across the system (Sammut, 2012, p 22). With the increase in demand for physicians due to rapid aging, higher efficiency can be achieved through teams of physicians and mid-level providers such as Nurse Practitioners using evidence based care. Better efficiency of these teams will reduce the need for rationing and re-engineering of care could lessen the demand for physicians and, in turn, workforce requirements and health care spending (Goodman, 2011, p. 75). Conclusion Healthcare is rapidly changing and struggling to keep up with the increasing demands and lack of supply of providers. The Patient Protection Affordable Care Act makes many promises to improve cost and access to care, but brings with it many ethical dilemmas. Rationing is a very real part of healthcare economics and a major cause for debate. Quantum leaders in fields such as healthcare economics and healthcare policy will be crucial in educating consumers and developing systems to improve patient outcomes and control healthcare costs.

Ethical Case Analysis References Cohen, A. B. (2012). The debate over health care rationing: Deja vu all over again? Inquiry Journal, 49(2), 90-100. DOI:10.5034/inquiryjrnl Feather, R. (2009). Emotional intelligence in relation to nursing leadership: Does it matter? Journal of Nursing Management, 17(3), 376-382. Retrieved from

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http://ehis.ebscohost.com.spot.lib.auburn.edu/ehost/pdfviewer/pdfviewer?sid=2f49ffd97ea2-4a55-aa21-f005eb7c0216%40sessionmgr114&vid=4&hid=116 Giltinane, C. (2013). Leadership styles and theories. Nursing Standard, 27(41), 35-39. Retrieved from http://ehis.ebscohost.com.spot.lib.auburn.edu/ehost/pdfviewer/pdfviewer?sid=2f49ffd97ea2-4a55-aa21-f005eb7c0216%40sessionmgr114&vid=8&hid=116 Goodman, D. (2011). Preventing ruin, or the ruin of United States health care? A requiem for rationing. The Journal of Legal Medicine, 32, 61-76. DOI:10.1080/01947648.2011.550829 Klein, D. A. (2011). Evaluating social value: On the intersection of mortality and economics in the distribution of publicly funded medical care. The American Journal of Bioethics, 11(7), 18-20. Retrieved from https://aumnicat.aum.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true& db=rzh&AN=2011208888&site=eds-live Milstead, J. (2013). Health policy and politics a nurse's guide. (4th ed.). Burlington, MA: Jones & Bartlett Learning. Paris, J. J. (2011). Rationing: A decent minimum or a consumer driven health care system? The American Journal of Bioethics, 11(7), 16-18. Retrieved from

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https://aumnicat.aum.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true& db=rzh&AN=2011208883&site=eds-live Porter-O'Grady, T. & Malloch, K. (2011). Quantum leadership (3rd ed.). Burlington, MA: Jones & Bartlett Learning. Sammut, J. (2012). Treating health as an economic problem. Policy, 28(3), 18-22. Retrieved from https://aumnicat.aum.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true& db=buh&AN=84200345&site=eds-live Schneiderman, L. J. (2011). Rationing just medical care. The American Journal of Bioethics, 11(7), 7-14. DOI: 10.1080/15265161.2011.577511 U.S. Department of Health and Human Services. (2013). About the law. Retrieved from http://www.hhs.gov/healthcare/rights/index.html Waterman, H. (2011). Principles of 'servant leadership' and how they can enhance practice. Nursing Management, 17(9), 24-26. Retrieved from http://ehis.ebscohost.com.spot.lib.auburn.edu/ehost/pdfviewer/pdfviewer?sid=2f49ffd97ea2-4a55-aa21-f005eb7c0216%40sessionmgr114&vid=12&hid=8

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