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Ethical Case AnalysisBrandie WeidmanAuburn University/Auburn MontgomeryAbstractIn 2010 congress passed the Patient Protection and Affordable Care Act (ACA) which initiated a complicated and controversial reform of the United States health care system. The ACA was passed to improve access to health care and containment of costs, as well as improve the quality of health care. The ACA plans to accomplish this by regulating competition among insurance companies and encouraging universal health care coverage. In 2014 a Medicaid expansion will allow all qualified individuals with incomes below 138% of the Federal poverty level to receive coverage in order to improve access to care. Estimates vary, but the expansion could increase the number of individuals with health care coverage by 32 million. The ACA is a federal mandate which gives each state its own autonomy on how to apply the provisions into practice. This paper is an analysis of a case study on the impact the ACA will have on North Carolina’s uninsured population. Increasing the number of insured individuals will have a dramatic effect on the health care system at all levels. Leaders will be essential in the adaptation of change and the need for health care providers will be on the rise. Economists differ on the impact the ACA will have on the economy, but a projected economic analysis is included in this paper. An application of the ACA to macro and micro systems is also included. Although the full effect that the ACA will have on health care is still unknown, mixed views have been noted, and whether positive or negative, the impact on health organizations will be substantial. Good abstractEthical Case AnalysisBeginning in 2014 the Affordable Care Act (ACA) will allow adults who could not previously qualify for Medicaid become eligible if their income is no greater than 138% of the Federal Poverty Level (FPL). This paper is an analysis of a case study on the projected impact the ACA will have on North Carolina’s uninsured population comparing 2011 to 2014. In 2011 a childless adult in North Carolina could not qualify for Medicaid even if he or she was unemployed, poor, or homeless (Milstead, 2013). According to the case study childless adults will have the largest increase in eligibility than any other population, increasing from 0% to 138%. The ACA’s expansion of Medicaid eligibility will ultimately increase access to care, but the road ahead will be a bumpy one. The estimate for new enrollees varies by more than 10 million individuals, which means a possible $64 billion annual variance (D.I., & L.L., 2012). New physicians and advanced practice nurses will be needed to care for the new Medicaid participants, leaders and policy makers will be needed to make changes and enforce them, and employees will be needed to enroll individuals into the program. Summary and SynthesisUnder the ACA qualifying for Medicaid will be based on income as percent of FPL and some states will allow individuals with higher incomes to be eligible. Enrollment will be simplified, more accessible, and a streamlining enrollment process will provide improved opportunity for eligible individuals to enroll. Hospitals and healthcare organizations will have access to enroll individuals on the spot as part of Express Lane to enrollment (Milstead, 2013). In the case study a comparison of the populations that will be affected, which includes individuals with incomes from 0% to 250% of the FPL, is illustrated. Medicaid eligibility, as well as North Carolina Health Choice program eligibility, is available in the illustrations. The affect the ACA will have on the presented populations is either an increase in percent of eligibility or it will remain the same. There is not any population that will lose eligibility due to the implementation of the ACA. Currently, the North Carolina Health Choice Program offers eligibility to children 6-18 years of age, who do not qualify for Medicaid, and whose family’s monthly income is equal or less than 200% of the FPL. Although this number will not change in 2014, Medicaid eligibility will increase from 100% FPL to 138% FPL for those children (Milstead, 2013). With more children eligible for the Medicaid expansion and the additional government funding for the Heath Choice Program, there will not be any children unable to qualify for coverage.Consider subheading sections for summary and synthesis of the caseLeadershipThe goal of the ACA is to improve health care and containment of costs by implementing policies that lead to an improvement in health care quality (Cleary & Wilmoth, 2011). Implementing health reform will be done at both the state and federal level, therefore the need for leadership in healthcare policy will be on the rise. In 2009, when healthcare reform began to make noise, advanced practice nurses came together to form six national organizations to establish a united front on advanced practice issues (Milstead, 2013). Nurses are needed to be involved in these organizations, specifically nurses with a passion to make positive changes in healthcare delivery. The ACA Medicaid expansion is estimated to bring over 10 million new enrollees which will eventually become patients, therefore an increase in workforce will be needed. Included in the ACA is a National Workforce Commission to serve as a national resource to ensure the health workforce is adequate in numbers, possesses skill sets needed, and effective workforce retention practices are present (Cleary & Wilmoth, 2011). There is a projected shortage of over 300,000 nurses by 2020, which means the commission will play a large role in ensuring there is not a decrease in quality of care. However, this also means that the leadership role will have to progress with the change of times. With an increase in patients and a potential decrease in workforce, leaders will have the challenging task of changing the framework of practice, and guiding the transformation to make the required adjustments. Leaders must ensure that standards of performance are always met by creating an environment in which innovation and engagement with change is embraced (Porter-O’Grady & Malloch, 2011). The nursing profession is the backbone of the healthcare sector and nurses must have a good understanding of the purpose of health reform. They must also be equipped with leadership skills and leadership behaviors that meet the challenges of modern healthcare. Leadership is a process which sets the direction for the future. Effective leaders adapt, innovate, and reinvent their organization by enabling staff to work effectively to fulfill the organizational goals. The future of health care is uncertain, but one certainty is that change is inevitable. Therefore, leaders must own and champion the change through investment of personal time and attention and actively communicate the change throughout the change process (Bush, 2012). Adapting to and implementing a large-scale system change is challenging for leaders, and the leadership style used is vitally important. In order for the ACA for have a positive impact on the uninsured population of North Carolina and to ensure organizational effectiveness, a transformational leadership style is essential. A transformational leader is one who is able to inspire and motivate staff to follow in accordance with a plan for change, while being dynamic and flexible and empowering the attainment of personal and organizational goals (Poulson, Smith, Hood, Arthur, & Bazemore, 2011). A strong transformational leader is associated with positive work attitudes, which leads to a constructive organizational climate with committed staff members, and ultimately improved quality care for patients (Aarons, sommerfeld, & Willging, 2011). A positive organizational climate is characterized by well established roles, high levels of fairness, growth, and advancement, and low levels of emotional exhaustion and depersonalization, leading to staff retention (Aarons, sommerfeld, & Willging, 2011). A competent transformational leader will have the skills and characteristics needed to manage the changes ahead by increasing self-awareness, exhibiting ethics and integrity, valuing effective communication, and exhibiting leadership stature. However, no matter the leadership style, leaders and staff members alike must be braced for a journey into the unknown when it comes to the future as health care providers, while keeping all eyes on the ultimate goal, which is providing quality care to all patients. Might add some information about other leadership styles. Think reader doesn’t know there were other choicesEconomic AnalysisAccording to Milstead (2013) economics is the science that is involved in the processes of finance with an intersection of health policy and health finance. The case study provides two figures which illustrates eight different populations and compares their eligibility for Medicaid and North Carolina Health Choice in 2009 and 2014. Currently the ACA is still a work in progress, and any economic analysis is only an estimate or a prediction of what the future holds. Many critics disagree on the economic impact the act will have, and due to health insurance exchanges, the impact will vary state to state. As of December, 2011, $4 billion in federal money was given to states to implement the ACA (King, 2012). Although millions of uninsured individuals will benefit from new coverage, how the coverage will be funded and if adequate funding will be available is a debatable question.The ACA is intended to be funded by a variety of taxes and offsets. Many believe that the ACA is just a major tax increase that will be paid by everyone from low-income Americans and small businesses to huge corporations (Sherer, 2012). A major increase in Medicare tax on families with incomes over $250,000 is projected to bring the government $210.2 billion over a 10 year period. Insurance providers will be charged an annual fee which has a projection of contributing $60 billion over a 10 year period. Taxes on pharmaceuticals and high-cost diagnostic equipment will increase and even a 10% federal sales tax on indoor tanning services will be charged. Projected offsets include reducing Medicare funding for policies and reducing Medicare home health and hospital payments (Sherer, 2012).The above examples are just a few of the planned funding methods and actual figures will not be obtainable until implementation takes place. Some benefits of the ACA are already in effect, such as 600,000 new adult Medicaid enrollees in seven states. There are 12.8 million consumers who will receive more than $1 billion in insurance-premium rebates (McDonough, 2012). One provision in the ACA is that all individuals have some type of coverage by 2014. However, if an individual is currently eligible but not enrolled, and induced to enroll due to the mandate, the government will still only provide that state with the current 50 to 83% for coverage in those cases. Disagreement over how many such people will enroll exists, and governors fear that the increased expenses without increased funding will stretch their budget (McDonough, 2012). Childless, low-income adults (see format for level 2 headings p. 62 APA)According to the ACA childless adults with an income no greater than 138% of the FPL, which is an annual income of $15,414 or less, can qualify for Medicaid beginning in 2014 (Milstead, 2013). Currently 35% of poor adults living without children are uninsured due to decreased access to private and public health insurance, and only 12% have employer-sponsored coverage (Beaussier, 2012). They are only covered by Medicaid in certain states with waiver programs, and North Carolina is not one of those states. Due to their low-income level, they often cannot afford job-based coverage when it is offered, nor can they afford individual –market insurance. Childless, low-income adults are more likely to report they are in fair or poor health compared to other low-income groups, which may be one reason why they have been denied access prior to the ACA. However, beginning in 2014 this will no longer be the case. The government will finance 100% of their coverage from 2014-2016 and then it will change to 90% financing from the government and 10% financing from the state (Beaussier, 2012). North Carolina Health ChoiceThe Children’s Health Insurance Program (CHIP) has served as a critical source of coverage for children since 1997. Under the ACA CHIP will continue its role in providing coverage to children and funding for the program has been extended through 2015. The federal CHIP match rate in fiscal year (FY) 2011 was 75.3%. Starting October 1, 2015, North Carolina will receive a 23% increase in their federal CHIP match rates, with a cap at 100% (North Carolina Department of Health and Human Services, 2011). New enrollment and outreach programs, simplification efforts, as well as the increase in funding will strengthen the future of the program. However, with the state of the current economy and the current debt crisis, the availability of funding is questionable. North Carolina Health Choice is not an entitlement program and the North Carolina Division of Medical Assistance (DMA) monitors the funding for the program and notifies the Division of Information Management (DIRM) if funding is no longer adequate to support additional enrollments. If federal and state matching funds are insufficient to cover all eligible individuals an enrollment freeze is implemented on a county level. DIRM establishes a waiting list and as funds become available DMA notifies DIRM and applications on the waiting list are reactivated. The affected county is notified and the process of reactivating applications for enrollment is initiated (North Carolina Department of Health and Human Services, 2011). The ACA was established with provisions to ensure that funding is available and ideally decrease the national debt crisis. However, successful implementation and adequate funding will likely vary from state to state and a plan for change must be put into effect at the system level. Macro and Micro SystemsDeveloping and deploying a successful macrosystem’s plan for change is dependent upon microsystems. Microsystems are the smaller systems enveloped within the macrosystem that provide the front line of care and act as the agent for change (Kosnik & Espinosa, 2003). Microsystems providing optimal performance including quality, safe, and cost effective outcomes enables the macrosystem to facilitate transformation at all levels. Therefore, the microsystems will play a critical and essential role in transforming the macrosystem to successfully achieve the goals of the ACA. For the purpose of this case study the macrosystem is the state of North Carolina and the microsystems are all of the health care organizations within the state. Very nicely explainedThe ACA has provided many immediate benefits that are currently available for the state of North Carolina. By taking advantage of the benefits allowed, North Carolina and its residents will be more prepared for the undertaking of a full scale change in 2014. According to , small businesses may be helped by a tax credit to help make providing health coverage affordable. Residents, who were affected by a loophole in Medicare Part D, will be mailed a one-time rebate check for $250.00. Individuals currently insured will have more protection in the insurance market. Young adults are allowed to remain on their parents’ policy until they turn 26 years old if they do not have job-based coverage. Also, affordable insurance for uninsured with pre-existing conditions will be available due to a $145 million fund provided by the federal government. Finally, for the first time North Carolina has the option of Federal Medicaid funding for the low-income populations, irrespective of age, disability or family status. Although the above are all included in the ACA, the state of North Carolina, as a macrosystem, has the role of making the information available and accessible. The state must provide a supporting infrastructure for the microsystems to lean on and develop an integrated database through which information is readily available and easily accessible. With the state of North Carolina as the macrosystem, the microsystems include the hospitals, health departments, private physician practices, or any setting in which care is administered from a provider to a patient. New and innovative solutions will be needed to build an organizational plan for change and the microsystems are the place to link the vision with the delivery (Kosnik & Espinosa, 2003). The ACA is on the verge of bringing about the largest change health care history. Health care providers must work together and educate each other on new policies. Not only will the implementation of health care change, but the process for billing and reimbursement will change exponentially. Therefore, policies and regulations must be well understood by all levels of the system to ensure funding and payment at the highest level. Organizations will likely experience a decrease in funding, an increase in patients, and overworked staff members. An emphasis on efficient use of limited resources, cost-effective practices, and ensuring that services continue with little or no disruption is a must. ConclusionThe future of the ACA is uncertain and many changes are likely to still be made. The ACA will have a substantial impact on the uninsured population in North Carolina and coverage will be provided to those who thought that it would never be possible. If the ACA accomplishes the goals that it projects to accomplish than health care will thrive, and the overall health of American individuals will improve due to increased access to care and improved quality of care. However, if it is possible for the ACA to accomplish these goals is a remaining question among a large majority of Americans. Once the ACA is fully initiated, health care providers must be prepared and accept the challenges of proper implementation. Whether ACA is accomplished in full or not, the health care progression it does accomplish will be viewed by some as positive and others as negative. The American government’s responsibility to its people will forever change as well as the battle inside legislation to find common ground. There is nothing wrong with the progression of society via healthcare, but to what cost? There must be common ground. Have they found that at this point; time will tell?ReferencesAarons, G, A., Sommerfeld, D. H., & Willging, C. E. (2011). The soft underbelly of system change: The role of leadership and organizational climate in turnover during statewide behavioral health reform. Psychological Services, 8(4), 269-281.Beaussier, A. L. (2012). The patient protection and affordable care act: The victory of unorthodox lawmaking. Journal of Health Politics, Policy and Law, 37(5), 741-768.Bush, P. W. (2012). Leadership at all levels. American Society of Health-System Pharmacists, 69, 1329-1330.Cleary, B., & Wilmoth, P. (2011). The Affordable Care Act – What it means for the future of nursing. Tar Heel Nurse, 73(2), 8-12D.I., L. L. (2012). Affordable Care Act likely to create uncertainties in Medicaid enrollment, costs, and physician workforce needs. AHRQ Research Activities, (381), 13-14.King, M. (2012). Health reform: Special report. Health reform turns two: After passage of the Affordable Care Act, the work-and the criticisms-persist. State Legislatures, 38(3), 12-17.Kosnik, L, K., & Espinosa, J. A. (2003). Microsystems in health care: Part 7. The microsystem as a platform for merging strategic planning and operations. Joint Commission Journal on Quality and Safety, 29(9), 452-459.McDonough, J. (2012). The road ahead for the Affordable Care Act. New England Journal of Medicine, 367(3), 199-201.Milstead, J.A. (2013). Health policy and politics: A nurse’s guide (4th ed.). Burlington, MA: Jones & Bartlett Learning.North Carolina Department of Health and Human Services. (2011). Family and Children's Medicaid MA-3255 NC Health Choice. Retrieved from ’Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing innovation, transforming health care (3rd ed).?Sudbury, MA: ?Jones & Bartlett Learning.Poulson, R. L., Smith, J. T., Hood, D. S., Arthur, C. G., & Bazemore, K. F. (2011). The impact of gender on preferences for transactional versus transformational professorial leadership styles: An empirical analysis. Review of Higher Education & Self-Learning, 3(11), 58-70.Scherer, R. (2012). Is the Obama health-care law a huge tax increase? Christian Science Monitor, 1.Brandie what a nice job you have done, great references! Ethical Case Analysis from a Leadership Perspective to Include the Economics of the CaseFormal Paper Ethical Case Analysis Grading RubricCriteriaPts. PossiblePts. EarnedCommentsSummary and Synthesis of the Case2018Nice job with this section, could increase synthesis someSummary And Synthesis Of The Implications From A Leadership Perspective3025Might add some information about other leadership styles. Think reader doesn’t know there were other choicesEconomic Analysis2020Well doneApplication to macro and micro systems2020Very well doneAPA, grammar, spelling & punctuation109Format level 2 headingsTotal 10092Case with guidance questions is found in Milstead p. 202-204 10 pages maximum. This is a scholarly paper and it is expected that APA style will be follow. An abstract should be included. Reference pages will not count in the page count. ................
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