Background
Despite the highest per capita expenditure on health, the United States health care system has been criticized for being too costly, unsustainable and out of reach of millions of americans. The Affordable Care Act (ACA) aims to improve access to health care services by instituting system wide health reforms, expanding health insurance coverage and setting up institutional mechanisms that promote cost savings, improve quality of care and mitigate population health risks by improving preventive health care services. Owing to the complexity of U.S. health care system and diverging political opinion, the act has been a controversial piece of legislation. Among the most vexed issues is the recent legislation granting autonomy to states to opt out of ACA. North Carolina is the prototype of states opposed to implementation of ‘Obamacare’. This paper provides a brief overview of the repercussions that North Carolina’s abolition of some of the key aspects of ACA has on the state’s uninsured population, its implications for the health care providers and the quality of services. It briefly examines the ethical issues that are at the centre of the ongoing debate on ACA.
Affordable Care Act
The Patient Protection and Affordable Care Act (PPACA) was enacted in March 2013 by U.S. federal government in an attempt to bring about fundamental reforms in the health care system. The overarching objective of ACA was to remove systemic barriers that prevent equitable access to quality and affordable health care services. The act envisages expanding insurance coverage by introducing new institutional mechanisms, optimizing mix of private sector and public sector players, and laying an unequivocal emphasis on quality by modifying regulatory framework and promoting a culture of efficiency and healthy competition. The ACA employs a holistic approach to management of chronic diseases with a mix of interventions that include timely screenings, follow up visits and incorporating patient education in treatment.
Impact on individuals and health care providers
ACA puts in place normative standards for insurance coverage for people at different income levels. These include:
- Lower income strata: Widening of the eligibility criteria for Medicaid
- Middle level income strata –
- Provision of tax credits;
- Access to direct purchase of insurance by institutionalizing ‘Health Insurance Marketplaces’
Medicaid in its original form had gaps, most notably, in the coverage for adults. Indeed typical Medicaid beneficiaries included only specific sub segments belonging to low-income groups, e.g., children, pregnant women, the elderly, or individuals with disabilities. Owing to this lacuna, As a result, many adults without children found themselves excluded from the scope of Medicaid irrespective of their income bracket. The ACA aimed to fill in these gaps by extending Medicaid to nearly all nonelderly adults with incomes at or below 138% of poverty.
Political divide
Ever since its inception the ACA has been a highly contested issue both for political as well as technical reasons. In its entirety the act is a complex piece of legislation that is bound to have its critics. This is more so since the impact of ACA will only be visible after a relatively longer period of time. More than anything else, the implementation of the act highlights the key role of states in health system reform. The mutual conflicts of interest became more visible after the landmark ruling by apex court in 2012 making it optional for states to ascribe to certain aspects of the legislation, most notably, on the Medicaid eligibility criteria.
Political divide between Republicans and Democrats has been fuelling this controversy. Republicans are essentially against the legislation while the Act was a major part of Democrat’s political agenda. In states that have adopted ACA, systematic efforts aimed at information dissemination, enrolment campaigns and ownership of state led online health insurance exchange are making a difference.
North Carolina typifies the challenges and issues facing the states that are opposed to ACA. The state administration’s stand on ACA has been largely influenced by political affiliation and has vacillated between pro-Obamacare and anti-Obamacare. The conflict persisted until 2013 when in another landmark development, the Republicans voted against two major provisions of the act, namely:
- Health insurance exchange
- Widening of Medicaid inclusion criteria.
The fiscal implications of this development included return of federal funds earmarked for health insurance exchange. The abolition has had serious repercussions for more than 300000 individuals below the poverty level. In addition to being denied insurance coverage, the abolition rendered them ineligible for the subsidy provided under health insurance exchange.
Furthermore, individuals in the higher income slabs, paradoxically, became eligible for benefits through the exchange. In other words, a significant proportion of the population is effectively too poor to qualify for subsidies that could have helped them access insurance. Consequently, the state is almost certainly going to underperform in its targets for reducing uninsured proportion of its population.
Ethical concerns
The implications for health care providers is a major cause for concern as they will inevitably find themselves catering to a larger proportion of uninsured population at a time when there are significant cuts in Medicare reimbursements, At the same time, there are barriers for people to access the insurance exchange run by federal governments due to lack of patronization by state authorities. This will typically have a greater effect on underserved segments like immigrants and minorities. Some social initiatives to bridge the gap between uninsured population and opportunities for enrollment in federal exchanges have begun to take root. In the face of North Carolina’s resistance to reforms, the onus is now on community-based organizations and non-governmental organizations to fill in the gap. However, there are obvious limitations to the authority and capacity of social groups to undertake such tasks when compared with state administration. This is an inherent ethical concern as states are virtually acting as gatekeepers for access to equitable health services.
One of the drivers of the ACA has been the lack of distributive justice inherent in the health care system. For example, the emergency care was often rendered to uninsured at the cost of insured segment of population. This was reflected in proportionate compensatory increase in insurance premiums for the insured. However, to require all citizens to be insured could also be potentially harmful for poor. The ACA therefore incorporates the ethical notions of ‘beneficence and non maleficence’ as an integral part of the flagship ‘Affordable Insurance Exchanges’. It also places an onus on plans that provide freedom to consumer to make his selection according to his requirements. Wider implementation of Electronic Medical Records would also bring ethical issues related to privacy and confidentiality of patient information. Indeed, one of the ethical challenges will be to ensure patient information, consent and confidentiality in the new dispensation.
References
- Oberlander J, Perreira K (2013). Implementing Obamacare in a red state--dispatch from North Carolina. New England Journal of Medicine; 26;369(26):2469-71.doi: 10.1056/NEJMp1314861.
- The Kaiser Commission on Medicaid and the Uninsured. The coverage gap: uninsured poor adults in states that do not expand Medicaid. Menlo Park, CA: Kaiser Family Foundation, October 2013.
- Ricketts TC (2013). How the Affordable Care Act will affect access to health care in North Carolina. N C Med J. 2013 Jul-Aug;74(4):324-9.
