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Ethical Case Analysis from a Leadership Perspective to Include the Economics of the Case
Lisa Sims
Auburn University/Auburn Montgomery
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Abstract
Leadership and economics were discussed in a case study regarding the impact of The
Affordable Care Act (ACA) on North Carolina. The impact of the ACA on the uninsured
population in 2009 was compared to effects after implementation of the ACA after 2014. The
implications from the leadership perspective were discussed and how the ACA would benefit
North Carolina to improve quality of care and provide assess of medical coverage to the
uninsured. The economics and the systems within health care are discussed and the process by
which they incorporate strategies to enhance the ability to provide care to meet the health care
needs of the uninsured. The case study shows the expansion effects of the ACA on Medicaid and
North Carolina’s Health Choice Program.
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Ethical Case Analysis from a Leadership Perspective to Include the Economics of the Case
Health care is an issue in the United States due to rising costs for providing health care
along with an increase in the number of people who are either uninsured or under-insured. The
development of this problem has been affected by changes in technology, ideology/culture, and
structural factors. Technology has affected the problem in an interesting way. We have better
health care than ever from a medical and technological standpoint as science has solved many
problems and produced new technologies to address medical issues. These new technologies are
expensive, and health care costs have risen in part to pay for these technologies and for other
services that are truly benefits for the consumer. The technology has also seen to it that people
live longer, often requiring medical care for a longer time. The aging population has altered the
demands placed on the medical system and created new needs and new areas of concern. The
issues with health care that affect the personal, political, economic and social aspects of systems
within health care along with communities. Tens of millions of Americans are without health
insurance, or are inadequately covered, or have only intermittent coverage (Kaiser Family
Foundation, 2011).
Numerous reform proposals have been offered which propose outcomes that everyone
needs good health care. The Affordable Care Act (ACA) was passed in March 2010 which is a
health care law that focuses on improving the current health care system by expanding health
coverage, controlling health care costs, and improving the health care delivery system (Kaiser
Family Foundation, 2011). Provision of the ACA include: 1)Medicaid expansion to 138% of the
federal poverty level for people under the age of 65 2)health insurance to individuals who do not
have access to public or employer coverage 3) regulations that prevent health insurers from
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denying coverage for any reason and increasing the premium because of the health status 4)
requirement that all provisions of the law be implemented by 2014 5) penalties will be enforced
for employers in excess of 30 employees that do not offer coverage to their employees. This
approach is considered the one that is likely to have a long-term effect and that will be capable of
achieving the desired goals. The question raised is whether health care is a right or a privilege.
The greatest opposition to overcome is the fear of loss, fear of coercion and fear of interventions.
Ethical issues are of concern as health care providers face multiple challenges as they attempt to
develop the most appropriate treatments and interventions for patients based on a respect for
patient autonomy and rights, but on their recognition that patients may have conflicting needs
and interests that affect their health care choices. Also of concern is the financial burden to cover
medical care for the uninsured and is it too high or impossible to control.
The health care law of 2010, The Affordable Care Act (ACA), offers the potential to
improve access to health care, improve quality of health care, the overall health of the population
and decrease costs associated with health care (Silberman, 2011). According to Healthcare.gov,
2012, North Carolina is one of the states where health reform will make a difference. This is seen
is a case study of “The Impact of the Affordable Care Act on North Carolina's Uninsured
Population” (Milstead, 2013). The case study shows the income of federal poverty level
determining eligibility for Medicaid and NC Health Choice in 2009 and compares it to the
changes based on the Affordable Care Act (ACA) provisions of 2014. According to the case
study, the populations that will benefit from the changes in Medicaid policy for North Carolina in
2014 include children 6-18 years, working parents, nonworking parents and childless adults,
which allows for an income up to 138% of federal poverty level (Milstead, 2013). In 2014, under
the Medicaid policy for North Carolina, pregnant women will be eligible to receive Medicaid
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with an income up to 185% of the federal poverty level (Milstead, 2013). This calculates to
annual income of $40,792. North Carolina is ranked the 10th largest state with a population of
9,656,401(Silberman, 2011). In 2009, there were approximately 1.7 million non-elderly people
uninsured (Silberman, 2011). Historically the state has a strong and diverse economy and a lower
than average poverty level (Silberman, 2011). This is the reason why the childless, low income
adults have been the last population to become eligible for publicly funded health insurance.
North Carolina has historically maintained strict eligibility standards for Medicaid (Silberman,
2011). Also, North Carolina has opted not to adjust the medically needy standard with inflation
(Silberman, 2011). The North Carolina Health Choice is another insurance program that provides
insurance to uninsured children of low-income families who cannot afford private insurance but
do not qualify for Medicaid (National Academy for State Health Policy, 2011). Under the
Affordable Care Act (ACA), the Health Choice Program is authorized through FY 2019 and
extends funding through FY 2015 (National Academy for State Health Policy, 2011). There is
chance that North Carolina will incur additional costs to ensure coverage for the newly eligible
and the increase in enrollment due to the changes with Medicaid as it applies to children 6-18
years. Since the North Carolina Health Choice Program is not an entitlement program, there may
not be enough funds to cover this program. If this happens, the state may be able to reduce costs
in other programs that serviced the individuals that were uninsured. With the changes of the
ACA, there will be an increase in eligibility for the Medicaid program for children 6-18 which
should then decrease the number enrolled in the Health Choice Program. The ACA does not
include coverage for immigrants who are undocumented or immigrants who have been in the
United States for less than 5 years (Milstead, 2013).The ACA provides North Carolina the
opportunity to increase coverage of health insurance and improve the quality of the health care
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system and overall health of the health care population.
The struggle to reach high quality and cost effective care can be done through leadership,
a culture that focuses on safety, and improvement in processes. Leadership is very much
involved with meaning and belief systems. Executive decision making is accomplished through
leaders’ knowledge of the nature of the world, the nature of other people, and the nature of
themselves. Leaders not only work with the meaning systems of their employees, they are shaped
by their own meaning systems. It is important for them to become conscious of those meanings
and beliefs that shape their decision making and envisioning in order for them to work
effectively at an organizational level. North Carolina has advisory committees that are working
together to ensure that the decisions that are made are in the best interest of the state. The North
Carolina Department of Insurance (DOI) and North Carolina Department of Health and Human
Services (DHHS) are working with the North Carolina Institute of Medicine (NCIOM). They are
focusing on the following sections of the Affordable Care Act (ACA): Medicaid, health benefits,
health care workforce, quality, new models of care, fraud and abuse and overutilization
(Silberman, 2011). The ACA challenges the leadership of health care professionals to improve
outcomes and make systems more efficient. Health care professional must confront the changing
funding environment and balance the benefits to the patients with those to society and the
economy.
Economics is the topics of the debate in health care. Two concepts that are often used
interchangeably in error are health care economics and health care finance (Milstead, 2013).
Health economics is a science that deals with the issues of efficacy and effectiveness of the
health care system (Milstead, 2013). Health care finance deals with the means in which health
care will be paid (Milstead, 2013). The increasing costs related to both health care and health
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care insurance, together with growing restrictions on government funding for health care services
for the needy, create an environment in which more and more people lose access to health care
services. The government seeks to impose health insurance mandates upon the business
community in an effort to take up the slack in health care access. Health care as it now stands is
reactive, a response to illness that generally treats patients who have been pulled out of the
economic cycle by illness.
Macroeconomics and microeconomic have an impact on the effectiveness and efficiency
of health care. The macro system includes the maintenance system in society, or the institutions
that define structural boundaries. These include Medicare, Medicaid, State Children’s Health
Insurance Programs and Tricare (Milstead, 2013). These systems are ideally suited to holding
down costs, building efficiencies, and providing the highest quality of service for the consumer.
The United States has probably the most market based health care system of any developed
country (Ricketts III, 2011). The micro system deals with the patterns of observable action and
interaction between individuals which include individuals' perceptions of, attitudes toward, and
beliefs about the system. This includes health care professionals and consumers. The Affordable
Care Act (ACA) is very complex and will impact 17% of the economy (Silberman, 2011). There
are questions raised as to if the ACA will actually ensure universal coverage and be able to
contain health care cost (Silberman, 2011). Regardless of how a nationalized system is
implemented, the following experiential factors must be considered. First, any national
healthcare system will be dependent upon technology and thus will be costly to maintain.
Second, there is no standard formula for implementation of a national healthcare system as each
country has its own set of social, political, cultural, and economic factors to consider.
Consequently what system works for one will not automatically work for another. The
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cooperation and collaboration of key stakeholders such as medical professionals and government
policy makers must be present in order for any system to be successfully enacted.
The Affordable Care Act (ACA) will assist in identifying structures that can be held
accountable for improving quality. The changes in health care may represent an opportunity for
creativity. A viable plan for health care allocation must take into account on individual’s health,
which is intimately tied to the well-being and economic structure of society, as well as the direct
effects of placing the financial burden for health care on society.
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References
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Ricketts III, T. C. (2011). New models of health care payment and delivery. North Carolina
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