NURS 8100 Discussion: Unintended Consequences of Health Care Reform
The PPACA of 2010 fostered new provisions for health care and the structure of healthcare delivery. The individual mandate to obtain insurance is one provocative provision. While this provision attempts to increase access to health care, it raises questions on
how the existing system could sustain the potentially large influx of newly insured individuals. Another provision calls for new models of health care provider organizations to ensure delivery efficiency and continuity of care. In this week’s media presentation, Dr. Kathleen White discusses the accountable care organization, which comprises a group of providers coordinating care across a variety of institutional settings. Yet becoming an accountable care organization may present a number of challenges.
The provision of quality healthcare is the aim of the American government. Achieving this objective entails a consideration of a number of issues. One of them is increasing the number of people who are covered by the medical insurance schemes. The other one is increasing the affordability, availability, and accessibility of high quality care. There is also a need to improve the cost efficiency of healthcare services. Accordingly, the best available care should be provided with a focus on the optimization of the healthcare resources. In a bid to achieve these objectives, the Affordable Care Act was adopted in the US in 2010. The policy has been effective in delivering the objectives. The success can be seen from evidences such as increased insurance coverage for citizens, expanded accessibility of care, and reduction in costs of healthcare over time in the state (Morrison & Furlong, 2019). Despite these improvements, there have been policy recommendations to either repeal or replace the Affordable Care Act. Consequently, there is an increased need for the investigation of the effects, politics, and options associated with this policy. Therefore, this research paper explores the proposed policy to repeal or replace the Affordable Care Act. It explores aspects that include the definition of the policy issue, application of policy analysis framework, policy options, and building consensus on it.
Definition of Policy
The Affordable Care Act is perceived as one of the policies that have significantly shaped the healthcare system in America. The policy has expanded alongside improved insurance coverage in the U.S. in two mechanisms. Firstly, it has expanded the total number of citizens covered by the medical insurance. This has been achieved using Medicaid expansion and the provision of cost subsidies to those purchasing private insurance exchanges. The second way entails the fact that the policy has upgraded the scope of the coverage through its enhancement of benefit design (Willison & Singer, 2017). Despite these benefits, there have been policy initiatives aiming at the repeal or replacement of the Affordable Care Act. The first attempt to repeal the policy was between 2011 and 2012 where the Republicans and Democrats voted for the repealing of the Job-Killing Health Care Law act. However, the Democrats voted it down in the house of Senate, thereby, prompting Obama not to adopt the policy recommendations. The proposal was also unsuccessful despite the pressure from President Trump (Béland, Rocco & Waddan, 2016). Therefore, repealing or replacing the affordable Care act remains a hotly debated policy initiative for the Americans in the modern era.
The proposed policy on whether the Affordable Care Act should be repealed or replaced has significant effect on the policy arena. One of the health policy stakeholders that have been keen on the proposed policy is the American Association of Family Practitioners. According to a statement from the organization, it does not support the proposal since it violates the fundamental right to access to quality healthcare by the citizens. According to them, their organization strongly advocates patient access to primary medical care and healthcare coverage. It also strives to ensure that the high costs of healthcare are managed to increase the access of patients to their needed care (AAFP, n.d.). Therefore, they anticipate that repeal or replacement of the Affordable Care Act will worsen the existing disparities in access to healthcare.
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The American Nurses Association has also provided their insights into the proposed policy. According to association, the Affordable Care Act should not be replaced or repealed. As cited in their response, the proposal would affect adversely the universal access to care by the citizens through high costs of healthcare (ANA, 2017). It will also hinder the optimization of the primary as well as community-based interventions that are utilized to promote health care access with cost-efficient innovative and value driven models of care.
It can be seen from the responses from the above organizations that the proposal to repeal or replace the Affordable Care Act has significant effects on the policy arena. Firstly, it increases the need for the exploration of alternative and sustainable models of improving access, coverage, and cost of healthcare in the US. Secondly, it raises the need for the policy makers to explore the ways in which the current provisions of the Affordable Care Act can be improved to achieve its goals. Lastly, it increases the relevance on the need for active stakeholder engagement in the exploration of the need to repeal or replace the Affordable Care Act.
Current Politics of the Issue
Currently, the status of the proposed policy to repeal or replace the Affordable Care Act is uncertain. The uncertainty arises from three main challenges that face its implementation. They include the issues that must be addressed in the regulatory implementation of the essential health benefits, barriers facing small group markets and individuals in most of the insurance exchanges, and the push for selling health insurance by the Trump administration across states. Generally, the Republicans support the initiatives that aim at repealing or replacing the Affordable Care Act. Their support can be seen from 2011-2012 where their proposal to repeal the Job-Killing Healthcare Law. In 2013-2014, they proposed an act that aimed at repealing the Patient Protection and Affordable Care Act. However, it was unsuccessful.
However, the Democrats have constantly opposed the move by the Republicans. According to the Democrats, repealing or replacing the act will result in significant adverse outcomes. One of them entails increasing the cost of care to the low-income earners in the country. They also argue that it will result in the potential collapse of the health insurance market in the U.S. Lastly, the proposal will lead to the elimination of the protections provided to the vulnerable in the country such as the mentally ill and elderly (Aron-Dine & Broaddus, 2018). Health organizations such as the American Nurses association and American Association of Family Practitioners have supported the bases of opposition by the Democrats. Consequently, it remains evident that replacing or repealing the act is only possible if sustainable, practical, and all-inclusive plan is introduced in the state.
Level of the Policy in the Policy Making Process
The establishment of a policy in any state undergoes several steps. They include policy building, formulation, adoption, policy implementation, evaluation of its effectiveness, and termination. The proposed policy to repeal or replace the Affordable Care Act has passed the building phase and is now at the formulation and adoption stage. The policy formulation and adoption stage is characterized by the policy makers coming up with an approach that can be utilized to solve a problem. There is active involvement of different stakeholders that include the executive branch of the government, interest groups, and the courts. Often, parties are invited to provide their views concerning the proposal. There is also the involvement of the president in the process. The Congress and the Senate are required to vote as a way of determining whether it should be adopted or not. The majority of the voters in both houses win and the proposal is either rejected or embraced. The proposal to repeal or replace the Affordable Care Act is at this stage. Different stakeholders have been invited to provide their views concerning it. The Senate and Congress have also voted to express their views on the issue. The president is also involved in determining the effectiveness and appropriateness of the policy.
The framework for policy analysis by Morestin (2012) will be used in this research. According to the framework, policy analysis is done with a consideration of dimensions that include effects and implementation. The analysis of the effects of the policy focuses on aspects that include effectiveness, unintended effects, and equity. On the other hand, implementation focuses on aspects that include the cost, feasibility, and acceptability of the policy. Therefore, the aspects are evaluated in considering the policy in terms of social, ethical, legal, historical, and financial contexts.
The adoption of any policy should promote social good. In relation to the model, the social effectiveness, unintended effects, equity, cost, feasibility, and acceptability of the proposed policy should be explored. The effectiveness of the policy mainly focuses on its effects on the health issue being explored. Repealing or replacing the Affordable Care Act is likely to increase the social costs of health. It will widen the existing inequalities in healthcare due to social determinants of health. It is also likely to increase the misrepresentation of the minority groups such as people of color in healthcare (Béland et al., 2016). Therefore, it is anticipated that the technical feasibility of the proposed policy is low due to it being socially unacceptable.
Ethics mainly focuses on ensuring that one does what is considered socially and morally right. It encompasses the consideration of ethical principles such as justice, veracity, non-beneficence and maleficence, and informed consent. The proposed policy changes will promote a reduction in the spending of the state agencies on health. However, there are unintended consequences associated with the decision such as increase in the costs of healthcare, widening of disparities in healthcare, and limiting the availability, access, and affordability of primary care (Morrison & Furlong, 2019). The cost, feasibility, acceptability, and equity impacts of the proposal imply that it will be violating the fundamental rights of the American citizens to affordable, available, accessible, and quality healthcare.
The historical facet of the policy analysis explores the developments that have influenced the need for policy change. As shown earlier, the adoption of the Affordable Care Act has resulted in significant benefits that include increase in the populations covered by the medical insurance and elimination of barriers to healthcare. The policy has however experienced some challenges. They include the rising costs of healthcare incurred by the state despite the projections of reducing them with its use. Scholars are also concerned that the policy will not have the desired sustainability in the long-term. As a result, there is a need for either repealing or replacing the act. According to the framework by Morestin (2012), the weaknesses identified in the current policy should be considered in exploring the possibilities of policy changes in the future.
The financial context of policy analysis focuses on the cost efficiency and effectiveness of a policy. There is a need to focus on whether the policy has positive socioeconomic and political impacts. The earlier analysis has revealed that the proposed policy changes will increase the social costs of healthcare. There is anticipated rise in the spending incurred by the citizens in seeking the care they need. The financial feasibility and acceptance of the policy are also low (Glassman, 2017). Therefore, there is a need to consider these financial implications when embracing the policy.
There exist theoretical underpinnings for the repealing or replacing the Affordable Care Act. One of them is the assertion that the act is increasing the cost incurred in healthcare rather than reducing it. For instance, it is projected that the cost of healthcare spending is expected to increase more than $1.8 trillion in the next decade (Senger, 2015). The act also has limiting payment reductions in its long-term projections. For instance, cutting the Medicare benefits by up to $700 billion by 2022 will affect adversely the ability of the elderly to access the care they need. There is also the assertion that the current policy has reduced the significance of the private insurance schemes. The introduction of benefit mandates in the new coverage schemes have led to health insurance cancellations for individuals who were privately insured. Lastly, the policy has not met its exchange enrollment targets. The policy was expected to cause a significant rise in the original projections in the enrollment rate to the medical insurance cover. However, this has not been the case since the enrollment has been below the projected targets (Senger, 2017). Therefore, it raises the concerns on the long-term sustainability of the policy in the state. The stakeholders of interest that have been actively involved in exploring the proposed policy change include the healthcare providers, health organizations, politicians, government, and non-governmental organizations. As shown earlier, the American Nurses Association has given its statement concerning the proposed policy change. Accordingly, it argues that the proposed policy changes limit equity in access to healthcare by increasing the costs of healthcare (ANA, 2017).
Three policy solutions can be embraced in relation to either repealing or replacing the Affordable Care Act. The first approach is not embracing any change on the current policy. This policy option assumes that the current state of the act should not be altered. It also assumes that the policy is effective in delivering its objectives. It therefore implies that there should be minimal advocacy efforts and leadership requirements in implementing the needed change. The focus should be on maintaining the existing state. The need for inter-professional collaboration is minimal since the stakeholders are satisfied with the policy. The benefits associated with this solution include minimal costs incurred in policy change, maintenance of status quo, and increased possibilities for the projected objectives of the policy being achieved (Glassman, 2017). However, it is associated with disadvantages that include the increased risk for continued rise in costs of healthcare, uncertainty in the future of the policy, and minimal or lack of inter-professional collaboration in analyzing the effectiveness of the policy.
The second option that can be considered is taking partial change. Here, some sections of the act can be repealed. A focus should be placed on improving the areas of the act that are prone to weaknesses and can undermine the sustenance of the policy. The assumptions in this decision are that some weaknesses exist in the policy that can affect its effectiveness. It also assumes that some components of the policy are likely to threaten the realization of the long-term goals of the policy. Therefore, there is a need for the adoption of transformative leadership approaches in implementing this decision. The focus should be on ensuring active stakeholder participation in the policy analysis. There is also a need for active inter-professional collaboration to ensure that the different views are taken into consideration in the policy making process. The benefit of this option is that the current policy will be strengthened by the elimination of its evident areas of weakness. It also empowers different professionals due to their active participation. However, the option is associated with the disadvantage of high costs and too much time needed for dialogue (Cohen et al., 2015). Despite these weaknesses, this option remains the most feasible intervention that can be used to improve the Affordable Care Act.
The last level of policy solution that can be embraced is radical change. The most effective option in this case would be replacing the Affordable Care Act with a new policy. The assumption in this option is that the act is ineffective. There exist alternative pathways that can be explored to increase health-related metrics in the US. The decision also assumes that the act is not sustainable in the long-term. This option requires significant advocacy interventions from the different stakeholders affected by it. There should be active stakeholder engagement to ensure that the new policy incorporates their diverse views. The leadership should also focus on ensuring sustainability of the new policy. It should be cost effective and practical in solving the issues in the current policy. This decision is associated with the benefit of possibly transforming healthcare positively by introducing new policies. However, it is expensive and requires more time for inter-professional collaboration. The decision also fails to improve on the weaknesses of the current policy. Therefore, rather than solving the uncertainty in some provisions, it is transferred to the new act (Cohen et al., 2015). This policy option is the least feasible among the three since radical policy change are difficult to be implemented in use.
My recommended solution is the adoption of partial change. It is true that despite the affordable Care act being effective; it has some weaknesses that threaten its sustenance. The weaknesses can only be solved by repealing some of the sections and not replacing the act or taking no action. It is therefore recommended that two interventions that include use of open channels of communication and active stakeholder participation be utilized to build consensus. There should be open communication on the changes that should be made on the policy. The different views should be incorporated into the process of changing the current policy. There should also be active stakeholder engagement. The different stakeholders should be involved in exploring the most effective options that can be adopted to improve the policy. Active stakeholder participation will also promote their empowerment and ownership of the policy alongside the sustainability of the policy provisions.
In sum, the Affordable Care Act has brought significant transformations to the US healthcare system. Similar to other policies, it is prone to some weaknesses that might threaten its effectiveness. As a result, a focus should be placed on improving its areas of weaknesses rather than replacing it. The whole process can be a success if active stakeholder engagement and open communication systems are embraced.
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