Vicki D. Lachman
Ethical Challenges in the Era
Of Health Care Reform
n truth, the United States is at the beginning of a
long overdue and a much needed health care
reform. We have seen the dismal statistics about
our high cost health care system and some of the
less than stellar outcomes (e.g., infant mortality)
(Callahan, 2011; World Health Organization [WHO],
2011)). The purpose of this article is not to complain
about the current health care system, but instead to focus
on existing reform efforts — The Patient Protection and
the Affordable Care Act (ACA), the ethical justifications
for its creation, and ethical challenges it brings.
Key Features of the Law
ACA offers new ways for consumers and providers to
hold insurance companies accountable. The most important parts of the law are features described in the following discussion. Because of space limitation, I will highlight some elements of the law that are enacted through 2014 and clearly impact nursing. These selected features
include insurance choices, insurance costs, rights and
protection, and people age 65 and older.
The intention of the law is to expand health care coverage to most U.S. citizens and permanent residents by requiring most people to have or purchase health insurance (HealthCare.gov, 2012a). Citizens will have a choice of private insurance, employer-paid insurance, Medicaid,
Medicare, or state-based insurance exchanges.
Affordable Insurance Exchanges. Individuals and small
businesses can purchase coverage through these
exchanges, with premium and cost-sharing credits available to individuals and families with income between 133%-400% of the federal poverty guideline (in 2011, the
poverty guideline was $18,530 for a family of three)
(Werhane & Tieman, 2011).
Businesses with 50 or more employees need to make
coverage available, and businesses with less than 25
employees will qualify for tax credits to offset their cost
(Kaiser Family Foundation, 2011).
Consumer Operated and Oriented Plan (CO-OP). The ACA
produces a new kind of non-profit health insurer, called a
Consumer Operated and Oriented Plan (CO-OP). CO-OPs
are meant to offer consumer-friendly, affordable health
insurance options to individuals and small businesses. By
January 1, 2014, individuals will be able to buy a CO-OP
Vicki D. Lachman, PhD, APRN, MBE, FAAN, is Clinical Professor, and Director, Innovation and Intra/Entrepreneurship in Advanced Practice Nursing, Drexel University, College of Nursing and Health Professions, Philadelphia, PA.
health plan through the Affordable Insurance Exchanges.
Pre-existing condition insurance plan. All covered benefits
are available to individuals, even to treat a pre-existing
condition. This program offers temporary protection for
people with pre-existing conditions until 2014, when
insurance companies can no longer deny individuals coverage based on their health status. Young adult coverage. Individuals can add or keep their
children on their health insurance policy until they reach
age 26. The law makes it easier and more affordable for
young adults to get health insurance coverage.
ACA holds insurance companies accountable. It also
helps individuals keep their costs down.
Value for individual’s premium dollar. ACA requires insurers selling policies to individuals or small groups to spend at least 80% of premiums on direct medical care and
efforts to improve the quality of care. Unfortunately, this
does not apply to self-insured plans.
Lifetime and annual limits. ACA restricts and phases out
the annual dollar limits a health plan can place on most
of its benefits. Furthermore, ACA eliminates these limits
completely in 2014.
Rate review. Insurance companies must now justify proposed rate increases for health insurance. Insurance companies cannot raise rates by 10% or more without first explaining the reasons to the...