Jeanne Merkle Sorrell, PhD, RN, FAAN
Citation: Sorrell, J., (November 9, 2012) "Ethics: The Patient Protection and Affordable Care Act: Ethical Perspectives in 21st Century Health Care" OJIN: The Online Journal of Issues in Nursing Vol. 18 No. 1.
Where justice is denied, where poverty is enforced, where ignorance prevails, and where any one class is made to feel that society is an organized conspiracy to oppress, rob and degrade them, neither persons nor property will be safe.
Frederick Douglass (1818-1895), speech on the 24th anniversary of Emancipation, Washington DC, 1886 (TeachingAmericanHistory.org, 1889/2012).
The issue of health care reform brings important ethical issues of justice to the forefront, as individuals, communities, and the legislature struggle with how to provide quality health care for the many without sacrificing the basic rights of even the few. The June 2012 Supreme Court decision that upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA), first enacted in 2010, provides some guidance to states, insurers, employers, and consumers about what they are required to do by 2014, when much of the law comes into force (White House, n.d.).
Provisions in the act are designed to expand insurance coverage, control costs, and target prevention (Gable, 2011). One of the primary targets is adults aged 19-64, since their access to health care and use of health services deteriorated between 2000 and 2010, particularly among those who were uninsured (Kenney, McMorrow, Zuckerman, & Goin, 2012). The PPACA includes reforms such as prohibiting insurers from denying coverage for pre-existing conditions, expanding Medicaid eligibility, subsidizing insurance premiums, and providing incentives for businesses to provide health care benefits. Insurance companies will no longer be able to drop clients when they become ill. The act has the potential to improve health outcomes across all income and age groups at a reduced cost. It may end up saving thousands of lives, as suggested by a recent study in which researchers found a 6 % drop in the adult death rate in three states that expanded coverage for low-income residents along the general lines of the PPACA, preventing one death per year for every 176 adults covered under expanded Medicaid (Sommers, Baicker, & Epstein, 2012). But in spite of these positive anticipated outcomes, the June 2012 Court decision that paved the way for implementation of the law has left the American public still sharply divided on the issue.
Goals for an Ethical Health Care System
What do Americans want from their health care system? Four fundamental goals have shaped our system. First, we want high quality health care that can provide the greatest benefits. Second, we want freedom of choice so that we can decide the “who, when, and where” for our health care. Third, we expect our health care to be affordable so that we have resources for all of the other things we need or want. Fourth, we want our fellow citizens to share in the costs and also benefits of health care (American College of Emergency Physicians, 2011).
With these common goals for our society, why is reform of the American health care system such a controversial issue? One probable reason is that there are significant differences in the priorities that Americans assign to these goals and important differences in beliefs and values. Social injustice occurs when all people are not treated with equal moral concern (Grace & Willis, 2012). The philosopher John Rawls (1971), in his book A Theory of Justice, placed our rights to liberty and justice on a new foundation of reason. His work revived the disciplines of political and ethical philosophy with his argument that a society in which the most fortunate help the least fortunate is not only a moral society, but a logical one (Knadig, 2011). He described the concept of a social contract, in which liberty is carefully balanced with individual rights and the overall good of society, with special emphasis on making the worst off as well off as they can be.
Myths of the Patient Protection and Affordable Care Act
Part of the controversy surrounding the PPACA is related to misinterpretations of the legislation which distort public opinion. Understanding the myths surrounding the legislation can help us examine the facts from the perspective of what is just for society.
What control will the government have? The PPACA is often characterized as a move toward socialism with a “government takeover” of health care. The act requires that most citizens and legal residents have health insurance, but this insurance could be from private companies, employers, Medicaid, Medicare, or from state-based insurance exchanges (Werhane, & Tieman, 2011). Persons who would be paying greater than 8% of their household incomes for health insurance would be able to obtain subsidized premiums through the insurance exchanges. The act does not call for government control of the health system. Instead, it attempts to improve both access and efficiency through a set of mandates to be carried out by states, insurers, and private health care providers.
Who will be covered? There has been much concern that the PPACA will provide free care to undocumented immigrants. This is not the intent of the act. It is anticipated that by 2014 the act will improve coverage for approximately 30 million of the 47 million presently uninsured, none of whom are undocumented residents (Werhane, & Tieman, 2011). The act neither provides free care for non-U.S. citizens, nor are they eligible for insurance through the state exchanges.
Will there be death panels? The ‘death panel’ controversy is an example of the importance of individual liberty in the health reform debate (American College of Emergency Physicians, 2011). There has been a great deal of publicity that the act will include physician panels that will decide which older adults will receive ongoing care. Of all the myths generated about the act, this has been most damaging (Werhane, & Tieman, 2011). The original version of the act stated that physicians would be paid for engaging in end-of-life counseling with patients, which was to be a one-on-one voluntary discussion not mandated by any government commission. Claims that the physician panel could ration health care were quickly and thoroughly discredited but the intensity and persistence of the controversy illustrates the fear of loss of individual control over health care decisions. The provision was eliminated from the bill but despite continuous efforts to dispel this myth, 40% of the population still worries that a government panel will be making decisions about end-of-life care for Medicare recipients (Werhane, & Tieman, 2011).
Will the PPACA increase the national debt? Estimates by the Congressional Budget Office indicate that over time, the PPACA will decrease the national debt. Yet, in a Kaiser Family Foundation poll, almost half of respondents believed that the opposite is true (Werhane, & Tieman, 2011). Long term financial benefits of the act, according to a report by Health and Human Services, include a reduction of government expenditures on Medicare of approximately $575 billion by 2019 (Werhane, & Tieman, 2011). Given the complexity of the issue and so many unknowns, it is difficult to predict costs over a long term, but it seems reasonable to consider the estimates by the non-partisan Congressional Budget Office.
Will small business be hurt? There has been a great deal of discussion about the negative effects that PPACA will have on small business. The facts, however, do not bear this out. Only those businesses with more than 50 employees will be required to make coverage available to employees and contribute to its cost or pay a fee (Werhane, & Tieman, 2011). Businesses with fewer than 100 employees can obtain coverage for employees through state-based insurance exchanges and those with fewer than 25 full-time employees that provide health coverage may qualify for a tax credit to offset the cost. Advantages that the plan includes for small business include a limit on the amount that insurance premiums can go up each year and elimination of surcharges that insurance companies now impose on businesses with insured clients who have serious medical conditions. Some companies' premiums may actually drop because the insurance exchanges are expected to offer lower rates to small business than insurance companies charge. Also, with the new options for individual health insurance, small businesses may be able to attract workers who otherwise would work for larger companies in order to get insurance benefits.
Ethical Responsibilities of Health Care Professionals
In order to respond to ethical considerations related to the PPACA, it is important to sort out myths from reality. Many health issues are rooted in societal injustices and unless we understand the true intent and anticipated outcomes of the act, we cannot effectively sort out ethical concerns to address. Health professionals have a moral responsibility to pursue actions that support delivery of effective health services and to discover and address injustice (Grace & Willis, 2012). Theories of distributive justice explore questions of how resources should be developed and distributed but a determination of what constitutes “fair” distribution as proposed by Rawls is difficult because people have different conceptions of what is good and a predisposition to seek power and advantage (Grace & Willis, 2012).
Efforts to reform the U.S. health care system have largely avoided the language of human rights (Gable, 2011). When access to quality health care is perceived as a right, and not just an option or privilege, health care reform embodies greater moral gravity. The PPACA changes the social contract, establishing a new norm that moves toward universal health insurance with a subtext that everyone deserves access to basic health care (Gable, 2011). It is interesting to note that this same mandate for "the right to adequate medical care and the opportunity to achieve and enjoy good health” was articulated already by Franklin Roosevelt in the “Second Bill of Rights” outlined in his 1944 State of the Union address (USHistory.org, 1944/2012).
It is important for nurses and other health professionals to consider how the implementation of the PPACA relates to their role in understanding and trying to rectify conditions of injustice in health care. Changes in social attitudes and resources may require the combined efforts of different disciplines to identify the originating problem and find a way to remediate it. A theory of social justice put forward by Powers and Faden emphasizes the need to focus on well being and its essential aspects as a social justice issue so that we can become closer to realizing the true nature of unfairness (Grace & Willis, 2012). Since nurses provide a service related to health and well-being, they have a responsibility to address factors that work against individual well-being and societal health (Grace & Willis, 2012). Through our practice, education, and interactions with diverse segments of society, we can gain a unique perspective of what constitutes injustice in health care and which individuals and groups are especially disadvantaged. Through understanding how certain human contexts and conditions erect and maintain barriers to the improvement of well-being, nurses and other health professionals can make important differences in helping to provide the human good of health to both individuals and societies.
Jeanne Merkle Sorrell, PhD, RN, FAAN
Dr. Sorrell is Senior Nurse Researcher in the Department of Nursing Research and Innovation at the Cleveland Clinic, Cleveland, OH, and Professor Emerita, George Mason University, Fairfax, VA. She earned a BSN from the University of Michigan, a MSN from the University of Wisconsin, and a PhD from George Mason University. Her scholarly interests focus on philosophical inquiry, writing across the curriculum, qualitative research, and ethical considerations for patients with chronic illness.
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© 2012 OJIN: The Online Journal of Issues in Nursing
Article published November 9, 2012