The American people like to think that they have the best health care system in the world. Unfortunately, the majority of the evidence does not support that view. According to the RAND Corporation and the Institute of Medicine, Americans receive the proper treatment only 50% of the time for their condition (2006, 2013). When compared to other countries, the Americans pay far more for their health care (Laureate Education, 2012a). United States (US) per capita health spending is double that of many other highly developed countries and the US is paying more and more all the time (Laureate Education, 2012b). The quality of the doctors and facilities are not the problem. North Carolina has primarily well-qualified physicians and first-rate hospitals (North Carolina Department of Health and Human Services, 2013). The problem is the organization of the American health system and the effects of rejecting the Medicaid expansion. Background
Almost one in five non-elderly North Carolina residents does not have health insurance. When compared to the rest of the US, North Carolina has the 14th highest rate of uninsured residents. Over 70% of the uninsured population has at least one full-time worker in the household (North Carolina Department of Health and Human Services, 2013). The uninsured population is less able to access health care and is more at risk for financial stress. The uninsured are less likely to seek preventative care and more likely to be hospitalized for health problems that could have been avoided (Grant, 2014). The uninsured population must pay the entire health care cost out of pocket as well. One of the leading causes of bankruptcy in the U.S. is the inability to pay health care bills for the uninsured population (Grant, 2014).
Under the current Medicaid eligibility rules, North Carolina’s rules eliminate childless adults from enrolling in the program. Through Medicaid, only a small number of low-income working families and non-working parents receive health care insurance coverage (Kovner & Knickman, 2011). The Affordable Care Act (ACA) was designed and implemented to expand coverage to the uninsured population. One way to expand coverage to the uninsured population is through Medicaid and private market insurance reforms (Kovner & Knickman, 2011). In 2012, the Supreme Court ruled that the Medicaid expansion under the ACA was optional (Hahn & Sheingold, 2014). North Carolina decided not to expand the state’s Medicaid program thus leaving approximately 377,000 uninsured.
North Carolinians of all ages and races are affected by the insurance coverage gap. If North Carolina were to choose Medicaid expansion, over two-thirds of uninsured North Carolinians would have a possibility of insurance coverage. Devoid of the Medicaid expansion, only 38% have a route to insurance coverage (Hahn & Sheingold, 2014). North Carolinians with incomes less than 138% of the federal state poverty level (FPL) still do not have health care insurance coverage (Milstead, 2013). The uninsured population would have benefited from the Medicaid expansion as well as the state’s health care providers. North Carolina Institute of Medicine data finds that as of January 1, 2014, North Carolina is losing out on approximately $5 million a day by not taking federal money associated with Medicaid (Searing & Alker, 2014). If the state had moved ahead with Medicaid expansion, this number would have continued to grow over time. Also, due to lack of knowledge about their eligibility and past enrollment obstacles, not all eligible individuals are enrolled in the program (Searing & Alker, 2014). The Effects of Rejecting Medicaid Expansion
By the end of the decade, nearly 90 million people would have been enrolled in the Medicaid expansion program if the state decided to do so. The 90 million people would have also consisted of those newly-eligible under the ACA optional expansion. Sixty percent of these new enrollees are expected to discard their private coverage in order to enroll in Medicaid. Taxpayers will fund the move from private to public insurance. Federal and state budgets will feel the financial strain as well (North Carolina Department of Health and Human Services, 2013). The restricted number of health care providers for the poor and uninsured population forces this population to contend with more people trying to obtain health care. North Carolina hospitals favored the Medicaid expansion. Some of those North Carolina hospitals rely on federal money that is received from Medicare reimbursements that help them meet expenses (North Carolina Department of Health and Human Services, 2013).
The hospitals now worry that having to cope with an ongoing stream of uninsured patients could bring them down. One North Carolina hospital, Vidant Health was already struggling financially before Medicaid’s decision. The state’s decision to not participate in the expansion left the hospital without more of Medicaid dollars. The financial strains lead the hospital to announce they will be closing their doors (North Carolina Department of Health and Human Services, 2013). The hospital will be replaced by a multi-specialty, 24/7 clinic without inpatient beds. The hospital payments that were built into the ACA would have financially helped the hospitals that desperately need the expansion money. Increasing the volume of uninsured patients isn’t going to help especially since Medicaid already pays below the hospital’s cost of providing care (North Carolina Department of Health and Human Services, 2013).
The Medicaid expansion would have helped outcomes in minority communities as well. Access to the availability of additional health screenings could lead to earlier detection of chronic diseases like diabetes and high blood pressure (North Carolina Department of Health and Human Services, 2013). It was estimated that at the end of 2012, the majority of uninsured, non-elderly persons in North Carolina were minorities. Of those in the minority bracket, 44 percent are Hispanic and 21 percent African American as compared with 15 percent of Caucasians (North Carolina Department of Health and Human Services, 2013). By not expanding Medicaid, North Carolina has been left completely of a health program that brings additional revenue to the state. Millions in revenue in North Carolina is being left behind as well as fewer health care jobs. North Carolina’s Quality Initiatives
Prospects to advance the delivery of health care to North Carolinians came about with the recent economic stimulus and federal health reform. The North Carolina Healthcare Quality Alliance (NCHQA) built upon its goals that would have seemed unmanageable not long ago (North Carolina Healthcare Quality Alliance Home Page, n.d.). “NCHQA is currently following projects in three areas: 1. Leading, supporting and encouraging projects to bring coordinated care to all patients regardless of payer. 2. Collaborating with primary care physicians, specialists, hospitals, CCNC and other appropriate providers to improved transitions, reduce readmissions, and improve the quality of care across providers.
3. Convening stakeholders across North Carolina to develop common quality reporting standards, with the goal of increasing transparency and reducing the impact of multiple reporting standards on providers (North Carolina Healthcare Quality Alliance Home Page, n.d).” As health care professionals in the state of North Carolina continue to practice, it would be prudent to keep in mind the quality initiatives set forth by the state officials. North Carolina’s quality initiatives address the concerns that are raised by the rejection of the Medicaid expansion (North Carolina Healthcare Quality Alliance Home Page, n.d). Although these three project areas are not the only initiatives, they are the ones being targeted. Ethical Implications
Health care experts have a moral responsibility to follow. Health care professionals have to act and support the delivery of safe and efficient health care services. The hard work that has been invested into reforming the U.S. health care system has sidestepped the issues related to human rights. Health care reform has moral importance when access to health care is not observed as a privilege but as a right. The ACA establishes a new standard that moves in the direction of universal health insurance. There has been suggestion that everyone deserves access to basic free health care. It is imperative that all heath care professionals consider how the ACA relates to their role. Conclusion
Drastic measures have been taken to attempt to positively impact the health care system in North Carolina. Whether or not all involved parties live up to the standards set, and meet the new initiatives, will determine whether or not the changes will be successful. It may take decades before we can draw a conclusion. As for now, the uninsured population of North Carolina as a whole seems to be suffering as well as health care institutions.
Grant, R. (2014). The triumph of politics over public health: States opting out of medicaid expansion. American Journal Of Public Health, 104(2), 203-205. doi:10.2105/AJPH.2013.301717 Hahn, J., & Sheingold, B. H. (2014). Medicaid expansion: A policy update. Virginia Nurses Today, 22(1), 5-7.
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