Organizational Responsibility and Current Health Care Issues
Patient Protection and Affordable Care Act (PPACA)
Health Law and Ethics

Patient Protection And Affordable Care Act History “After the enactment of the Affordable Care Act (ACA) in March 2010, numerous lawsuits challenging various provisions of the momentous health care reform law were filed in the federal courts. Many of those cases were dismissed, but some federal appellate courts issued decisions on the merits of the law. In November 2011, the United States Supreme Court agreed to consider several issues related to the constitutionality of the ACA arising out of two cases in the 11th Circuit Court of Appeals” (The Henry J Kaiser Family Foundation). Headline news featured the highly controversial Patient Protection and Affordable Care Act (PPACA), also referred to as Obamacare, during the week of 25-June-2012. In response to health care crises in the United States, PPACA advanced to the forefront. “[W]e must also address the crushing cost of health care. This is a cost that now causes a bankruptcy in America every thirty seconds. By the end of the year, it could cause 1.5 million Americans to lose their homes. In the last eight years, premiums have grown four times faster than wages. And in each of these years, one million more Americans have lost their health insurance. It is one of the major reasons why small businesses close their doors and corporations ship jobs overseas. And it’s one of the largest and fastest-growing parts of our budget” (Barak Obama, February 2009. p. 1). Precursors to these sentiments and goals were also echoed in 1993 by the Clinton presidential administration. The PPACA is a federal statute that signed into law by the President Barack Obama, on 23-March-2012. This health care reform directed legislation addresses several multiple aspects of restructuring including health insurance coverage and related subsidies, Medicare and Medicaid reform, health information/insurance exchanges, individual and employer mandates, immigrant status-based participation limitations, fraud/abuse and cost controls. Some private entities along with segments of the government challenged the constitutionality of various provisions of PPACA reform, its implementation, and implication. During the week of 25-June-2012, the United States Supreme Court held three days of hearings on the constitutionality of the Obama administration’s PPACA. The Supreme Court issued a Slip Opinion on 28-June-2012 upholding the constitutionality of the PPACA, including provisions for the expansion of Medicare and the individual mandate.

Implications of PPACA The PPACA is founded in social responsibility and the ethical concepts of utilitarianism and beneficence. It has far-reaching implications for both public and private sector organizational structures, governance, and cultures. For the first time in Unites States history, the federal government issued a mandate requiring most citizens to “maintain a minimum level of health insurance coverage for themselves and their tax dependents in each month beginning in 2014.” The effect of this requirement obviously influences the public from a financial perspective, but bears influence the on the private sector as well. Organizational responsibility is not only transformed by this legislation, it is enforced. As the Sarbanes-Oxley Act legislated corporate responsibility and accountability, PPACA does the same for health care in terms of social responsibility. Much unlike the heralded welcoming of the socially responsible Medicare in 1965, until very recently, politics rendered PPACA to a protracted state of controversy. The enforcement of social responsibility is inherent in many provisions of PPACA and health care organization must step in tune as they did upon the introduction of Medicare.

Ethics Relating to PCCA

One may argue that though the PPACA legislation is news-worthy, it is not in itself an ethical incident in need of remediation. Another might counter that argument with recognition that the legislation did arise from the identification of deficiencies in the U.S. health care system. This and the resultant political debacle link to many ethical issues and the congressional debate over the PPACA were highly contentious and protracted. This student is of the belief that confrontational politics fueled by underlying differences in moral beliefs and values and personal interests and profits are the root causes. The U.S. government system of checks and balances has become dysfunctional. Representatives of the people have become more representative of private interests. Remove profit from the government equation and perhaps true public servants would emerge and serve as intended. It is, however, unlikely that this could occur within the lifetime of the next few generations. Quietly spoken political resistance to provisions of PPACA that fortify the False Claims Act, prohibit physician self-referrals, mandatory compliance and ethics program requirements for nursing home providers, and enhance the anti-kickback statute speaks volumes about the culture, values, and moral sense of some government officials. From moral and ethical standpoints, the pre-existing condition provision seems more than equitable, yet some officials even opposed that segment of the law. These are some elements that shaped the moral dimensions of the health care reform debate.

Governance Structures

One PPCA provision addresses Health Information/Insurance Exchanges (HIEs). HIEs will not be fully operational until 2014, but planning and decision-making is in process now. In January 2013, states must demonstrate readiness for HIE operation. One major challenge facing the states with regard to HIE is that no standard governance model presently exists. “Health care organizations and physicians will require a basic understanding of the HIE governance models specific to them” (Carey, p. 60). In response to this need the Department of Health and Human Services (DHSS) formed the “State Health Information Exchange Cooperative Agreements Program, authorized by Section 3013 of the PHSA as amended by ARRA, is designed to promote health information exchange (HIE) that will advance mechanisms for information sharing across the health care system. Widespread adoption and meaningful use of Health Information Technology (HIT) is one of the foundational steps in improving the quality and efficiency of health care. The appropriate and secure electronic exchange and consequent use of health information to improve quality and coordination of care is a critical enabler of a high performance health care system.” In summary, this program focuses on preparing states to support providers in achieving HIE meaningful use goals, objectives, and measures. AHIMA recommends a foundation of bylaws, policies, and procedures consistent with state and federal law and a formal leadership structure. AHIMA also suggests “Formal workgroups that focus on privacy and security, technical, clinical, and financial issues...[to] develop the policies and procedures.”

Resource Allocation

Three emerging care delivery models, in particular, are addressed in PPACA. These are the Accountable Care Organization (ACO), the medical or health home, and the nurse-managed health center. An ACO, is collaborative patient-centric care shared among primary care clinicians, a hospital, specialists, and other health professionals accepting joint responsibility for the quality and cost of care provided to patients. The ACO will affect the culture of many organizations whose structure resembles the more traditional dual hierarchy. Lines of accountability and responsibility will change to reflect the amalgamated team approach. Organizational responsibility becomes a more prominent focus, and operational improvements must support this responsibility. Providers and payers must engage specialized human resources to address properly the emerging technical requirements for PPACA and HIEs that will engage the complexities of Health Information Technology for Economic and Clinical Health (HITECH), ICD-10, the Health Insurance Portability and Accountability Act (HIPAA) and 5010. Ezekiel Emanuel of the New York University School of Law identified delivery system reforms as essential to long-term cost controls, and enumerated ways to affect them. The importance of internal and external resources to conduct compliance and monitoring must not be overlooked. Legacy staff training should ensue as well. States must address both human and financial resource allocation tied to HIEs and sustainability. The information technology infrastructures required to support state-based HIEs is not in place in most states.

Conclusion PPACA is widely acknowledged as the most significant piece of health care legislation since the establishment of Medicare and Medicaid. It ushers in a sweeping overhaul of the U.S. health care system, bringing along complex changes in organizational responsibility affecting payers, providers, and members, touching every aspect clinical, administrative, and ancillary health care professions and systems. The government is struggling to keep pace with an industry evolving at light-speed and health care organizations must maintain pace as well. Implementation and oversight will pose challenges to both government and organizations. Furthermore, not all states are supportive of PPACA as demonstrated by attempts to nullify certain provisions. PPACA is a hot-point topic of the pre-election presidential opposition with promises to repeal the law despite the Supreme Court decision. The fight for equality in health care is not finished, but change of some for is inevitable. “The ethical principles that have for centuries shaped the relationship between patient and physician should also guide legislators, regulators -- and justices of the highest court -- charged with crafting U.S. health care policies that demarcate the boundaries of a physician's business practice (Joshua Perry, 2012)”
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