Running head: THE IMPACT OF THE AFFORDABLE CARE ACT ON NORTH 1

The Impact of the Affordable Care Act on North Carolina's Uninsured Population
Lori Dixon
Walden University
Policy & Advocacy for Population Health
NURS-6050-11

July 6, 2014
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The Impact of the Affordable Care Act on North Carolina's Uninsured Population
The Affordable Care Act (ACA) includes a Medicaid expansion that states have the option
to join, and if North Carolina joined they would receive a 65.4 million from the Medicaid
expansion over the eight-year period. It would increase coverage for over 500,000 North
Carolinians (NC Medicaid Exp., 2014). The purpose of this paper is to review the effect of the
ACA on North Carolinas uninsured population, how it will influence the economics of
providing care, and the ethical implications of the ACA on facilities and patients.
Effect on North Carolinas Uninsured Adults
The ACA changes Medicaid eligibility to all adults (regardless if they have children)
between the ages of 18 and 64, whose income is 138% of the poverty level (Milstead, 2013).
This provides an opportunity to help 1.5 million North Carolinians, and 41% of these individuals
are eligible for Medicaid under the ACA. Single adults with an annual income of $15,856 would
now be eligible, and this is a group that does not normally receive preventive care. The North
Carolina General Assembly voted to not accept the Medicaid expansion (Silberman, 2013).
Due to the vote to not accept the Medicaid expansion, these adults will have to purchase
health insurance through the health insurance exchange (HIE). These adults may not purchase
insurance even though they would receive a subsidy. Adults without insurance do not receive
preventive care, but access emergency departments for health issues. Preventive care is critical
to reducing the cost of health care and improving the health of Americans (McMorrow, Kenney,
& Goin, 2014). Due to North Carolina not accepting the Medicaid expansion, initially appears as
if this group of uninsured adults would not receive preventive care.

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The Influence on the Economics of Providing Care
The ACA also created the Prevention and Public Health Fund, and it issues Community
Transformation Grants (CTGs), and these grants will provide monies for preventive health care
(Randolph & Morrow, 2013). North Carolinas Department of Public Health (DPH0 applied and
received one of the largest grants awarded in the country. They will receive $7.4 million over 5
years, and cover 98 of the 100 counties in the state. The funding is being used to increase access
for physical activity, promote smoking cessation, healthy eating, and preventive care for
hypertension and diabetes. They also applied for a competitive grant funding, and their quality
improvement projects will create savings of $4.8 million. Finally, they also have started the
Triple Aim initiative, which is forming accountable care organizations (ACOs) in the state.
These ACOs are made up of public health departments and hospitals to improve population
health in the state. There are currently six ACOs in process (Randolph & Morrow, 2013). Each
of these may be able to help the adult population without insurance, but it does not provide these
individuals with any financial security for health care. Physicians will still absorb the cost of
care for individuals not covered by Medicaid, and hospitals will be receiving decreased funding
from the federal government based on an ACA-mandate (Crowley & Golden, 2014). The ACA
will have a positive impact on health care in North Carolina through the new programs the state
is initiating, but the future will show how much it impacts the uninsured adults in the state.
Ethical Implications
Health experts at Harvard University and City University of New York did an analysis of
opting out of the Medicaid expansion. They reviewed primary care and preventive screenings
across the country to determine what this would mean to the uninsured adults in North Carolina.
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They concluded that by opting out, that it would cost 455 and 1,145 preventable deaths per year
(Leslie, 2014). Do health care providers have an ethical responsibility to provide care to these
uninsured individuals to prevent these deaths? Currently, providers are providing at least limited
care without being reimbursed. Health care professionals do have a responsibility to help the
public sort out what is reality and what is a myth in the ACA. For example, one myth was that
there would be death panels, where physicians would decide which seniors would receive
ongoing care. This was based on an early version of the ACA that physicians would have to
provide one on one end of life counseling (Sorrell, 2012). As the United States proceeds through
health care reform through the ACA, there will be ethical questions that will need to be
answered. Patients will need to be better informed about what the ACA means to them, and
health care professionals will need to be their advocate.
Conclusion
The ACA provides additional funding to states that opt-in for the Medicaid expansion, but
North Carolina has voted not to opt-in. Consequently uninsured adults will not receive health
insurance through Medicaid, and may go without preventive care. Instead, the state applied for
grants to provide improvements in population health. These improvements may improve
population health, but providers will still be picking up the cost of uninsured patients that they
cannot get reimbursed for the care. Studies have concluded that there may be an increase in
preventable deaths; this creates an ethical dilemma for providers on the amount of care to
provide for uninsured patients. Providers need to understand how the ACA affects their state,
and they will need to educate patients on what it means to the patient.

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References
Crowley, R. A., & Golden, W. (2014, March 18). Health policy basics: Medicaid expansion.
Annals of Internal Medicine, 160, 423-425. Retrieved from www.annals.org
Examining the impact of the Patient Protection and Affordable Care Act in North Carolina [Issue
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Leslie, L. (2014, January 31). New studies: Medicaid opt-out costly for NCNew-studies:-
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studies-medicaid-opt-out-costly-for-nc/13349683/
McMorrow, S., Kenney, G. M., & Goin, D. (2014, January 16). Determinants of receipt of
recommended preventive care: Implications for the Affordable Care Act. American
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Population Health in North Carolina. North Carolina Medical Journal, 74, 330-333.
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Sorrell, J. (2012). Ethics: the Patient Protection and Affordable Care Act: ethical perspectives in
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doi: 10.3912/OJIN.Vol18No02EthCol01