Ethical and Policy Factors in Care Coordination


Care coordination is a process aimed at creating an effective and accessible healthcare system for all citizens. This presentation was prepared for a local homeless shelter and discusses the ethical and political factors influencing the development of this concept. Healthy People 2020 program addresses the social determinants of health that are particularly relevant for homeless and lower-income people whose environmental conditions significantly affect well-being (What is care coordination? 2018). Improved care coordination provides access to the medical care, public and economic support that homeless people need the most. However, while ethical principles dictate the achievement of better quality and accessibility, in practice, this is not always easy to achieve. There are various policies that can significantly increase the ability to receive health care for people of the lower socioeconomic strata.

Nursing Code of Ethics

The practice of nurses is guided by ethical principles, which are aimed at providing quality medical care to all who need it. The main document that regulates these aspects is the Nursing Code of Ethics compiled by the American Nurses Association (ANA). Four factors determine the performance of nurses according to the document: autonomy, beneficence, justice, and non-maleficence (Gaines, 2021). Autonomy refers to the individual’s right to make decisions and self-determination, which obliges nurses to provide patients with all the information about the benefits, risks, and possible complications. Beneficence refers to the need to act for the benefit of all with charity and kindness. Justice obliges nurses to make decisions with fairness, regardless of the patient’s characteristics. Non-maleficence prescribes achieving the best health outcomes with the least harm to the patient.

Healthy People 2020

The ethical principles of nursing promote the need to eliminate health disparities and establish equity. In particular, healthcare access and quality are some of the social determinants of health according to the Healthy People 2020 program (Social determinants of health, n.d). These aspects are the goal of better care coordination, which assumes that all people have access to healthcare, providers communicate effectively to ensure care continuum, patients receive all the necessary services and information (What is care coordination? 2018). Thus, these factors are consistent with the ethical principles of nurses who strive to achieve the best outcomes and treat patients with dignity and compassion. However, not only ethical principles have a significant impact on the achievement of care coordination, but also relevant policies.

The Affordable Care Act (ACA)

The Affordable Care Act (ACA) is a policy dedicated to expanding healthcare access for lower-income groups. Despite poor people “having greater medical need”, due to its cost and absence of insurance, many low-income Americans do not access medical care (Griffith et al., 2017, p. 1503). ACA is designed to improve insurance coverage and quality of care through the expansion of eligibility for Medicaid for the poor and subsidies (Courtemanche et al., 2018). However, Manchikanti et al. (2017) argue that ACA provides coverage for few people, which increases out-of-pocket costs and reduces the quality of care. This aspect may violate the ethical principle of beneficence since patients may receive poorer outcomes due to financial constraints. Moreover, despite providing care, health facilities risk losing income, which may be unfair.

Health Insurance Portability and Accountability Act (HIPAA)

Health Insurance Portability and Accountability Act (HIPAA) provides insurance for workers and their families who lost or changed jobs (Edemekong et al., 2021). Data protection and transmission standards established through this policy have greatly influenced the functioning of medical institutions and insurance companies. However, this policy imposes violation penalties and increases the amount of paperwork and the cost of implementing the storage system (Edemekong et al., 2021). These challenges can affect healthcare access and quality.

Moreover, lower-income individuals who often do not have HIPAA insurance can encounter adverse effects. The providers’ expenses to store and protect data can reduce access to healthcare. The quality of care can also be compromised when rapid information transfer is required (Edemekong et al., 2021). Lack of access to critical data may endanger patient health.

Medicare and Medicaid

Medicare and Medicaid are also important programs that have greatly expanded access to healthcare. Specifically, Medicaid focuses on helping low-income people, while Medicare is available to all citizens. In particular, both programs provide different insurance plans for patients. This policy has a significant positive effect on care coordination as it allows many people to receive the continuous care they need. At the same time, Medicaid and Medicare are associated with a number of ethical dilemmas. Primarily, these programs can be associated with medical fraud and abuse, which force providers to impose unnecessary treatment on patients (Medicare fraud & abuse, 2021). This aspect can result in worse patient outcomes and less effective treatment, which is contrary to ethical principles.

Additionally, these programs can result in additional financial hardship for people of lower socioeconomic status. Himmelstein and Woolhandler (2019) note that despite the expansion of access to healthcare in accordance with the ACA, the number of medical bankruptcies has not decreased. In particular, low-income people are at greater risk, as they “have few assets (such as a home) to protect, and face particular difficulty in securing the legal help needed to navigate formal bankruptcy proceedings” (Himmelstein & Woolhandler, 2019, p. 433). Thus, people are left unprotected from sudden out-of-pocket costs and subsequent economic hardships. Organizations need to provide legal support to their members and educate them about possible risks.

Healthcare for the Homeless (HCH)

A particularly important policy that affects the organization’s operations is Healthcare for the Homeless (HCH) program. This initiative provides the most vulnerable members of poor communities with health care in a variety of areas in addition to primary care, including substance abuse therapy, dental services, mental health services, and others (Lanese et al., 2021). This program allows addressing the complex medical needs of people of lower socioeconomic strata effectively. In particular, in the context of care coordination, HCH provides an opportunity for transportation, which is a challenge for the homeless, as well as options for continuous treatment for chronic diseases (Nestler et al., 2018). Combined with the Medicaid expansion, this program is extremely effective in increasing access to healthcare for homeless people.

Hospital Readmission Reduction Program (HRRP)

Another important policy that is part of the ACA is the Hospital Readmission Reduction Program (HRRP). This initiative aims to reduce the number of readmissions, which in the context of care coordination should positively influence the quality of care and reduce costs due to “investing in a system and networkwide resources” (Ibrahim et al., 2017, p. 2). However, some researchers express concern that this program has a negative effect on the most vulnerable groups of the population, including the poor (Fonarow et al., 2017). In this case, the ethical dilemma arises from the fact that providers may use inappropriate care strategies that put patients’ health at risk to reduce readmission rates (Fonarow et al., 2017). Thus, this program has the potential to have a negative effect on the homeless people.


The United States healthcare system provides its citizens with various insurance and care coordination programs, mainly dedicated to ensuring equal access to quality care. Nevertheless, although the analysis of these policies reveals some positive outcomes, negative aspects that violate ethical principles are also prevalent. Namely, in the framework of Healthy People 2020, the health disparities and equity in healthcare access and quality are emphasized. Existing policies such as the ACA, HIPAA, Medicare, Medicaid, HCH provide essential health care services for lower-income individuals and recently demonstrated significant improvements in ensuring healthcare access and quality. Nevertheless, equity issues are still predominant since these policies cover a small number of people, violating the justice principle.

Moreover, some of these policies contain other concerns, including increased out-of-pocket costs, medical frauds, and inefficient data transfers. The existing care coordination programs include positive outcomes that often persist along with violations of ethical principles. The current care coordination programs contain positive results that frequently last along with breaches of the moral tenets. Future research should address these violations’ presence in other programs and analyze ways to mitigate them.


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