Work Now, Play Later Essay Example for Free

Work Now, Play Later Essay There comes a time in life where one is forced to make hard decisions. Among those hard decisions are those of choosing between your personal and public life. As a freshman in college now, I’ve come to the realization of choices I have to make. I find myself having moments where I’m surrounded by my peers who love to party, drink, and smoke and I’m completely uninterested. Though these choices are considered immoral being the age that I am, this is what I’m choosing in order to build a brighter future for myself. In the reading provided â€Å"Mr. Rat,† the main character Matt had to make the choice of potentially losing his job or covering for a friend in a mutual work place. Matt chose to save face by throwing his friend under the bus. While Matt and I decisions on choosing our public life versus our public life are similar because the idea itself is considered immoral, our motivation for our actions differ. Having to learn to take of myself at an adolescent stage in my life has taught me that nothing comes easy and time is money. College wasn’t promised to me. I worked hours on end on scholarships and essays to get my foot in the door. I have a clearer understanding of my purpose here and my priorities are currently unmovable. I make the choice to continue to focus on school and purse my career instead going out and building my social circle. Friends come and go. I very well may lose a couple of them but they aren’t going to help dig me out of my financial hole when I’m in debt. As of right now, friends are not a priority. Having this type of mindset at 18 years old is not morally acceptable because it’s expected that I party and not be as mature. The general idea of choosing my public life over my friends is how I feel I connect to Matt in â€Å"Mr. Rat.† Society feels you should cherish your friendships so our actions are equally frowned upon based u pon what society feels our value system should be, despite the circumstance. Though Matt was in a corporate environment, he was also put in a place where his future was brought into perspective and made him see in the long run what mattered most. On the other hand, being only 18 years old and making such a decision under pressure in college is how Matt and I differ. Matt, in his late 20’s, is making this decision at work because he felt he was making a point and depicting a certain image to impress his boss. His friend was thrown under the bus in the process and could very well lose his job. In doing this, it shows how our motivations were also completely opposite. I simply realized I don’t have time to waste. I came here to earn my degree and to work in order to continue to support and provide for myself. I, personally, am not jeopardizing any of my friends’ futures to get what I want. Peer pressure is at its best when friends express how I should get out more and don’t need to be so uptight about everything right now. My mature mind set to stand my ground and focus despite my various distractions is all that I have to motivate me. Every choice followed by an action has a consequence. Matt’s choice to save his ass over his friends could lead to regret and loneliness in the future. The only gray area about my decision is the outcome in the long run. For right now, I do have moments where I get the feeling regret and loneliness since no one is necessarily as serious about my future as I am. I’ve learned to trust that my decision will pay off and I’ll eventually be glad when I come out on top. Friends will also come later. I just haven’t gotten there just yet. Though my choice is just as equally immoral as Matt’s, I do feel I had a better grasp on the concept because of my circumstance. I don’t feel choosing your public life to get over on a friend is right. His ego played a part in his decision and that’s not acceptable all the time. Matt could have very well side stepped the question or worked his way around it. Deciding to automatically drop his friend for greed is selfish. My ego may also play a part in my decision but it’s not interfering with anyone else’s life. It’s to earn self-accomplishment and success. Society’s views on my decision aren’t considered either because they won’t be there when I chose to be moral and fell on my ass.

Elasticity Of Demand In A Air Travel Context Tourism Essay

Elasticity Of Demand In A Air Travel Context Tourism Essay Price elasticity of demand and income elasticity of demand. (Ryan air British Airways Data) How are low-cost carriers such as Ryan air able to achieve cost savings? Fixed costs and variable costs. Critical analysis of the issues involved in the following article: BAA Airports: Notice of release of interim undertaking Conclusion Bibliography Introduction Ryanair isà ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦. British Airways isà ¢Ã¢â€š ¬Ã‚ ¦.. This document reports the findings of a review of the economics and business literature on empirically-estimated own-price elasticity of demand for air travel for Ryan air and British Airways. It refers to the data on page two of the assignment handout to both above airlines to illustrate and explain the concepts of price elasticity of demand and income elasticity of demand. The purpose of this study is to report on all or most of the economics and business literature dealing with empirically approximate demand functions for air travel and to collect a range of fare elasticity measures for air travel provide in the data on the second page of the assignment topic and provide some judgment as to which elasticity values would be more representative of the true values to be found in different airline such as Ryan air and British airways, furthermore will evaluate the accomplishment of cost savings of Ryan air through fixed costs and variable costs as well as writing a critical analysis the article on BAA Airports: Notice of release of interim undertaking'(mmc.gov.uk, 2010). Price Elasticity of Demand and Income elasticity of demand in the context of air travel demand: (Ryan air British Airways) We identified two distinct prices for air travel which are price elasticity of demand and income elasticity of demand from the case study for air travel demand which should distinguish among prices for: Low cost carrier (LCC) example of Ryanair and Full Service Carrier (FSCs) example of British Airways; business and leisure travel. Accordingly, to examine the sensitivity of the demand for air travel to its price, separate analysing of the price elasticity of demand is gathered for each of these two distinct markets. Price Elasticity of Demand Dunnett, A. (1988: 260) define Price Elasticity of Demand as a numerical value which describes the degree of responsiveness of demand to changes in prices. In addition Sloman (2005) believed that the demand for a particular good or service depends on a variety of factors. Key influences include, the levels of consumer income, the price and quality of the services in question and especially services that are close substitutes. As a general rule, once other influences on demand stay unchanged, a higher price for a product leads in a lower quantity demanded. However, the price responsiveness of demand varies from one good to another and from one market to another (FitzRoy et al, 1998). Since the availability of alternative modes of transportation that are reasonably close substitutes for air transport such as low cost airlines like Ryanair diminishes with distance travelled, it is expected that the demand for air transport will be less elastic for longer flights typical example of British airways with is a FSCs than for shorter flights typical example of Ryan air. Just considering an example where Ryanair (a low cost airline) flights to Milan from  £49.99 return and British Airways from  £628 return. The problem though with Ryanair is that you can find this cheap ticket if you book it about it well in advance. But if we try to book it on the same day before your journey the price has gone up at  £179.99 return when British Airways price will be still remaining the same until a week before your journey. Further, international travel tends to be widening over more time than domestic travel, so that the airfare is a smaller proportion of overall trip costs, which makes international travel less sensitive to changes in ticket prices. In addition, leisure travellers are more likely to postpone trips to specific locations in response to higher fares, or to shop around for those locations offering more affordable fares. Consequently, it is expected that the demand for air transport for leisure reasons will be more elastic than business travel who usually travel with FSCs. According to Anthony et al (2000) Ryan air prices management is systematically offering different prices to different customer segments in response to demand whereas (Kimes, 1989) suggests that the team in charge of yield management need to identify how changes in pr ice will affect their customers. Within the airline industries customer demand may be higher on week ends, during summer months, or at particular times of a day, (Belobaba, 1987). Managers must be able to forecast time-related demand so that they can make effective pricing and allocation decision to manage the shoulder periods around high demand period. However the corporate business traveller during the week becomes a leisure traveller when on holiday or at week-ends. Different occasion find the same consumer having different expectation and needs, (Buttle, 1986). Such a concept is termed elasticity of demand. According to the Data from the case study downloaded from Ryan air website, the price of the flight is far more higher than the price of the flight on other following days of the week day. However, when approaching the end of the week-end or school holiday, there is a huge demand and the increased demand drives the price up again as customer are returning from their vacation or family are going on holiday. Closer to the date and time of the scheduled service, the price rises, on the simple justification that consumers demand for a flight becomes more inelastic the nearer to the time of the service. The low cost airlines such as Ryan air follow the pricing strategy outlined above. Customers booking early with carriers such as Ryan air will normally come across lower prices if they are ready to commit themselves to a flight by booking early. This gives the airline the plus of important how full their flights are likely to be and a source of cash-flow in the weeks and months prior to th e service being provided. People who book late often regard travel to their planned destination as a need and they are therefore likely to be prepared and able to pay a much higher price very close to departure. Airlines call this price discrimination yield management but despite the consider name, at the heart of this pricing strategy is the straightforward but important concept price elasticity of demand. Ryanair has a seat pricing policy that causes fares to rise as a flight fills up (Ryanair.com, 2010). Following theory of supply and demand, if customer wants a seat so badly, they will pay more for it than otherwise. Income Elasticity of Demand It is defined as numerical values which describe the responsiveness of demand to a change in consumer incomes. (Sloman, 2005) Because of the recession, demand for low cost flights grew rapidly as family with higher income who were travelling with FSCs before would prefer low cost than traditional airlines and some current low cost customer with low income may prefer domestic flight or would just prefer not to travel by air. In air travel, FSCs are essentially joint products consisting of differentiated service bundles that are identified by fare classes. However the yield management systems employed by FSCs also create a multifaceted form of inter-temporal price discrimination, in which some fares (typically economy class) decline and some increase (typically full-fare business class) as the departure date draws closer. This implies that ideally, empirical studies of air travel demand should separate business and leisure travellers or at least be able to include some information on booking times in order to account for this price discrimination, and that price data should be calibrated for inter-temporal price discrimination: for example, the use of full-fare economy class ticket prices as data will overestimate the absolute value of the price elasticity coefficient. Within the set of differentiated service bundles that comprise each (joint product) flight, the relative prices are important in explainin g the relative ease of substitution between service classes. Given the nature of inter-temporal price discrimination for flights, the relative price could also change significantly in the time period prior to a departure time. In particular changes in real income and the prices of substitutes or complements will affect demand. Alternative transportation modes (road and rail) are important variables for short-haul flights, while income effects should be measured for both short and long-haul. Oum et al. (1992) provide valuable tools that occur when evaluating the demand models. Air travel demand can be affected by changes in the prices and service quality of other modes. For short-haul routes (markets) the relative price and service attributes of auto and train would need to be included in any model; particularly for short-haul markets such as low cost airline. Failure to include the price and service attributes of substitutes will bias the elasticity. For example, if airfares increase and auto costs are also increasing, the airfare elasticity would be overestimated if auto costs were excluded. The entry of low cost carriers leads to lower fares for a subset of traffic and competitors will offer a supply of seats to match these fares. Lower average fares should lead to lower demand elasticity estimates, while increases in the number of competitors in the market will lead to higher demand elasticity estimates. How low cost carriers such as Ryan air able to achieve cost savings? Fixed Costs and Variable Costs. Ryan airs business model is focus around its general low cost philosophy. That is Ryan air attempts to cut all non value adding activities as it strives to drive costs down to the total minimum. Below are typical examples how it drives its downwards which include selling directly to its customer over the internet or over the phone rather than via agents and middlemen, thus saving commission cost and administrative cost. Ryan air is a ticketless as most of it customer buy over the internet, in return for a booking reference that is exchanged at the checking counter at the airport for a boarding pass. The airline has no in flight meals which is a cost saving measure that cannot be much inconvenience to its customer since all Ryan air flights are short haul. Nevertheless has subcontracted catering services on its flights where customer can buy an in flight meal and drink should they wish which is another way of driving price. Cabin crew double up as cleaner and this helps Ryan air to promise a turnaround time at any airport of 30 min rather than 45-60 min that has FSCs been the norm. Another cost cutting device, is the typical example of the UK smaller airports such as London Luton, cheaper to fly to from than bigger airports such as Heathrow which it is use at least as its base as they are less congestion and facilitate turnaround times for aircraft to be a lot shorter. Fixed Costs Fixed Costs are defined as the Total costs that do not vary with the amount of output produced (John, S. 2005:82) Ryan air as a LCC operate in the environment of high fixed cost, fixed capacity in the short term, a perishable product and seasonal demand. Virtually all of airlines costs can be considered fixed. The cost of the capital tied up in the plane, the fuel it take to fly the route, the crew it will take to staff the ground and flight operations insurance, rent, etcà ¢Ã¢â€š ¬Ã‚ ¦ All these cost are fixed once the company decides to fly a particular route and the variable costs associated with serving another passenger on the flight are figure lively peanuts. Ryan air generates sufficient revenue through ancillary services such as car rentals, accommodation, currency, travel insurance, transactions, refreshments, to cover variable costs and offset at least some fixed cost. Management believes that providing these services through the internet allows Ryan air to increase sales, while at the same time reducing costs on a per unit basis. Variable Costs Variable Costs are defined as the total costs that do vary with the amount of output produced (Sloman, 2005: 82) The relatively low variable costs associated with many capacity- constrained Ryan air allow for some pricing flexibility and give operators the options of reducing pricing during low demand times. Ryan air always seeks for low variable costs. Below are factors that help Ryanair to maintain a low variable cost: One type of aircraft, management believes that its strategy of limiting its fleet primarily to three variants of a single type of aircraft from a single manufacturer enables it to limit the costs associated with personnel training, maintenance and the purchase and storage of spare parts, as well as affording greater flexibility in the scheduling of crews and equipment. Pricing is based strictly upon revenue maximization process that matches the aims and objectives of prices elasticity of demand Internet booking which cut paper and administrative costs No airport sales offices/ no cancellations Charging a surplus for excessive baggage Maximization of seat capacity per plane Use of less expensive airport as Ryan air been offered incentives is a controversial one Ryan air director of communications. Ryan air further endeavours to reduce its airport charges by opting, when practicable, for less expensive gate locations as well as outdoor boarding stairs rather than more expensive jet ways. Ryan air has entered into in agreements on competitive terms with third party contractors at certain airports for traveller and aircraft handling, ticketing and other services that management believes can be more cost resourcefully provided by third parties. Management attempts to obtain competitive rates for such services by negotiating multi-year contracts at prices that are fixed or subject only to periodic increases related to inflation. One of the typical example is the price of aviation fuel which is directly related to the cost of oil but Ryan air control this through hedging. All these factors listed above contributed to a low variable cost of Ryan air, a key component in any successful yield management system and provide an opportunity for leverage against its major competitors. Critical analysis of the issues involved in the following article: BAA Airports: Notice of release of interim undertaking

Wealth and How Money Influences Peoples Lives Essay -- Wealth Money F

Wealth and How Money Influences People's Lives Some people generate an adequate living working for others, some do quite well, while many people don’t do well. It is estimated that less than 16% of Canadians have more than $100,000 in their retirement funds while 38% have less than $10,000. Using money to make money is more likely to generate success. Using assets to generate wealth is likely to generate financial success. This is the principle in whihc my group is is based upon. Kiyosaki explains money does not calm your fears when desire forces you to spend. You have to avoid the trap. Rich people often have a fear of losing it all. A job is a short term solution to a long term problem. You must master the power of money. When the donkey drags the cart with the carrot on a stick in front of him, the driver is getting where he wants. For the donkey it’s an illusion. What intensifies fear and desire is ignorance. To spend your life in fear and never exploring your dreams is cruel. Just as in my business of MJM Productions. Instead of looking at how much certain ventures will cost, we must look at the posibilities which will occur as a result of that venture. Money does not calm your fears when desire forces you to spend. You have to avoid the trap. Rich people often have a fear of losing it all. A job is a short term solution to a long term problem. You must master the power of money. When the donkey drags the cart with the carrot on a stick in front of him, the driver is getting where he wants. For the donkey it’s an illusion. What intensifies fear and desire is ignorance. To spend your life in fear and never exploring your dreams is cruel. Just as in my business of MJM Productions. Instead of looking at how much certain ventures will cost, we must look at the posibilities which will occur as a result of that venture. Therefore it is essential that the accumulation of money does not blind me and my cohorts from our prime objective of empowering ourselves. Choose your thoughts. Think long-term and ask yourself: "Is this the best possible solution to my problem?" There is an old expression that "I am too busy working to make money." When you are too busy, you miss many opportunities. You often go into a restaurant and see a lot of things done wrong. Why can’t the manager see these things? Because he is too busy working IN the business ... ...before you pay any other bills. Then you will be motivated to find the money to pay all the other bills. Look after number one. Choose friends carefully. The power of association. Learn from all of them, whether they have money or not. When I seek out people who have money, I am not after their money but their ideas. Don’t listen to poor or frightened people. Wise investors buy an investment when it’s not popular. They know their profits are made when they buy, not when they sell. You become what you study. So, if you are tired of what you are doing and not making enough money, change the formula. This was a key factor in creating a sucessful business. Only by having co-workers which are dependable will ones business flourish. Be an "Indian Giver". Put your money into an investment and when it goes up, take your money back out and do the same again. If you buy some stocks and they go up in price, sell enough to get your original investment back and repeat the process. Assets buy luxuries. When the asset is generating surplus cash flow, then you use that surplus to buy the luxuries. Or in terms of this project, 50% goin towards a college education instead of luxuries.

Obsession in The Tell-Tale Heart and The Cask of Amontillado :: Tell Tale Cask Comparison Compare Essays

"Determination becomes obsession and then it becomes all that matters." -- Jeremy Irvine Poe presents the narrators of "The Tell-Tale Heart" and "The Cask of Amontillado" as devious, obsessed characters. Both are overpowered by the need to consume the life of their victim. Though they use different strategies to carry out the murders in different ways, obsession is the driving force in both. It is this obsession that inspires them to design cunning strategies and carry out the executions. The obsession of Montresor in "The Cask of Amontillado" and of the narrator in "The Tell-Tale Heart" is obvious throughout the stories. The narrator in "The Tell-Tale Heart" is actually obsessed with the old man's eye, rather than the old man himself. It is this obsession with the eye that drives him to commit the murder, despite his relatively good feelings toward the old man personally. This is why he is unable to harm the old man when the eye is concealed. His obsession with the eye is what controls him and his actions. Without it in sight to enrage this obsession, he is unable to harm the old man. This also is why he must shine the lantern light upon only that eye. By leaving the rest of the old man in the dark, he in a sense de-humanizes the victim. His obsession intensifies and takes full control of his actions. He eliminates the old man from the equation and is able to charge him and make the kill. Montresor in "The Cask of Amontillado" is similar to the narrator in "The Tell-Tale Heart" in that his obsession with consuming the soul of Fortunato influences his every action. However, it is with Fortunato himself that he is obsessed. He feeds off of Fortunato's pain, unlike the narrator in "The Tell-Tale Heart" who's obsession is with destroying a menacing inanimate object. Montresor's entire conspiracy is focused around making Fortunato suffer, and for him to know just who is causing this suffering. This is why he goes to such lengths to put together this intricate strategy. It could have been so much easier to kill Fortunato in some easier, quicker way. Instead, he dedicates himself to torturing Fortunato. He creates a plan that leads Fortunato into the depths of the catacombs beneath his home, and kills him in an excruciating manner.

The Lord Of The Flies :: essays research papers

The Lord of the Flies The adventure novel, The Lord of the Flies, was an epic tale that depicted the different facets of the human spirit. It was written by William Golding in the 1950's and recieved many awards. It was declared the "Outstanding Novel of the Year" by E.M. Forrester. The author did in no wat mean for this story to be biographical, but Mr. Golding depicted well the many different aspect of human nature. The book has been described as "provacative, vivid and enthralling," but Time and Tide said it best when they wrote, â€Å"It is not only a first-rate adventure story but a parable of our times." The novel took place on an island probably somewhere in the middle of the Atlantic. This can be inferred because of the fact that the boys are British and that they arrived on the island by way of a plane cradsh. The story also occurred during wartime. The story begins when a group of British boys crash on an uninhabited island. In the beginning they area all unruly and unmorginized. Finally, a boy by the nakme of Ralph decides to take charge and call a meeting. The boys declare him â€Å"chief† and then begin to follow his lead. Ralph is also assisted by another lad by the name of Piggy. The group of boys were getting along fine until Jack Merridew, a boy who wanted to be â€Å"chief† instead, decided to go his own way. He disobeyed Ralph and did things his own way. He was to preoccupied witdh his own whims to do the act that was most important on the island, which was to keep the signal going so they could be rescued. Finally, Jack went against Ralph and declared that if any of the other boys wanted to have â€Å"fun,† which meant acting like savages, that they should follow him. The boys splot up into two groups and then havoc insued. Jacks group went around hunting and being barbaric while the others tried to get rescued. In the end Jack had gotten all the boys except Ralph to run around loke wild animals. Then when Jack got tired of dealing with Ralph, he convinced wveryone to try and kill him. By then however, a navy ship had come an they could never get around to the nasty deed. There was more than one antagonist in the story, The Lord of the Flies. They were Ralph, Piggy, and all the other boys who tried to sustain order and law on the island. To begin with, Ralph was the â€Å"first† chief on the island.

Red, White, and Black by Gary Nash Essay

Gary Nash author of Red, White, and Black purpose to their readers is describing the early colonists, but also the relationships toward Europeans, the Indians, and the Africans. Nash successfully analyzes the impact of the colliding three cultures and interprets them to give an overall theme about the relationships between those who made America what it is today. He has shown another point of view to his reader that we grew up and was raise in a white people land; learning only the White people point of view through history. His purpose of writing Red, White & Black was to prove that Native Americans and Africans were not victims, but played as a active role to American history. Nash major theme that he covers in his book was about the three cultures in America and to interpret them overall. The theme is about the issue that Americans have towards the Native American and Africans. He wanted to examine and studied other culture history instead of only learning from the American side. He figures out that they were victims to the history and was just a role in the American history. His main point of time frame was from 1492-1796. The introduction to Nash research took place in Eastern and Northern America. Nash was against how the founding fathers came to America and affected the Natives and Africans. He was against how the founding fathers came to their land and changed their destiny of lives and culture because they took what belong to them first. Anthropologists call this process â€Å"transculturation† and historians call it â€Å"Social change. † His argument towards the historical terms is that we are studying a dynamic process of interaction that shaped the history of American Indians, Europeans, and Africans in the North America in the 17 & 18 centuries. Gary B. Nash was arguing of something different than what is written to us. He believes of what the founding father want us to know and was marked down through history. But reality during those times American Indians and Africans had a big destiny change when the European came along. They changed and affected their lives in there home land. Gary B. Nash written Red, White, and Black purpose was mainly to let people know that, what’s ever that was passed down from the founding father in history is only what their views were and marked down in papers. How the Americans European changed the lives of all Native American and African that was located at Eastern and Northern America.

Ethical Challenges in the Era If Health Care Reform

Ethics, Law, and Policy Vicki D. Lachman Ethical Challenges in the Era Of Health Care Reform n truth, the United States is at the beginning of a long overdue and a much needed health care reform. We have seen the dismal statistics about our high cost health care system and some of the less than stellar outcomes (e. g. , infant mortality) (Callahan, 2011; World Health Organization [WHO], 2011)). The purpose of this article is not to complain about the current health care system, but instead to focus on existing reform efforts — The Patient Protection and he Affordable Care Act (ACA), the ethical justifications for its creation, and ethical challenges it brings. I Key Features of the Law ACA offers new ways for consumers and providers to hold insurance companies accountable. The most important parts of the law are features described in the following discussion. Because of space limitation, I will highlight some elements of the law that are enacted through 2014 and clearly impact nursing. These selected features include insurance choices, insurance costs, rights and protection, and people age 65 and older. Insurance ChoicesThe intention of the law is to expand health care coverage to most U. S. citizens and permanent residents by requiring most people to have or purchase health insurance (HealthCare. gov, 2012a). Citizens will have a choice of private insurance, employer-paid insurance, Medicaid, Medicare, or state-based insurance exchanges. Affordable Insurance Exchanges. Individuals and small businesses can purchase coverage through these exchanges, with premium and cost-sharing credits available to individuals and families with income between 133%-400% of the federal poverty guideline (in 2011, the overty guideline was $18,530 for a family of three) (Werhane & Tieman, 2011). Businesses with 50 or more employees need to make coverage available, and businesses with less than 25 employees will qualify for tax credits to offset their cost (Kaiser Family Foun dation, 2011). Consumer Operated and Oriented Plan (CO-OP). The ACA produces a new kind of non-profit health insurer, called a Consumer Operated and Oriented Plan (CO-OP). CO-OPs are meant to offer consumer-friendly, affordable health insurance options to individuals and small businesses. By January 1, 2014, individuals will be able to buy a CO-OPVicki D. Lachman, PhD, APRN, MBE, FAAN, is Clinical Professor, and Director, Innovation and Intra/Entrepreneurship in Advanced Practice Nursing, Drexel University, College of Nursing and Health Professions, Philadelphia, PA. 248 health plan through the Affordable Insurance Exchanges. Pre-existing condition insurance plan. All covered benefits are available to individuals, even to treat a pre-existing condition. This program offers temporary protection for people with pre-existing conditions until 2014, when insurance companies can no longer deny individuals coverage based on their health status.Young adult coverage. Individuals can add or k eep their children on their health insurance policy until they reach age 26. The law makes it easier and more affordable for young adults to get health insurance coverage. Insurance Costs ACA holds insurance companies accountable. It also helps individuals keep their costs down. Value for individual’s premium dollar. ACA requires insurers selling policies to individuals or small groups to spend at least 80% of premiums on direct medical care and efforts to improve the quality of care. Unfortunately, this does not apply to self-insured plans.Lifetime and annual limits. ACA restricts and phases out the annual dollar limits a health plan can place on most of its benefits. Furthermore, ACA eliminates these limits completely in 2014. Rate review. Insurance companies must now justify proposed rate increases for health insurance. Insurance companies cannot raise rates by 10% or more without first explaining the reasons to the state or federal rate review program. Rights and Protecti ons The ACA puts consumers in charge of their health care, not insurance companies. The following rights and consumer protections are available. Preventive care.Individuals may not have to pay a copayment, co-insurance, or deductible to receive recommended preventive health services, such as screenings (e. g. , mammograms and colonoscopies), vaccinations (e. g. measles, polio, or meningitis), and counseling (e. g. , smoking cessation, weight loss, healthy eating). Doctor choice and ER access. Individuals can choose any available participating primary care provider and they can access out-of-network emergency rooms without prior approval. ACA prohibits health plans from requiring a referral from a primary care provider before women can seek coverage for obstetrical or ynecological (OBGYN) care. People 65 and older. ACA offers eligible elders a range of preventive services with no cost-sharing. ACA also provides discounts on drugs when older adults are in the coverage gap known as the â€Å"donut hole. † July-August 2012 †¢ Vol. 21/No. 4 Ethical Challenges in the Era of Health Care Reform TABLE 1. Views of Liberal Egalitarians vs. Libertarians and Free-Market Advocates Liberal Egalitarians Libertarians and Free-Market Advocates Health care is a fundamental good and access to this good Role of government is confined to protecting the freedom of all allows us to become full members of society. ersons to choose their own goals and means to pursue them. This right to health care must be exercised by removing all People have a right to non-interference. barriers to access. Justice, equality, and community are values. Freedom and personal responsibility are values. Health care is a right. Health care is a commodity. Single-payer system is the solution. Decentralized market mechanisms with personal payment are the solution. Preventive services. The list is significant and begins with an annual wellness visit. Other important preventive services include bone mass measurement; cervical cancer creening, including Pap smear tests and pelvic exams; colorectal, prostate, and diabetes screening; influenza, pneumonia, and hepatitis B immunizations; and many other services. There are other services and features in the ACA that could be discussed, but we will now move to discuss the ethical justifications for the ACA. The controversy it has created in the eyes of individuals with a free-market or libertarian view will be compared to those with a liberalegalitarian outlook. Ethical Justifications for the ACA Since 1986, the Emergency Treatment and Labor Act has prohibited hospitals from refusing acute care to any ndividual who could not afford to pay (CMS. gov, 2012). â€Å"Consequently, $100 billion of care annually is ‘costshifted’ onto patients who can pay, almost all whom are insured. This shift raises the average annual health insurance premium roughly $1,000 for every insured family† (Crowley, 2009, p. 10). This lack of distributive justice for the insured is one reason why insurance is being mandated in ACA. It is equally unfair to mandate that all citizens have insurance if insurance is not affordable, as this could cause significant harm to individuals and families already struggling financially.Therefore, the ethical principles of beneficence and nonmaleficence are supported by the features of Affordable Insurance Exchanges and the development of Consumer Operated and Oriented Plans. Ethical reasoning for health care reform has relied primarily on distributive justice as justification for change, specifically due to lack of access to care for the underinsured and uninsured (Lachman, 2009). According to the U. S. Census Bureau, 46. 3 million people in the United States were uninsured in 2008 (ProCon. org, 2012). The United States is the only developed nation in the world hat does not guarantee health coverage. Table 1 offers a comparison of views of persons who support distributive justice, see health care as a right, and therefore want a single-payer system with those individuals who want to continue the free-market system. â€Å"To single-payer advocates, the primary goal of health policy is ensuring that everyone can obtain some minimal level July-August 2012 †¢ Vol. 21/No. 4 of health care† (Sade, 2007, p. 1429). Making access to health care widely available permits individuals to be fully functioning members of society and the moral ommunity (a group of people drawn together by a common interest in living according to a particular moral philosophy). On the other hand, Americans who are libertarians and free-market advocates mostly look beyond the natural (genetic) and social (upbringing) lottery that places some at a disadvantage and instead look to the individual’s free will and personal responsibility for actions (Callahan, 2011; Pariser, 2012; Trotter, 2011). They believe health care is one of the many options from which to choose to improve the ir lot in life. Their belief in personal responsibility can make them unsympathetic o people with unhealthy lifestyles for whom they would ultimately have to spend their insurance dollars. They also resent having to fund treatments they personally would not choose (e. g. , transplants, mechanical ventilation for person in persistent vegetative state). Though many wealthy individuals support health care reform out of benevolence, they do fear the loss of freedom which is central to their value system. However, two additional factors drive change for health care reform — significant cost and quality problems. In 2007, health care expenditures totaled $2. 2 trillion, 16. 2% of the U.S. economy. Health care employs more than 14 million people and is the largest industry in the United States. Of the 193 WHO member states, the United States is ranked first in per capita health care expenditures ($6,719) (ProCon. org, 2012). The present health care system is not giving the utility f or the dollars spent. This cost problem is a reason that ACA has a focus on physicians counseling individuals on end-of-life options. It found that about 30 percent of Medicare dollars are spent during the last year of life, and half of that is spent during the last 60 days. In 2009 dollars, Dr.Gordon calculated, that amounts to $70 billion a year, much of it spent on futile care that prolongs suffering (Brody, 2009, para 20). Unfortunately, politics initially got in the way in 2009 with the â€Å"death panel† jargon and this counseling was dropped from ACA; however, this end-of-life options counseling was incorporated into 2011 Medicare reimbursement for health care providers (HealthCare. gov, 2012b). 249 Ethics, Law, and Policy WHO (2011) statistics also indicate the money spent is not putting us at the top of the list in quality outcomes. The infant mortality rate for the United States in 2009 was even deaths per 1,000 live births, ranking the United States 43rd among WHO nations. Rates for Sweden, Spain, Italy, Germany, France, Czech Republic, Slovenia, and Iceland are all half of the United States rate. Quality is a focus of ACA in the preventive realm and with quality measurement. Two essential principles of the ACA are that: 1. Provider reimbursement for health services is based, in part, on the relative quality and patient experience of the care provided. 2. Information about that comparative quality and patient experience will be publicly accessible. Quality and patient satisfaction will be rewarded by ata from hospital comparison required by the Hospital Consumer Assessment of Healthcare Providers and Systems for Medicare patients. â€Å"The implications of Value-Based Purchasing (VBP) regulations for hospitals are clear — FY2013 implementation at 1% of base DRG payments, rising to 2% by FY2017† (Acton, 2012, para 2). Hospitals will have to earn it back by achieving and maintaining high quality and positive patient experiences. T his consequential focus in the patient care experience supports the autonomous choice of the patient for hospitals and physicians. Ethical Challenges of ACA Legal ChallengeBefore discussing three key ethical challenges health care providers will face, the legal challenge before the Supreme Court needs to be addressed. This challenge determined if the ACA requirement to purchase health insurance violates Article 1, Section 8, Clause 3 of the U. S. Constitution: Congress shall have the Power To lay and collect Taxes, Duties, Imposts, and Excises, to pay the Debts and provide for the common Defence and the general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States†¦ (Werhane & Tieman, 2011, p. 83)The argument against this mandate is that the government has never required people to buy any good or service as a condition of lawful residence in the United States. However, every working person is required to pay into Social Security and Medicare. The counter argument is that these are government-mandated and governmentrun programs. This argument ultimately could support a Supreme Court decision of only a government-run singlepayer system, an action libertarians and free-market advocates oppose. Second, there are requirements for car insurance for drivers, and flood insurance for persons ho live within authorized distance from a possible flood plain. Because all people will need health care at some point in their lives, the argument could be made that insurance should be a requirement so as not to burden the moral community with the costs of those who do pay for insurance (Hamel & Nairn, 2011). 250 On June 28, 2012, the U. S. Supreme Court endorsed most of the Patient Protection and Affordable Care Act, including the contentious individual mandate that requires most Americans to obtain health insurance. In a 5-4 decision, the court said the federal government has he power to fine Americans who do not ac quire insurance because it is considered a tax (Jaslow, 2012). Electronic Medical Records The requirement for electronic records could generate a significant ethical challenge for privacy and confidentiality. Unfortunately, the $20 billion for health information technology from the American Recovery and Reinvestment Act (ARRA) did little to change the current HIPPA privacy paradigm (Crowley, 2009). Furthermore, it is likely patients will carry their personal health records in their own electronic devices or retrieve them through the Internet.A transformation in rural health care is likely through telehealth and telehomecare. These innovations will bring expertise to patients to facilitate the best choice in their treatment decisions. The challenge will be to assure informed consent and confidentiality in this expanded digital age. Chronic Disease Management Individuals with chronic illness benefit significantly from palliative care services, not just at end-of-life care but througho ut the disease progression. The ACA focus on chronic disease management is best exemplified by this phrase: â€Å"An integrated care approach to managing illness hich includes screenings, check-ups, monitoring and coordinating treatment, and patient education† (HealthCare. gov, 2012b, para 1). Feministic ethics, with its focus on managing the particulars of any person’s situation, celebrates this personalized service to individuals who must manage illnesses often for many years. In her book, Caring: A Feminine Approach to Ethics and Moral Education, Nell Noddings (2003) argued that a morality based on rules is inadequate. She contended this approach loses the richness of the moral dilemmas people face, and nly situational and contextual knowledge of the individual can help resolve the moral quandaries of life. Shaping Health Care Policy According to the Code of Ethics for Nurses, provision 9 (American Nurses Association [ANA], 2001), nurses have an obligation to  "work individually as citizens or collectively through political action to bring about social change† (p. 25). This responsibility to shape social (health care) policy calls for nurses to voice concerns about the meaning of the rejection of the individual mandate for society. The libertarians and free-market advocates reinforce a caricature of American individualism and weaken a sense of responsibility for oneself and fellow citizens†¦It neglects one side of the equation, forgetting that we are not only individuals with the freedom to choose, but also members of society called to uphold a common good. (Hamel & Nairn, 2011, p. 94) continued on page 245 July-August 2012 †¢ Vol. 21/No. 4 Ethics, Law, and Policy REFERENCES continued from page 250 Therefore, nurses and nursing associations have the ethical challenge to stand firm for patients and ensure the long-term sustainability of our health care system.Nurses need to advocate for the people without a voice — t hose discriminated against because of health status and lack of insurance. Conclusion ACA has provided a forum for debate about not only health care insurance, mechanisms to maintain financial stability of its systems, and strategies to ensure access to millions of people, but also has contributed to defining American society’s values. It is easy to argue against the individual mandate impingement on choice and freedom. 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