The ACA: Here Are (Mostly) Reasons Why Not

Doc, Cure My Boredom
I am a seasoned, dedicated, and (according to my colleagues and patients) terrific clinician. I have been practicing as an APRN since the mid-80s. I cut my teeth in primary care and geriatrics for more than 10 years, then spent the next 14 in cardiology. With the enactment of the ACA and the shifted focus on primary care, I returned to primary care practice in 2012.

After three years back in primary care in rural Vermont, where I had my own panel of patients, I finally had enough. I was recruited by our local VA to develop a heart failure program; I have been with them since the beginning of this year. (What a godsend! I love my job again.)

The problems in health care, especially primary care, were more than I could sustain. My younger, less experienced colleagues were dropping like flies. I agree the ACA is a first step. But in our rural state, it resulted in many people with health care coverage (a very good thing) but the majority on Medicaid (not a good thing). At the risk of sounding unsympathetic, the problems lie with the government’s control of this enterprise. These patients deserve health care, but they don’t deserve an open checkbook. With our help (I can assure you, in Vermont, there are tremendous resources to help the poor), patients need to take some responsibility for their health.

Despite biweekly office visits, case managers, home care, and social work involvement, patients get bored and decide to visit the emergency department (ED) for minor issues. Medicaid pays for it, no questions asked. One patient, for example, came to my office in the morning, where I did tests and outlined a plan of care. She went home and one hour later presented to the ED for the same (nonacute) issue, because she didn’t want to wait for the plan to work. Unhappy with that visit, she presented to our local tertiary medical center later that day. Since that hospital doesn’t access our records, this patient underwent yet a third evaluation (including x-rays) on the same day, with the exact same plan of care outlined. Medicaid paid for every single thing—my tax dollars at work.

This isn’t an anomaly. Every day, I had endless encounters with this “open checkbook” approach and patients’ need for immediate gratification (despite being educated on their health problem, its expected duration, and a clear plan of care). Our culture has become centered on immediate gratification, and there is a lack of personal responsibility for one’s health. Patients—all of us—need to take responsibility for our health.

With so many people on state-sponsored plans as a result of the ACA, patients have no “skin in the game,” so to speak. They are poor, and I sympathize with that. Yet, unless they are made aware of the cost of these “boredom ED visits” and expensive tests, etc, this behavior will only continue to bankrupt the system.

Unfettered health care expenditures are not only unsustainable, they are also beyond aggravating for my many patients who pay exorbitant amounts of money on high-deductible plans. Those are the people I worry about most. They are being priced out of their health care!

So yes, the ACA is a first step—but not a good one. It simply didn’t go far enough, and it has led to burnout and chaos in the frontlines, increasing costs, and a boon to the insurance companies.

Until we eliminate private insurance companies from the equation, put every citizen on a level playing field, and expect a collaborative approach with our patients (as well as ownership of their health), it will only get worse.

Peg Sullivan, MSN, APRN
Windsor, VT

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