Obamacare: A scholar’s tale

The chant to “repeal and replace” Obamacare threatens six years of my scholarly life. My newest book, Nursing with a Message: Public Health Demonstrations Projects in New York City, begins and ends with Obamacare, otherwise known as the Patient Protection and Affordable Care Act or, more simply, the ACA. In between I write about innovative nurse managed health clinics in New York City in the 1920s and 1930s. These clinics were established as “demonstrations” that sought to bring high quality, cost-effective, and carefully coordinated health care to individuals and families too poor to access private medical services. They faced the central dilemma of the post-World War I era. With mortality rates from infectious diseases rapidly declining, more chronic illnesses like diabetes, cancer, and cardiovascular disease had emerged as the leading causes of adult deaths. Without cures, what should clinicians do?

The answer: prevent them from occurring in the first place.

So my public health nurses took up the challenge of health promotion and prevention. These nurses visited schools, churches, and homes to encourage neighborhood residents to engage in healthier lifestyles through diet and exercise, to value preventive physical examinations even when not ill, to make dental care routine, and to establish vision and hearing assessments, part of a battery of tests that would identify “defects” before they became problematic. It was important for adults to engage in these kinds of activities rather than illness care. It was even more important, they argued, for their little children who were seen as particularly vulnerable.

There were many bumps along the way, but my public health nurses essentially established the norms of primary care for those who had been shut out of the fee-for-service medical system. I ended the book with a strong sense of optimism. President Obama had just committed more federal dollars to expand similar types of clinics today, although now known as federally qualified health clinics (FQHC). The experiences of my nurses stood as a “lessons learned” story.

Things converged in January. Two widely reported and data-based articles in the prestigious journal Health Affairs showed that the healthcare provided in these FQHCs, typically called community health clinics, to those shut out of our traditional medical system do, in fact, work. The first study found that, in states that expanded Medicaid eligibility, FQHCs saw more patients, provided more treatments that brought asthma and hypertension under control, and delivered more recommended preventive services such as Pap testing and body mass assessment. The second study also looked at the effects of Medicaid expansion. It found FQHCs also saw more patients. More importantly, these patients had insurance they gained through the ACA. And as interviews with those who managed these FQHCs reported, more insured patients meant more money to expand into such areas as dental and mental health care.

Also in January, Atul Gawande wrote an article titled “The Heroism of Incremental Care” in the New Yorker. Gawande, a neurosurgeon, had struggled to understand the allure of primary care to his physician colleagues. So he spent time with them in their clinics – both a specialty clinic like the John Graham Headache Center in Boston’s Brigham & Women’s Faulkner Hospital and with generalists in a teeming primary care practice in the city’s Jamaica Plain neighborhood. He talked with practitioners committed to seeing patients over a course of a lifetime, comfortable with “watchful waiting,” and trusting that strong relationships forged with patients would bring them immediately back if symptoms worsened. Gawande also saw a healthcare system that financially supported none of this despite mountains of data on how this kind of incrementalist care delivered such profound changes in peoples’ lives. And, he concludes, we can wait no longer. New technologies have given us the ability to almost constantly monitor and “course correct” the body and brain to prevent their breakdown. We have a “moral imperative” to make the kinds of changes that will take advantage of these opportunities and make this happen or we can leave people suffering – and dying. To Gawande, it is that simple.

And it is as simple that we need continued support for the maintenance and expansion of the healthcare delivered in community health centers, care delivered by nurse practitioners as well as physicians and physicians’ assistants. I am glad that there seems to be discussions about keeping coverage for pre-existing conditions and young adults on their parents’ health plans in the “repeal and replace” debates about Obamacare. But for those poor, vulnerable, and dispossessed individuals, families, and children served by FQHCs it is life – or suffering, or death. We must fight to see their survival and their expansion, not because it is the data-driven or financially sound thing to do, but it is now the moral thing to do.

Patricia D'Antonio, PhD, RN, is Killebrew-Censits Term Professor in Undergraduate Education Chair, Department of Family and Community Health, and director of the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania.



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