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An Opportunity to Close Health Care Gaps






With the absolute, final-final deadline for 2014 sign-ups now completely passed, and despite numerous speed bumps, implementation of the Affordable Care Act is well under way. From my view as a bedside nurse and advocate for patients and health care workers for more than 30 years, I see a chance to close some dangerous gaps in our country’s health care systems.

In the U.S. we like to think of ourselves as the best at everything. And it’s true that we have the finest health care—for those who can afford it. Unfortunately, for the average American our care is also the most expensive, with some of the poorest outcomes, in the industrialized world. Many Americans, pre-ACA, had no access to anything but emergency care, due to cost and/or pre-existing conditions. These are the biggest gaps ACA seeks to close.

My mother had her hip replaced in 2009. I’m thankful I was there, as an informal case manager, to help her navigate her health care system. She received good care, but there were alarming gaps. Her regular doctor was not told what medications had been sent home with her from the hospital. She, like many seniors in her situation, also required a reliable point of contact to answer questions.

Our system is riddled with such trouble spots. We have providers who don’t talk to each other. Doctors who threaten to drop seniors from Medicare. Differences in urban and rural access. Inequities between coverage for physical and mental illnesses. Patients forced to use the ER to manage chronic conditions. The ACA requires our health care systems to provide more value and greater quality.

Our pre-ACA system was designed around sickness, not wellness. Too many care decisions have been driven by profit incentives, with too many patients talked into unnecessary and expensive procedures. Too many Americans without insurance or with pre-existing conditions, unable to get preventive care, have ended up crowding into our emergency rooms, where care is far more expensive, fragmented and may come too late.

I see the ACA realigning financial incentives toward keeping patients well, with a greater focus on preventive care and better management of chronic conditions. More emphasis will be placed on identifying risk factors for conditions like diabetes and hypertension that lead to debilitating outcomes and skyrocketing costs. Under the ACA, more Americans should have ready access to mammograms, colonoscopies and other diagnostics. Early detection leads to earlier treatment and helps prolong lives.

As our country’s health care systems and communities focus on reforming the American diet and offering a better health care experience, we’ll see fewer patients admitted to hospitals, which will evolve into mini Intensive Care Units—only for the sickest. Hospital care is not only expensive but many times frightening, impersonal and dangerous. Under the ACA we may welcome a return to more traditional and personal models of care.

We’ll also see more outside services such as call centers, doctor-patient visits via SKYPE and tele-medicine. Already, moles and wounds can be photographed from a clinic or doctor’s office and forwarded to specialists for diagnosis and treatment. Patients in rural settings may no longer have to travel long distances to consult with a specialist.

The ACA is going to result in the biggest changes to health care in America since Medicare. Considering how much most Americans cherish Medicare, I see that as promising. One thing I know will never change. Nurses like me will always advocate for our patients.

(Denise Duncan has been a registered nurse since 1983. In 2004, she was co-researcher on the first-ever study of nurse perceptions of medical errors and their causes, published in The Journal of Nursing Care Quality. She is Executive Vice President of United Nurses Associations of California/Union of Health Care Professionals, representing more than 22,000 nurses and health care professionals in Southern California.)

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