As the first enrollees in the Affordable Care Act begin seeking care at my hospital, I wonder how my practice as a Registered Nurse will change. We’re told the goal of the new law is to remodel healthcare in the United States into a system that promotes wellness and prevention, rather than just providing care to sick people. This seems like a great objective, but I worry that the switch may compromise the quality of the care our patients receive.
As a bedside RN working at an acute care hospital in Oakland, California, I care for an incredibly diverse patient population. Most of my patients have had health insurance through employer-based programs, private purchase, or Medi-Cal. Most have interacted with the health care system prior to being admitted to my hospital.
Now, I will take care of patients who are new to health care. Some haven’t had care in a long time (or ever). Some may have pre-existing conditions that enabled insurance companies to refuse them coverage. As they enter my care, their needs may be more complicated.
Last year, I cared for a patient who—like many patients covered through the ACA—hadn’t been to the doctor in years. She didn’t seek care until she was quite debilitated by Type 2 Diabetes.
My experience caring for this woman exemplifies the stress that patients who have never had health care may put on my hospital and nurse colleagues. This woman never had an IV in her arm nor had she ever stayed overnight in a hospital. Now, she was told that when she went home, she’d need to check her blood sugar with a glucometer four times a day and inject herself with insulin. I spent a lot of time with her, explaining things to ease her anxiety.
During that shift, one of my other patients said, “You must be busy. I haven’t seen you all night.” My heart sank. He was fine physically, but I could tell he needed someone to talk to for a few minutes. Unfortunately, I had to get back to my diabetic patient. Preventing her blood sugar from dropping took priority over spending time with my lonely patient. Unfortunately, there were no extra nurses to care for my other patients.
In fact, executives at my hospital recently proposed reducing our inpatient nursing staff. They note that the number of patients admitted for overnight stays has decreased in the last few years. They say medical and surgical care has improved, and better primary care has kept patients healthy enough to avoid hospital admissions. The ACA permits hospitals to continue shifting patient care from the expensive inpatient setting to the cheaper—and more profitable—outpatient setting.
The problem with that diagnosis? My patients are not healthier. With the ACA, there are more patients entering hospital infrastructures that have been diminished. Patients visit the emergency room and wait longer before being admitted. When they do get admitted, rather than being sent home and told to follow up with their primary care physician, they are often much sicker and require more care.
This new burden is falling heavy on the hospitals and staff. Nurses are working harder than ever with fewer resources.
It’s a killer combination: hospitals delaying and denying care to patients as the ACA enables more Americans to buy into this deeply flawed system. If the ACA is successful in contributing to keeping patients out of the hospital, inpatient care will be reserved for patients with acute, severe illnesses and the number of hospital nurses will drop dramatically. Meanwhile, other patients will be managed in the outpatient setting and more nurses will move into home health and advice nursing.
But it’s unrealistic to assume all the care I give my patients in the hospital can be done at home by family members, friends and the occasional visit by a home health nurse. In a hospital, patients benefit from a huge team of health care practitioners.
Consider my new diabetic patient. She benefitted from the ongoing support of nurses to teach her about diabetes, visits from the dietitian to help with her menu planning, and the assistance of a social worker who helped her identify additional resources. Her doctor monitored her blood sugar to see how she responded to the treatment. When, after a few days in the hospital, she checked her sugar, determined her insulin dose, drew it up and administered it to herself, I had tears in my eyes. She deserved that care and I was proud she got it. While I hope the ACA will get care to millions of other Americans, I worry that it may make it harder for people to get comprehensive, timely care from trained and compassionate health care practitioners, including nurses like me.
Amy Dertz is a Registered Nurse and has worked at Kaiser Permanente Hospital in Oakland on the Adult Medical/Surgical/Oncology Unit since graduating from California State University, East Bay in 2007. She lives in Richmond, California. This piece originally appeared at Zocalo Public Square.
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