I have been volunteering in free clinics in Virginia for the last 6 years. I worked in the Fredericksburg, VA free clinic last night, and realized that almost every patient I cared for last night has the potential to be helped by health system reform.
My first patient last night was a 22 year old female who was complaining of some gastrointestinal symptoms. This was her first visit to the free clinic. What was discouraging is that she had visited the emergency room 3 times in the last month before one of the emergency physicians suggested she enroll at the free clinic. She had CT scans and blood tests, but little information or education regarding her diagnosis or treatment plan. I found myself thinking about the stark differences between 3 visits to an emergency room as compared to 3 visits to a primary care office. In 2014, when she will be able to have health insurance through the Affordable Care Act (ACA), she will have access to the continuity of care of a primary care physician.
Caring for this patient last night triggered thoughts of a number of writings that address current and pre-ACA problems with the health system. She was seen in the emergency department 3 times in the last month, despite her lack of insurance and lack of ability to pay, due to the Emergency Medical Treatment and Active Labor Act, known as EMTALA. This was passed in 1986 when Ronald Regan was our President. Andrew Sullivan points out that EMTALA was the first step towards socialized medicine in the United States, but a remarkably inefficient, ineffective and expensive step. The health insurance expansion of the ACA will give over 30 million Americans access to new options for care instead of the emergency department.
I knew last night I might read, write and think a little bit too much about health reform when I found myself trying to calculate the cost of those 3 ER visits, and contrast that to 3 visits to my office. Alas, I am not a health economist, but few will attempt to argue the ER visits would be cost effective. I thought about the remarkable cost savings achieved in Camden, New Jersey, that Atul Gawande described earlier this year. My patient last night would have benefitted greatly from a program like the one in Camden, with access to support that potentially will come from the next phase of health reform. Medical Homes and Accountable Care Organizations, as we develop them, can deliver better care and dramatically lower costs. These reforms will also help the 39 year old diabetic I saw last night who has gone without her insulin for the past 6 months, and the 62 year old with emphysema who continues to smoke.
Reforms that will be achieved through full implementation of the Affordable Care Act, and ongoing efforts at delivery reform, give me great hope that Americans I have been caring for in free clinics will someday soon enjoy a healthier future.
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