When I launched my private practice, it was on the Eastern Shore of Maryland in a small town.  I joined a physician who had been in practice for several years.  I managed to keep my schedule light for a few weeks so I could study for my Board Examination.  I had just finished my residency training but I was no stranger to outpatient practice.  After my return from the exam which I opted to take in Orlando, I never saw fewer than 20 patients a session.  The busiest days saw us seeing 30 or more patients.  I admit that many walked in but most were scheduled.  This was in early 90’s which was the beginning of the rise of HMO’s.  My practice was hospitable- sponsored.  In less than 1 year, I had repaid the hospital the loan and started to make a profit.  Many of my patients were uninsured but a significant number were Medicaid, Medicare and HMO. I welcomed the Clinton Health Plan and even was interviewed by local newspapers.  Sadly, for my community, it never happened.

The Affordable Care Act (ACA) will change the number of uninsured patients in the US.  While I was on the Eastern Shore in the 90’s, it was apparent that many of the residents had no way out of the cycle of poverty and the health problems neglected from being uninsured.  The reality played out in the Emergency Room of the local hospital day and night.  Being uninsured affected every family. Our community had business owners who were farmers, fisherman, mechanics, contractors and shop owners.  Many made too much money for Medicaid but they could not afford the cost of private insurance.  Many of them landed in the ER with serious medical conditions they had ignored.  Some even called my office and were seen as emergency visits.  One particular case was a bit scary.  One of my staff called and brought her brother in.  He was complaining of chest pain and would not go to the ER. They came to the office and I did an EKG.  To my surprise the brother was having an acute myocardial infarction.  He was uninsured and was still refusing to go to the ER even as the ambulance arrived.  We did get him there.  He and I had a tense ambulance ride together to the tertiary care hospital and I handed him off to the cardiologist who greeted us both and whisked him off to the Cardiac Intensive Care Unit.  Weeks later, the community came together for a fund-raiser.  I attended and was to my surprise honored by everyone for my excellent care.  Unfortunately, I had to leave to go to the ER to care for a patient that was not so fortunate.

I had hoped that the HMO’s would make healthcare affordable but that did not happen.  The reality for patients then and now is that if you lack insurance, you end up in the ER.  I worked with the local health department.  My office was ground-zero for many programs.  We saw patients enrolled in the Breast and Cervical Cancer Screening Program, Vaccines for Children and participated in every pharmaceutical company sponsored free medication program. We saw patient from the Mental Health programs, Drug treatment programs, and Adult Daycare.  My practice had so many patients enrolled in Pharmaceutical Company Patient Assistance Programs; one company invited me to give a presentation to a group of providers.

I was a member of the steering committee and a board member of the new Federally Qualified Community Health Center (FQHC) in our town. It was our answer to tacking the rate of uninsured patients.  It was hard work to get the grant written, not by me thankfully but I did read it and had to give input on the clinical operation.  I also had to pledge my service which meant clinical sessions, on call coverage and hospital admissions.  I was also involved in recruiting the first full-time provider.  We were fortunate to be designated a National Health Service Corp (NHSC) site.  This allowed us to recruit a NHSC scholar who could use our site and a 3-year commitment to repay medical school loans. The good news is that built into the Affordable Care Act is increased funding for the NHSC.  The program is now expanded and will allow an increase in primary care providers in areas where they are needed.  We were fortunate to get a brilliant young Family Physician in our community. The CHC is still there but it is now part of a bigger network. Across the US, FQCHC are providing care to uninsured and under-insured patients.

Medicine for me has always been about helping my patients. The Affordable Care Act is going to change the delivery of medical care in the US.  I am gearing up for all the excitement.  I work now as a Medical Director for Student Health Services at a major university.  All fulltime students are required to have insurance either through their parents or a plan that is sponsored by the school. The plan is also available to part-time students.  It is very affordable for students.  My task is to help students be informed about what is covered and how to access care using the insurance plan. The Affordable Care Act requires that the policy meets all the same criteria as plans to be provided by other plans.  It must provide preventive services, emergency care and coverage of medications.  There is no restriction for preexisting conditions.   The next dilemma will be if there is the capacity to care for all of the patients.