Here’s an important segment of the social engineering component of the Affordable Care Act (ACA), passed under the Obama presidency:

The ACA provides a strong emphasis on preventive medicine and primary care through insurance reform, increased reimbursement for primary care providers, funding to educate these providers, and incentives to attract providers into primary care. The Nurse Practitioners (NPs) are especially well prepared to educate providers on the use of evidence-based preventive care and to assist the U.S. healthcare system in its transformation toward this model.

In other words, under the rubric of preventative medicine, millions of people who might not have gone to see a doctor prior to ACA are being encouraged to go.  To meet the cost of those millions of new patients, new institutions like urgent care centers are springing up.  Physicians’ Assistants (P.A.s) and Nurse Practitioners (N.P.s) are being used to treat these people as well as more serious cases.  The medical schools do not turn out enough M.D.s to treat the 30 million people (new “patients”) who are being channeled into the American health care system.  As my primary care doctor (an M.D.) told me, there is increasing pressure on him to have a practice of only very sick people.  He frankly told me that he does not want the stress of treating only the very sick all day, every day.

So, in the post-ACA morass, we have too many people going to see M.D.s who don’t need an M.D.  We have too many very sick people that have to wait a very long time to get an appointment with an M.D.  And...we have increasing numbers of P.A.s and N.P.s supervising the care of very sick people.  With millions of dollars pouring into the health care system from the federal government, it becomes a boon to hospital income to have less qualified personnel who need to be paid less than M.D.s.  It’s a morass depicting itself as “needed reform.”  From the Hippocratic Oath to do the least harm, the health care world has shifted to the “principle” see the most people and diminish the quality of health care.  There is a trade-off between the numbers served, which increases, and the quality of care and professionalism, which decreases.

When this writer had major heart surgery in 2020, instead of a second surgeon being present during the surgery, as had been the case for heart surgeries and all major surgeries for many decades, a P.A. was included.  Even while I waited on my stretcher to be wheeled into the operating room, I asked the nurse in charge why I did not see a second surgeon as part of the assembled team.  This paradigm shift was in the official surgery summary report.

Additionally, the heart surgery wing of the major New York City hospital (where many of the patients had life-or-death issues) was headed up by an N.P. and a P.A.  Only five years before, I was in the gastrointestinal wing of the same hospital for surgery, where the majority of cases were less life-threatening than the cardio wing, but an M.D. was always in charge and sometimes visited my room, once with a team of residents who were learning about the post-surgical progress.  Five years later, other than a one- minute visit by my surgeon and a five-minute visit by my anesthesiologist over a six-day period, only one M.D. appeared in my hospital room along with my assigned P.A., with their sole purpose being to tell me when I would be discharged.

This shift in attentiveness and expertise was, I believe, at least in part because of the shifts in emphasis regarding health care priorities brought on by Obama’s legislation regarding health care.

Governmental statements summarizing the ACA are obscurely written but can be “translated.”  For example, the National Institutes of Health writes, “Accountability for care may be spread across provider types and over a period of time, which incentivizes those providers to work together and integrate services and provides some degree of risk transfer.”  In English, this means that the ACA discourages individual medical practices.  This would of course mean that patients could be scheduled to see more than one doctor in a given visit, and this would cut costs.

A second change noted by the NIH regarding health care delivery under the ACA states, “Groups of providers (e.g., accountable care organizations or ACOs) with access to data and information systems, and the people who can interpret those data and information, can better provide and coordinate care, and manage costs given the risk and accountability.”  The translation: government payouts incentivize greater use of computerization in the health care system.  This writer’s wife at one point had a cardiologist who sat behind his desk and took notes about what she said, and he looked at his computer most of the time.  Sometimes he came out from behind his desk and looked in her mouth using the light from the flashlight in his iPhone.  At no point did he ever listen to her heart or lungs with a stethoscope. 

A health care organization advertising in NYC says that elderly people will like their examination centers because doctors will listen to them (notice: the ad does not say “examine them”) while an assistant to the doctor takes notes on his tablet.  Cost-cutting becomes a higher priority under the ACA.

Not only is the practice of medicine being affected clinically, but the wider use of N.P.s under Obamacare is part of the federal government’s attempt to extend the tentacles of its power into the home under a disguise of “caring.”  An article about the increased use of N.P.s under Obamacare states, “Nursing’s emphasis on preventive healthcare can be traced to Florence Nightingale’s Notes on Nursing, first published in 1859.  She recognized that patient care must first be focused on providing a healthy home environment which she described as having pure air, pure water, efficient drainage, cleanliness, and light.”

According to the writers, increased involvement of N.P.s beautifully connects medicine with the environmental goals of having a healthy, clean, environmentally safe home.  Do the writers of this pro-N.P. article remember when M.D.s normally would make house calls?  Do they believe that homes became healthier and more environmentally sound during the 1940s?

Are you satisfied?  The ACA is a case of monumental overreach and complexity.  The reorganization of medical practice has been less than satisfying.  Costs have risen.  Service has declined.  Life expectancy in the USA declined 2.6 years from 2019 to 2021.  National government-run health care continues to be a non-starter.

Image: Pkd2016 via Wikimedia Commons, CC BY-SA 2.0.