The ACA and Me: A Dispatch From the Trenches

Argonauta: The Beach at My Back/ oil stick on paper, 2010 by Julianna Paradisi

Argonauta: The Beach at My Back/ oil stick on paper, 2010 by Julianna Paradisi

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology.

 “Reality is the leading cause of stress among those in touch with it.”—Jane Wagner

By 2014, up to 30 million Americans will have gained access to health care insurance under the Affordable Care Act (ACA). As a nurse human being, I support increased access to health care. However, it is naive to believe it can be accomplished without sacrifice.

My job is a casualty of the ACA.

But let’s backtrack:

It’s more accurate (but less dramatic) to say that our country’s need of better health care delivery significantly affects my job. Most hospital nurses are familiar with Medicare tying reimbursement to patient outcomes. Further, built into the ACA is a requirement that hospitals expecting Medicare reimbursement form accountable care organizations (ACOs):

Under the proposed rule, an ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the patients they serve with Original Medicare (that is, those who are not in a Medicare Advantage private plan). The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries. The ACO would be a patient-centered organization where the patient and providers are true partners in care decisions.

In other words, hospitals are expected to stop competing for Medicare dollars and work together to reduce duplication of services, decreasing costs within their communities. This is not an entirely new idea in health care. Trauma and neonatal tertiary care centers existed before I graduated from nursing school. They provide advanced health care technology to communities unable to afford them.

ACOs go beyond this concept, however, mandating “partnerships or joint ventures arrangements between hospitals and ACO professionals.”

For example, one hospital will purchase the most advanced machine for radiology, while its competitor will invest in the latest laser surgery technology. Patients needing either will be referred to the center in their community providing that service, thereby increasing its number of billable Medicare patients, decreasing cost and duplication of services. This is my understanding of some of the changes taking place in accordance with the ACA. May I remind you, I am a staff oncology nurse, not an economist.

Here’s how ACOs affect me: My job as an oncology infusion nurse is being combined with those of another hospital offering similar patient services. The short version: After 20 years of employment, along with my coworkers I will have a new employer.

I know it’s just business. I go to work, and every two weeks receive a paycheck for my hours. Every two weeks, my employer and I are even. Still, it feels a little like how I imagine if, after 20 years of marriage, your spouse informs you he is leaving for no particular reason: “It’s not you, it’s me.”

Initially, I couldn’t help but feel abandoned.

A person’s reaction to such situations is clouded by sentiment. There are concerns about possible changes to regular work routines. There is worry over potentially commuting to other work sites. The funniest one occurred while I perused the hospital gift shop, lamenting to myself about the loss of my employee discount. Then I remembered: “We don’t have an employee discount, you sentimental fool!” Feelings of rejection play tricks on memory.

On the other hand, the new employer presents a very attractive job offer. In fact, some of the benefits are much better. I cannot resist this lover employer. Sometime this fall, just short of 20 years with my current employer, I will have a new employer.

Health care delivery in the United States is not only unjust—it is unsustainable. The ACA is one effort to fix both of these problems, putting the health care industry in flux. The question is not, “Will it change?” but “How?” Collectively, insurers and physicians have known this for a while, and react politically. Nurse leaders attend meetings in Washington, representing nursing’s voice in the conversation. The influencers with the most money have the biggest lobbies, but it’s too soon to call the final product of these discussions.

I continue to support increased access to health care; however, it is naive to believe it can be accomplished without sacrifice.

I am reconciled to the change occurring in my career. In fact, I will go so far as to say I am cautiously optimistic that I will find the change beneficial in some ways. As in any 20-year relationship, it’s not like my old job, while very good, was perfect.

I was recently considering all of this while strolling through the hospital lobby, where I ran into a friend from another department. “Hey, I hear your unit is getting a new employer. How’s that working for you?” he asked. “Oh, fine. No worries,” I replied. “I still have a job. You know, I’m a nurse. We come with the room.”

I could still hear his laughter all the way from the other end of the hall.

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. Cynthia Taylor October 1, 2014 at 10:59 am

    First, let me say that I did enjoy the article. I found myself thinking that I have some of the same concerns and sighs of relief. However, as an almost 40 year nurse, I am out of a job, and cannot find another one that I CAN do. That is, not working 12 hour shifts, not standing on my worn-out feet and legs, and as a result of job loss, no decent health insurance. At my age of 60, I had always been assured that if I worked hard, had a good work record, that I would have a good retirement and be able to live out my life happy and reaping the rewards of one of the most admired and respected professions in the country. After losing my job, I went through a whole bunch of emotions and outrage that this could happen. And we mention job change, changing employers, lack of duplication of services, etc. etc. I bring to the table another concern/idea: grief over job LOSS, sudden inability to pay bills and mortgage, worry about where to find health insurance, and jealousy that the younger, lesser trained nurses and even CNAs are getting the jobs that once went to RNs. Now employers have found that they no longer have to pay RN wages, that electronic charting makes even the poorly educated able to pass regular charting requirements–just fill in the blank or box! Simply hit a button; no need to write out or fill in blanks which require spelling and punctuation skills!
    I wonder if anyone has considered this phenomenon? No wonder RNs my age are being weeded out. The sad part is that we are not eligible for social security yet, and retirement plans do not kick in until after age 60, otherwise you are penalized for taking that hard-earned benefit that we sacrificed family, holidays, weekends for. And for what? To save the government money? It is difficult to be the same considerate, patient, and career-loving person after having lost so much!
    I would hope that those nurses who are so whimsical, care-free and flippant would stop to think about how they would feel if they lost that all-important job. This has brought about one important change in me: that is a cautious appreciation for the employer who pays the wages, and gives good evaluations (although it is no predictor of imminent job loss) as well as keeping up with government issuances like ACA. Please, please nurses—realize it could happen to you, and you may not see it coming! Do not assume your job is safe,even if you have been employed for years. You are dispensable.

  2. […] the possibility of some subspecialties being more boring than others. Her comment coincided with my current change of employers, which I’d previously written about, also for Off the Charts. Surprisingly, or maybe not, I find myself recharged by the change, even though I hadn’t […]

  3. JParadisiRN June 10, 2013 at 3:23 pm

    As the comments indicate, not only is the personal political, but for nurses, in our world of rapidly changing health care, the political is also personal.

  4. Peggy McDaniel June 5, 2013 at 10:56 pm

    Great post Juliana! Change is the only constant in life and the US Healthcare system needs to change. Along with change is always a feeling of uncertainty and even loss as you describe. It is stressful and nurses in particular resist change. Keep us posted on the transistion and I hope you get a discount with the new employer. 😉 Cheers!

  5. Julia Weinberg RN June 5, 2013 at 3:19 pm

    I appreciate your commentary here about the ACA and its effects concerning “Staff Nurses”.

    I will address your last sentence, because it is so ON POINT, as staff nurses we are a part of the room charge. Unlike Drs, administrators, manager or materials uses and pharmacuticles, and yet who is it who is spending 24/7 365 days a year with patients and helping them to heal and get out of the hospital and ensuring they do not return back in less than 30 days? NURSES! Where is it indicated anywhere our value added, we get blamed and discipline if something untoward happens due to not having all nurses need, like the right staffing mix, the tools and equipment to do our best care delivery and when economics take a nose dive who is layed off or kicked out as part of the room charge Nurses and assitive personel.
    In my 30 years as a practicing bedside clinitician (staff nurse), I am working on trying to get carved out and in a budget line noticed the actual charge rate each patient should have as part of their line item bill-one day soon, I will see reality. When that does happen I believe we will really see how it is the provision of our product nursing care for each individual patient makes in outrcomes which can then really be measure specific.
    By: Julia Weinberg RN

  6. Lois Roelofs June 5, 2013 at 12:29 pm

    As a retired nurse, I’m now only a consumer of health care. Good to hear your nursing perspective of the ACA.

  7. Betsy Marville RN June 5, 2013 at 12:06 pm

    I am glad to see you embrace the changes positively. Transition is always hard and some will have to face major changes. The PPACA’s ACOs are designed to reduce readmissions and coordinate care better than what we do today. No longer will a patient be sent home without follow up to make sure that they filled their prescriptions and are following their discharge instructions, including physician and/or nurse visits. As an ICU nurse, I was always frustrated when the chronic illness patients returned soon after surviving acute complications of their diseases. The revolving door was no good obviously for the patient or costs. Changing the culture from “we make more money the sicker you get,” to “we get paid more to keep you healthy” will take major adjustments and some time to get it right. The important thing is that we stop fighting the law before it even begins, and to work out the problems as we go. As you pointed out, the system we have been working in is not sustainable. The more nurses get educated on the PPACA and how to make it work for their patients and nursing, the better healthcare reform will be. Check out

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