The enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) represents the culmination of decades of thoughtful discussion among health policy visionaries, notwithstanding the U.S. Supreme Court's ultimate decision. During the Congressional deliberations, the President proclaimed: "(N)early a century after Teddy Roosevelt first called for reform, the cost of health care has weighed down our economy and the conscience of our Nation long enough. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year." ACA will provide needed health care to an additional 32+ million Americans; the priority being patient-centered primary care with an emphasis upon preventive-oriented, interdisciplinary, and integrated health services. The Institute of Medicine (IOM) has stressed that the health care needs of older Americans will be particularly difficult to meet given the current severe shortage of geriatric specialists, as will be the case with an increased demand for chronic care management.
Those fortunate to live in rural America (e.g., your Delta areas) have long appreciated the special "challenges" and "opportunities" involved. Diana Shaw, CEO of the Lana'i Community Health Center: "Lana'i has only one real town and only 3,000 residents. There are no chain stores or shopping malls. There is no movie theatre or night life to speak of, no public transportation, and rental cars cost about $150 a day. There is no pharmacy, and career options are extremely limited due to the focus on tourism. There are no stop lights, only one gas station (with gas last year close to $6.00 a gallon), and only about 30 miles of paved road. Everything on the island has to be flown in or brought in on the barge (which only comes once a week – weather permitting), and this can lead at times to prices which approach double what is seen elsewhere – even in rural communities on the Mainland. From a health care perspective, we have significant gaps in the area of women's health (among other issues, Lana'i does not have mammography capabilities on island), oral health (only one dentist serves the island, flying in on Monday and out on Thursday), behavioral health (no psychiatry, no inpatient substance abuse facilities, no domestic violence shelters on island), and limited on-island case management, prevention, and continuity of primary care. Babies are not born on the island, and mothers-to-be must relocate to Oahu or Maui at 36 weeks to avoid endangering the mother or baby. What in most other communities is a joyous family occasion, on Lana'i is a stressful, expensive occasion, with mothers-to-be separated from their 'ohana.'
"We have focused recruitment efforts on the young clinician – but found that they have their choice of places to live and work, and most have young families and want schooling options and activities for their children or work for their spouse. Also isolation presents a challenge to the young clinician who is used to being able to refer to specialists and having a host of colleagues at hand to discuss a case. Advanced Nurse Practitioners (APNs) remain the best option for our health center – and, actually, the most suitable option for our patients. The skills and mindset learned during their many years of nursing fit well with the needs and language challenges of our patients. APNs are more affordable. We have been lucky to be part of several training programs and especially helpful, when one considers our top diagnoses include stress and other behavioral health disorders, to be part of a clinical psychology training program. We recently resolved our problem of not having a psychiatrist on our island by using videoconferencing (VTC) technology. Our patients have been very pleased with this VTC option, but it took us over a year to find a provider on Oahu who would work with us due to their hesitance to use VTC as a medium. The challenges are many – but many hands make light work. Why are we doing this? Our greatest resource are the people of Lana'i – they are hard-working, sweet and friendly once they know you've come to stay. Our island is a gem."
Psychopharmacology (RxP) is an integral component of primary care. Although involved in the RxP movement from the beginning, it is impossible to predict the next state to enact prescriptive authority. Will Hawaii and Oregon overcome their vetoed bills? The numbers of colleagues completing advanced training continues to grow. As of the Fall of 2010, 276 graduates had been admitted to take the APA PEP (Psychopharmacology Examination for Psychologists), developed by the APAPO Practice Organization's College of Professional Psychology. With the advances in educational technology, those on their clinical internships should soon have ready access to medication decision protocols. Over the years, slightly more than one third of our State Associations have established task forces to coordinate RxP activities, with nearly a quarter having introduced relevant legislation. Today, several of the States pursuing this, such as Arizona and New Jersey, were initially expected by their leaders to be the "last in the nation." Guam has finally issued regulations for their 1998 legislation. Nursing, in collaboration with AARP, is systematically addressing practice barriers restricting their Doctor of Nursing Practice (DNP) scope of practice, pursuant to another IOM recommendation. Fundamental change always takes time; oftentimes, longer than one might expect.
A concluding reflection: Having recently retired from the U.S. Senate staff after 38+ years, I am intrigued by the experiences of other senior colleagues. Former VA psychologist Rod Baker: "My definition of a 'good retirement' -- Doing what you want, as much as you want, and whenever you want. And, if you are not doing that, you only have one person to talk to." Aloha,
Pat DeLeon, former APA President – Arkansas Psychological Association – April, 2012
