With the failure of the American Health Care Act (AHCA) on Friday and the declaration that "Obamacare is the law of the land" by our lawmakers, an angst that I had since before our President (45) was elected has been quelled, at least for now. I am relieved and I quietly celebrate for the individuals and families I pledged to serve upon my graduation from medical school. Now that the law has not been repealed, it will be my duty to ensure that the legislators hear the cries from physicians and patients and continue to fund the law in meaningful ways. I will return to work at the beginning of the week able to reassure my patients that, for now, anyway, they will not be stripped of their insurance.

I know there are some doctors out there that think the Affordable Care Act (ACA) is disastrous. I believe it was imperfect but a godsend for my patient population. The only thing better would be a single-payer system, "Medicaid for All!" as is now being chanted across the country by Progressives. Because, why not join all of the other developed countries in the world in recognizing health care as a human right we want to provide to all of our citizens, regardless of their ability to pay?

Let me back up and trace my roots in medicine just a little bit here. As a medical student at the end of my third year, I was disillusioned. I wondered if medicine was really for me, which was a tragic realization after three grueling years of school and thousands of dollars in student loans. I had liked the baby delivering part of my OB rotation but hated vaginal hysterectomies. I loved pediatrics and wanted to follow the baby as well when I was on the OB side of things. An unwitting mentor pointed me in the direction of family medicine, and I never looked back. A year of public health school at the Harvard Chan School of Public Health (then the Harvard School of Public Health) reinvigorated me. It reminded me of all of the reasons I wanted to go into medicine in the first place. A mini-course on Community Health Centers that I took during the winter semester gave me a more specific aspiration--I would train and work in a federally qualified health center (FQHC), eventually assuming a leadership role and helping in program development to address the social determinants of health in my community.

It was with that aspiration that I left Harvard and Boston, where we had a health system that provided nearly universal coverage to Massachusetts residents, to Seattle, Washington, where no such system was in place but where FQHCs were abundant and thriving. I chose my residency program specifically because it had several community health center (CHC) sites and the CHC I was to fall in love with comprised exactly the community I wanted to serve--majority African American with a sizeable Latinx, monolingual Spanish-speaking population. I came to Seattle wanting to experience what an FQHC could provide without as replete of a safety net as available in Massachusetts under "Romneycare."

I think through the end of medical school and the beginning of residency, part of me didn't believe that the Affordable Care Act would see the light of day, with the opposition throughout the entire process from the Republicans and not-so-distant memories of Bill Clinton's failures to institute his own health care reform. Disheartened after a Democrat was the most vocal in striking down the idea of a single-payer system, I stopped following the legislation as much. I was deep into transitioning from my intern year to my second year of residency as I began to see the impact of the ACA at my own health center.

Our health centers, which comprise two clinics, had an overall uninsured rate of 50% before the ACA. This was higher than for any other FQHCs in the county and was higher than the state mean. This was because of our unique demographics--poor black and Latino patients who were not so poor to qualify for Medicaid but whose jobs did not provide health care or who were unemployed at one clinic and low-wage earning young white people whose jobs did not have benefits at the other clinic. With the advent of the ACA, in two years our uninsured rate dropped from 50% to 20%, with many people qualifying for Medicaid under the expansion and others having insurance available for them through the marketplace.

In the first months after the ACA, we saw a decrease in our patients after a few of our patients' insurances had been upgraded, or they bought better plans through the marketplace that allowed them to leave the community health center for private clinics. That time period was short, however, because we had a rebound of patients who hadn't had good insurance before who were now Medicaid eligible, and a few patients whose insurance had changed and could no longer attend their former clinics.

I personally had visits with patients who struggled without insurance acquire insurance after the ACA. With me, piece by piece, we began to fully address their complicated health problems, getting them the testing and specialty care they had always needed but could never afford. Practicing medicine in this setting became a lot easier. I still saw uninsured patients every day, especially my undocumented patients who did not quality for health care under the ACA, but so many of my patients could now get the care they needed without us searching for the right charity care program.

Around the country, over 20 million people who were previously uninsured now had insurance, and we don't know how many more who were underinsured now qualified for care under the Medicaid expansion. If I took the patient stories from my clinic and extrapolated it out to those 20 million people, in spite of its imperfections, I could only see net benefit in the signing of the ACA into law. I could only imagine the millions of stories of relief, of empowerment, of hope, of determination as people felt finally in control of their health.

So in the late evening on November 8 when I realized that 45 was going to be our next President, I curled into a ball on my sofa and cried. I cried for my patients, for the hopeful faces I see every day. My thoughts went to individuals and families that I knew would lose coverage if the ACA were repealed as 45 promised, as Republicans had been salivating about for the last 7 years.

What ensued over the last several weeks, culminating in the last 48 hours of the bill's life, was chaos. It was shameful. In one of its last iterations, proposed cuts to mammography and maternity care were added on to the bill that already promised to do away with the required birth control benefits of the ACA and defunded Planned Parenthood for one year. And it just seemed eugenic to poor women to not provide adequate tools for family planning, not fund their maternity care and defund their cancer screenings.

I understand that the reason the bill did not even pass the House was not because of a bunch of bleeding hearts for the 12 million who would lose their insurance after a year. One of the major contenders, the Freedom Caucus in the House, thought the AHCA did not swing far enough right. For all the reasons that the bill did not pass and for all of the reasons the ACA is not repealed, I am thankful.

I came of age as a physician with the ACA. I've grown with patients who were once uninsured but now have insurance and are able to get all of the medications, health care maintenance and specialists visits they need. And to repeal a law that provided health care to millions who previously had no access with a replacement that would save money by immediately strip millions of insurance was cruel.

Admittedly, since I work among the most marginalized populations, I didn't see one of the major drawbacks of the ACA, which were the rising premiums for the middle class. Most of my patients are at 200% of the poverty line or below. Most who have private insurance have it subsidized through their employer and did not feel the premium spike as much as those who relied on insurance through the marketplace. I have seen fluctuations in medications and services covered by some of the major insurance companies in the Market Place that I believe are secondary to the changes that came about with the ACA. The New York Times also outlined, in countng the law's failings, that we do not know if this increase in insured Americans improved health outcomes at all. It's too early to tell.

Also, since I work at an FQHC, we get reimbursed more by Medicaid than private clinics, so whereas there were many clinics overwhelmed by the influx of Medicaid patients and subsequently put new limits on the Medicaid patients they would attend, our clinic welcomed these patients with open arms and saw overall improvements in our budgets.

One has to work with the most underserved populations to feel the pulse of the ACA, to get to its heart, to where its benefit was maximum. Many people do not know these spaces exist, and many physicians do not practice in this space. As one who does, who always has, and always wants to exist in this space, let me tell you, the ACA is invaluable.

Please remember my patients as we communicate with our lawmakers about actual, meaningful and operational reform of this landmark law.

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