Enforcing the Line
Trisha takes a break from work—at home, in her own safe place. She meets with me outside her home, in my camper trailer. She calls it cozy and homey. My dogs and cats pile on top of her. We start chatting about nothing in particular at first. The television runs in the background. My husband stirs awake in the bedroom.
She sighs as she sits down on my small couch. I can hear relief in her voice and see her body relax. The conversation starts slowly. We’re both still waking up. She pets the cat as she begins the harder parts of her career.
I felt nervous about questioning someone whose job depends on compliance. In a way, I am asking her to comply during this conversation, extending her workday into her personal time. It’s a delicate balance. She pauses longer before answering. I adjust my tone. She chooses her words carefully. This is a privilege for me, as her job requires strict limits on what she can share outside her office.
Hundreds of cases can cross Trisha’s desk on any given day. Now, only a few remain as the merger takes its first steps. In such a high-stress situation, enforcing boundaries she did not choose takes a toll on her.
She adjusts herself on the couch before beginning.
“Working with specific government programs is somewhat expected,” she says. “You might assume the rules would be clearly established and easy to understand, but the bureaucratic system is often built on very complex documents. In healthcare, policies and guidelines are constantly changing. One rule applies one week, then updates shift expectations before there’s a full explanation of why. It becomes an exercise in trusting leadership and governing agencies.”
She is largely accountable for outcomes she did not design. She holds it in her body—in her stomach, where stress likes to ferment. She places her hands around it, as if protecting it from this conversation.
She once had to deny cancer treatment because the insured was not “sick enough” to meet the criteria.
My stomach drops when she says it. I open my mouth, then close it. It isn’t my place to fracture her steadiness. We sit in the quiet aftermath of a decision that altered someone else’s life. The room around us buzzes with life—a laugh track flickers. She pets the cat. The coffee has gone cold.
“This experience can be both very difficult and very rewarding,” she says. “It depends on personal accountability. In life, we are responsible for our reactions, but not always for our actions. I am responsible for carrying out tasks others have decided on. If those tasks align with my personal ethics, it’s a personal victory. If they conflict, it triggers an internal response. My service mentality and drive for professional success require me to set aside my personal beliefs and trust in leadership.”
She says it as if she has rehearsed it. Perhaps she has.
When she enforces a rule she didn’t design, her authority does not originate with her; it is something she wears like a borrowed uniform, stiff and ill-fitting. She hears the crack in their voices, feels the ache of saying no when every part of her wants to say yes, and still she has to stand behind a decision that was made far away from the person on the other end of the line.
“That authority truly comes from within,” she continues. “I could easily ‘pass the buck,’ challenge the request, or avoid taking action. I recognize that, as a professional, I might not have all the answers to justify every action. In the current situation with UCare, I’ve been given directives that don’t make sense to me and seem contradictory to my years of experience in this role. Still, I have to acknowledge that many things happen behind the scenes to bring us to where we are as a company. Many people and agencies are working to move this process along, and as a cog in a wheel, I have to trust the people and agencies in place to carry it out.”
When she calls herself a cog in a wheel, something tightens in my chest. The metaphor protects her. If she is a cog, the outcomes are not solely hers. The denial is not personal. The harm is structural.
I nod. My body holds the tension for her.
I want to inquire more. To reopen what keeps her steady might be a question—or a luxury.
She did not create the rules. She does not know where they originated. Her competence requires her to carry them out anyway.
“This is challenging and very personal to me,” she says. “Even when I don’t fully agree with what I’m expected to do, I’ve made a commitment to the process set by others. That includes difficult decisions and expectations that don’t always align with my personal beliefs. It can feel like a mental struggle when my ethics are tested, but my stance has always been to adhere to the boundaries imposed on me to the best of my ability. Sometimes that means I have to ‘mask’ my feelings and regulate my emotions to get the job done.
As someone who deeply values self-growth and self-awareness, that can be hard. There are moments when I have to swallow my own feelings—my own self-care, really—to honor someone else’s boundary or expectation. I pause and ask myself, ‘Will this benefit someone else?’ If the answer is yes, I find a way to quiet my feelings and give myself grace for bending. I remind myself that I am a cog in a wheel. What I do as part of an expectation or directive is not only about me. By respecting that authority, I’m honoring my commitment to be of service.”
She has wept for the insured, carrying their fear and confusion long after the call has ended. Each story lingers in her chest—a missing paycheck, a wrecked car, a sudden diagnosis— until it feels like her own life is beginning to unravel.
She goes on to say, “I roll with the punches.”
Fewer files are in her inbox. The work persists even as the institution prepares to close.
I ask her what happens when someone does not accept the boundary—what an appeal is meant to do.
“Appeals are the system’s promise of reconsideration. When new information surfaces— or when someone refuses the boundary imposed—an appeal reopens what was closed. It is a conversation conducted through forms instead of voices. The decision stands, but it must stand again. An appeal can escalate. When internal review fails, the case may be referred to an Administrative Law Judge. The company and the patient stand before someone outside the wheel, arguing over whether the boundary should have held.”
She speaks of leadership with trust. I hear something quieter beneath it.
There are days when her voice carries the office into the living room. The sentences are tighter. The pauses are longer. I recognize the cadence she uses with claimants when she is choosing her words carefully, the way her tone pitches up. It appears in conversation with my husband. It appears in small disagreements. It appears when she is tired.
We used to argue quickly and forget just as fast. Lately, there is more calculation— restraint. I do not always know whether I am speaking to my mother-in-law or to the professional who must measure every phrase.
There are moments when I ask her to explain the system, and I can feel her withdrawing —not defensively, but protectively. There are things she cannot say. There are things she should not say. My questions, meant to clarify, sometimes brush against the boundaries she enforces.
She answers anyway. Carefully. Even when the language is clipped. The conversation continues, even as the system narrows.
When she visits after a long day, I do not challenge the policy. I listen. I try not to feel the weight she is carrying. I aim to be compassionate without becoming reactive. There is discipline in that—staying composed when someone you love talks about harm they had to enforce.
The system narrows her language. I narrow mine in response. When she is tired, I let the metaphor stand. I let it hold her together. My resistance exists more on the page.
I shift in my seat, laptop sliding to the top of my lap. I take notes as she talks.
When she describes a denial, I feel it in my chest. It does not feel like my place to fracture her steadiness. She carries enough weight in the office. I do not add mine to it.
There is a discipline to listening without unraveling. She speaks about directives that contradict her experience. I do not tell her what I think about leadership. I do not ask who decided. I let the room remain intact.
If she must regulate herself all day, I tell myself the least I can do is remain regulated in return.
The feeling does not disappear. It moves somewhere else. It waits. Sometimes it surfaces later—in writing, in questions I ask more sharply on the page than I ever would across from her on the couch. We share a bodily closeness to the system’s effects and a constant effort to stay human within it.
On the page, I reopen what I leave undisturbed in the room.