Health after Oil will occasionally offer reports from practitioners who are aware they are working in health systems that are unsustainable and in need of transformation. We begin this series with two practitioner accounts of reactions to the implementation of President Obama’s recently Supreme Court upheld health legislation. The first is by Dr. S., a psychotherapist in a rural setting. She discusses the possible implications of the Affordable Care Act (ACA).  The second post is by Michael Bennett, a nurse, commenting on how the ACA has overlooked the issue of ecological sustainability. Dan Bednarz, Ed. 

Obama’s Affordable Care Act as Prelude

By Dr. S.

As a solo mental health practitioner in a remote rural California community, I’d like to share my experience with what is happening along the way to the collapse of our health care system. I opened my private psychotherapy practice in this rugged and remote area of California in 2006 because it was a community where there were no locally based full-time practitioners. Residents who needed mental health care were either foregoing treatment or driving an hour each way for their 50-minute hour of talk therapy or their 10-minute “med check” with a psychiatrist.

I reasoned if I established mental health services here in this rural community when the health system/economy was still running, then as the collapse unfolded I would be able -in this localized setting- to offer my services in whatever alternative socioeconomic system of exchange emerges.  While there is still no local psychiatrist here, over these past six years I have been able to establish a successful private practice. This has been made possible by 1) advertising in the local community newspaper, 2) working hard to get into as many insurance networks as possible so that people with insurance can see me and 3) offering a sliding fee scale for clients without insurance.

While I have always favored shifting health care to a single-payer system, I did not oppose President Obama’s Affordable Care Act (ACA). As this “reform” is beginning to take shape in California, however, I am seeing that it will most likely put me out of business and thus leave our rural community once again without access to local mental health services. This is not only an economic concern to me but personally and professionally frustrating because the localization of health services will be critical in the net available energy descending society we are now entering.

Today I want only to discuss why the ACA is working against my efforts to build a localized practice.

From what my clients and I are experiencing the actual implementation of ACA appears designed to channel or “incentivize” existing and newly insured clients into large bureaucratic urban-based profit-making HMO’s centered around primary care providers. This type of care occurs in clinic settings where fee-for-service payments to free-lance providers such as myself are eliminated. Instead the HMO gets a per-enrollee allotment and then covers provider salaries or fees to nearby providers in closed or limited networks. This would not necessarily eliminate private practitioners like myself from participating since, theoretically at least, we could negotiate agreements with the HMOs to accept whatever payment the clinics would offer. Even if this is possible, however, this is not the direction the HMO’s appear to be taking.

Instead, they seem to be moving toward hiring or contracting with select providers in highly populated areas, often using interns or newly graduated professionals –to whom they can offer low fees compared to more experienced and higher credentialed therapists. These interns and recent graduates are expected to use cookie-cutter, evidence-based, treatment protocols for as brief periods as possible. In other words, the profit of the HMO, not therapeutic efficacy, gives every appearance as being the primary goal.

While I can’t be positive that what I have encountered in my case is happening on a widespread scale or is a conscious HMO strategic goal, my experience to date and is one that I strongly suspect is growing more common as the new changes take effect. I have as yet been unable to pin down what the rules are or will be. My locally based medical biller is also trying to ferret out how this system will work.

This past month I have lost four clients and expect about third of my practice to disappear within the year now that California is eliminating the Healthy Families program and pushing those children I served through it into MediCal. MediCal children living here can only be seen at a clinic about a half hour away over mountain roads. This facility has limited mental health services (as per described above) and parents of my Health Start clients beg for any chance not to have to take their children there.

Of the clients I’ve lost thus far, two are disable elderly gentlemen who thought they were on Medicare, which I am able to take. Since payment can be months after treatment begins, I discovered only recently that Medicare has denied my billings for both these men. They had no idea that they had assigned away their Medicate benefits to HMO’s that would not reimburse me or other providers they had been seeing. We have appealed but each of these two client’s insurers have now denied me either network status or an emergency single agreement for these men. The providers they accept are an hour to an hour and half away. One of the men cannot drive; the other has a car that cannot make that long of a trip, nor can he afford the $50+ average round-trip cost of gasoline to get into the cities where the providers are located.

In the latter case the patient had been referred to me by an MD, who is in the network and had indicated on the referral he sent to me that this was a Medicare patient. Upon discovering that he could no longer see me and his oncologist this client regressed into a suicidal depression from which he has just started to emerge. For three weeks all we dealt with in our sessions was his panic about losing his providers.  I assured him I would work something out for him to pay me on a hardship agreement, and we have done that, but he has cancer and his oncologists are with UCLA. They, too, are not in this network and UCLA will not work out another payment plan. So my client has decided to “wait” on his cancer appointments until October 15th when he hopes he can change insurance companies to one that his oncologists and I are in.

Of note in this latter case is that the client’s mental health insurer is a foreign-owned company that is four levels down the hierarchy of bureaucracy: Medicare (which I’m in), AARP, United Health Care, (which I am in) and Independence Medical Group (which will not accept me). Getting into each of these networks requires hours preparing extensive paper work and long delays in getting confirmation of acceptance or denial. I have spent six years gaining entrance into the major provider networks. In the case just described I spent an entire weekend getting requested materials together for them to justify my being able to see the patient.

So, is there any wonder this system is sinking and, moreover, moving in the opposite direction it should be headed?

The Affordable Care Act’s Fatal Omission?
Michael Bennett, MSN, RN

As a nurse I have a participant observer’s point of view to offer in contrast to those of many who have analyzed the recent Supreme Court ruling upholding President Obama’s Affordable Care Act. I’m not going to offer one more opinion about the morality or legality of the individual mandate or how the insurance companies and health care providers will have to adapt to the changes and how it can be repealed.

The proverbial elephant in the room (and perhaps the ACA’s fatal flaw) from my in-the-trenches standpoint is the sustainability question, How on earth is this health care system going to survive?  The question has two components: First, the billions of dollars required to implement and sustain the ACA.  Second, and most important, I’m talking about the viability of a system that is inextricably dependent on a ready supply of resources that are being consumed faster than they can be replaced. This rarely addressed issue was raised three years ago in the context of how sustainability was totally absent from the debate about the drafting and passage of ACA.[i]

Despite my awareness of the problem, when I am at work as a staff nurse, I unwittingly contribute to it.  I necessarily consume a steady stream of disposable single-use products during the course of caring for my patients – pre-filled plastic saline syringes, plastic and paper medication wrappings, plastic IV fluid and blood product bags and tubing and their plastic wrappings, plastic lumen caps, plastic isolation gowns, plastic cups and straws, plastic juice containers (and there are excellent evidence-based reasons for all of it).  I run around to my patients’ rooms with a “Jetson” – essentially a computer cart that is on 24 hours a day, 7 days a week – to scan wristbands and medication bar codes prior to giving medications.  Then I sit down at desktop computers (also on 24/7) to document my assessments, page physicians and mid-level providers as needed, and write progress notes on my patients.  I try to use alternatives as much as possible, for example, often there are cloth isolation gowns in the isolation carts that I use.  And the non-profit hospital I work for has chosen to purchase cups with post-consumer recycled content, to virtually eliminate styrofoam, and to divert dozens of tons of waste through their recycling program.  Nevertheless, I can’t help but wonder, even in the midst of my frenzied compulsory consumption, how this will all continue as we progress further along the downslope of Hubbert’s Curve.

There is plenty of evidence that we have, in fact, reached and surpassed the peak of global oil production, despite insignificant variations from year to year and the fact that we can still rely on fossil fuel resources whose production has yet to peak (e.g., coal).  But no matter what your position on peak oil, it’s hard to argue with the fact that oil and other fossil fuels are resources that we are consuming faster than they can be replenished.  And knowing first-hand about how the healthcare system operates, it’s also hard to ignore that modern medicine is almost literally dripping with them, given the amount of oil-based plastic products that pervade it, the amount of oil required for the production and transport of pharmaceuticals, and the predominantly coal or nuclear electricity required to run our health care facilities and power our electronic medical records.

Although I welcome any and all information to the contrary, I would rather spend less time rehashing the problems, since there is already a wealth of information about them[ii] and, instead

focus on something we can all agree on – how to ensure the health and wellness of all people REGARDLESS of the availability of cheap fossil fuels.

What is your vision for a sustainable healthcare system? Whether you are a healthcare professional or interested citizen, please consider submitting an essay to the Health After Oil blog (dangpgh@gmail.com). If you do not have the time to submit an essay just join the conversation over at the Sustainable Healthcare Group. (https://groups.google.com/forum/?fromgroups#!forum/sustainablehealthcare).

[i] Bednarz, Dan and Jessica Pierce. “The Ethics of Sustainable Healthcare Reform.” Health after Oil, August 28, 2009.

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