This week has a certain nostalgia for me. I am working the last four shifts in my home, Humboldt County. Nestled between pristine redwoods and dramatic cliffs overlooking the west coast of California, I want to stay here, but cannot. I am feeling the full force of the United States health care crisis. In the four years I have worked here eight of ten obstetricians in the southern half of the county have left, and now I find I am one of them.

Two obstetricians, far apart geographically and serving two different hospitals, are all that is left to serve an area once supporting 10 obstetricians. Both doctors are men over 60, who have a tough future ahead of them. Without outside help there is no way they can see all the patients that will need them. They have to remain within 30 minutes of the hospital and can be told to come to work any time of the day or night. They can never have a moment off, a full night’s sleep, a drink of alcohol to ring in the New Year. Watching a full length movie, or having a nice dinner with the spouse without interruption is a thing of the past. Neither of the remaining doctors can get sick or injured. This is really asking them to be super human and there is no cavalry on their horizon. In fact, if Catholic Health Systems is successful at closing one of the two hospitals, only one physician will remain.

As a young person, I wanted to take my medical skills to a disadvantaged third world nation. Looks like I got my wish—right here in the US. How did we get here?

Humboldt County illustrates many of the ills, both old and new, this broken system imposes on the citizens, and particularly the women, of the US. To really see the complexity, you have to look at all the levels putting pressure on this shattered system.

National:

If you were listening to American propaganda news casts last week, you heard the Affordable Health Care Act (ACA) or “Obamacare” shut down thousands of private health insurance plans and that President Obama lied when he made the campaign promise, “If you like your health care plan, you can keep it.”

The standard set by the ACA was so low any real health insurance plan could have stumbled over it dead drunk and in the dark. So why are some of the plans failing?

For decades, the health care system in America has been plagued with “Junk Insurance.” These are plans that call themselves insurance, but if someone on the plan actually got sick, the insurance would not cover anything. Companies get away with this, because all health insurance contracts read like real estate derivative scams; they are so complicated, no one can understand them. It is not legally fraud. The customer signs a contract that does actually say they won’t get coverage for their heart attack, stroke, appendicitis, car accident, etc. It says it in fine print, in ways no one is intended to decipher.

People enrolled in these plans pay monthly premiums that are slightly less than real insurance, believing they have a great deal. Sales people, who “explain” the plan to them, give them that impression. But should they actually become ill or have an accident, they quickly find their premiums were wasted. They have been duped into believing they actually bought something. The truth is, those people would have been better off uninsured than paying premiums for years for no real benefit.

Even if you had real insurance you are a victim of this sort of scam. As junk insurance became more profitable, legitimate insurance companies found they could cover fewer and fewer benefits for the same price. It has created a race to the benefit bottom.

So the Affordable Care Act got rid of all those types of insurance, right? Wrong. The ACA apparently was never meant to stop scam insurance. Those plans were still operating even before the President caved in to media pressure and allowed new fraudulent insurance plans to continue. You might even be enrolled in one right now. Turns out I am.

When my adult daughter, who is getting a graduate degree and still on my insurance, hedged at going to the doctor for a check up this year, I proudly told her that she need not worry. The Affordable Care Act guaranteed that as of August 1, she could go for her annual, get her birth control and her immunizations for free.

15 Covered Preventive Services for Adults
1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
2. Alcohol Misuse screening and counseling
3. Aspirin use for men and women of certain ages
4. Blood Pressure screening for all adults
5. Cholesterol screening for adults of certain ages or at higher risk
6. Colorectal Cancer screening for adults over 50
7. Depression screening for adults
8. Type 2 Diabetes screening for adults with high blood pressure
9. Diet counseling for adults at higher risk for chronic disease
10. HIV screening for all adults at higher risk
11. Immunization vaccines for adults–doses, recommended ages, and recommended populations vary:
Hepatitis A
Hepatitis B
Herpes Zoster
Human Papillomavirus
Influenza (Flu Shot)
Measles, Mumps, Rubella
Meningococcal
Pneumococcal
Tetanus, Diphtheria, Pertussis
Varicella
Learn more about immunizations and see the latest vaccine schedules.
12. Obesity screening and counseling for all adults
13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
14. Tobacco Use screening for all adults and cessation interventions for tobacco users
15. Syphilis screening for all adults at higher risk

22 Covered Preventive Services for Women, Including Pregnant Women
The eight new prevention-related health services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, 2012.
1. Anemia screening on a routine basis for pregnant women
2. Bacteriuria urinary tract or other infection screening for pregnant women
3. BRCA counseling about genetic testing for women at higher risk
4. Breast Cancer Mammography screenings every 1 to 2 years for women over 40
5. Breast Cancer Chemoprevention counseling for women at higher risk
6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*
7. Cervical Cancer screening for sexually active women
8. Chlamydia Infection screening for younger women and other women at higher risk
9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*
10. Domestic and interpersonal violence screening and counseling for all women*
11. Folic Acid supplements for women who may become pregnant
12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*
13. Gonorrhea screening for all women at higher risk
14. Hepatitis B screening for pregnant women at their first prenatal visit
15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women*
16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older*
17. Osteoporosis screening for women over age 60 depending on risk factors
18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
19. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
20. Sexually Transmitted Infections (STI) counseling for sexually active women*
21. Syphilis screening for all pregnant women or other women at increased risk
22. Well-woman visits to obtain recommended preventive services*
Learn more about Affordable Care Act Rules on Expanding Access to Preventive Services for Women.
(Effective August 1, 2012)

26 Covered Preventive Services for Children
1. Alcohol and Drug Use assessments for adolescents
2. Autism screening for children at 18 and 24 months
3. Behavioral assessments for children of all ages
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
4. Blood Pressure screening for children
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
5. Cervical Dysplasia screening for sexually active females
6. Congenital Hypothyroidism screening for newborns
7. Depression screening for adolescents
8. Developmental screening for children under age 3, and surveillance throughout childhood
9. Dyslipidemia screening for children at higher risk of lipid disorders
Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
10. Fluoride Chemoprevention supplements for children without fluoride in their water source
11. Gonorrhea preventive medication for the eyes of all newborns
12. Hearing screening for all newborns
13. Height, Weight and Body Mass Index measurements for children
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
14. Hematocrit or Hemoglobin screening for children
15. Hemoglobinopathies or sickle cell screening for newborns
16. HIV screening for adolescents at higher risk
17. Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary:
Diphtheria, Tetanus, Pertussis
Haemophilus influenzae type b
Hepatitis A
Hepatitis B
Human Papillomavirus
Inactivated Poliovirus
Influenza (Flu Shot)
Measles, Mumps, Rubella
Meningococcal
Pneumococcal
Rotavirus
Varicella
Learn more about immunizations and see the latest vaccine schedules.
18. Iron supplements for children ages 6 to 12 months at risk for anemia
19. Lead screening for children at risk of exposure
20. Medical History for all children throughout development
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
21. Obesity screening and counseling
22. Oral Health risk assessment for young children
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
23. Phenylketonuria (PKU) screening for this genetic disorder in newborns
24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
25. Tuberculin testing for children at higher risk of tuberculosis
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
26. Vision screening for all children

Health and Human Service

I was flabbergasted when she was actually charged for all those things in October of this year—long before the media ganged up on the President. I called Aetna, my insurance carrier, sure there had been some error. I was told it was no error, and if I had questions, I should contact the state. Since my employer is in South Carolina, I had to contact the insurance board for that state. Here is my conversation with the board:

Rosa Rivers
Senior Insurance Regulatory Analyst
Consumer Service Division

You requested clarification on the ACA law in regards to contraceptive and immunizations. A grandfathered health plan isn’t required to comply with some of the consumer protections of the Affordable Care Act that apply to other health plans that are not grandfathered.  If you have health coverage from a plan that existed on March 23, 2010 — and that has covered at least one person continuously from that day forward — your plan may be considered a “grandfathered” plan.

If your plan is a grandfathered plan it is not required to provide certain recommended preventive services at no additional charge to you.  This would include charges for contraceptives.  This would be the only reason the company is not paying for contraceptives.

The above also applies, but also the ACA requires coverage on vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) prior to September 2009 with no co-payments or other cost-sharing requirements when those services are delivered by an in-network provider.  The immunization vaccine you listed in your email is not on the recommended list. [Note from author: This is an inaccurate statement. HPV vaccine is covered. See the lists above.]

Sincerely
Rosa Rivers

TP: When can I expect the health care plan to cover contraception if it is “grandfathered?”

Rosa: There is no specific end date for grandfathered status.   When a company significantly alters its a health plan it can cause the plan to lose its grandfathered status.  Companies must send out notices advising if the plan is grandfathered or has lose its grandfathered status.

In other words, insurance that didn’t really insure anything, could seek “grandfather status” and completely ignore the ACA rules, as long as the insurance was created before the ACA went into effect August 1, the policy didn’t change too much after that, and they had at least 1 person enrolled.

So Obama went to extremes to honor his promise that you could keep your insurance, even to the point of giving insurers a way to keep junk insurance going indefinitely. Due to the grandfather clause, the ACA didn’t really guarantee Americans they would actually get anything out of their insurance. But, it did demand that its citizens enroll in something calling itself “health insurance” by the end of the year, delivering thousands of paying customers to the insurance companies and guaranteeing tax subsidies to these companies.

Even these concessions were not enough. People on these plans do eventually become ill, and realize they have been duped and drop the insurance. Or they complain to their employer that the insurance is worthless. So these plans must periodically shut down, change their names and enroll (fool) a new crop of customers. They needed to create “new” junk insurance plans every year. What the insurance companies are complaining about is that junk insurance plans created after August 1, or who did not go through the grandfathering process, will not be allowed to continue after January 1.

The real lie here is being perpetrated by Aetna, Blue Cross and Goldman Sachs (yep, they are in this too) and a host of other insurers who lead people to believe their premiums are going to cover a future health care crisis, which they will clearly never do. In fact, they are the ones who have been lying about their products for decades.
 
What these companies are peddling does not deserve to be called “health insurance” at all. They are the ones that should be held to account here, not the President. These plans don’t deserve to be “grandfathered,” rescued by the President or Congress, or supported by the Clintons. These plans deserve to die.

So what does this mean to the people of Humboldt county and thousands of other rural communities across the U.S? ACA will still support under insurance and high deductible insurance. That means people are sicker when they finally seek help, and they are still at risk for medical bankruptcy. In bankruptcy, or just nonpayment, it is the hospitals, labs and health care providers who foot the bill because they have already provided the service and won’t get paid.

Woman’s health care is hit the hardest by this betrayal. Supposedly, one of the hard won benefits of the ACA was the end of “separate but equal” health care for women. Women and men get charged the same or women get charged more for their health care, but cannot find health care that supports contraception and obstetric services. The grandfather clause, Obama’ s cave in to religious groups on birth control and abortion, and now his reversal on scam insurance means women will still face a barrage of insurance that does not cover their medical needs. Women will have to come out of pocket for these needs. That means more nonpayment for these services for doctors and hospitals and more pressure to decrease these services.

Finally, there is Medicare. Medicare reimburses gynecologic procedures at a rate of about 1/3 what is paid for similar skill level and time as other services, reinforcing the “separate but equal” health care system for women in this country. Those inequities fly below the radar and no one is even offering to fix that.

State:

Medicaid (state insurance for the poor) pays doctors very poorly in general. In California, it reimburses Gynecology less than it costs to provide the care. It pays a barely adequate amount for Obstetrics. Most obstetric patients have Medicaid because they are young and have not had time to establish themselves financially. Commercial insurance, conversely, pays well for gynecology and poorly or not at all for obstetrics.

In California, the playing field for doctors is uneven. The more established doctors in town are getting three times as much for every Medicaid patient, due to previous programs the state offered to rural doctors that new doctors cannot enter. When I came to Humboldt, I had to compete with these more established practices while getting lower rates for everything I did with Medicaid patients (about half of my practice). I did this by joining a large group. But when all the other doctors in the group moved or retired, I found myself having to pay all the overhead on my own. One of the ways I survived was to stop seeing obstetrics and Medicaid patients. This shifted my patients to gynecology with commercial insurance—the highest reimbursement profile. It allowed me to continue practicing for six months and gave my staff time to find work elsewhere. But it also decreased the physicians seeing obstetrics in town by one.

Multiple times the state has voted to open Medicaid to all the state citizens. This may have leveled the playing field and increased the reimbursement to doctors and hospitals because Medicaid would have had more funding. Right now, Medicaid in most states covers more than most insurance and could be provided to a state’s citizens for less than commercial insurance. Unfortunately, the law the people voted for was vetoed by the Governor each time.

County:

Santa Rosa, Ukiah, and Crescent City, cities in other counties surrounding Humboldt, are also recruiting for obstetrics for similar reasons. At least in our area, the crisis is wide spread. Santa Rosa can afford to pay more and clearly offers bigger practices and more city. It is likely to divert candidates from the smaller hospitals.

Humboldt and the surrounding counties are finding it very difficult to recruit, because reimbursement is so poor. With 50% Medicaid, a new physician may not be able to meet overhead demands. They could make more on Medicaid if they joined an existing practice with their special reimbursement rates, but the two surviving practices in Humboldt both have issues. Catholic Health Systems is considering closing the obstetrics ward in the southern half of the county, where one of the practices is based. The other practice is headed by a person who has a history of multiple partnership rifts. Catholic Health Systems could recruit into their own clinics, which also have a higher reimbursement, but this would mean the new doctor could not prescribe ANY birth control, further limiting birth control availability within the county. They have already interviewed a candidate for a position in that clinic.

Catholic Health Systems made a bid for Crescent City hospital. Crescent City is suffering its own lack of obstetric services. If the Catholics did buy Crescent City’s hospital, that would stop sterilizations in all hospitals along the Northern Coast of California except for the one small hospital in the north end of Humboldt that remains secular. Doctors from other cities along the coast would have to leave their practice area to do sterilizations on their patients in Northern Humboldt. Something they cannot do without partners to cover their practices in their absence.

Then there is a question about what the Catholics would do with Crescent City’s labor and delivery unit. Would it close that obstetric unit as it threatens to do with the labor and delivery unit at the southern end of Humboldt County? How far is too far to drive in labor?

This situation could be helped by a county-run health system. After all, the Health Department is county run. It’s not such a stretch to expand the Health Department’s responsibilities to meet the health needs of all the inhabitants of a county if they can not be met by commercial and private industry. I tried to set up a county run health care system in Arizona eight years ago and then network the various counties to provide care throughout the state. This is how universal health care in Europe first got started in the early 1900’s. Unfortunately, I discovered there is a federal law preventing counties from doing just that, because it would compete with commercial insurance. The federal law has never been tested and in the age of ACA, might be outdated. I would love to see a movement to organize single payer health care, county by county, in this country and right now, that might be the best solution.

Hospital:

As I mentioned earlier, Medicaid is the biggest payer of obstetric services in the rural sector. Although it pays physicians adequately for obstetric care, it pays hospitals poorly. Hospitals can only break even on obstetrics if they do very large volume or are in an affluent area where Medicaid is not such an issue. All the rural hospitals I have served lose money on obstetrics and that makes it the lowest service on the totem pole. Obstetrics is the last to get new equipment, always runs lean on staffing and is the last for recruitment. Right now, the staffing in Humboldt’s obstetrics wards is so sparse, the nurses are calling around to beg other nurses to come in and work, every time I am on call. The last time I was on the ward, a nurse actually broke into tears on the phone to one of her colleagues begging her to come in and help.

If this was any other type of business, the solution would be to close the department that wasn’t making any money and consolidate the work into another department. And Catholic Health Systems is considering doing just that. They are trying to close the obstetrics ward in the southern half of the county and force women to drive the extra 20 miles to the middle of the county. Unlike other nations, there are no rules or laws to prevent Catholic Health System from closing a ward and limiting access.

In fact, because our health care is own by private for profit interests, closing obstetrics at BOTH hospitals and letting obstetrics patients find their own solution outside of the hospital system is not out of the question. Only strong public objection and the communities withdraw of charitable contributions has stopped Catholic Health Systems from closing the southern obstetrics ward so far.

Health Care Provider:

My case illustrates the difficulties of making a living at this profession. I am not the first doctor to be driven out by financial difficulties. It is also not the first time for me to leave an area due to the financial collapse of a group. This is a recurring story in all of rural America for Obstetricians. My troubles started back in Arizona when my group adopted Electronic Med Records (EMR).

One of the first elements of the ACA to go into effect was the requirement for doctors and hospitals to use EMR. Technology that is marketed naturally, has to be convenient and useful so people will buy it. If the government forces you to buy something, there is no pressure on the manufacturer to make it work for the user whether it is a computer program or a health insurance plan.

The ACA asked doctors to invest in technology that was unproven, expensive, and takes about 2 to 5 times as long per patient as pen and paper. It is the poster child for inappropriate technology. Additionally, it is prone to errors and has a terrible safety profile. Orders are incorrect more often than pen and paper, they end up on the wrong patients, and labs get missed due to the difficult to read screens.

My former group in Arizona went under due to EMR and the expense and slow down in seeing patients that came from the conversion. The company that sold the program to us went out of business and so we invested in a $250,000 program that became junk after the company folded, taking our patient records with it into oblivion. It was a disaster we never quite recovered from and eventually I took the new job in Humboldt, only to find the older physicians in the practice unwilling to commit finances to EMR. One by one they retired, rather than invest in the available systems, or take the decrease in compensation Medicare and Medicaid threatened if we did not convert, leaving me without partners to share costs.

If EMR does not make health care cheaper or more safe, one might wonder why the government was so hot to trot to convert all the US to these untried software programs. One of the main requirements of the EMR programs is that they are able to provide the government with statistical information. That, in and of itself, is not concerning and might actually be useful to track types of care that decreases disease over large populations. But remember, this is a government that colluded with corporations to collect huge volumes of information on everyday people illegally. And then lied to Congress about it. A few months ago, I became much more concerned about the data collection EMR is performing.

Women of Humboldt County:

This all filters down to women in Humboldt and the rest of rural America. Routine care is likely to be delivered by a less specialized provider—Midwives and Family Medicine physicians. The remaining obstetricians in Humboldt have both hired multiple midwives to assist them. This is probably alright, as these providers are qualified to give routine care and they do spend more time with patients. Patients requiring a more specialized level of care are going to have little or no choice about who provides the care and their visit will be crammed into a schedule that is already too full.

Birth control remains an issue. The only place offering sterilization is one small hospital in the north end of the county. Even though some of the doctors have privileges to do sterilizations in the north, the doctors who are left might not have coverage for their practice in order to get away and do their sterilizations in the North.

It also puts into question quality issues. Recently, lactation (breast feeding) counseling and home health visits for new mothers have been cut and I think other very good programs will also be cut soon. The nurses and physicians who are left are not enough. They are being run ragged. Patients who need a critical level of care will soon face a doctor and a nurse who are much more stressed and less supported than previously.

Patients in the South end of the county could be facing the closure of their obstetrics ward and a longer drive in labor, or in an emergency, putting them at increased risk. I think it is a matter of time until disaster happens.

And for all that chaos, I would stay if I could. I like it here. I like the people and the family of bears that live in my neighborhood. I love the calm of the redwoods and the moodiness of the ocean. But, financially, I’m beaten. I have been working 2-3 jobs to recover. Next year, I am moving to Washington State, and starting over . . . again.