Editor’s note: This commentary is by Vicki Harrison MSN of Barnard, retired from 45 years in social work and community health nursing, with a subspecialty in mental health and substance abuse.

Believe it or not, “social determinants of health” have been a main study of social work and community health nursing for 100+ years. Bachelors of science students in community health nursing spend their senior year studying their communities and learning how to be effective in community health assessment and care. Informally, midwives and herbalists have always intrinsically understood these human circumstances and their wide-ranging effects. Prior to the last several years, very few doctors were ever interested in discussing these factors, as these factors did not MAKE MONEY! This is the wrong time for such a complex, expensive, undoable, potentially privacy-exposing program in a U.S. system that provides minimal safety net and a tiered health care approach.

Dartmouth-Hitchcock and UVM Medical Center are the big players here, and OneCare represents their taking of resources via privatization. The goal is to decrease health expenses in a money-making venture where providers receive funds based on their care effects. U.S. Public Health Infrastructure was deconstructed 25 years ago. Further, nursing, growing in its educational basis in the 1980s, began to assert its priorities for underserved populations, and was promptly sidelined by the stated priorities of ‘managed care.’ The lack of creative nursing perspective in the media is profound. Nurses, however, are trusted 90% vs. physicians trusted at 45%.

Nursing always provides the check and balance to medicine. Licensed nurses are trained to provide only appropriate care to patients. Thus, in whatever setting we specialize — ICU, orthopedics, medical, or community health — we integrate the expected medical standards into patient care, questioning and seeking clarification of inappropriate MD orders for a patient condition and executing nursing standards. 

After 45 years, first in community social work, and then nursing in multiple communities across this country, great community betterment occurred by local innovators. The “big players” — the hospitals, MBAs, and MDs, would routinely subsume these projects after a few years. These young projects were solving human health problems that did not generate MONEY for the top of the food chain.  If they did not control the spending and direction of these funds, they plotted to take these projects over and redirect these to their priorities.  

Multiple soul-killing phenomena came alive by these practices in the U.S. over the past decades. Repeatedly, the top of the food chain in the community, big money earners, re-directed the community priorities toward their ends — genetic testing, expensive therapies, new modalities are available to the 30% or so who have great health insurance and “the worried well.” The community’s wider needs, whether for people of color, reproductive services, STD services, LGBTQ services, mental health, substance abuse, equitable access to care, was not found PROFITABLE by the status quo money/health care folks.  

The U.S. has a very poor health-assuring safety net by choices made as legislators/local leaders compromise away many “shared values,” creating circumstances folks of color have long had to tolerate, now shared with white folks. Stagnant wages, diminished affordable housing, poor job options, inaccurate and substandard media narratives, and lack of opportunities create unrest. 

Accountable care organizations (ACO) are an idea born from Medicare Advantage plans, which have been with us in the U.S. for 35 years. THEY have not saved any money, and are subsidized by the federal government. In fact, health care costs have increased by 5-10% yearly since the early 2000s. Accountable care organizations were birthed as skilled nursing facilities, which used to have nurses, and home health organizations — truly nonprofit, high standard, community-based organizations, were defunded, and standards dropped by the federal government/legislators and “privatized.” Privatized in skilled nursing facilities, hospice and homecare means there is more private money for the OWNERS — big jets, multiple nice homes, private schools, and very limited care for the patients with lesser-trained staff.

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What has saved the most money in U.S. healthcare has been reducing days in the hospital for planned procedures or discharging patients to poorly reimbursed nursing facilities or homecare where very few visits were allowed. The MBAs, MDs, and scads of administrators (people, who provide absolutely no hands-on care at all), fill the health care system, so we gain less care, just copays, deductibles, and complete confusion regarding what we could do, as the rules are so complex and obscure. We need skilled health care when we are sick. We need public health from a public health system, not a privatized OneCare option run by the Big Boys, who just can’t get enough money in their pockets. The sausage must be squeezed back to a level playing field for all. This will be new but rewarding. There is plenty for all, but the aggressive players must be contained. A U.S. jobs program must simultaneously begin, so the unskilled health care folk have new work. We can no longer feed that bottomless pit of U.S. greed and wealth. I trust humans who have a decent wage ($15 minimum, $23 average), access to housing choices, healthy local food, good schools, clean water, et.al, can make healthy choices for themselves. We do not need another big entity ensnaring us in their webs and websites that have never been information secure, nor ever will be in the current internet system. Agribusiness, the medical industrial healthcare complex, must be deconstructed so local, integrated, fairly-incentivized initiatives may emerge. It is time to get your “OneCare Fantasia” off our neck. Family leave, health care for all, $15/hourly will go a long way to better health.