Not Signing On

My professional associations fought for years to become approved Medicare providers, and, in January 2024, this will come to pass.

I won’t be signing on.

The primary reason, and one that is sufficient unto itself, is that I do not work with any insurance. Having a vast bureaucracy wedge itself between my clients and me, forcing me to diagnose grief as a mental disorder (for example), and to pathologize the search for meaning as life takes its confusing twists and turns, is against the principles under which I trained for this profession. To be alive entails suffering; to help those who suffer is not necessarily something that can be reduced to diagnostic and intervention codes. I can do cognitive-behavioral therapy and other science-based work without reducing the client and the heartache to a series of codes.

There are other reasons, which, if the simple fact of not working with insurance were not sufficient, would add weight to the argument.

It would limit my clients’ options. Some people want to self-pay for services, and if they have Medicare, and I have contracted with Medicare, I can no longer offer them that option. The rules would impose limits around what I can and cannot do, even when it does not cost Medicare anything.

Second, it would complicate my practice. As with all insurance companies, an online billing process for electronic submission would be necessary. My simple process of recording of payment and making a bank deposit would be replaced by electronically keeping track of what was paid, what is outstanding, what requires additional documentation or some other time-consuming and frustrating process, copays and coinsurance and deductibles.  A conservative guess would be an additional five hours a week spent in this process, five hours that I believe would be better spent with a client or two, a professional training, a walk in the park.

Finally, there is the issue of insult. I am presuming that the Medicare per-session reimbursement for either of my professions, Mental Health Counseling and Marriage & Family Therapy, will be the same as Clinical Social Workers. It is my understanding this is the case with third party payors. With this as the expectation, then, by accepting the terms of Medicare, I would be acquiescing to the bizarre notion that my work as a psychotherapist is only about three-quarters the value of a clinical psychologist’s work. Of course, there are many clinical psychologists far more skilled than I; on the other hand, after many years in the field, I do not agree that any randomly selected clinical psychologist is necessarily my superior as a psychotherapist.

It is not the money; I work on a sliding scale, based on household income, and, as you might imagine, a number of my clients pay considerably less than Medicare would.  However, the arrangements I have with God give me a sense of peace, not injustice.  A client who pays me less because she is in poverty is part of my relationship with the Lord; an insurance company that pays me less because people who do not understand my profession have, via a dart board or an indolent board room debate or perhaps a roll of the die, have decided thus is tyrannical injustice; “Because we said so.”

So, while many in my profession are exuberant, feeling validated that our profession has achieved recognition on par with other mental health professionals, I shrug. If this makes them happy, I am glad for them. I hope that the process is fair and that my misgivings will turn out to be unwarranted.

But I won’t be signing on.

Two Old Ladies

There is a kind of dignified poverty encountered in 19th century British literature. Clean, neat, quiet, well-read, hard-working and uncomplaining, these people, dwelling on the fringes of society, are portrayed as reading classics by candlelight after a long day of work, perhaps aloud, while another family member darns a tired sock for the umpteenth time. They take in mending and other tasks from their social betters, and are sometimes invited to large gatherings where they meekly take seats on the periphery. They are fictional creatures, bound up as minor characters in musty books.
My (great-) Aunt Ann and Aunt Marion lived that dignified poverty, although it was the 20th century, in the cold water flats of Jersey City. My grandmother’s younger sisters, their time spanned Jersey City’s deterioration and ended before its re-gentrification.
Passing them on the street, you would not notice them: two older maiden ladies, often arm in arm, purses tucked under their coats in fear of purse-snatchers. Who would give a thought to two old ladies? They kept an extra dollar in one shoe, just in case. They dressed neatly, and well, and cared for their few possessions so that they could be worn for many years. Cursed with a genetic tendency to lose their hair in middle age, they wore demure, neatly styled wigs. Aunt Marion, being a bit flashier, had sparkly corners on her cat’s-eye glasses, and a preference for the color red. They worked in sweat shops and at other menial jobs. Aunt Ann, for a long time, operated the elevator in a business office skyscraper, an opportunity to work in a cleaner, quieter environment. Neither had an 8th grade diploma – the meaning of “graduation” in their time and place. They could not drive. They traveled little, to visit family sometimes. Their tiny apartment was sparklingly clean. They read classic literature, were knowledgeable about history, current events, and the activities of the people they loved. They loved, it seemed, everyone. They were cheerful and generous beyond their means, unflaggingly loyal to their nieces, their nieces’ children, and their children. Devout Catholics themselves, spending considerable time daily in prayer for others, they were remarkably tolerant of astonishingly stupid and bad behavior among their extended family. It mattered not how grievous the misdeeds: the errant youth was, at heart, Aunt Ann and Aunt Marion would assert, “a good girl,” or “a good boy.” After all, look how good she is to her mother; see how thoughtful he is towards his sisters. Anyone whose deity is harsh and unforgiving never met someone like Ann or Marion. The closest they came to criticizing was sharing a sidelong look and a single, slow nod, a kind of connection possible between two sisters who grew up together, raised two nieces from ages 8 and 15 together when one of their older sisters died, and shared the same ancient double bed most of their lives.
Strolling past, you would have looked through them, and unless you are a very special person indeed, you have looked through, perhaps, thousands of people like Aunt Ann and Aunt Marion. Not out of meanness, but because the people of the remnant – that pure and poor bit of holiness – are so often, apparently, invisible. Besides that, both poverty and old age frighten people, and thus we look away. If not away, exactly, then certainly not directly at them.
They have been gone for many years now, and I still regret that I was not a good-enough niece, certainly not worthy of the fondness and praise they heaped upon me. From Florida, I sent some homemade cookies now and then; a randomly spaced letter between birthday and Christmas cards, small gifts that I thought they might like at Christmas. I mentioned, during their lifetimes, my befuddlement at their level of praise for what a good girl I was to my mother, who loved them dearly and called them often. She stopped what she was doing to look at me and said, “Please. Do you think anyone else gives a thought for two old ladies?”
A sad question, that: who gives a thought for two old ladies, or an old man or two?
How hard is it, to give a thought for any other person? “People will not remember what you said or did, they will remember how you made them feel,” is the theme of the “most important award” at our granddaughter’s Catholic school, and one we were proud to hear she had won at the end of second grade. It is good to know that the kindness and sweetness we experience from her flows outwards, beyond the family. Her precocious insight into human nature is something she wields only with compassion. At seven, viewing Goodbye, Christopher Robin, she watched WW I veterans stomping balloons and announced, “They are doing that to learn not to be scared. “ She makes people feel special. Perhaps she has a touch of her great-great-great aunts’ spirits.
The gift of presence is that quality of attention: the attention that lets someone know that right now, they are the most important person, and whatever they are doing with you is most worthy of their attention. (My aunts, having read Tolstoy, could have told you all about it, but only if you brought it up first. They would not show off, and they would never broach a subject that might embarrass someone else.)
How powerful their capacity for presence within their humble, dignified way of life, a life that seems invisible to those who will not look at them. Then again, who would give a thought for two old ladies?