In Honor of Nurses’ Week: Nursing, the Finest Art

Plate 2 La France Croisée (The Cross of France), by Romaine Brooks, 1914. National Museum of American Art, Smithsonian Institution, Washington, D.C.

Plate 2 La France Croisée (The Cross of France), by Romaine Brooks, 1914. National Museum of American Art, Smithsonian Institution, Washington, D.C.

What thoughts cross your mind on seeing this arresting portrait?

I find it difficult to limit myself to just one word. Courage. Tenderness. Strength. Ingenuity. Passion. Patriotism. Dedication to preserving life, regardless of the cost to herself, is shown even in the utilitarian cap holding her hair back from her face, preventing wound contamination while protecting her neck from sunburn and falling debris. This nurse has been through a lot, and is prepared to go through more. Amid the battlefield chaos, tragedy and triumphs of World War I France, this nurse dramatically exemplifies traits inherent to the profession of every era. She inspires me! 

My eye is drawn to the not-quite-standard red cross sewn onto her cape. In her collection Nursing, the Finest Art, M. Patricia Donahue chooses the characteristic “Humanitarianism” to describe this painting, and tells how the Red Cross was founded in response to earlier battlefields.

“Humanitarianism – a philosophy that asserts the worth and dignity of the individual; a philosophy that guides nursing in its caring functions. Humanitarianism has long been a motive for rendering nursing care. This interrelationship is frequently demonstrated by nursing’s involvement with agencies such as the Red Cross. A great humanitarian, J. Henri Dunant, was instrumental in setting up this international organization that would provide volunteer nursing aid on battlefields. The stimulus for this development was his journey to Italy to secure a meeting with Napoleon III of France. At Solferino he was witness to the horrors of the bloodiest battle of the war between France and Austria. Depressed by the lack of medical services, Dunant enlisted local people to give whatever aid and nursing care were possible. His subsequent appeal to various European governments finally culminated in the International Red Cross, an organization committed to humanitarian services. Dunant repeatedly referred to Florence Nightingale and her work in the Crimea as the inspiration behind his crucial trip to Italy. Her work had also fortified his belief in the feasibility of such an organization. Each government agreed to honor Red Cross nurses as noncombatants and to respect their hospitals and other facilities. In addition, societies in neutral countries would be permitted to render services to either side. Nurses have consistently occupied a place for honor as they have carried out the humanitarian mission of the Red Cross during time of peace and time of war.”

Details: The name of the painting is La France Croisée (The Cross of France). Painted by Romaine Brooks in 1914, it normally resides at the National Museum of American Art, Smithsonian Institution, Washington, D.C.

For a short time, however, we in the Midwest have a unique opportunity. From March 10 through June 21, La France Croisée is featured at the Shine On: Nurses in Art Exhibition at the Columbus Museum of Art. (Check out the other special displays listed here, too, to soak in some beauty and creativity.) This Michigan nurse is thinking a road trip to this event would be great therapy for overworked, winter-weary nurses.  For those desiring the arm-chair version, the Wall Street Journal has done the honors in a fine photo line-up





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Spring in the Woods

Again He gives commandment;
The winds of summer blow.
The snow and ice are melted,
Again the waters flow.

Psalter 402:5b
a versification of Psalm 147

Spring officially happened over a week ago, and many of us in Michigan felt a little let down at the return to freezing temperatures. After a week indoors, it seemed to me that a walking tour of springtime in the woods might be worth a little cold.

It was!

Before I even left the yard: crocuses. This lavender-striped variety is my favorite. Isn’t that deep purple at the base spectacular?

Giant Crocus boring through natural mulch.

Giant Crocus boring through natural mulch.


Entering the woods, I found clusters of Snowdrops naturalized from the Centennial Farm my sister and her husband now own. His grandmother’s green thumb is evident in swathes of perennials, faithfully returning and spreading each year.

Purity in white and green

Purity in white and green


Heading into swampland, I’m grateful that the cold has firmed the access road enough to support my walking shoes. Only a week ago, it was knee-boots only. Another sign of spring!

But I’m not alone. Suddenly the scent of buck musk fills the air, almost strong enough to make me gag. Assuming the deer is straight upwind from me, I know I won’t see him, because he’s also backed by the blazing sun nearing the horizon. Canny beast! There’s a reason he has evaded local hunters this long.

And he’s not alone, either.

Tracks: how many kinds do you see?

Tracks: how many kinds do you see?

Fawn prints are another welcome sign of spring!

The snow has been gone for a few weeks in this area. Although standing water still freezes over at night, it’s draining away to the major ditches en route to Lake Michigan.  Remember crunching “hollow ice” in the mud puddles when you were a kid?

Hollow ice

Hollow ice

Trees make wonderful reflections on swamp water, even as their shadows reveal the colors under water.

Swamp thaw

Swamp thaw

Time to head back home. The angle of the sun is glancing off early-blooming moss in the north yard, contrasting red stems to green base. Not sure how well I captured it here….

Blooming moss

Blooming moss

Thank you for walking with me!


PS. If you were counting types of tracks, the number I found was five:  three kinds of vehicle, the fawn, and me.


Naturalized Snowdrops, 2015

Naturalized Snowdrops, Spring, 2015


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Does Michigan Need an Exchange, after All?

One week ago, the Supreme Court heard King v. Burwell, the challenge to subsidies applied through the federal exchange. If sustained, this will directly affect approximately 237,000 subsidized Michigan residents. (My calculation using the 2014 HHS subsidy rate of 87%, since the 2014-15 enrollment of 311,000 is not yet fully analyzed by HHS.) Will Michigan’s citizens and legislature join one U of M expert and the governor of Michigan in revisiting the Michigan state exchange question, which failed twice under voter outrage? I strongly urge against such action.

States in the same situation have considered creative paths to a nominal state exchange: piggy-backing onto existing state exchanges, or looking to HHS for a form which “hereby declares the Michigan portal to the federal exchange to be a state exchange for purposes of ACA subsidies.” Spectacular state exchange failures like Maryland, Oregon and Nevada effectively nix the idea of erecting an expensive new state exchange to original specifications.

State Exchange fxn

But has anything really changed? Should Michigan now reverse its position on the Exchange?

Nothing has changed, except to highlight the failures of the ACA. The federal exchange has signally failed to decrease costs in Michigan. A state exchange would still expose Michigan patients to this burdensome federal program, expose Michigan taxpayers to greater state budget increases, and expose Michigan employers to financial penalties to balance the subsidies. Robbing Peter to pay Paul is no solution to expensive healthcare.

In addition, I say “No” to a state exchange because there is a better way. As federal policy makers prepare their responses to a possible change in ACA interpretation, Michigan policy makers and residents have better options than waiting to follow their lead.

Patients and Providers

Federal programs like Medicare, Medicaid, the VA, and the ACA by definition provide “population care.” Dividing us into demographics, they collect masses of data on us, and tell us what care we get based upon their research experts’ definition of “best practices.” In this scenario, society’s needs hold center stage. Payment is from society as a whole, and the pot is fixed. Big and clunky bureaucracy delivers rigid, slow service. Patients’ ideas and choices for their own care fade into the background. “Good” physicians are the best data-collectors and administrators. Forget what is best for you personally.

Is this really the best we can do?

Exchange for Healthcare

I say, most definitely not. We can and must do much better. The core of care is where it always has been: between a patient and a provider.

Complexity costs us. Without the subsidies, exchanges, insurance mandates, codes, enrollment and coverage ambiguities of population care, MI residents have an opportunity to return to individual care. Nothing is more affordable, and nothing can surpass the excellence of care based upon an individual professional’s knowledge and relationship with you as an individual patient. Dramatic price deflation results from simplifications like these:

  • 10,600 Michigan residents are enrolled in the Sharing Organizations, a far more stable alternative to date than Obamacare.[1]
  • By cutting out the middle man, concierge and direct pay physicians across the US are offering care that suits all income levels. Michigan has great potential to innovate affordably by expanding a good start in this growing movement.

State Policy Makers

“If it moves, tax it; if it keeps moving, regulate it; if it stops moving, subsidize it.”

Reagan never saw the ACA, but was there ever a more perfect description of the plight of modern healthcare? With all due respect to the central planners among us, theirs is not the way to greater abundance, excellence, or lower prices in healthcare. Rather, Michigan policy-makers should acknowledge the forces of supply and demand by removing regulatory barriers to affordable care in Michigan. Some have already started:

  • Transparent pricing for hospitals: SB 147, introduced by Senator Joe Hune. Hospital A may charge 50% more than Hospital B for a given surgery. Shouldn’t we be able to shop around before signing up for expensive care?
  • De-commission Certificate of Need, soon to be enrolled in the House. Why should industry representatives have the final word on new healthcare services entering the market?
  • Dozens of state mandates add to the cost of each health insurance policy sold in Michigan.
  • Occupational licensure increasingly acts as a tax upon Michigan healthcare, especially harmful to entry-level and specialty jobs.
  • General regulations affect healthcare more than any other industry. What if hospitals, nursing homes, and physicians had their regulatory burden cut in half?
  • State appropriations for health corporations supposedly provides care and jobs, but since when is the state better than taxpayers at choosing where to spend our money?

Michigan has a long way to go to welcome medical innovation and excellence, patient choice and individual care. Our time is limited, and the need is great. Let’s get together on this!



[1] Updated 8-31-2015 to link to Sharing Organization blog post.


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First Sign of Spring

Okay, yes… this is a pretty big deal in this year of the most persistent sub-zero temps in Michigan for over 85 years.

I’m not threatening to move…. yet.

I can even still admit that snow is beautiful. (It helps if you ask when I’m not driving in it.)

One of my favorite ways to enjoy winter is sipping hot cocoa and toasting my toes by the fireplace of an evening. Coming within five pieces of firewood from the end of the stack by the middle of February is one good way of getting pretty close to the line of tired of winter.

As for those deep cups of hot cocoa, loaded with mini-marshmallows and peppermint stick twizzler, that tasted so great back during Christmas break? Meh. We’re no longer on speaking terms.

All of which to say… I’ll take my first sign of Spring in Red, White, and Blue.


Maple buds are swelling and turning red!

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The Obamacare Exchange in Michigan


The Obamacare Exchange Bill passed the MI Senate November 10, 2011 by an expedited procedure. Suspending the rules of the chamber, which required at least three days for final text review before a floor vote, the Senate sent SB 693 through committee vote, floor vote, and over to the House Health Committee all on the same day, with no opportunity for public comment on the record. (Journal of the Senate, pp 4-6.) A Facebook conversation with my Senator, right up to the time he went to vote, was less than effective. As closely as I can recall, his words were, “You don’t understand, Obamacare is the law of the land, at least this will put the state in control of Obamacare instead of the Federal government.” No amount of evidence that state implementation of PPACA Exchanges was optional, that it unnecessarily entrenched bad law, and that the nature of federal programs was federal control, could alter his determination to vote for passage of the bill.

 After the ensuing public outcry, the MI House proposed a more transparent path. Individuals and organizations from all over the state prepared to attend the House Health Policy Committee Hearing on the bill. The day of the hearing, January 19, 2012, dawned with Michigan under 6-12″ of fresh snowfall and shrouded in blizzard. Regardless of how many were kept home by the weather, 9:30 am saw the large committee room packed to the exits, all seats full and the back of the room several rows deep in standing guests. Ushers in their red coats kept order and at last brought the pile of testimony cards forward to the clerk, my own among the others. Chairing the hearing at the head of the committee dais was Representative Gail Haines (District 43, Oakland County).

I attended with friends from West Michigan, and was invited to testify as a member of Docs4PatientCare, a physicians’ group formed to oppose state roll-out of Obamacare. One by one over the next several hours, the names on the cards were read into the record: supporting the bill, opposing the bill, testifying, not testifying. One by one, individuals and organizations from all over the state sat at the witness table and spoke into the microphone. Occasional applause  at particularly passionate or well-argued opposition to the bill was rapidly quelled by the chair. Finally, she announced the final name from the stack of cards. It wasn’t mine. For a moment, I stared unbelievingly at the clerk. Quickly completing another card and surreptitiously touching the sleeve of an usher beyond the railing, I asked him to bring it to the chair’s attention. Thankfully, he did.

This is my testimony.

Madam Chair, Members of the Committee, and guests. My name is Abigail Nobel. I am a Bachelor’s-prepared nurse of 23 years, Board-Certified in Ambulatory Care Nursing.

I have been passionate about nursing since I was 3 years old, but I will be the first to grant that my profession faces major problems. My goal is to stop Obamacare until it can be repealed. Even when that is done, we will still be left with major problems in healthcare. It just so happens most of them are caused by poor government policy. Let me give some examples from my experiences in various areas of care.

As a Nurse’s Aide working my way through college, I had to haul ninety-year-old nursing home residents out of bed at 6 AM, because regulations dictated how many hours were allowed between supper and breakfast. No excuses for these elderly survivors of life!  This was the first time I felt the gut-wrenching impasse of being forced to choose between obeying the law and giving good patient care. Unfortunately, it would not be the last.

As a nursing student, I learned that OB providers had the highest malpractice insurance, not because they were bad doctors, but because when it came to babies with problems, juries would award any amount.

In surgery, well-established protocols were scrapped in favor of nationwide “best practice” standards, putting Michigan patients at risk because a surgeon in Florida amputated the wrong body part.

In postoperative care, I learned that patients’ vital signs were routinely over-monitored –a nurse might take extra vitals, but woe to one who skipped any, no matter how stable the patient or how sore their arm from the BP cuff!

On medical units, regulations mandated I stay at the side of a comfortable patient instead of going to ones who needed me–simply because the standard number of minutes had not passed since administering a medication the patient and I both knew was safe for her.

I left homecare soon after the day it took eight hours of stultifying paperwork to document one hour of patient care.

Not all of healthcare’s micromanagement comes from insurance and government. Some comes from hospitals themselves as they give a whole new meaning to “preventive medicine“. Healthcare law is so complex, and the threat of lawsuits so frightful, that many hire full-time lawyers to guide their policy. This is in addition to industry lobbyists who jockey for legislative advantage to improve their market share.

Throughout my nursing career, I have noticed that patients who paid the least for their care were often the most resistant to education about lifestyle change, the key to up to *90% of hospital admissions.

In short, top-down organization and government regulation of healthcare have been tried and failed abysmally either to control costs or to improve patient health. Furthermore, these ever-tightening controls have served to actually increase costs due to heavier documentation and staffing requirements of the over-regulation. But it’s not like there are not better options for legislative action! In my lifetime healthcare has never enjoyed a free market environment. It is well past time to turn to genuine free market solutions.

Please, be clear about Michigan’s policy going forward:

  • Insurance is not care; and healthcare is a service, not a right.
  • Repeal existing regulations such as Certificate of Need and BCBS/Priority Health monopoly protections which stand in the way of innovation and entrepreneurship in the real healthcare marketplace, which is found in our yellow pages across Michigan.
  • Reduce reliance on 3rd party payers by promoting direct pay, HSAs, and a culture of patient independence rather than reliance upon insurance or government programs.
  • Reverse the trend to single payer.
  • Michigan previously passed legislation to reduce the cost of malpractice litigation. Please revisit this area and consider further reforms in all areas I’ve mentioned. More information is available at and other resources like Cato Institute.

Finally, please draw the line for special interest groups. We Americans have a long, proud tradition of helping our neighbors in person and through charitable organizations both secular and religious. Let us assume our proper role of love and accountability. It is not one for which government of any level is suited.

Thank you.

* The data available in 2014 indicates a number closer to 80%. Sources available upon request.


Testimony given that day, combined with opposing letters, petitions, phone calls, emails, and social media messages from thousands of constituents led the Michigan House to let SB 693 rest in committee until the end of the 2011-12 term, effectively killing the Michigan State Exchange.

The following session, the Partnership Exchange was a sort of half-way measure that advanced through the legislature by a reversed course. Greased by $30,670,000 from HHS, it slipped through the House on February 28, 2013, tucked into spending bill HB 4111. Opponents  hardly dared hope to stop it in the Senate, but again, citizens actively protested and the bill died without a floor vote.

Medicaid Expansion was the third and final major component of Obamacare which depended upon state cooperation to become effective law. Telling the story of how it became Michigan law will take another blog post, but for purposes of this post, it remains the only part of Obamacare “owned” by the people and officials of the state of Michigan.

The consequences of locking Obamacare Exchanges out of Michigan law are numerous, and multiplying.

  • Michigan businesses are free from the Obamacare penalties that come with the State Exchanges.
  • Michigan taxpayers are free from the state-level financial burden of building and maintaining the State Exchanges.
  • As Obamacare’s high deductibles, high premiums, and denials of care become more apparent, more people are realizing that the free market has been the better alternative all along. In overcoming the natural human dislike for change, not having a State Exchange means Michigan residents will have one less barrier to jettisoning Obamacare. They will not face the oddly personal attachment that often comes with state health programs like Britain’s NHS, despite all quality evidence to the contrary.
  • Obamacare enrollment puts people off for several reasons. Besides the initial sign-up problems at, the premium prices are very high — too high for most people unless their plans are subsidized. If the Supreme Court decides for the letter of the law in King v. Burwell, the Federal Exchange will lose all subsidies. That means that all Obamacare enrollees residing in states without a State Exchange, like Michigan, will face full prices on their plans. Barring another administrative rule change or Congressional legislative fix, many Obamacare enrollees would abandon the Federal Exchange and look elsewhere for affordable care. Loss of enrollment numbers are the kiss of death for this new federal program, rendering it unsustainable both politically and actuarially. (Yes, there’s a name for the science of insuring people!)

It is not too much to say that stopping the Obamacare State Exchange in Michigan may have been the beginning of the end for Obamacare itself.



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He that pays the piper…

The Call:

“I took my prescription to the pharmacy today because I had to be somewhere else after my visit on Friday. The pharmacy said the insurance wouldn’t pay for it unless the doctor gave them more information. But he said I needed to start it immediately, I really need him to call the insurance company right away.”

The nurse is thinking, but does not say…..

On a Saturday? 

For a $20 antibiotic that you could have paid for in cash yesterday, and have been well into the treatment phase of your infection by now?

Come to think of it, in Mexico, it is probably available over the counter, without seeing the doctor at all. It probably costs less money there, too.

But premiums these days are enormous, and people want to get their money’s worth out of insurance more than ever before. And many Americans feel insurance should cover everything, since healthcare is now a right. So people get upset when they don’t get what they need, when they need it.

Has anyone noticed that paying directly is the only way that happens— that when others are involved with paying for something, they have a say in how the money is spent, and it takes longer?

I wonder… is it just possible that this back and forth, indirect payment, and expanding coverage may have something to do with our  premiums going up?

Have we in America completely forgotten that “He that pays the piper calls the tune”?

“I’m sorry, Ma’am, the insurance company is closed on weekends. I will pass along a message, but you will need to contact the doctor’s office on Monday.”

The Back Story:

Insurance companies keep costs down by listing the cheapest, first-line drugs in an approved formulary.  Prescriptions for these drugs are processed automatically by your insurance when you present your card at a pharmacy. Over time, doctors become familiar with the most common insurance formularies, and are guided by them in their prescription-writing. Patients may not even be aware of their insurance company’s role in determining their medications– until they need a medication that isn’t on the preferred list.

When a patient asks a pharmacy to fill a prescription for the more expensive second-line or “off-formulary” drugs, it will be denied until the prescribing physician provides additional prior authorization or pre-authorization. Company policy requires the doctor to convince the insurance representative that for particular reasons, the (generally) more expensive choice is necessary and first-line drugs will not work for you. Finding the “magic words” to persuade the insurance representative often requires repeated phone calls and multiple forms, or even proof that first-line drugs failed you recently. “Prior Auth.” consumes hours every day from doctors and staff at the typical office, contributing to higher medical practice costs and patient charges.

It becomes a battle of wills between the two offices, and the real question is whether the patient comes out the winner. Can you ever be sure that the final decision was for your health, and not for someone else’s bottom line, or peace of mind?

He that pays the piper calls the tune. Are you calling it, or is your insurance company?

To become the one calling the tune:

Web search or call to obtain your health insurance formularies. Find out if your new and routine medications are first-line on the formulary.

Consult with your doctor whether a formulary recommendation is best, and why.

Most patients will view an experienced physician’s statement that “This is the medication I have found to work best for this problem” to be a perfectly valid reason — but you should be aware that your health insurance may not agree. Be prepared to make the decision to pay cash because it’s your body and you trust your physician more than you need to have insurance cover this purchase…. or not.

The rules of comparison shopping apply to healthcare, too. Cash is king: check the yellow-pages and on line. Ask friends what they do for affordable meds. Direct purchase is the answer for many people. I have been happy with both product and service at Canadian Pharmacy Online. Other professionals recommend GoodRx for the coupons and price-checker for major US pharmacies. I tried it today and (pending phone confirmation) my next refill just may be local: the GoodRx free coupon saves me an amount comparable to Canadian Pharmacy Online, over 50% off the usual local price. Email refill reminders are a helpful option, too. And for routine medications I get at least a 3-month supply. Time is money, too!

And always, always, always be the final quality check that you have the right med and it’s doing the right things in your body.

He that pays the piper calls the tune.

Start calling it!


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Stood A Birch

Stand of Birch trees overlooking the Chain of Ponds, Northern Maine. Abigail Nobel, 2009.

Stood a birch, white and green,
Such a sight as rarely seen.
Sudden the storm, complete the fall–
Hollow the core revealed to all.

Stood a man, clean and strong,
A well-known sight for miles around.
One false step–Notoriety!
Feet of clay. Astonished, we?

Flaws of nature are everywhere,
Man and tree, whoever they be.
Yet of fallen trees may seedlings rise,
And to broken saints, God grace supplies.

Abigail Nobel, BSN, RN, MA

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The Clinic

Quebec City across the St Lawrence Seaway from Levis. Abigail Nobel, 2009.


We are not here to save you,
But we can tell you Who is.

We are not here to carry you,
But to come beside you as you learn a new way to walk.

We see you not as a victim,
But as made in the image of God.

We are not here to judge you,
But to inspire you to grow.

We believe the only thing worse than blaming you for your circumstances,
Is assuming you are incapable of overcoming them.

–Abigail Nobel, BSN, RN, MA

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Introducing my new website

Fall Harvest, West Michigan
Thanks for stopping by and welcome to my new blog!

I decided to start a blog because I am concerned about the growing wall between patients and the doctors, nurses, and others who provide care. For patients, it is called an “access” problem– care costs too much, it’s hard to find, and paperwork is a hassle. For providers, it starts with expensive education and proceeds to a lifetime of other red tape. For all of us, the problems are increasing. Why? How did we get into this mess? (Hint: it happened long before Obamacare.) What can we do to make it better?

My last two years have been spent reading political philosophy and health policy while completing a Masters Degree from Hillsdale. I have been a nurse since 1989, and I was a nurse’s aide before that. I like being efficient, and roadblocks irk me.

Especially roadblocks that harm patients.

Roadblocks that harm both patients and professionals are even worse, and no amount of reading can make me philosophical about the state of healthcare today.

I plan to write about the barriers and potential solutions I see in healthcare. The focus will be life here in Michigan, but much is generally true across the US. Certain nuggets of wisdom about healthcare hold for all times and places. And practical answers are my favorite! It seems the more difficult life becomes, the more ingenious people get.

Some of my every day life of faith in God, family, and living in the country will probably show up here, too.

That’s it for now! If you’d like to be kept updated with my posts “Like” this post or subscribe to my blog.

Thank you!

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