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Elder Care: the Gold Mine Insurance Companies Love and Hide from You

The ugly truth about why insurance shouldn’t even have the word “insure” in its meaning nor Medicare the word “care” in its name

Felicia Willems. Affordable Care Act. Photo Wikimedia Commons.

Felicia Willems. Affordable Care Act. Photo Wikimedia Commons.

Here’s the Catch-22: we need insurance to cover the illnesses and diseases that challenge our well-being, yet these are precisely the very things that deny us the coverage--the dreaded pre-existing condition. I hear lots of debates about the Affordable Care Act and what we should do about it, but why aren’t we talking—or asking our elected officials—about dismantling the choke-hold the insurance lobby has on our country?

Former President Jimmy Carter famously stated: “The measure of a society is found in how they treat their weakest and most helpless citizens”. I can confirm that if or when you enter this category you will have strong opinions about the insurance industry.

Have you ever felt relieved when you found out that your insurance company is going to cover a medical procedure or medication that you needed? Why is that? Why can’t we expect our health insurance to cover our medical needs as determined by our doctors?

There’s nothing like having one’s parent come and live with her to get a crash course in health care. Not that I don’t have my own horror stories about navigating the health insurance morass: but for now I am in reasonably good health. (That sound you hear is me knocking on wood.) It’s not only health care–caring for our elderly population is another lesson in bureaucracy and frustration. Health care. Elder care. Two institutions meant to provide support and protection for ourselves and those we love are really ill-disguised goldmines for providers to make money off of our most frail and vulnerable populations: the sick and the elderly, some of whom are both.

Since my dad moved in with us almost three years ago we’ve experienced some specific circumstances that brought out the hypocrisy prevalent in our current healthcare and eldercare models. A year ago, my dad, age 88, fell off my front porch and broke his ankle. The bone was re-set in the emergency room and sometime after midnight he was admitted as a patient and given a bed. A social worker came around the next day and said he’d probably have to go to a skilled nursing facility for rehab and hinted that he might be discharged as early as the next day. This was bad news to me. Anyone who has dealt with the arbitrary rules of Medicare knows a patient has to be in the hospital for at least three days before such a treatment is covered. But it’s not three days like you and I understand days; it’s three midnights, meaning that the night he already spent in the hospital didn’t count. If a patient is discharged without the three-day requirement, any care afterwards–even essential to the patient’s recuperation–is out of pocket.

Elder Care. Photo

Fortunately, my dad’s ankle needed another procedure and it would require anesthesia. He would make the three-day cut. That gave us another issue to contend with. Dad is a Type 1 diabetic, which means his body doesn’t produce insulin and he needs an injection when he eats. Every time I’ve given this information to hospital staff, I always get that look that says, “You don’t really know what you’re talking about, do you?” (Most adults have Type 2.) In the hospital, dad is put on a completely different dosage of insulin that always results in spiking his blood sugar. I didn’t understand–why wouldn’t they continue his regular dosage and maintain consistency with his glucose levels? One guess: insurance.

I didn’t realize how diabolical that policy was until his most recent hospitalization for pneumonia. I went to visit him just as he was given a golden-brown grilled-cheese sandwich, a cup of apple juice and a side of fries for lunch, but he didn’t touch it because he hadn’t been given any insulin. I buzzed the nurse to get his injection and she said, “We don’t give insulin until the blood sugar reading reaches 150.” His was 95. I explained (again) that he needed insulin with lunch or his blood sugar would skyrocket. Nope, she couldn’t do it. When I threatened to bring in his own insulin, the nurse called the hospitalist. The hospitalist said she understood, but “the pharmacy won’t allow me to prescribe him insulin.” To her credit, she had the decency to look embarrassed about saying that out loud.  I persisted and he was finally given a shot. This is just one way health insurance fails the patient, by limiting actual medical decisions made by medical professionals and expecting a person’s condition or disease to conform to the insurance companies’ policies.

But back to the broken ankle. After a few months in a skilled nursing facility, Medicare decided he didn’t need anymore “skilled” services and he was discharged to go home.  The physical therapist concurred and said dad had progressed as far as he could. His progress didn’t include walking on his own, but apparently that was beside the point. We couldn’t bring him home in a wheelchair without extensive modifications to our already modified home, so we did the only thing available to us and transferred his care to an Assisted Living Facility (ALF).

Actually, that’s not quite accurate: I could have kept him at the rehab center until he could walk, but the cost—over $400 a day—would have been out-of-pocket. Choosing the ALF over the rehab facility was easy—the daily rate was still less and he didn’t have to share a room with a guy who blasted FOX News all day.  However, even with the “assisted” distinction the basic rate at an ALF only includes services one might find at any independent residence; any actual assistance is added on à la carte depending on what the resident needs.

We ended up paying about $2000 more each month because of the additional “assistance” he needed: help with his daily living activities like dressing, going to the dining room, bathing. Dad was administering his own insulin shots before meals, but he became easily flustered when the aides showed up to escort him. (He felt they were rushing him.) The aides reported these “events” to the nursing staff and they decided he wasn’t safe doing his shots. So, rather than train the aides to work with his needs, they suggested another tier of service: med management. For another $1500 a month. This is the point at which we brought him back home. He had graduated to a walker by that time, so he would be able to get around the house again.

He might have been able to stay had he had access to a long-term care policy. These are helpful in either utilizing a facility or bringing in help, unless you don’t have one. My dad was disqualified for a policy because he has diabetes: just the condition that would require long term care at some point. His other medical complications–heart disease, legally blind, mild cognitive impairment–require additional care, but also get in the way of qualifying him for any programs. That’s the Catch-22, isn’t it? We need insurance to cover the illnesses and diseases that challenge our well-being, yet these are the very things that deny us the coverage–the dreaded pre-existing condition. I believe it’s gotten to the point where insurance shouldn’t even have the word “insure” in its meaning nor Medicare the word “care” in its name.

The national conversation begins and ends with whether or not we should have the so-called Medicare for all, single payer or continue with the Affordable Care Act. What I don’t hear is how we have allowed these kinds of businesses to set the bar for caring for our sick and elderly. Why aren’t we talking—or asking our elected officials—about dismantling the choke-hold the insurance lobby has on our country? Have we become so complacent that we simply accept that this is the way it has become? Are there other options? Why are we all okay to accept–and pay for–this Machiavellian system of care?

We have all become subordinate to the insurance companies and Big Pharma. In 2018, Blue Cross Blue Shield, The American Hospital Association and Pharmaceutical Research & Manufacturers were three of the top twenty lobby groups spending more than 20 million dollars each in Washington. (Business Insider).  Also in 2018, 62 CEOs of health-care companies made a combined total of $1.1 billion in compensation even as more Americans are borrowing money to cover their own healthcare costs (GQ).

If the insurance companies aren’t covering our medical expenses with all their money, I wonder what they are covering?




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