Cost of Staying Healthy

There are times when I think I’m the only one who cares if I remain healthy.

Once I start drawing social security, the actuaries know the sooner I die the less I draw from what I’ve contributed.

Insurance companies certainly don’t want me to stay healthy. If I never had another physical, I could have a heart attack or fall from weakened bones when I’m 75. It would cost someone to treat me, but I probably wouldn’t last long, and my total costs past age 65 will be relatively modest.

As it is, I insist of staying healthy. It turns out not to be a decision many can afford. This year it costs 21% of my gross and 27% of my actual take home pay. The percentages will be slightly smaller when I draw social security.

My health program is simple. An annual physical, which is not covered by today’s medicare part B, supported by blood work which may be covered. Every other year, I see the eye doctor, which is not covered by any insurance option, have a bone density test which is covered by medicare, and a mammogram, which currently is only 80% covered by the government and the rest by medigap J.

The prescription drugs I take are preventive, rather than life sustaining, and in that sense voluntary. In addition, I take vitamins for my bones, including calcium citrate, magnesium, and vitamin D, along with fish oil. They cost something like $30 a month.

I need exercise for my bones and to keep my cholesterol levels low. Only some medicare advantage programs cover the cost of a gym or wellness center. One I used was $30 a month, another $60. I tend to get bored by them, and keep promising myself I’ll do more on my own. Simple walking is supposed to be enough.

Diet is another factor. My preference for dried lentils, rice and frozen vegetables is relatively inexpensive. If I chose the recommended healthy diet with fresh fruits and vegetables, more meat and fish, my food costs would be more than I could afford.

I look at what I pay to stay healthy, and think about an Indian woman I worked with. For some reason, her husband, then in his early 30's, had undiagnosed diabetes. When he finally saw a doctor in August, he checked himself out of the hospital because his mother was ill. By Thanksgiving, he couldn’t walk. When his wife got him to the doctor, his organs were shutting down and nothing could be done. He died before Christmas, leaving two young children.

His death was costly to his family, but only cost insurance programs a few days in the hospital. It may be the ideal for a capitalist concern, but as a child of a diabetic I expect more for myself.

Medicare Part D

Medicare Part D, the program that covers prescription drugs, is a world of Potemkin web sites.

Everyone explains the program has three phases. No coverage for the first $310 and no coverage after $2,830. Another part of medicare takes over after you spend $4,550. The $1,720 between is the infamous doughnut hole where the patient pays everything. Insurance, of course, is available to cover those extra costs.

After that simple information, everything is hidden. The deductible and the doughnut hole running balance counts everything you and the insurance company pay, except the premium.

You know what you pay, without the help of fancy websites. You cannot find out what the insurance company says it pays or, for that matter, if that list price is in fact what it does pay. The excuse is prices change weekly. The real reason may be more nefarious.

I began with the government’s medicare site which ranks plans by zip code. All the rest of the cost information is useless, since it only calculates premiums and co-pays. I discovered there were 47 available plans, of which six had ratings of four stars or more out of five. Those six are offered by four companies. Three charge standard co-pays, and one charges 25% of the unknown drug costs.

I called all four, and asked them to mail information. The one that charges by percent still has sent me nothing, despite two requests. I should note I live in a primarily rural county with high rates of diabetes, alcohol caused accidents and heroine use. While Medicare allows insurance companies to offer rates based on an individual’s health and age, most choose the location option which places me a high risk group. No doubt the one that won’t send information is willing to offer something in other parts of the state, but tries not to offer anything here.

Next, I made a list of the drugs I took in the past year, figured what I paid currently, and what I thought the actual insurance company cost was, based on one of those websites that list costs for Canadian and American sources. I used the numbers it listed for CVS drugstores.

Every month I need a bone density drug that’s listed as tier 2. I currently pay $30 a month, and the drug website listed it as$104, or roughly 29%.

Almost every month I need a hormone replacement that’s listed as tier 2. Again, I currently pay $30 a month and it was listed as $104.71, and again I now pay roughly 29%.

Those two drugs alone would cost $2,520 for a year, just $310 less than the coverage cut-off. Any other drug requirement would take me into the area where I paid everything again, unless I paid a much high monthly premium.

Because of serious muscle problems this past year, I took Celebrex and expect to need to buy it maybe six times in the coming year. My insurance company only grudgingly authorizes the use of the anti-inflammatory after the doctor writes a letter showing any alternative would cause serious stomach problems.

My co-pay was $55, and my local drug store couldn’t tell me in fact what it would cost me if I didn’t have insurance. The listed price for the tier 3 drug ranges from $50 a month in Canada to $122 for the American company I’ve been using as a standard. However, I suspect the number is much higher.

One medicare part D plan charges $42 for Tier 2 and $90 for Tier 3, with a monthly premium of $34. The total cost per month is close to $208, with no deductible.

The second provider charges $38 for Tier 2, $73 for Tier 3, and a monthly premium of $33, for a rounded monthly total of $183. If I allocate its $180 minimum deductible for the year, the monthly rate rises to $198.

The third charges $33 for Tier 2, $90 for Tier 3, and $47 a month, for a total of $202, with no deductible.

If price alone could be calculated, the choice would seem simple. However, I’ve never heard of the people who provide the second plan and only know they’re in Texas, while the others come from people with reputations, AARP and a national drug chain.

Since losing coverage when one reaches the doughnut hole depends on what the companies say they pay for the drug, everything ultimately depends of their veracity. One, AARP, has a plan that will cover the gap between Medicare and catastrophic coverage, and the premium difference is $556 year. It’s only worth it if the cost of drugs is greater than that. Since I can get no reliable information on Celebrex, I have no idea how much I would spend.

Once I go through a year on Medicare, and get the periodic statements that indicate exactly what the drugs cost, I can make a more informed decision the following year. However, the first year is an absolute blind pig shoot.

Medigap

I’ve always had an ambivalent attitude towards AARP. I always thought joining would be a bit like becoming a teamster: I would pay my dues, knowing I was contributing to activities that improved my life, even though I suspected I didn’t approve of everything the organization did. Now that the radical conservatives are considering targeting it as a way to destroy health reform, I might actually be willing to make a contribution beyond my dues.

The market for supplemental medicare policies grew from the fact that while the government sets the price for services, it tends to only pay 80% of that price. The rest is left to the patient.

My father had some kind of policy when he died from lung cancer in the 1980's that seemed to have covered everything. However, by the time Congress was considering the medicare drug proposal, anarchy (or genuine market competition) had taken over the supplemental medicare insurance industry.

Congress defined several levels of coverage, and that’s all any company can offer. The competition, if any, lies in prices and reliability of services. Most cover the medicare deductibles, but only plans F and J cover the 20% gap. The only difference between the two, is one offers $120 for "preventive care not covered by medicare"and $1,600 for "at home recovery."

Getting a definition of "preventive care not covered" is impossible. One reason I have bone density problems is my body doesn’t absorb vitamin D. Each year, as part of my physical, my doctor orders blood work to check my vitamin D levels. I can’t find out if that test would be covered by medicare or, if not, if it costs more than $120 and would be covered by plan J. I do know this year my insurance company set the amount that could be reimbursed at $75 of the $315 the lab billed.

Once I had some idea which medigap policy I needed, I found getting information on what was available where I lived nearly impossible. Every website tells you to check your state’s insurance regulator’s website to find what’s available. It took the better part of two days to find that site, and then all it provided was a list with 800 numbers that did not include AARP’s provider, UnitedHealthcare.

Of the 31 companies the state listed, 30 offered plan F and two offered plan J. So much for finding competitors with AARP.

If I go with UnitedHealthcare, it’s because I know the AARP card will be recognized anywhere (except possibly the state of South Carolina) and that it has a large enough pool that it can offer lower rates, if it’s so inclined. More important, even if AARP has put itself into the unfortunate position of both consumer advocate and company shill, it’s continued success depends on satisfying the former group of notoriously cranky people and that may exert some pressure on the quality of service and price.

Medicare Advantage

There are times when I wish Congressmen had no staffs. Then when some family member needed help selecting an insurance plan, they couldn’t turn it over to someone else, who would then call a friend who would call a friend, eventually reaching someone who helped write a 1,100 page law and knew the right person in the industry to issue the perfect policy for the relative.

Understanding the simple basics of medicare options took nearly two full days of surfing the web when my boss thought I was doing something worth my salary. I finally found that, like IBM programming manuals, everything on websites made sense once I had already figured things out for myself, but nothing made sense until then.

I had always assumed that medicare coverage just happened when I turned 65, and I could afford the smaller social security paycheck because I wouldn’t need to pay so much for private insurance.

I also assumed my mailbox would be filled with circulars from various medicare providers. When I got nothing, I called by insurance agent to get advice on what I still called supplemental medicare insurance, only to be told (1) my agent didn’t handle medicare related policies, (2) I had to register with social security, and (3) the best thing to do was call AARP.

Calling social security was easier than AARP, and within minutes I was registered. It took three weeks, however, to receive a piece of cardboard that confirmed my account. It came the same day as a notice from my current insurer saying my rate next year, if I were still 64, would rise from $366 a month to $453 and convert from a PPO to an HMO. It would only be $405 if I lived in a more metropolitan area, filled with more accidents and pollution.

The first thing I had to learn was the meaning of medicare parts A and B. The first covers hospitalization and is free. The other covers medical needs and costs $96 a month. It rises to $110.50 next year, but no one at Medicare seemed to know that. It only found out when I got my first bill.

That’s $1,326 a year. If I remain healthy and only see my doctor once a year for a physical, supported by blood work and an every other year bone density test, I’m essentially paying all my own medical expenses. The physical is explicitly not covered by Part B, and it’s still not clear if the geriatric lab work would be covered.

However, someone rear-ended my car some years ago, and three times in the last ten years I’ve had to go through physical therapy to overcome muscle problems caused by the whip lash. Each clinic charged at least $100 a visit, in addition to my co-pay. If that happens in the future, as it may, I’ll get some benefit on my $110 a month investment.

The next thing I had to learn was that what my father had as supplemental insurance no longer existed after Bush added the drug benefit. Now, one must choose between a heavily advertised medicare advantage plan or a secretive medigap policy. The one is essentially a nicely packaged HMO or PPO that front ends medicare, handles the drug benefit and may add a few other things. Real coverage is only available from an insurance company.

In this state, there are several bottom feeders, defined as those who are working to sabotage health care reform, who offer medicare advantage plans. In addition, there’s a local HMO I vowed to never use after a one year stint when they seemed more interested in generating cash in the form of co-pays required to get referrals than in serving my needs. I finally found my own doctor and paid my own expenses for the rest of the year.

There’s the PPO I currently have who did not have a service agreement with the primary hospital in this region until this spring. Confirming that took some phone calls. The company’s central office said that it was true, but no one at the hospital had worked there long enough to understand my question. As my insurance agent said, that agreement isn’t strong enough to use as the basis for a decision - it could be cancelled any time by either side.

Blue cross simply says they’re no longer offering a medicare advantage plan in the state next year.

When I talked to people who are already on medicare, I found they have no idea what they have. My boss’s mother only knows what she has is free and I must be some kind of fool to be paying anything more than the deeply resented monthly fee.

When she got bubonic plague this year and was hospitalized for five days, she says she only had to pay a few co-pays for follow-up appointments and part of the price of the ambulance because it wasn’t an emergency. Why getting an 80-year-old woman having trouble breathing and a high fever to the hospital isn’t considered an emergency, I don’t know, especially when they discovered e-coli had broken from its confinement as a consequence of the plague.

She says she has no drug coverage, but also says she’s a member of that HMO I boycott who offers medicare advantage with or without drug coverage. The one has no premium, which means she is essentially getting only medicare part B, with no assigned doctor.

Another friend’s father put her mother into a dementia care center this year, and discovered none of the costs are covered by his policy. He won’t tell her any more than that it’s with the HMO/PPO that didn’t have an agreement with the hospital in the state capital, so I know it’s medicare advantage and not the supplemental he may have thought he had.

Once I made the decision to use medigap instead of an advantage plan, I learned why the HMO’s and PPO’s are popular. My current physician doesn’t accept Medicare. I can still see her if I’m willing to pay my expenses. When I called the first name on the list of doctors she recommended, his receptionist said he also did not accept Medicare. The other two aren’t accepting new patients. Or rather, I can make an appointment in November for March or May, two months after my current prescriptions expire.

Even having good insurance isn’t enough to guarantee treatment in this part of the state.

Elephants Can Remember

F. Scott Fitzgerald famously wrote "there are no second acts in American lives."

When I was rereading Agatha Christie’s Elephants Can Remember, some unexceptional sentence crystallized the pattern in her mysteries that for people who labored for the British Empire, there were three, clear and distinct acts: one’s youth in England, one’s time in India and one’s retirement back to England. If one had children abroad, they were sent home to relatives to ensure the first act.

The pattern fits the basic quest motif of a young man setting out to prove himself, then returning home. Home, in Christie’s mysteries, was rarely the actual birthplace, because, with World War II, there were no unchanged homes. Even her St. Mary Mead had been developed. Still there were places in England where returned colonials could cluster.

Her books also include the unfinished stories of people who leave for South Africa, Australia, New Zealand and Canada that is the theme people attribute to Fitzgerald’s comments in his notes for this unfinished novel, The Last Tycoon. Once people achieve or fail at whatever it is they first intend, there is nothing left to do, no place to return.

Michigan is like the England of primogeniture where there was so little opportunity, younger sons had to leave to live, then to the military or church. Most people in my high school graduating class have moved elsewhere as the economy shifted south and west. Some have returned to care for their parents, or have moved to be near their children to be looked after. But for most, the temporary move has become a permanent alienation from their childhoods.

Perhaps it’s why we cling to the idea of our class reunions. Nearly half the people I graduated with keep in touch with the local reunion committee, although far fewer actually make the trip cross country to the events. We maintain a collective fiction that we were once a community, and that some part of us still cares about those people we really don’t want to spend any time with again.

If I say these are people with whom I spent 13 years of my life, it makes the relation sound stronger than many marriages. If I try to think of one person I actually saw most days of those years, I cannot. People came and went, we moved from five elementary schools and several country ones to a single junior high, peer groups changed.

And yet, in a community where people were able to spend their entire public school life, there were ties. For many, churches like the Methodists, Catholics and Baptists brought children together from the scattered neighborhoods. For boys, there was organized softball in summer, for girls Camp Fire Girls or dance lessons in winter. There was the swimming hole, the skating pond and area lakes where children with similar interests became aware of one another.

I grew up when television sets were just being purchased and our youngest years weren’t spent in isolated living rooms with siblings watching whatever was on. In those years, the two available stations were both the same network, and there was often little worth seeing anyway.

We also came of age before conglomerates began buying, then downsizing local industries and people had to move with their parents when they were in high school. Only children of the college faculty and oil field workers led the migratory existence that characterizes so many today.

In the first years after graduation there were those who attended or sent back notices of Fitzgeraldian bravado that hoped to prove they had finally gotten the best of those who snubbed them then. That wish for vengeance or triumph has inspired many class reunion novels, including Jane Haddam’s Somebody Else’s Music and Jo Dereske’s Miss Zukas and the Island Murders.

But with time, none of my classmates has achieved great success and few have even had the stable marriages they had expected. We have had to settle for whatever it is we have become. If we’ve been able to overcome the demons that drove us in adolescence and can care about who we once were, no matter how ruefully, then indeed we do care about these people who were part of that world.

Our class has become a collective illusion, a virtual community we inhabit as we age that gives us a sense of that third act when social and economic realities have made the actual return impossible.