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Narrative Matters

Getting The Elderly Their Due

PREFACE: Complexity is a constant feature of our daily lives. Unfortunately, it can be the enemy of efficiency and can, in some cases, prevent important health services initiatives from functioning at all. Being large and multifaceted programs, Medicaid and Medicare easily fall victim to these problems. In the following essays two citizens, one medically naïve and the other medically sophisticated, discover some of the arcane aspects of the Medicaid and Medicare programs. David Carliner, an expert in insurance coverage for the elderly, relates the story of an elderly woman who is struggling to make ends meet, unaware of her entitlement to Medicaid benefits. Gordon Schiff, a physician and health policy veteran, discovers, incredibly, his own ineligibility for Medicare. Although unrelated, together these two stories leave one wondering if simplification is not the most important reform that might be brought to bear on both the Medicaid and Medicare programs.

It was a typical call. "Please come over and help me go through my papers." Mrs. Smith complains that she does not understand why she gets so much mail "about the doctors." We promise our members a single place to call for questions, so we respond.

Our Baltimore-based organization, a for-profit Medicare HMO, assists elderly people—overwhelmingly poor and female—in applying for governmental health insurance programs. I accompany a colleague from our sales staff to Mrs. Smith’s apartment as part of a program to give senior leaders the chance to witness what other team members do and to see firsthand the impact of our work on an individual level. On a more typical day I sit at my desk, far from the reality of our members’ lives, engaged in policy and administrative tasks such as working with the federal and state governments to provide comprehensive services for HMO members.

Overwhelmed And Uninformed

 
Our visit to Mrs. Smith (not her real name) occurs on a brisk winter day just before spring. Optimism is in the air in most parts of the city, but not in her neighborhood just blocks from my office, where half of the houses are boarded up. Many of the occupied homes are used as bases from which to sell cocaine. Inside this "war zone" is a subsidized senior high-rise, operated like a fortress. Only after we are inspected are we allowed to enter this safe zone.

Mrs. Smith meets us at the front door, anxiously awaiting our arrival. After decades of manual labor, she shows significant signs of aging. Her torso is stooped forward, with one hip six inches higher than the other. She looks like a geometric impossibility, like she should not be able to walk. But somehow she does.

We enter her two-room apartment, a combination kitchen/dining room/living room with a separate bedroom and bath. It is quite neat and orderly. We sit at a card table that is covered in papers, grouped and bound by large paper clips and then further aggregated and wrapped in rubber bands. The apparent compulsive organization is a ruse. Medicare Explanation of Benefits forms are mixed in with bills for supplemental policies, housing notices, information from Social Security, from Medicaid—the list goes on. There is no apparent rationale to how the documents are organized; some are current, others decades old.

We begin to sift through them, trying to piece together a story. As we are reading, Mrs. Smith brings over more and more papers. Her filing system is most unusual: Under each cushion on each piece of furniture she stashes additional clipped and banded stacks of papers—thousands of them. How typical is this scene, I wonder? How many other older Americans are bombarded by the unintelligible paperwork that our health care system produces?

We ask a few questions. With each response, we realize that Mrs. Smith does not understand what coverage she has or the programs for which she is eligible but not enrolled in. So we turn to the tangled mess of records to solve the mystery. Like detectives, we look for clues. After considerable study, we have it wrapped.

Mrs. Smith’s sole source of income is a monthly Social Security check of $574.27. She has a small bank account with less than $2,000 in it and no other assets to speak of. Somehow for ten years or more she has been paying $150 a month for a Medicare supplemental policy that covers Medicare’s deductibles and copayments.

However, she appears to be eligible for the Qualified Medicare Beneficiary (QMB) program—a Medicaid program that pays for Medicare premiums and high copays. Medicare by itself pays for less than 60 percent of total medical costs for a typical beneficiary like Mrs. Smith, making supplemental coverage essential for the poor elderly. QMB, in effect, foots the bill for all of the items covered by her supplemental policy. Like many of her several million peers nationwide, Mrs. Smith is not aware that such a program exists and that it is free. We explain to her that she does not need the Medicare supplemental policy and that she has been wasting $150 a month.

But the story gets worse. Mrs. Smith hasn’t been taking her medicines for several months because she needs money for food. Drugs (which Medicare does not cover) also are not covered under her supplemental policy. She could have been using the "wasted" money from that policy for needed medications. Better yet, she is eligible for a state-run drug assistance program that provides prescriptions for a mere $3 copayment (Maryland is one of many states that offer some sort of drug coverage for people like Mrs. Smith). The coverage is free to all who are eligible, but, as for the QMB program, most people don’t know they are eligible. Mrs. Smith, like many of our Medicare clients, is dually eligible because her low income qualifies her for Medicaid’s QMB program.

People who are dually eligible receive one of the nation’s most complete health care benefit packages. Depending on the level of Medicaid assistance for which they are eligible, these persons can have first-dollar coverage for all acute and long-term care services, including access to unlimited drug coverage. Before that can happen, however, the government must find a way to make people like Mrs. Smith aware of their eligibility.

Some 6.7 million Americans are enrolled in both Medicare and some form of Medicaid. But a General Accounting Office report published in April 1999 found that 43 percent of all Medicare beneficiaries who are eligible for Medicare savings programs (what used to be called buy-in programs because the state bought into the program for the beneficiary) are not aware of these programs. A small percentage of these people elect not to obtain Medicaid coverage because of the welfare stigma. However, the vast majority of unenrolled-but-eligible persons simply do not know that the program exists or are intimidated by the application process.

Making A Difference

Top Overwhelmed And Uninformed Making A Difference Another Kind Of Reform

 
Action plan for Mrs. Smith: Terminate supplemental coverage immediately. Apply for the QMB and state pharmacy assistance programs. In forty-five minutes we developed a plan to eliminate the $150 a month expense for the supplemental policy and put in motion plans to replace that coverage with free coverage and to get Mrs. Smith coverage for prescription medications.

For the Mrs. Smiths among us, fulfilling an action plan like this one requires great perseverance and know-how. As health care administrators, we understand the system and the various applications that must be completed. But how are lay people—especially the old and infirm—to be expected to navigate the complex, baffling administrative web that we have spun? People have to apply for Medicare and Social Security at local offices of the federally run Social Security Administration (SSA). Two separate applications are required for these programs, and some local SSA offices ask for face-to-face interviews. Medicare beneficiaries have to apply for Medicaid and the various Medicare savings programs at state-operated offices—usually one office will accept applications for both Medicaid and the Medicare savings programs, but not always. Some states require in-person meetings; others allow people to mail in their applications. State application requirements for pharmacy assistance programs run the gamut and often are coordinated by yet another state office. Each of these applications requires extensive documentation that can be extremely difficult for the elderly to produce. Little wonder that so many people are not getting the full advantage of these programs.

Mrs. Smith wept as we left. Although she didn’t understand how we were going to do it, she knew that our efforts were going to greatly improve her life.

Another Kind Of Reform

Top Overwhelmed And Uninformed Making A Difference Another Kind Of Reform

 
The low-income seniors we serve are grateful for everything that we do for them. The social, psychological, medical, and environmental hazards of living a life of poverty take a toll on our clients. They come to us with an average of seven to nine chronic illnesses, which makes caring for them complex.

Mrs. Smith and her peers should know about the programs that augment Medicare, including Medicaid, but they do not. More would if the government were to launch an educational campaign to raise awareness of the interrelationship between Medicare and Medicaid among medical and social service professionals as well as among dually eligible beneficiaries themselves. SSA databases also could facilitate outreach efforts.

States, too, could help more poor elderly persons by streamlining application processes—for instance, by allowing them to apply for federal and state health insurance programs at a single location. The elderly would probably not be as easily scared away if the federal government and states were to develop a shortened, uniform application to assess eligibility for all of these programs. Reforming the application process would go a long way toward ensuring that those in need receive the richest benefits for which they are eligible.

One noteworthy private effort to help seniors understand the public programs for which they are eligible is a Web site created by the National Council on the Aging, www.benefitscheckup.org. Initiatives such as this are a good first step. But Web-based solutions won’t reach those who lack computer access, and guidance about eligibility provides only part of the answer for seniors who need help navigating the application process itself.

While our country debates how to modernize Medicare—reforms that will take years— we need to act now to fix the programs that we already have in place. The Mrs. Smiths of America—our mothers, our aunts, our grandmothers—can’t do this themselves. They are relying on us.

Editor's Notes

 
David Carliner, david.carliner{at}elderhealth.com, is cofounder and senior vice-president of development for Elder Health in Baltimore, Maryland. Elder Health operates a Medicare HMO in Maryland and soon will be licensed in Pennsylvania. The organization helps major Medicare HMO providers in ten states to identify persons who are eligible for both Medicare and Medicaid. Medicare capitation payments for these persons are higher than are those for the non–dually eligible.

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