Making The Right Move. Gillian Eades Telford
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of systems and services, and for many people, it is shrouded in mystery. This chapter follows the story of Mrs. Martino, whose encounters with the health system are quite typical for many elders. Research shows that family help is usually the first line of defense, and formal care provided by the health system is accepted only as the last resort. This chapter helps you understand the kinds of services available to elders and their families — before a crisis forces you to make a quick decision.
The health care systems in the United States and Canada are very different, so not all of the information in this chapter may apply to you. However, the basic concepts of the care needed for elders are the same wherever you live. Your doctor, regional health board, or local state department of social and health services can help you determine how to receive the best possible care for your needs.
The Health Care System in the United States
Because health care in the United States is not government subsidized, many people carry private health insurance (usually through their employers or unions). If you do not have private health insurance and you have no assets, you are covered under Medicaid. Medicaid is a federally supported, state-operated public assistance program that pays for health services for people with low incomes, including elderly or disabled persons who qualify. Medicaid pays for long-term nursing facility care; some limited home health services and may pay for some assisted living services depending on the state. Medicaid pays for the care of half of the clients in us skilled nursing facilities.
Medicare is the largest insurer in the United States and insures more than 40 million people. It is a federal health insurance program for people —
• age 65 and older,
• of any age with permanent kidney failure, and
• under 65 with certain disabilities.
Medicare provides primarily skilled medical care and medical insurance under the following schemes:
• Medicare Part A is hospital insurance that helps pay for inpatient hospital care, limited skilled nursing care, hospice care, and some home health care. Most people get Medicare Part A automatically when they retire as part of their social security benefits.
• Medicare Part B is medical insurance that helps pay for doctor’s services, outpatient hospital care, and some other medical services that Part A does not cover (like home health care). You must pay a monthly premium to receive benefits under Part B. The cost in 2003 was $58.70 per month.
Medicare Supplemental Insurance (often called Medigap) is private health insurance that pays Medicare deductibles and coinsurances and may cover services not covered by Medicare. Most Medigap plans will help pay for skilled nursing care, but only when that care is not covered by Medicare.
Health maintenance organizations (HMOS), pre-provider organizations, provider sponsored organizations, and private fee-for-service organizations all contribute to Medicare-managed care plans. A professional or group of professionals from any of these organizations paid by Medicare oversees and provides medical services for the people they insure, including hospital care, home care, and long-term care. Since Medicare is a co-payment plan and rates differ depending on the services, the people they insure need to partially pay for these services. Bear in mind though, that the physicians in these organizations are the gatekeepers. To save the organization money, they can control the number of tests ordered and the type of treatment recommended. (Note: Medicare is for people 65 and older.)
Social health maintenance organizations (S/HMO) provide the full range of Medicare benefits offered by standard hmos, plus additional services. These may include care coordination, prescription drug benefits, chronic care benefits covering short-term nursing home care, a full range of home and community based services such as a homemaker, personal care services, adult day care, respite care, and medical transportation. Other services may include eyeglasses, hearing aids, and dental benefits. Membership offers other health benefits that are not provided through Medicare alone or most other health plans for elders. There are currently four s/hmos participating in Medicare: Portland, Oregon; Long Beach, California; Brooklyn, New York; and Las Vegas, Nevada.
The Health Care System in Canada
In Canada, basic health care is universal and free. This means that in each province everyone is entitled to see a physician and to have access to hospital care at no cost to the individual. The Canada Health Act’s principle of portability means that care should be the same in each province. However, the Health Act refers to acute care hospitals, illness, and disease treatment by physicians — nothing else. While some provinces have chosen to include other aspects of health, such as home care, it is not consistent across the country. Some provinces include home care as a universal right, and others do not include it. Another gray area is long-term care. Some provinces include nursing home facilities as universal, others are pay as you go, and still others pay for different levels of nursing homes depending on your income.
Because of cutbacks to the Canadian health care system, many people also carry private health insurance to supplement their provincial benefits.
The Health Care System: Mrs. Martino’s Story
Mrs. Martino had moved into an apartment in the same neighborhood as her family home a few years after her husband died. There were many reasons for the move. The location of the family home was wrong: it was too difficult to get help up the hill, and the grocery stores were miles away. In the winter, she was snowed in for days at a time and she felt isolated because she couldn’t drive in the snow and ice. The bus system was infrequent, and the bus stopped a few blocks away. By moving into an apartment in the same neighborhood, Mrs. Martino aged in place within her community but not in her dwelling.
Mrs. Martino had two children. Like her, her son and his family lived in Victoria, British Columbia, while her daughter and her family lived in Edmonton, Alberta. Socially, Mrs. Martino had a wide circle of friends. She had many interests and kept her mind and body occupied. She was a member of the nearby seniors’ center and joined in exercise classes, crafts, and other activities. She loved playing Scrabble and bridge and kept her mind active through a study group. She also swam every day.
She was fiercely independent although, like so many other elders, she had a combination of chronic medical problems that had developed over the years and had been diagnosed and treated by the family physician.
Family physician and pharmacist
Mrs. Martino was a diabetic with a thyroid problem and congestive heart failure. She was also losing her sight because of macrimal degeneration and glaucoma, and had some hearing loss that was caused by a decrease in the size of her hearing canals. Under her family physician’s direction, she was able to control these chronic conditions through medication and diet. She bought her medication from a pharmacist who always carefully explained what each medication was for and how and when to take it. Fortunately, these conditions were not a bother to her. She had no disability and could do everything she wanted.
Mrs. Martino’s medical conditions are common to many elders and can be controlled through visits to the family physician, with occasional visits to specialists to confirm the management and treatment of the chronic conditions. Most elders visit a pharmacist to obtain their medication.
Activities of daily living
In medical terms, at this point, Mrs. Martino managed well with the activities of daily living (ADL). This means that she was able to cope with the actions essential to maintaining independence, such as walking on flat surfaces and stairs, being able to sit and get out of a chair or in and out of bed, being able to dress and bathe herself, and being able to do her teeth and hair and eat her meals. Medical professionals evaluate an elder’s ability to perform these activities, and then use the results to assess how much care the person needs. (See more about assessment in Chapter 3.)
However, Mrs.