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Ask a Care Manager: Health Insurance – Medicare for More?

With the spirited debates around some of the aspects of the Affordable Care Act (ACA) concerning health insurance coverage, it made me think about Medicare, health insurance for adults over the age of 65. Discussions around a more inclusive Medicare are popping up politically as the nation still tries to objectively understand healthcare, who has it, who doesn’t. I thought it might be helpful to take a historical look at this important issue and review how it works.

My grandparents, working farmers in upstate New York and born in the late 1890s didn’t have Medicare or any health insurance to depend on. President Lyndon Johnson made Medicare law in July 1965, four years after my grandfather died. Prior to that time, health insurance was either gained through a person’s employer, purchased privately or more often than naught, didn’t exist.

People called the doctor only during an emergency and seldom if ever, went to a hospital. The doctor went by horse & buggy in those early years to see patients at home. Payment for his visit was either in cash or a chicken, eggs or fresh produce from the garden. By 1950, not quite 50 years ago average life expectancy for a man was 65, for a woman 71 years old. In 2018 the average life expectancy for women is 81.1. For men it is 76.1 years. We are living longer than expected with those over 80 years old the fastest growing segment in the U.S.

The first president who introduced the concept of health insurance was President Teddy Roosevelt who in 1912 included national health insurance on this platform. However, nothing was done during his administration. It didn’t come up again until thirty-three years later in 1945 when President Harry S. Truman called on Congress to create a national insurance fund open to all Americans. He too was unsuccessful and another 20 years and several presidencies went by before national health insurance became a reality.

During John F. Kennedy’s presidency in the 60’s, a national study was completed showing that 56% of Americans over 65 had no health insurance but he was not successful getting anything through Congress. Finally enacted and signed into law by President Lyndon B. Johnson, Medicare is the accepted insurance for almost all individuals 65 and over. Recent figures show over 55.5 million Americans on Medicare, 10% of which live in California receiving benefits.

Medicare, the insurance can be confusing to the newly eligible. There’s no doubt about it. It’s not attached to Social Security completely although a portion can be deducted from the monthly social security payment. A more recent change allows for means testing in that some pay more for monthly premiums than others based on income. Eligibility for Medicare is at age 65 although Social Security can be taken as early as 62 with reduced benefits or with full benefits at age 67. Not so with Medicare which at this time is at age 65. The only exception is when a younger individual has been disabled for 2 years. Not signing up timely can involve penalties. Understanding what Medicare covers and what it doesn’t can feel like a thousand piece puzzle. It isn’t really but to the uninitiated, it can be a formidable challenge. Most people once they’ve chosen a plan stay with that plan in part because of the confusion of the three parts of the insurance that are offered and paid for separately. Bundling them together under a Medicare Advantage Plan i.e., Kaiser Senior Advantage, Humana, etc. puts all the benefits and costs in one plan which to some solves the problem of what to purchase and from whom. There are pros can cons to choosing a Medicare Advantage plan one of which is the lack of portability if you move from one geographic area to another. Stand alone Medicare however can be taken wherever you move although supplemental and drug plans may vary by location.

How does Medicare work – What are the plans?

Medicare A & B – Deducted from monthly Social Security payment (white card with red & blue stripe – shows Hospital (Part A) & Medical (Part B). If a person is on a Medicare Advantage plan, the Medicare coverage is “locked in” to the HMO who carries the plan.

Medicare Supplement (Medi-gap) – Plans offered by insurance companies that in California coverage must comply under Standardized Medigap plans A-N and are offered at varying costs to the consumer.

Medicare Prescription Drug Plan – Part D – Prescription drug plan to pay for prescribed medications covered within the formulary. Offered by insurance companies in conjunction with pharmacies. Costs and covered drugs may vary widely.

Additional points to consider:

  • If you are in a Medicare Advantage plan or a newly enrolled Medicare member and actively considering a move, investigate closely if coverage is available in your new location. Note: It takes approximately 6 weeks to disenroll from a Medicare Advantage plan to regain stand alone Medicare.
  • Never disenroll or drop any type of Medicare/Medigap/Part D –plan before you have its successor in place. You need coverage. You want coverage. You don’t want to have to worry if you’re covered.
  • Local insurance companies and brokers carrying Medicare supplement plans and prescription drug plans are usually very knowledgeable about all of Medicare. They also may be able to talk with you about Medi-Cal, a health insurance supplement plan available to lower income Medicare recipients.

If a person is not eligible for Medicare or Medicaid (Medi-Cal) due to income, their choices are limited and can be more than they can afford. This is particularly true for working adults with no employer-offered health insurance. Health insurance premiums are based on age and health conditions. Thus, coverage for an older adult with health issues may be beyond their budget. They go without coverage and “hold their breath”. Or…a person has employer sponsored health insurance but they want to change jobs or move. They may be locked into place simply because of their health insurance coverage tied to their job.

The Affordable Care Act enacted a decade ago has helped more Americans access affordable healthcare. There is however a sizeable gap for individuals particularly 50 to 64 who may have lost their job, been laid off, lost coverage and cannot afford COBRA or private insurance. They may have chosen to retire early and put off important health screenings or even needed treatment hoping to wait until the magic age of 65 and the implementation of Medicare. How helpful it would be if individuals could access this coverage earlier and remain healthy well into old age.

I wonder if 50 years from now our descendants will just accept the benefits of the Affordable Care Act (ACA), have universal coverage and that healthcare is an accepted benefit for all Americans. My grandparents and parents are long gone. However, I am most grateful to have health insurance. Yes, it can be complicated. It doesn’t pay for everything. Thanks to all the Presidents and members of Congress who continued to work on this for all of us. It’s a partial security net that’s holding for some of us. Let’s support the effort to expand the net for more adults. It can be a long time to “hold your breath”.


Carol S. Heape, MSW, CMC is Founder/CEO of Elder Options, Inc. providing comprehensive Aging Life Care Services for Families in Sacramento Region/Placerville/South Lake Tahoe since 1988. www.elderoptionsca.com

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