Chapter 20: Health and affordability
Health is a contentious issue in many countries. For the aged it is a serious problem, even in countries with good health care services. In this chapter we will look at the methods of health care and do a shallow dive into what health care will mean to us as we age. We will look at this subject in much more detail in our series on health, where we will look at common problems and the different modalities we can use for them. In that series we will also be getting health care professionals such as Doctors, physiotherapists, dieticians, biokineticests, and chiropractors to give us health tips. However in this chapter, we have to understand the nuts and bolts of health care. Health care will be one of our major cost and concerns. If we decide to move, health must be foremost in our minds as we age.
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Sally was offered a job in Australia, in her capacity as a software specialist. The salary was $160 000. Before committing to what looked like a generous offer, Sally did her maths. The Australian Medicare system provides free or subsidised medical treatment for all permanent residents. Anyone living or working in Australia (even temporarily) who isn’t eligible for Medicare treatment should have private health insurance. Health insurers offer two basic types of insurance: hospital and ancillary. Hospital cover contributes to the cost of in-hospital treatment and accommodation as a private patient, in a private or public hospital, while ancillary cover contributes to the cost of out-patient medical services that aren’t covered by Medicare, such as, chiropractic, dental treatment, physiotherapy, and spectacles or contact lenses. Ancillary insurance may also include ambulance cover, home nursing and other services, although there’s usually no refund for X-rays or prescriptions. There are payment limits for ancillary cover, both per visit limits and annual limits. A one year waiting period is in place for existing conditions. Sally has a husband who suffers from a form of muscular dystrophy and Barrets disease. She would have to pay for his treatment as a private patient, since no insurance would cover him that first year. He needed to see a chiropractor and physiotherapist around times a week, or ended up in extreme pain as his muscles continually contract, forcing the bones to move. He needs a cardiologist and a gastro specialist twice a year, plus a physician every three months. His medication needs are substantial. The salary that looked so generous definitely did not stand up to the amounts her husband would need to remain in good health. Sally turned down the job in favour of her existing health policies, which meant she could afford to live well and give her husband the care he needed. |
Life would be easier if we had followed the World Health Organisation (WHO) recommendations in every country, while we were young. WHO recommends prepayment financing mechanisms such as health insurance, to protect against financial risk and also to improve access to healthcare{9}. The main strategies for healthcare, are the use of subsidies and sliding scales for premiums. Common prepayment schemes employed are National Health Insurance (NHI) schemes and Social Health Insurance (SHI) schemes.
We may have schemes that are:
Subsidies can be by way of governments paying for indigent populations, in part or in full. This could also be in the form of tax credits. A third option for subsidisation is from donations made by non-governmental organisations for the premiums of the poor.
Countries allow for subsidising premiums and increasing the quality/quantity of services in the health insurance package, as this effectively reduces the real cost of health to households, improving affordability of these services. However, financial sustainability challenges are found in health, due to cost escalation. Other cost factors in health will be influenced by the broadness of the health benefit package, and the proportion of members that are exempt from contributions.
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South Africa is trying to put in a mandatory National Health System. The South African health insurance system has a voluntary private health insurance system, which is quite unique, because you are free to decide to join a medical scheme or leave one. It is not a condition of employment that you must join a medical scheme. Other countries such as the USA, have used health insurance, as a vehicle, to achieve health policy objectives of access to care for a significant proportion of the population. Many countries have made health insurance mandatory. The medical schemes industry in this regard, is quite unique to South Africa, as it is a voluntary membership. Medical schemes are non-profit organisations governed by the Medical Schemes Act. Schemes have to match premiums and benefits paid to providers or members, over the period of a scheme year. Applicants are guaranteed acceptance, although limited underwriting may be applied. It is advised to employ a broker for a medical scheme, unless you know the environment. There are onerous responsibilities related to moving a member from one scheme/insurer to another. Outside the medical scheme environment, we find a number of Health insurance products issued by for-profit (insurance) organisations, who rely on underwriting and actuarial knowledge to predict expected future claims over the long term. They may refuse cover to a person based on the perceived risk of that person. To cover the expense of medical care, a product is added on to medical schemes by members is gap cover. This covers the gap between what a medical scheme will pay and what the service providers (doctors etc.) will actually charge. South Africa has a public health system funded by general taxes, for which public sector health facilities are the main health service providers and all South Africans have an entitlement of access to this public health system, regardless of membership to medical aid. This right of medical care has been written into the constitution for all those living in the country. Most the South African and many foreigners use the public health services due to the cost of the voluntary medical aids and private health care. The National Health System will limit that right to public health care to only South Africans and South African permanent residents. State run institutions though in the country, are not (at time of writing) well managed and long waits are expected by the users of the system. Often there is a lack of medication. Presently the state of cleanliness, access to medical personal and accommodation in certain hospitals has been widely criticised.
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Older people are driving the growth and direction of the healthcare industry and healthcare consumption forecasts may be expected continue to grow. The reason for this is that aging carries its own problems.
Direct health risks associated with aging.
We need to understand each aspect of aging risk and see if we can minimise the risks.
Cognitive abilities are the mental skills you need to carry out to carry out any task from the most simple to the most complex. Cognitive abilities change throughout our lives. It is a normal process of aging and a subject of interest to the medical community. We have been geared to expect certain amount of cognitive decline as a normal part of ageing. Vocabulary will be resilient to brain aging and may even improve with age while conceptual reasoning, memory, and processing speed, decline gradually over time unless we actively use these skills. Some people, will experience a severe deterioration in cognitive skills, leading to dementia and will be unable to cope with ordinary day-to-day tasks. This deterioration will require special care. This slowing of speed of brain processing begins in young adulthood. As an educator I believe it is because we stop learning as we start doing repetitive tasks but not challenging tasks which require us learning new skills.
Cognitive dysfunction needs care. Both the physical and mental care aspects have to be considered. It must be stressed that some people do not show signs of aging as much as others, so this area is complex and certainly you should not think, that you will deteriorate, because you have reached a certain age. There will be many factors that will change the picture. Life style and preventative care being of extreme importance, as is your own attitude to aging.
Pets and grandchildren, have shown themselves to be aids to cognitive health. Certain organisations take animals into old age homes and retirement villages to give the inhabitants the love that a dog or cat can give. If you do want pets, consider an older animal, senior animals often are unwanted, so it seems a good fit for us. If you do have an animal consider their care if you cannot look after them. We have created a trust for our animals, as seven dogs, 30 garra rufa fish and two cats may be a lot for someone to take on.
Long-term care covers a wide range of medical services provided over an extended period of time. Long term care is not a senior situation alone, as it is experienced by the youth as well as the aged. Disorders such as asthma or allergies all need long term care. There are two types of long term care seniors will require; personal care and medical or skilled care.
Personal care is where you will need assistance with the normal activities of daily living and includes the supervision of an individual who is cognitively impaired. This care can be given by less educated individuals, than skilled care will require. Most long-term care isn't medical in nature, but rather personal care, nevertheless the costs can be considerable. Such long term care is normally covered under a countries’ social welfare program and not the province of national health programs or medical insurance. Insurance products may be obtained to cover the cost of frail and assisted living costs, but they may be too expensive for the pensioner unless bought when the person is young.
Medical or skilled care will include primary and specialised health care. Such care includes nursing or any category of medical care. A person may need occasional care to daily or even hourly care. Costs can vary considerably for the different medical services.
Although it is tempting to save money by trying to deal with health care costs on your own, it really pays to see the right health care professionals and get your health right for a better quality of life. Try not to skimp on this expense! Most of us will need primary healthcare, so that is where we will start.
Primary health can be called essential health or basic health care. Primary health care is for those sneezes and sniffles as well as more serious illness. Primary health care is an approach to health and wellbeing centred on the needs and circumstances of individuals, families and communities. It covers the provision of health services, including diagnosis and treatment of a health condition. Primary health provides support in managing long-term healthcare, including chronic conditions like diabetes, in as far as it is often the first, and sometimes the only contact, of the individual and the health system. A primary health care provider will direct the person to specialist or hospital care, should they believe it is necessary. To illustrate how a primary health care system would work: high blood pressure (hypertension) would be treated by a primary health care point, while cardiac problems would be referred to a secondary specialist in a primary health care system.
Good dental care is a requirement to a healthy old age, but is often not on the national health list of treatments. Even if you have false teeth, the mouth changes and bad fitting dentures can cause immense pain and infections. Implants come loose. An annual dental check-up should be high on your list of to –do things along with the delightful experiences of a prostate gland check-up or pap smear.
I have a husband who normally moves like poetry in motion, he is athletic and is just a pleasure to watch, but his hearing is going in one ear due to his injuries received and not treated in the army. Every so often I notice him fall or move clumsily. Often being off balance is due to our ears, they do take a tremendous beating if we listened to boom- boom music or shot weapons in our misspent youth. Black Sabbath needs to be a lot louder to us as we get older, doesn’t it?
Eyesight is a massive problem and can be a reason for accidents too. Get those eyes checked if possible once a year. For those on National Health systems, this is where private insurance may be a good idea.
Teeth and jaws becoming misaligned can also cause balance problems. My daughter, the chiropractor, adjusted my jaw, after I had prolonged toothache which the dentist could not fix. I was a little off balance with it and put this unbalanced feeling down to the throb in my jaw. She did her magic and wow! Suddenly accident prone gran was no longer falling and I felt rejuvenated, until I ate the next toffee at least.
Accidents happen to us all, but when we get to the new middle age they do seem to be more serious. We heal slower and we break quicker. We need to be aware that part of our health costs will involve being pro-active and healthy.
If you do find you are not a flexible as you were, then start yoga or a stretching class. Any movement class such as dancing makes us more flexible and helps with our balance and will stop fall frequencies.
If you can afford a gym or an exercise club then join one for the social and exercise rewards, your health will thank you.
When we retire it is okay to have the occasional off days, but it is not okay to be in a permanent state of hating tomorrow. Depression is real, the treatment is getting out of bed and getting involved in something that makes you realise life is not over. Drugs are not the answer here, but activity is a good replacement. You can change the world, little by little by being involved. Have a look at our section on volunteer work to get some ideas on what to do. Depression for me gets solved by me writing books, or cleaning the house with loud music blaring. You are welcome to copy me.
While we dealt with the abuse that family members and carers may inflict on the elderly in chapter 16, here we need to add to it. Thugs seem to be in every society and as we age we are more vulnerable to them. While pulling an arm, with a thug snatching a bag may mean a two day pain for a twenty year old, for us folks, it’s a serious injury and months in pain. Being active can help us appear less vulnerable and heal quicker.
Abuse in the health system is another aspect we do not hear much about. It is however very prevalent. My 76 year old doctor has told me how medical professionals will over service elderly people if they have insurance, and underservice those that do not have sufficient funds, or who are on a limited national health system. Over service means you get too many consultations or sent for too many tests. It can also mean you are sent to specialists or operated on when a simpler solution is available.
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Diana age 63, lives in a high income area. She is not active, overweight and smokes many cigarettes a day. She started with a problem of urine seepage. To date she has had 8 operations for this situation. Each time the operation is effective for a few months. Her doctor and specialist work in the same building. Both tell her she will need these operations regularly. Aphiwe age 65, lives in a low income area, she also had urine seepage problems. She uses the public health system. Aphiwe was given exercises and a diet to control the urine problem. Within three weeks she says it went away. Speaking to a senior physiotherapist and my own gynaecologist, both agree that it would be better for women with this very common problem, to do pelvic floor exercises. Both agree the operation is an expensive quick fix method that rarely is a permanent solution. |
Due to cost restraints on some health systems, older people are subject to a total cost of treatment. If the cost of treatment for an older person exceeds this cost then you will find your health care provider reluctant to undertake further treatment. There are still systems that consider the elderly not good candidates for organ transplantation, dialysis, or advanced surgical procedures. With a heart conditions costing around $80 000, it is easy to see how the costs can mount up with the elderly persons.
In any health care system the elderly are vulnerable, as the elderly do not contribute and are in effect representing a cost carried by the youth of that country. As the numbers of elderly increase, and in some countries out of four people on a public health systems one will be elderly, the youth are becoming more reluctant to pay the higher contributions required, putting strain on the system. Often these people, without private means, will be underserviced. Underserviced means you do not get the correct tests and will be given cheaper medication, without the underlying health condition being correctly investigated.
Certain doctors have told me by prescribing medicines they get to meet their quotas in pharmaceutical sales and will be rewarded with prizes. It definitely is not an honest world out there.
Ethicist Daniel Callahan has argued that expensive medical care be limited for elderly patients in his highly controversial book, “Setting Limits — Medical Goals in an Aging Society{10}.” A nurse told me, when treating my mother in the UK, that after age 70 most countries believe the elderly have had a full life, and disorders such as erectile dysfunctions should not be given expensive public treatments.
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Doe’s had surgery for a blood clot, hip replacement and Gus has had several open heart surgeries. All very, very expensive. Although Doe worked for just a short time after being a stay at home mom, she made sure that when she did retire from her last permanent job that she remained on the medical aid. Doe believes they would not be alive without this care. Doe suggests at least a hospital plan should be taken out but is happy with her choice of a network plan as it works out cheaper than paying a hospital plan and doctor’s consults.
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What to do about health service management. Get knowledgeable about your condition. Ask why this drug or that drug is given to you. Tell your health professional you do not want over medication. All medicines will re-act in some way with your body and the other medication. Ask about side effects of any medication given and write it down or record the advice given.
Be active, not in physically demanding sports, but taking walks, or doing something controlled such as yoga, or light exercise. Activity is an answer for many ailments, as it increases the blood flow and releases feel good chemicals in the brain.
The level of specialisation, the disease would need, will affect the cost of the treatment. Few Health systems will support the cost of biological drugs and new treatments due to two reasons. Costs and evidence based treatments. Most diseases have an associated medical protocol described, called an evidence based treatment, and only after substantial tests will that treatment plan be replaced with another evidence based treatment. Health systems will normally pay for the existing evidence based treatment only. A doctor can not deviate from those norms if they wish to be paid.
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Walter Pike has prostate cancer. Although at 71 he is still working actively and is independently wealthy, he is taking part in an experimental study at the Steve Biko hospital in Pretoria. He had to fight his medical aid to pay for the treatment initially, but after winning that fight, is having the treatment free anyway because he is willing to be a guinea pig. |
Do all people need to pay for medical care? Depending on your health system you may need to budget for private health insurance over and above any publicly available treatment. Long waiting times are prevalent in many public health systems and for older people this can be detrimental.
With age comes a lack of good health and for the unlucky few frail care or some form of assisted living is required. Alzheimers and senility will also require some form of care. When you become frail there are certain options you can look at:
When an elderly person is no longer able to cope with the demands of everyday life, he or she can apply for assistance from municipally funded home-help services if they are available.
Being cared for in your own home is definitely first prize. Carers can be appointed to come in or live in, and take care of the person. This is not normally medical care which is required, or it may be very basic medical care such as medicine management. A basic caregiver course is around 8 hours and then there is an exam. Such short trainings mean the normal a care giver is not a trained professional, having basic first aid only. That said, these people are normally dedicated to others. Having home care is not a cheap exercise. In South Africa, rates are around R20 per hour or R160 per day. In the UK most carers earn around 95 sterling per day while the USA is in the ball park of around $12-15 per hour.
Some countries will provide free or subsidised home based care, based on the situation and resources. Home based care can be temporary or terminal care, and costs can increase depending on the level of care required and the skill of the carers. Nursing staff may also do home based visits and even do live in services. Nursing visits may be paid for in a limited form by a medical plan or even the health services of the country. For many elderly people, these nursing visits will keep them in good health and out of hospital. Full time nursing will need the person to go into a home, unless the pockets are very deep.
Recuperative care:
This care type is normally after surgery or an accident and is temporary in nature. Often recuperative care is fully covered under a medical plan. Such care may have home nursing or be in a step down facility. The cost of care will depend on the services required for each situation.
Frail and dementia care:
When a person requires frail care or care for certain dementias, we assume this is terminal care- that means it will continue till death. Dementia can be resolved if it is from pain, however there are dementias which may not ever be resolved, such as Alzheimer’s disease. There are registered organisations that deliver 24 hour care, and they vary considerably in price.
Frail care insurance is available. As financial planners we often recommend such insurance particularly to the children of parents that do not have substantial means to pay for such care. Some countries do have facilities, free or subsidised for these poor souls. For those on the NHS in the UK, funding from the NHS will cover the full cost of your care, if you are deemed to have a healthcare need, whether in your own home, or in a care home. However for most countries, it is difficult for people with dementia to meet the criteria for eligibility, because they are often assessed as having social care needs, rather than healthcare needs. Social care will be means-tested in most countries. In certain cases home based care can be considered as an option, depending on the level of dementias or medical services required.
Palliative care:
Palliative care uses both specialized medical and nursing care for people with chronic conditions. It focuses on providing relief from the symptoms, pain, physical stress, and mental stress at any stage of a chronic or terminal illness. The care will consist of relief not treatment. Palliative care does not equal impending death, but will mean the patient has an expected limited life span. Hospice will fall into this palliative care category. Hospice care, is normally provided to individuals who have been diagnosed with six months or less to live.
Increased need for health expenses.
Older and younger generations often require a support or safety net in health paid for by the working people. The generation that is presently retiring, often has parents that are still alive and children still dependant on them. Conservative estimates put 49% of unpaid family caregivers at over 50. This burden of care can scupper the best laid pension plans, if not considered carefully. In any retirement plan we need to understand the costs of health and understand the requirements of health costs when we start our retirement journey. Health care costs will increase at a cost higher than normal inflation. New developments in health may be expensive, may be effective and may be needed or desired. We accept we will have health costs and at retirement must determine what we will require.
Should we not want advanced life-saving care after a heart attack, or a tube feeding you as you wander with the fairies, then we will need to look at a living will or an instruction which the family can give to the medical team, if you are not able to refuse treatment yourself. You may also consider a Power Of Attorney For Health Care. A sample of both a Power Of Attorney For Health Care and a living will from Schedule 3 National Health Act 61 Of 2003 of South Africa is attached.
The guideline for both the living will and Power Of Attorney For Health Care can also be found on our website www.yesterdayspeople.com. Both documents must be done while you are of sound mind.
The living will should be signed and a copy given to your house doctor as well as copies kept by trusted family members. Your country may have certain requirements so it is best to speak to a financial planner about this matter.
It is important to ensure your loved ones can be contacted if you are hurt or unable to talk. Keeping an ICE number in your mobile phone memory is important as the emergency services are trained to look for such a number. The ICE acronyms stand for (I)n (C)ase (O)f (D)eath and (I)n (C)ase (O)f (S)ickness. There are other apps such as my SOS which can be used as well.
Health is a fundamental need in retirement. We need to determine what it will cost twenty years into the future as our life span will require it. Without analysing our health needs any retirement plan will be doomed to failure.
There are certain things we ourselves have control of. Activity is one of those needs we have to undertake. Failure to do so will result in ill health or injury.