GIVING IT UP

Context controls meaning.  Today the temp is hanging around zero fahrenheit and will go well below at night over the next week.  Cold “snaps” of a few days are one thing, week-long sieges are another.  Gradually the house becomes harder to heat, one becomes more reluctant to walk to the post office for the mail (2 blocks), and animals lose their energy reserves.  And the cost of the heat rises.

This time the cold coincides with a bursitis or something of the sort in my right shoulder and arm.  It has happened before.  Painful, sleep-depriving, etc.  So after a night of getting up to check the temp and drafts, getting up to take an aspirin or whatever, getting up because . . .  oops, the cat just left to sleep somewhere peaceful.  

At 7:30AM I finally reach resolution and slide into sleep.  The phone rings at 8AM.  A g.d. insurance “licensed agent.”  Wants to "guide me through the maze."  If he were a “salesman” he would be illegal.  I have the phone number for turning him in.  I’ve made a grid to analyze the various plans. With a black fibertip I eliminated his company.  The “context” is that under those conditions NOTHING is acceptable.

Now that I’m up anyway, I’m reading every scrap of info and making phone calls, sorting into the cardboard catfood-case trays.  But also doing a bit of internal reflection on my own dysfunctional assumptions.  I forget that though the health issues in the media are almost always framed in terms of what will preserve life -- take this pill and you’ll live for two weeks longer than the average !! -- most meds are meant to address the possibly very long interval between a chronic problem developing and any actual death.  This bursitis is probably here to stay and I’m only 75.  How much is freedom from aching worth over the next ten or even twenty years?

I hear young people, poor people, rez people, ASSUMING that they will not live very long anyway.  They are TOLD their lives will be short -- and shorter if they aren’t obedient.  Lengthening what is already a miserable, painful and demeaning life is not motivation for compliance with med protocols.  Comfort now, please.  Our constant warnings that smoking will “shorten your life” flip over so that nonsmokers who die of lung cancer, like nondrinkers who die of cirrhosis, are ASSUMED to have secretly done this “bad thing” and therefore can be legitimately blamed for dying, while “we” are safe.

I’ve discovered that around here the social assumptions that interfere with financial help like Medicare are numerous:

1.  The duty of a person is to save for their old age.  Anyone who doesn’t save for old age is probably a bad employee, a job jumper, or incompetent.  Or maybe they did a bad thing like going bankrupt, which means they are bad business persons.  (Anyway, thinks the critic secretly, “They remind me that I’m really having a lousy life because I’m saving for old age -- what if I don’t live that long and it's all for nothing?”)  A prosperous old age is an entitlement for good people so they can go on cruises or gamble in Vegas.

2.  Any divorced woman is a) probably promiscuous and deserves what she gets; or b) must have gotten a big alimony settlement so she’s sitting pretty for life.

3.  Anyone with a fancy education who comes from a big city is only coming to a small rural town in order to lord it over the rest of us and probably has resources beyond what we can imagine which they are hiding because they involve something shady.  

Back to practicalities.  I could go straight to insurer-provided mail-order prescriptions that would come in 90 day increments instead of fussing with a thirty-mile drive to a pharmacist every thirty days, but I would be depriving myself of Janet’s advice and she WILL dependably mail my meds.  On the other hand, since Care Mark CVS drugstores own SilverScript, my insurance company, they will give me a 20% discount on over the counter meds at their stores.  I never read that before.  Since the truth is that I spend more on aspirin, acid-reducers, and famotidine, etc. than on prescriptions, this could be pretty nice.  I should keep track of my OTC meds for a year and see what that’s worth.  (Any of the shrewd consumers in Valier would have done this long ago.)  But it feels like a bribe and, of course, I know that the idea is that once in the store I’ll blow money on trivia.

People here are extremely numerate.  They can calculate on the back of an envelope what their barley profit will be, given last week’s rain.  They can calculate interest on farm equipment in their heads.  But they have very low emotional IQ’s.  They don’t recognize abuse and if they do, they see it as legitimate enforcement of morality.  They have no consciousness of humanities, read only trash, watch lurid television, believe nonsense, and hate change.   To them male vs. female is sort of like Democrat vs. Republican -- both bifurcations self-serving and arrogant.   This entire preceding paragraph is stereotypical and pejorative.  Prove me wrong.  I will be delighted.  And it DOES affect governmental programs that are meant to be equally applied, fair and non-stigmatic.

As far as the assumptions of government, watch “West Wing.”

In the end, I called SilverScript to set up a payment program for what I owe.  Of course, they want it to be an automatic deduction from my bank account but I don’t want to do this because it’s come to grief in the past.  For instance, the bank will deduct the payment before it is due, so my balance comes up short and someone out there gets a rubber check.  Which means a fine from the bank and a fine from the receiver of the check.   Potentially $60 for a couple of dollars of overdraft.  All our penalties are money.  All our children will be bankrupt.

The bank used to call you up to tell you to come and fix it.  Now the world is computer debits and credits without human dimension or intervention.  The assumptions are built into the computers by people who live in cities where they have mail delivery to their address, cafes nearby, high incomes (they don’t say, as Montanans do, “good-paying jobs”) with status, black wardrobes and ten-foot-square apartments.  They’ll call me back.  (NOT.  They'll stall until after Dec. 7 so I can't pull out.)

I’ll just stay with SilverScript, keep better records, pay more attention, address the real problem which is ME, suspended between suspicious paranoia and knowing that MOST (not ALL) of the people out there keyboarding along in carrels are NOT out to skin me alive.  They are likely to live somewhere around here, where the phone answering businesses locate, where high school kids are taught to be obedient, clean and numerate.  But entirely without humanities which might teach them relativism which is moral rot.  Zero tolerance for being different.  A steady snow of contempt.

It’s like a horse.  Once a horse figures out they have all the power, you can only ride them if they care about you.  And they care about who feeds them.

MORE PLAN D

The most important revelation in my investigation of Plan D is that it is NOT required.  I can simply choose not to subscribe.  That moves the consideration to a whole new level.  Also, according to the 2013 rules, a person who receives Extra Help can change companies anytime -- not just before December 7.  

The most discouraging aspect of this search has been that no matter WHOM I ask for help and advice, what I get is a pitch for or against “Obamacare” -- which is irrelevant.  They told me when I was doing public relations with the media that if someone asked me a question I either could not or did not want to answer, I should answer a question that was similar but not the same.  I hear this strategy among politicians and even doctors again and again.  Sometimes they don’t even do “similar.”  Just change subjects.

I will not depend only upon the advice of doctors about which drugs I should take, the same as I will not depend upon insurance companies to tell me which policies I should engage.  The influence of big pharma, the many instances of flawed studies and reversed recommendations, my hospital chaplaincy which gave me access to patient files and physician reviews, and my brief brush with statistics, have all told me that medicine is NOT magic, that what cures one person can damage the next, and simply perpetuating oneself is not the best goal.  I barely managed to resist the craze for estrogen replacement at menopause.  Everyone talks about testosterone as psychoactive -- try switching in and out of estrogen!  It’s being thirteen again.

So, where am I?  Personally, I mean.  What Plan D should I choose?

1.  QUALIFICATION:  I'm under the poverty line as currently defined.  It moves yearly.  I’m on the boundary and could be pushed out in a different year, but now I get Extra Help.

2.  DIAGNOSIS:  My only conditions are “metabolic syndrome” and “ocular migraine”.  That means age and behavior driven glucose and blood pressure levels that are marginally too high as well as tired eyes from obsessive reading and writing.  These are all best managed with diet and exercise -- very minimal medication.   But these latter must be monitored with formidably expensive lab tests.  Much of medicine now is based on these tests rather than direct observation of the body.  For a five minute conference with a nurse-practitioner, a blood draw, and multiple panels of statistics that showed the same figures as last time, I was billed $546, all paid for by Plan B.  NOT Plan D.  

At this “checkup” I asked for the new “shingles” vaccine but there was none on hand in the clinic (which means a new billable visit to get the shot) and no one knew whether it is covered or under which plan.  Ideal levels of glucose vary in the minds of various physicians.  Some say that slightly older people should maintain slightly higher levels.  Others think that lower is always better and will push a person close to the danger level, I discovered from experience.  One cannot relax vigilance. 

3.  DEDUCTIBLE:  This is the amount a person is expected to pay before the insurance  begins to pay.  On the list I’m looking at, most companies specify a little over $300, but if one is classified as “Extra Help” (meaning poor) then the deductible drops to maybe $65.  Some companies offer NO deductible. This is a good thing since the total cost of my drugs for the whole year is less than $300 -- at non-negotiated prices.  The cost of my YEAR’S drugs  if the insurance company has negotiated special very low prices for the meds is little more than $65.  Of course, the insurance companies owned by drug store chains have a lot of leverage for deals -- probably as much as a small African country.

4.  CO-PAY:  Some policies ask the patient to pay part of the cost of drugs, separately from the issue of what is deductible.  Co-pays, like deductibles, can be arbitrarily changed by the insurance company on the first of every year AFTER you have had the chance to change policies.  There is some kind of relationship which is meant to allow the insurance company to preserve its profit.  BUT a person with Extra Help can change any time.  No advisor knew this, though it’s in the Medicare book, which is about the size but not the helpfulness of my MAC OSX operator's handbook.

5.  MONTHLY PREMIUM:  In the beginning this was the essence of the game: put your money in the pot and gamble on whether you’ll need it.  Now it is the subject of negotiation and accommodation.  If you are poor enough, you will get Extra Help with your premium.  Extra Help also lowers your deductible.   Medicare “Extra Help” will not necessarily pay all your premium, but Montana (among other states) will pay what’s left, so possibly the total covers ALL the premium.  But don’t get to assuming there is NO premium, which is sort of my mistake.  Someone has to cover it and you’d better check out who is doing it or risk -- as I did -- neglecting $8.50 payments until it has become a $450 debt.  Since the insurance company made no fuss about it, I suspect there is some mechanism for the government to compensate for deadbeats like me.  (I AM paying off this debt.)  Plan B payment is simply deducted from your SSI check before you get it, leading to the illusion that there is no premium.

6.  GAP COVERAGE:  Another negotiating chip: as soon as this phenomenon was invented, it could be widened, discounted, redefined.   The idea is that if over time you exhaust a certain amount of insurance coverage, you are suddenly not covered.  Then at some late date you’re covered again.  Makes no sense to me.

7.  ACCEPTANCE OF GENERICS:  Some plans require generics, others require name brands.  There are enough small differences in formulation that some people don’t benefit from generics or vice versa.  Another wiggle point that benefits Big Pharm.

8.  ACCEPTANCE BY DOCTORS:  Some docs will accept whatever Medicare pays and others won’t.  There’s a strong sense of entitlement on the part of the docs as well as a tendency to want to push the easy stuff off onto, for instance, nurse/practitioners.  When all they do is look at test scores and then follow the indicated formula, there’s not much difference, but there is a definite culture diff between the two levels of education as well as culture diffs within the medical profession, esp. if you include O.D.'s with M.D’s.  Only one nurse-practitioner, a man, has ever given me a checkup by really looking at me, checking reflexes, feeling my feet and so on.  Maybe one-third of docs (male or female) have done the same.  But the bills for service were the same.

9.  SPECIFIED FORMULARY:  Whole separate booklets specify what meds the insurance company will pay for.  I don’t get it.  I guess some treatments are considered ineffective or dangerous.  One suspects thumbs on scales.  Why the fancy word: “formulary?”

10.  LEVEL OF SERVICE:  The constant complaint when it comes to drugs issued by free clinics, whether it’s the Indian Health Service or a public health HIV-AIDS service, is that the drugs arrive after long waits, inaccurately provided, handed over with contempt, sometimes not in stock, and so on.  Of course smart drug store chains high-light good service since it is something they can require of their employees without extra investment of money. But somehow service provided to people who are needy is often given with contempt.  Isn’t it reasonable to give needy people MORE kindness?

11.  CONFLICT OF INTEREST:  And here’s where I balk and begin to think of just going without Plan D.  Big Pharma is involved with the politics of government health care and insurance -- like CareMark drug chain owns SilverScript.   Also, it is forbidden for insurance salesmen to pitch their plans to Extra Help people -- so who are all these “agents” who call instantly if I pull up an insurance company on the computer?  They are “licensed” -- that means nothing.  Maybe passed a test.  Semantics.

12.  SCARE-MONGERING:  Every person is in danger of dying at every moment of their lives.  A flaming piano could drop out of the sky on you before supper.  It’s not likely, but it’s possible.  We all are held taut between wanting to risk for the possible benefits and even for a possible increase in skill and experience, but wanting to stay safe enough to risk again on another later day.  Everyone has to find their own trade-off.

So I have to think about the likelihood of me needing much more expensive drugs in the future: cancer, heart, trauma.  I get a coupon for being such a clean living non-risker.  I also have good genes, for which I thank the precluded ancestors of myself who lived such hard, dangerous and probably defiant lives that they were killed early, thus removing their faulty genes from my pool.  There’s also something to be said for my mother who believed in cod-liver oil, farm food, and donkey labor by kids.

CALLING PLAN D, MEDICARE, SOCIAL SECURITY, AND THE PHARMA/INSURANCE INDUSTRY

All across the country every day huge pools of people sit down in cubicles, put on headsets, and straighten the three-ring notebooks in front of them.  Most of them are people of color, overweight women, and men who either are not equipped to or not interested in carving a career.  They answer questions all day, sometimes about a guarantee, sometimes a complaint, sometimes as customer service for orders and so on, and sometimes to explain government services.  Their computers, alongside their answer books, can pull up detailed information about you.

I once applied for one of these jobs and listened in with auxiliary headphones.  The people were calling because they had opened charge accounts and discovered that without them actively choosing it, they were paying for death and mutilation insurance policies on that account.  It would not pay them or their survivors, but rather the account.  The call center was supposed to discourage them from canceling the insurance. The interviewer considering hiring me thought I would be perfect for this because I had been a minister.  Many of the callers were distraught, clearly poor, and -- judging from accents -- in the Deep South.  I could barely understand them.  I withdrew my application.

When I worked for the City of Portland, I had the same sort of job but this time answering questions about city codes and regulations, which were recorded in a three-foot row of books with thin paper and fine print.  Sometimes they were about bad landlords or a wish to build something.  Many were about flood plain regulations, which are based on maps which were hard to interpret.  So one quiet afternoon I composed a one-page summary of answers and principles to send to callers.  At the top was the legal right to ask for a hearing on their problem.  The plans examiner who handled these determinations was a great libertarian and defender of rights, but my inclusion of the right to ask for a hearing set his hair on fire.  Visions of endless hearings rose in the smoke.  I had to throw my summary away.

No one’s hair is bursting into flame this time around.  If I feel it beginning to happen I’ll just run out and stick my head in the snow.  But I got up at 4AM this morning, determined to understand what is going on.  I’ve prevented further debt, thanks to BigSkyRX, and am not trying to challenge my $450 accrued owed premiums, but trying to understand the whole system.  On Friday the library will host “Navigators” who will try to answer as many questions as they can.  Every question I asked on my phone call journey sent the operator off for a conference with a supervisor because the question/answer was not in their book.

Somehow in 2011 I was moved from "Level 1" to "Level 4".  This reflects one’s relationship to the poverty level, which the lawmakers use as an index.  The idea is to measure the depth of your poverty and respond to it by the amount of help provided.  But the poverty level doesn’t stay put; it’s redefined according to some formula managed by Social Security.  I presume it’s probably involved in taxing as well.  You might be gratified to know that very rich people have extra premium payments.

Medicare is closely related to Social Security.  There are four plans:  Plan A is hospital stays and other serious and usually emergency things.  I've never used it.  Plan B is the general medical.  I mostly use it for my eyes.  It’s managed directly by Centers for Medicare and Medicaid Services.  I recently changed eye docs because the one I had been using kept pushing for things I didn’t need, esp. cataract surgery.  Also, he billed as soon as he prescribed rather than after the tests were delivered, so some of his payments were denied since the service had not been delivered.  My eyes are doing very well -- there is no increased diabetes damage though that was how the original diagnosis was made.  That same doc referred me to another doc who had been in court for double-billing Medicare.  She is no longer in practice.

I don’t use Plan C.  Plan D  is for drugs and I get two answers about whether it is voluntary -- yes and no.

What I needed to know this morning was the formulas for the four levels, but no one could answer that question.  Then I wanted to know why in 2011 I was moved from level one to level four, though my income only changed slightly due to COLAs.  So far I’ve talked to Social Security (they’re on the east coast which is why I called them so early), Medicare, Special Help, BigSky RX, and SilverScript.  I was interested to realize that CareMark, a pharmacy business, owns SilverScript.  (Walmart also owns a Plan D insurance company.)  I’m supposed to use a pharmacy in the “CareMark Network” which luckily owns the new ShopKO (previously Pamida) in Shelby.  Lucky, because Janet the pharmacist is really good at what she does and absolutely trustworthy.  

It strikes me that insurance companies owned by pharmacy chains are a conflict of interest.  In fact, the whole thing strikes me as a ball of snakes.  The big squeezers.  It is evidently the Caremark connection that is sending me all the chiding robocalls, ten-year-old sweet thangs on the phone, and computer letters, urging me to take more drugs.  Of course, they’re very persuasive to some nurse-practitioners and docs.  At least where I am most people are middle-class enough that our clinics and pharmacy chains are pleasant and clean.  But everyone is too unquestioning to suit me.

The most recent blowup over prescribing statins is only one python in the struggle.  Stigmatized patients are exposed to low-end providers in shoddy settings “because they’re just scum anyway or they’d get jobs.”  There’s a rising unwillingness across the nation to help people who are “not like us.”  More and more people are “not like us.”  More and more are immigrants, old, homeless, disabled, suffering from PTSD or brain trauma, and so on.  Some were here long before anybody else. (Native Americans -- remember them?)  Some churches feed on them, offering help and the assurance of prosperity in order to fill the pews with faithful people.  

On the hopeful side, I’m reading more and more analysis of society, new ideas, individuals willing to risk by uncovering the struggle, and the realization that nations, even the “democratic” ones, are being replaced by intertwined and international corporations.  A few, not so hopeful, are forecasting revolution.  There are already demonstrations in the streets.  Since so many young people are out of work and poorly educated but somehow idealistic, it is a good use of their time and an inevitable development.