One mans perspective from the inside
By Anne Stanton 9/7/09
The tough health decisions get made quietly with little notice. I was in Livingston, Montana, last week, getting together with friends, including a popular river guide who regularly takes people out on the Yellowstone. His clients are rich folks who have health insurance up the wazoo. He turned down our offer for a late dinner, telling me that he cant eat past 7 p.m., or he gets truly awful acid reflux and stomach pain. He wont see a doctor because he doesnt have health insurance.
Then there was my old neighbor, a pretty 38-year-old, who had muscle pain in her legs that sometimes crippled her. But she didnt go to the doctor either. She feared a diagnosis would count against her as a pre-existing condition and shed never get an insurance company to sign her on.
Joseph Sloan, a state worker, sees the back end to these stories.
What could be minimal medical costs for medicine and periodic doctor visits, he said, has the potential of becoming a full-blown catastrophic event and a chronic ongoing medical issue. And that means a potentially heavy burden for taxpayers.
People with severe functional limitations are potentially eligible for Medicaid, Medicare or a variety of other government programs. The individual may also qualify for either monthly Social Security Income or Social Security Disability Income depending on their earning record or income. These payments could last a lifetime or until the individual gets better.
Sloan has worked for almost three decades for the states Disability Determination Services office that makes the medical determination on Social Security disability claims. If a person qualifies for disability, they will get a monthly check. On top of that, their beneficiary may also receive government health benefits through the Medicaid or Medicare programs.
Over nine million workers and family members get disability benefits, and about 6.5 million people get monthly survivor benefits, according to the Social Security website.
These benefits can make a significant difference. For example, a 35-year-old worker with expected lifetime average earnings of $40,000 a year and who has a spouse and children could get about $2,020 a month from Social Security if he or she became disabled. If that same worker were to die, his or her family could receive about $2,580 a month from Social Security in survivors benefits, according to the website.
Sloan, who favors a universal health care plan, said that the debate over health care must include the discussion of the savings that will occur with the current patchwork of government programs that rely on medical evidence to make the determination. Sloan believes that hundreds of millions of dollars could and will be saved if every citizen has medical coverage and the availability of basic routine medical treatment.
Heres an interview with Sloan and his recommendations for Congress and
NE: What changes have you seen in your 30 years of work with the State of Michigan DDS?
SLOAN: It used to be only the poor people who had no medical insurance. Now there are 47 million folks reportedly without insurance. In the old days, nearly everyone who worked had insurance. Thats not the case anymore.
NE: How does that affect you?
SLOAN: When were trying to determine whether someone is disabled, we first look at the persons medical treatment history. We try to get a longitudinal history from their physician and look to see when they first received treatment for the alleged condition, type of treatment, response to treatment, and so on. This information normally gives us a realistic picture of the persons condition, functioning level, and pain level. Now, with so many people walking in the door who have no insurance, we have no opportunity to secure a medical history because they havent been seeing anyone.
NE: So what do you do?
SLOAN: We have to paythe taxpayers have to paya doctor for a consultative physical exam. Sometimes we also have to pay for ancillary studies such as x-rays, lab studies, treadmill testing, etc. Every government program that requires a medical determination is faced with the same dilemma. They are forced to purchase these evaluations and/or testing simply because there is no other way to get the medical evidence. I have to believe that all of these evaluations multiplied by 50 states runs into the hundreds of millions of dollars.
There is also another moral dilemma that arises with this process. One person gets a determination based on a one-time-only medical evaluation of a person. The otherwho is insuredhas medical evidence from their attending physiciansdoctors who have seen them many times for many years and can advocate on their behalf, if needed.
Certainly in most circumstances, you would think the person who has medical records from their own doctors or psychiatrists would have a better opportunity for a correct determination.
So if we have universal health care, we could potentially save millions of dollars in all of these government programs. And, just as importantly, everyone would be on the same level playing field. How fair would that be?
Universal health care could also help reduce fraud because we could investigate those physicians or medical clinics that have an unusually high number of disabled claimants. Those claims could undergo special review to further assess the validity of the determinations. Of course if the specialist or center treated infectious diseases, renal failure, cancer, etc. then the severity of those patients medical condition would be expected to be much more severe than a family practice clinic.
NE: I heard everyone is turned down the first time they apply. Is that true?
SLOAN: Its more like 60 percent of the applicants are turned down. These numbers vary from state to state. There has also been a great effort to make the right decision as early as possible. So if the person does not have regular medical treatment, it could take longer to go through the consultative exam process.
NE: I saw on the Social Security website that there are 250,000 more applicants for disability as compared to last year for the first six months. Thats a 22 percent increase. Wow.
SLOAN: For years I have been saying that things could not get any tougher and then the next economic crisis happens and things do get tougher.
This time everybodys getting laid off, people whove worked in a plant for 30 years. They will tell us, Im 48. Ive had a heart bypass, Ive lost a few fingers on my right hand. Nobody wants to hire me. And theyre right. Their old employer found a way to accommodate themmaybe they didnt make them lift the heavy stuff or gave them a lighter workload. But how are they going to compete with someone who is younger with perfect health in this job market?
NE: Does this heavier workload stress you out?
SLOAN: I think its pretty safe to say were all under terrible stress. I am District Chairperson for UAW Local 6000, which represents many of the state workers in the region. The workloads in all of the social programs have increased while our funding has been reduced. Its not only the physical stress of longer hours, mandatory overtime, and an increasing workload, but the psychological strain from seeing so many people in such dire straits. Most of our claimants for Social Security Disability are in pretty bad shape. Many cases are simply heartbreaking. We see the cancer cases with little chance of survival, the kids born severely disabled, premature babies, crack babies, and folks with severe mental illness.
Our employees are dedicated and highly skilled and are busting their asses to keep up, but still the workload continues to increase. The state has put our agency into emergency status and most of our adjudicative staff is exempt from furloughs (forced days off that the state is imposing on other departments). So I think it is safe to say its pretty bad.
NE: Why does a person have to wait five months to get a disability check once theyre determined to be eligible for benefits?
SLOAN: If President Obama is looking for a way to help this population of folks, hed get rid of this five-month waiting period.
I believe the waiting period was originally established with the idea that many people had long-term disability benefits that would last for five months. I think that kind of coverage for most people is long gone. Many social programs started during a period when unions had a lot of influence. Now the Chamber of Commerce is calling the shots.
We do recognize that some conditions are more acute and these claims are fast tracked for quick determinations. Many of these claims are processed in a few weeks, but everyone has to wait five months.
NE: Do you hear stories of people abusing the system? Basically faking an injury?
SLOAN: Everyone thinks they know a cheater, and I think thats why President Obamas plan is having such a hard time. But I have two things to say. One, sometimes someone on disability might tell you they have a chronic back problem when they want to hide their real health issueAIDS, for example. Secondly, if you know or think you know someone is cheating the systems call the SSA and we will look into your concerns.
NE: Do illegal immigrants get Social Security benefits?
SLOAN: All the claims that we adjudicate at the DDS do have a social security number, and we assume the number is legal. Theres another side to this issue. Advocates for illegal immigrants argue that they pay into the Social Security system using a fraudulent Social Security number. Bottom line, they are paying in, but will never see any benefits when they retire.
NE: Do you see other cost savings besides fewer people on permanent disability?
SLOAN: Many uninsured people use the emergency room when medical care is necessary, and thats costing all of us. The hospitals pass on the cost to people with insurance, which makes the premiums go up. An emergency room visit costs around $600 compared to a doctors visit of $60.
At our office, we see records of people going into emergency rooms with boils, severe poison ivy, infected teeth. We will look at the records and see the emergency room doctor gave the person with an infected tooth some antibiotics and pain medication and told them to see a dentist. They will continue to go back into the emergency until they are able to get the tooth pulled out.
NE: What sort of program would you support?
SLOAN: I would love to see government run universal health care that includes everyone. The plan would include hospitalization, medication, dental, mental health, and substance abuse treatment.
The plan would treat all pre-existing conditions, and since everyone was covered, we could save millions of dollars in paperwork by not having to qualify people every time they seek medical treatment. I think we will have to allow folks with financial means to piggyback additional coverage on the basic plan and let people have the ability to purchase liposuction, butt tucks, etc. if thats what they want.
I also think we will need to open additional medical schools to increase the number of family practitioners, internists, etc. We need to give these med students some financial incentives to enter specialties or give them free med school if they agree to work for the VA for 5-7 years. I think that we need to give our veterans the option to have their own health care delivery systems because their problems are so unique. They of course would have the option to stay in the universal plan if they choose.
I have no idea how to solve the abortion issue but if we have universal health care maybe the needs for abortion will significantly decrease with good sex education, the availability of safe birth control methods, etc.
Still as you alluded to earlier, what do we do with the illegal immigrants? I believe thats the deal breaker. How can we cover them if we dont even know who they are or how many there are? How can we assess the true cost of this program without this information? I have a million questions regarding these folks, but that is for another day.
NE: But how could the private sector ever compete against a government program?
SLOAN: The average CEO of a major insurance company makes $7 million a year. I think thats outrageous. I wont worry about these folks. Insurance companies also have thousands of people in fraud prevention that wont be needed. And consider that if 47 million people will now be getting medical services, were going to need more labs to perform blood studies, urine samples, etc. We are going to need lab techs, LPNs, RNs, physicians assistants and, of course, doctors.
Maybe we can put some of the medical facilities in all of the ugly buildings that we have empty around TC. It will take patience and strength to start treating this many additional folks, but I think we will be so much better in the long run. Healthy people can work and pay taxes. Healthy people are better parents, spouses, and children. People will no longer have the excuse that they cannot work because they have no insurance to get the treatment they need. We are going to need janitors to keep the buildings clean and maintenance folks to shovel the walks, plow the parking lots, etc. The loss of jobs in the insurance industry will be unnoticeable with the creation of other jobs.
Our office handles claims from all over the state, including the distressed areas like Saginaw and Muskegon Heights. People in clean, beautiful TC would be amazed how bad things are in other parts of the state. I think that without a universal health program of some type soon, we are going to have social unrest directly related to this issue.