Disability: The Hole Between Insurance and Medicaid

Today, we welcome Ashley Blackmon, who discusses the structural impediments to healthcare coverage in Georgia. No one should have to choose between groceries and healthcare.

He looked like a deer in headlights. His brother started screaming at me from across the room. After the brother’s tirade, which I took in silence, he stomped out.

“I apologize for him.” My patient said, “He is just upset by what you said. And my heart is doing a million miles an hour too.” I felt bad. But I had steeled myself for this. Anytime I am referred to see a patient for the first time for surgical evaluation, I let them know what their chances are. And usually they are very slim.  

The brother’s tirade was one I had heard before. He was angry that the patient’s chart labeled him as “non-compliant.” Non-compliant is a term we use in healthcare to explain that a patient does not follow up or take medications as prescribed. It is important to document because it can influence if higher levels of care are implemented or not because the patient may not complete long-term therapies. Non-compliance and

yellow surface with round hole cut, revealing a ladder
Photograph by JnL (2005). Retrieved from Flicker.

starting a patient on a long-term therapy can cause more harm than good. But this label can also be a one-dimensional analysis, dismissing as behavior what may well be more much more complex. My patient’s brother insisted it wasn’t that he was non-compliant but that he couldn’t afford his treatments.

Unfortunately, my patient fell into the Disability Hole. He once had health insurance offered by his place of employment. However, as his health declined, he eventually had to leave his job and file for disability. Since (social security) disability rates are based on previous income, his income was considered too high for him to qualify for Medicaid. He would have to list that he had been disabled for 2 years before being able to qualify for Medicaid in the state of Georgia. The income level to qualify for Georgia Medicaid is alarmingly low (~$16k – $29k/year for a one-person household). This means someone making $2,000/month on disability can be denied by Medicaid. But let’s say this person is paying $900/month in child support and $700/month in rent. That only leaves $400/month for utilities, gas, groceries, and medication.

Therefore, my patient forfeited most of his medication and doctor’s appointments. He said he would have to pay out of pocket for his appointments and couldn’t afford that $200. I was crestfallen and frustrated for him.

My patient had heart failure. It is a progressive, life-threatening disease that was diagnosed when he was still able to work. He went to his appointments and took his medications. However, since the disease progressed, he lost his job. He filed for disability and Medicaid. His disability was approved but his Medicaid denied. Now he has to choose between medications and food. He has to find a new place to live. Try to re-negotiate his child support. Try to budget better. And try to wait out his two years before being allowed to apply for Medicaid again.

If he lived that long.

He was able to get two of his medications for free. But since he was unable to pay the $200 fee to see his primary care provider, and not get his other medications, the progression of his disease sped up.

And that’s when I met him. Coming out of shock in the ICU. Talking about surgery to save his life. Ironically, he would now be able to qualify for emergency Medicaid that our case manager could arrange and try to retroactively pay for this hospitalization and his future hospitalization for surgery. He’s now “too sick.” He doesn’t have to wait for his 2-year window to pass.

But how long would that window have been if he had his Medicaid right away? Would he have been able to stave off the disease a little longer? I absolutely believe so. He may have even been able to get better! Heart failure is progressive but can be dynamic as well. With appropriate care, some people can recover some heart function. He may have been able to go back to work. He potentially would not have needed surgery so soon.

If Medicaid had approved his coverage, shelling out the $200/visit and the ~ $20/month in medications (which may have been at most ~$1,000-$2,000/year) for prevention on the front end, my patient may not have needed hospitalization and emergency coverage. Now, Georgia Medicaid is going to pay for his hospitalizations, his follow up appointments, his medications, his surgery, and all of his post-op appointments with all of the specialists now involved in his care. This will exceed hundreds of thousands of dollars if not millions before he dies from complications of his disease.

His last day before discharge he looked up at me with tears in his eyes. “Thank you.” He said, “Your team has helped me more than anyone else. I will do anything you say so that my 3-year-old will get to be around me a little longer and have some memory of me.” I was grateful and cheerful on the outside. But on the inside, I felt a moment of bitterness. The health disparities have to stop. We have to prevent the holes that people fall into. The Hole costs us much more money in the long run. But more importantly, it costs us in quality of life and time with those we love. Time never has a price tag.

ashleyAshley Blackmon is a mother, wife, sister, daughter, woman, artist, teacher, nurse. Loves her daughters and the nursing profession.

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