Chapter 15
Occupational and Insurance Problems
In This Chapter
Following airline regulations
Being denied certain jobs
Finding the law on your side
Working the medical-insurance system
Maintaining coverage when your employment changes
Obtaining long-term care and life insurance
After we got his diabetes under control, one of my patients wrote to his mother, “Dear Mom, I’m not working, but my pancreas is.” Most people need to work, and some people even want to work. People need to work for the same reason that a certain man did not turn in his brother-in-law who thought he was a chicken: We need the eggs (though not too many).
As a person with diabetes, when you try to get a job, you may run into various forms of discrimination. Part of the problem is the fear that the company will have to pay higher insurance premiums if it hires a person with a chronic illness. Part of the problem is a lack of understanding of the great strides that have been made in diabetes care so that a person with diabetes often has a better record of coming to work than a nondiabetic.
In this chapter, you find out what you need to know when you apply for work, health insurance, and life insurance. You discover how to work the healthcare system so that you derive the greatest benefits possible at the lowest cost.
Traveling with Diabetes
Whether you travel for your job or for pleasure, if you need insulin injections and must carry syringes and needles, you have to follow the rules of the Transportation Security Administration (TSA) if you fly within the United States. Airlines outside the U.S. may have different rules; check with your airline before you travel overseas.
The TSA instructs that you should “make sure injectable medications are properly labeled (professionally printed label identifying the medication or a manufacturer’s name or pharmaceutical label). Notify the screener if you are carrying a hazardous waste container, refuse container, or a sharps disposable container in your carry-on baggage used to transport used syringes, lancets, etc.” Updated information is available at the TSA website, www.tsa.gov/311. You can also call the TSA call center at 866-289-9673.
The TSA permits prescription liquid medications and other liquids needed by persons with disabilities and medical conditions. These items include
All prescription and over-the-counter medications (liquids, gels, and aerosols) including K-Y jelly, eye drops, and saline solution for medical purposes
Liquids including water, juice, or liquid nutrition or gels for passengers with a disability or medical condition
Life-support and life-sustaining liquids such as bone marrow, blood products, and transplant organs
Items used to augment the body for medical or cosmetic reasons, such as mastectomy products, prosthetic breasts, bras or shells containing gels, saline solution, or other liquids
Gels or frozen liquids needed to cool disability or medically related items used by persons with disabilities or medical conditions
If the liquid medications are in volumes larger than 3 ounces each, they may not be placed in the quart-size bag used for personal liquids of less than 3 ounces. They must be declared to the Transportation Security Officer.
Specifically with respect to medications for diabetes, notify the Security Officer that you have diabetes and are carrying your supplies with you. (Medication and supplies you are going to use should be in your carry-on luggage.) The following diabetes-related supplies and equipment are allowed through the checkpoint after they have been screened:
Insulin and insulin-loaded dispensing products (vials or box of individual vials, jet injectors, biojectors, epipens, infusers, and preloaded syringes)
Unlimited number of unused syringes when accompanied by insulin or other injectable medication
Lancets, blood glucose meters, blood glucose meter test strips, alcohol swabs, meter-testing solutions
Insulin pump and insulin-pump supplies (cleaning agents, batteries, plastic tubing, infusion kit, catheter, and needle; insulin pumps and supplies must be accompanied by insulin)
Glucagon emergency kit
Urine ketone test strips
Unlimited number of used syringes when transported in sharps disposal container or other similar hard-surface container
Sharps disposal containers or similar hard-surface disposal container for storing used syringes and test strips
Here are some suggestions for managing your diabetes if you’re changing time zones:
Obtain a list of doctors in the countries you will visit who speak your language. To find English-speaking doctors, you can contact the U.S. embassy in each country or go to the website of the International Association for Medical Assistance to Travelers, http://iamat.org/doctors_clinics.cfm.
If using an insulin pump, change the basal hourly rate to the same dose every hour so that whether it’s 8 a.m. or 8 p.m., the same dose is given. When you arrive in the new time zone, you can adjust the basal rate back to your usual doses.
If you use long-acting insulin, change a single dose to two half doses 12 hours apart.
Stick to your regular schedule using local time for any oral medications.
Wherever you go, make sure you wear a bracelet or necklace that identifies you as a person with diabetes.
Knowing Where You Can’t Work
You may have grown up watching Eliot Ness on television and had your heart set on being a member of the Federal Bureau of Investigation. If you require insulin, forget it. The FBI has a policy called a blanket ban on hiring certain groups of people, including people with diabetes who take insulin. A blanket ban does not take into account the condition of the individual, the past employment history, the way the person manages his or her diabetes, or the responsibilities of the position. It simply says, in effect, “You’ve got the disease, so you can’t work here.” This policy is a throwback to the days before 1980, when a person with diabetes could never be sure what his blood glucose was doing.
Another important institution that has a blanket ban in place is the United States military. If you have any kind of diabetes, you are not eligible to serve. If you develop diabetes after you’ve been in the military, you will probably be discharged. This policy doesn’t make a lot of sense because many countries have people with diabetes in their military forces and have no difficulty with them, but so it goes.
Fortunately, blanket bans in the United States are falling faster than Alex Rodriguez home runs. For example, the Department of the Treasury lifted a blanket ban on becoming a member of the Bureau of Alcohol, Tobacco, and Firearms if you have insulin-requiring diabetes. Recently, several states lifted a ban on hiring people with diabetes to be school-bus drivers. This action resulted from lawsuits against several school districts that fired drivers with spotless driving records just because they had diabetes. (This reversal doesn’t mean that no safeguards against risky drivers exist. Drivers are being evaluated on a case-by-case basis before they are accepted to drive children, which is fair.)
Previously, commercial drivers with diabetes could drive within a state but could not cross state lines. Now the Department of Transportation (DOT) looks at people with diabetes on a case-by-case basis to determine if they’re fully able to drive commercially from state to state. As long as the person has no history of hypoglycemia with unconsciousness, the DOT grants an exemption that permits the individual to drive between states, with reconsideration taking place every two years.
At one time, people with diabetes who took insulin were banned from becoming firefighters. Now they are permitted to serve in this work, too, on a case-by-case basis. However, the rule says they must have a hemoglobin A1c of less than 8 percent. I believe this policy needs to be changed because people function perfectly well at higher levels of hemoglobin A1c, even at 10 or 11 percent.
Another blanket ban that is falling is the ban on piloting airplanes. For 37 years, a person who took insulin could not fly a plane. In 1996, the Federal Aviation Administration (FAA) reconsidered its ban based on the great advances in controlling diabetes. The FAA decided to permit people to fly privately but not for commercial airlines. Even if they have a private license, however, they can’t use it outside the airspace of the United States. Applications for a pilot’s license are evaluated on a case-by-case basis.
Is there ever a justification for a blanket ban? The answer is no, and it has been proved in a number of studies. In one study of accidents of all kinds, people with diabetes actually had fewer accidents, including automobile accidents, than groups of people without diabetes. In another study of people over age 65 with diabetes, the rate of automobile accidents was no greater than that of the nondiabetic groups.
Becoming Familiar with Workplace Law
A number of laws protect you in the workplace if you work in the United States, but the most important is probably the Americans with Disabilities Act (ADA) of 1990. This act states,
The determination that an individual poses a “direct threat” shall be based on an individualized assessment of the individual’s present ability to safely perform the essential functions of the job.
In 1998, the U.S. Court of Appeals ruled that the ADA protects Americans with diabetes. The act applies to employers with 15 or more employees. What the ADA means is that you are qualified for a particular job if you can perform the essential functions of the job as determined by the employer, with or without reasonable accommodation. Therefore, you can’t be discriminated against in hiring, firing, promotion, training, pay, or any other aspect of employment because you have diabetes. Your boss cannot ask whether you have diabetes but can expect you to pass a physical examination to verify that you are well enough to do the job.
The Federal Rehabilitation Act of 1973 is an important law that protects you when you apply for a federal job or a job in a company that receives federal assistance. A person with diabetes is specifically protected under this law. The most important provision states,
No otherwise qualified handicapped individual in the United States shall, solely by reason of his handicap, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity conducted by the Executive agency. . . .
To exclude you, federal agencies have to prove that you will not be able to perform safely if given the job. That proof is hard to come by and puts the burden on them, not you. They must decide on a case-by-case basis. As I note earlier in the chapter, the FBI and the military are exempt from this law.
Curiously, a problem arose in the Americans with Disabilities Act when diabetes began to respond so well to treatment. Only a person with a disability could sue under this act. In a perfect example of a Catch-22 (where you can’t avoid a problem because of contradictory rules), people with diabetes were no longer considered disabled, so even though they were discriminated against, they couldn’t sue. In 2008, President George Bush signed the Americans with Disabilities Act Amendments Act, bringing diabetics again under the act.
What can you do if you run into discrimination on the job due to your diabetes? You can contact the U.S. Equal Employment Opportunity Commission (EEOC). You can find your nearest EEOC office on the web at www.eeoc.gov/field/index.cfm or call 800-669-4000. You may have only 180 days from the alleged discriminatory act to file the charge.
Navigating the Health-Insurance System
You can get insurance for your medical care several ways. This section describes the most common forms.
Private insurance
If you or your child has diabetes, you can count on several things being true when you interact with the medical insurance system in the United States: You may be denied coverage more often, and you will pay more out-of-pocket than families without diabetes, even when you have coverage.
If you are an older adult with diabetes, your bill will be one and a half times as much for medical care as a person without diabetes, although Medicare pays for much of it. You want to be sure that you are not medically shortchanged in an effort to save money.
The good news is that you can get health insurance, although you may be turned down more often. The type of insurance you can get is the same as the nondiabetic population: Blue Cross/Blue Shield, health maintenance organizations (HMOs), CHAMPUS, and so on.
Currently, there are two major forms of payment for medical care — fee-for-service and capitated payment — with a lot of hybrids in between. The old fee-for-service method pays the medical provider — whether a physician, a lab, or a hospital — based on the number of services provided. More services and procedures mean more profit for the provider. So the incentive is to do more in order to make more money. (Not that providers would ever do more than is necessary for the money.)
The other main method of reimbursement is capitation. Here the provider gets a fixed amount of money for each patient. The risk is divided among many patients so that if one costs more, ideally another will cost less. This system is the basis of the health maintenance organization (HMO), which hires physicians to provide the care. HMOs look to enroll people who cost as little as possible for their medical care. The incentive is to do less in order to save money, which is then kept by the provider. (Not that providers would ever do less than is necessary for the money.)
Because they seem to end up costing less money overall, capitation plans are growing while fee-for-service plans are declining. The government is even encouraging HMOs to enroll Medicare recipients in order to reduce costs. At the same time, the government requires HMOs to enroll people who cost more, like most people with diabetes.
As a healthcare consumer, you want to look for a large group containing many patients because such a group can spread out your extra expenses among many people who don’t consume as much medical care. Before you sign up, ask several questions:
What is your total annual cost, and how often is a payment required?
Will you have a deductible, meaning that you have to pay the first so-many dollars before the insurance starts paying?
Will you have a copayment, meaning that every time you use a provider, you have to pay some dollars?
Does your plan pay for durable medical equipment, like an insulin pump (see Chapter 10), which can be very expensive? (You want to ask this even if, when you sign up, you may not foresee a need for it.)
Will your plan pay for your diabetes medication and diabetes supplies, and to what extent?
Can your physician order any medications you need, or is he or she restricted to certain medications?
How often will you need to travel to the pharmacy to pick up medications? (Some plans make you go back every 30 days.)
Are you covered for specialists, particularly eye doctors and foot doctors?
Are you limited to certain hospitals, certain physicians, and certain laboratories? (If so, this restriction may be much more inconvenient for you, not to mention possibly requiring you to change from a physician with whom you are very comfortable.)
Is home healthcare included in the plan, and to what extent?
Each state has its own laws concerning the way medical insurance is offered in that state. Some states allow medical underwriting, through which a company can refuse to insure a person with a particular medical condition. Other states forbid this practice. To learn the rules and regulations in your state, go to the site of the Georgetown University Health Policy Institute at www.healthinsuranceinfo.net. You can also get a copy of its publication “A Consumer Guide for Getting and Keeping Health Insurance.” Unfortunately, the site no longer provides up-to-date information, but it still offers links to insurance policies in many states.
After you sign up for a plan, you need to be vigilant to be sure you are getting what you paid for. You and your physician may need to make many phone calls to get what you need, but if you persist you can often come away with a “Yes.” Even goods and services that are excluded in your original contract may be provided by the insurance company if you’re persistent.
Big changes on the horizon
The Patient Protection and Affordable Care Act signed by President Obama in March 2010 will have profound effects on the ability of the person with diabetes to get affordable medical care. Beginning in 2010, insurers could no longer deny insurance coverage to children because of preexisting conditions. In 2014, adults will have the same right through the new American Health Benefit Exchanges. Also beginning in 2010, insurers could no longer drop people who are diagnosed with a new condition such as diabetes or its complications.
Here are some other important provisions of the new law:
Creating the Cures Acceleration Network to finance research into cures for diseases
Creating a new National Diabetes Prevention Program to fund grants for community efforts to help people with diabetes
Allowing young adults to remain on their parents’ plan until age 26
Requiring restaurant chains with 20 or more locations to post calorie counts for every item they sell
Allowing employers to use workplace wellness programs to reward employees
Permitting no annual limit on benefits after January 1, 2014
Allowing no coverage waiting periods greater than 90 days after January 1, 2014
Reducing and eventually eliminating the amount that Medicare patients have to pay for their medications (the doughnut hole) by 2020
Providing more payment for preventive medical care
Insurance for low-income patients
In the United States, you may be eligible for health insurance for low-income patients, called Medicaid, if your income falls below certain levels that are listed at this website: www.medicaid.gov/Medicaid-CHIP-Program- Information/By-Topics/Eligibility/Eligibility.html.
Each state sets its own guidelines and administers the program for itself. You obtain a card that shows you are eligible and take it to your doctor, lab, or hospital. Many doctors do not currently accept Medicaid patients because of the low level of reimbursement. Another provision of the Act signed by President Obama is reimbursement of primary care doctors at the same level as Medicare reimburses them beginning in 2013.
High-risk pools
About 45 percent of the U.S. population gets its health insurance through their employer in a group health program. Another 27 percent gets its insurance through government programs like Medicare, Medicaid, military healthcare, and Native American care. People who don’t get insurance through one of those sources can get insurance at a high premium, usually, but some people have had a chronic medical condition and can’t find insurance at any price.
For those people, about 34 states have formed pools of clients who can’t get insurance anywhere else. The premium is usually higher than private insurance, but at least the members can get insurance. President Obama’s Health Act helps these people as well by lowering the premium for these pools. By 2014, the insurance exchanges will take over from the high-risk pools.
To find out if you qualify and where the locations of the state high-risk pools are on the Internet, go to the Health Insurance Research Center at www.healthinsurance.org/riskpoolinfo.lasso.
Changing or Losing a Job
One of the major reasons why people with diabetes used to stay in jobs they didn’t care for was their fear of losing their health insurance. These days, this worry doesn’t have to stop you, because several laws protect you from the loss of health insurance if you change or lose your job.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) stipulates that your employer must keep you on your current health insurance for as long as 18 months after your job ends and longer if you are disabled. If your child is at the age when he or she is no longer covered under your policy, the child’s coverage can continue for up to three years. You, rather than your employer, have to pay the premiums for this continued insurance.
If you are leaving work because of retirement at age 65, sign up for Medicare without fail. It is a generous program (which you supported while you were working) that recognizes the specific needs of people with diabetes. Since 1998, Medicare has expanded its coverage to include blood glucose monitors and test strips after your physician certifies the need. It also offers payment for specific types of outpatient diabetes education programs, as long as they are considered necessary by your physician. And recently it has begun to pay for nutrition counseling and eye examinations. Most plans pay for an insulin pump, insulin, and syringes. To find out more about Medicare, call the Medicare Hotline at 800-633-4227. The government provides a hotline for the hearing-impaired at877-486-2048.
Some employers have conversion policies that allow you to stay with your insurance company if you leave work, but with individual rather than group coverage. These policies can be pretty expensive.
Some states offer “Pooled Risk” health insurance for people who have lived in the state a certain number of months but can’t get group or individual coverage. Check with your state insurance office.
Considering Long-Term Care Insurance
People with diabetes are living longer and longer, and you’re going to need a way to pay for your care when you can no longer pay health-insurance premiums. When you’re 90, your 88-year-old wife will most likely not be in a position to pay for your insurance, nor will your 65-year-old daughter. Medicare doesn’t cover most of your long-term care expenses. Medicaid does cover some long-term care, but not everything you may need. This is where long-term insurance may help, if you can afford it. Obama’s Healthcare Act steps in here by allowing payment of monthly premiums through payroll deduction to buy long-term care as of January 2011.
If you have plenty of money and want to protect it from the financial hit of a long-term illness, long-term insurance is for you. If you have little money, then the years of premiums are going to wipe out your savings, and you may end up needing to drop the policy before you even use it.
One big problem is that many companies that sell long-term insurance don’t cover people with diabetes. If you can get this type of insurance coverage while you’re still working, you may be able to get into a large group where your particular illness is not considered and the premiums may be relatively low. However, you’ll obviously be paying those premiums for a longer time than if you start coverage when you are older.
Before you buy, you should check several important features of a long-term care insurance policy:
What are the benefit triggers, the physical limitations that trigger coverage? To make this determination, generally insurance companies look at activities of daily living, such as the ability to bathe yourself, dress yourself, eat without help, go to the bathroom, and get out of bed. When you can’t perform one or more of these tasks, benefits begin.
How much of the cost of care does the insurance pay, some or all?
What levels of care does the policy provide? Your policy may offer coverage only for adult day-care services or may cover anything up to and including living in a nursing facility.
Is a waiver of premiums built in so that you don’t have to pay premiums when you are disabled?
Is the policy guaranteed renewable so you can renew no matter whether you use it, although the premiums will be higher?
Whatever you do, if you buy long-term care insurance, make sure you take good care of yourself so you live long enough to get some benefit from it.
Shopping for Life Insurance
As you may expect, the situation with life insurance and people with diabetes is in a state of flux. Insurance companies like to calculate your chance of dying and charge you (or turn you down) based on those calculations. Many companies are using calculations based on the life span of people with diabetes in 1980 or before. Using those statistics, diabetics clearly died earlier than their nondiabetic friends. Thus, the cost of life insurance is greater for people with diabetes than nondiabetics.
As new studies are done, they should indicate that the life spans of people with diabetes and nondiabetics are approaching equality. In some cases, people with diabetes, who take better care of themselves than people without a chronic illness, are living even longer. So the situation is improving, and insurance companies will catch up sooner or later. Can you imagine the surprise if insurance companies were ever to charge people with diabetes less than others because of their good habits?
Insurance companies look at levels of blood glucose and the hemoglobin A1c. Try to get yourself in excellent control before you apply. You may be able to save a bundle or get your insurance much more easily.
With the Internet, you can quickly find and compare the cost of insurance at numerous companies based on your age; your habits (warning: If you smoke, you pay through the nose); and the presence of conditions such as diabetes, high blood pressure, and high cholesterol. Many companies take a standard rate for a healthy person with no diseases and add 50 percent more if you have diabetes. Of course, your actual cost depends on your specific circumstances, including your age when you first buy the insurance.