Don’t leave home without it. No, not American Express Travellers cheques but health insurance. With changes to OHIP coverage for out-of-country hospital visits and rising U.S. health care costs, any snowbird who pays a visit to an American hospital will face hefty bills. To make things even more complicated, the recent growth in competing travel health insurance schemes in Canada has created a minefield of policies that must be entered with caution.
Luckily for snowbirds, the newly formed Canadian Snowbird Association is trying to make these changes a little easier to cope with. Formed in March, the Association boasts 8,500 members and is looking for more. They hope to advocate for the rights of snowbirds and collect information on private insurance plans to help seniors make the right decisions.
Communications co-ordinator Don Slinger says he will have a list of appropriate private health insurance policies ready by the end of August. The Association has been meeting with private insurance companies to find out the best plans.
“Snowbirds shouldn’t be in a hurry to get insurance,” says Slinger. “Many insurance companies are using the situation to exploit panic-stricken seniors.”
Slinger warns snowbirds never to go down to the U.S. without extra insurance on top of OHIP. “OHIP is just a drop in the bucket of the cost of a stay in an American hospital. Unfortunately, a lot of people still take the chance.
“I had been going south for 12 years without a problem until a ruptured appendix. It ended up costing me $12,000 for an eight-day hospital stay.
“When we met with the government they weren’t sympathetic. They said snowbirds are a wealthy group and can afford the payments. However, a lot of people are on fixed incomes and won’t be able to afford to go south with these higher costs.”
Slinger advises against buying coverage after arriving in the U.S. The Snowbirds Association emphasizes that it believes in medicare and will fight hard to ensure it provides full coverage for seniors.
Gerry Byrne, a vice-president at non-profit insurers Blue Cross warns against buying U.S. insurance because companies require a medical exam and skim off the healthiest people for full coverage. But Blue Cross itself will introduce rates based on age and medical conditions in September.
American health insurance plans have long been criticized for hurting older seniors and those with ongoing medical conditions. In these schemes, the healthiest seniors pay low premiums while seniors with chronic conditions are saddled with higher rates or, worse still, refused coverage. Unlike medicare – which covers everybody regardless of their health – private insurers are tempted to reduce their costs by covering only the lowest risk group – favouring the young and healthy.
Unfortunately, a quick survey of travel health insurance plans shows this trend to be in full bloom in Canada. Credit card companies, which have recently begun to offer travel health insurance, are revising their conditions. The Royal Bank’s Visa Gold card will drop coverage for seniors over 65 starting Nov. 1. The Canadian Imperial Bank of Commerce and Scotia Bank Visa cards still offer coverage to seniors – but both are revising this. American Express’s annual plan has no age limit, while its per trip plan has a higher rate for seniors between 60 and 74 and doesn’t cover anybody 75 and over.
Suzanne Deul, who helps market the Toronto Dominion Bank Visa card, blames the insurance companies for changes. “Because of high costs, the pressure is on to change policies. We are trying to be more equitable but the insurers want age restrictions. In some ways it could be justified to charge more for people who attract higher costs.”
With so many health insurance companies losing money covering seniors, the challenge for private insurers is to make covering seniors profitable without excluding people. To this end, Robin Ingle, president of John Ingle Travel Insurance, has instituted changes to increase the money available for more expensive hospital stays.
“About one-third of our policy holders are over 65, and we have a lot of snowbirds. This group is only getting bigger, so instead of raising rates and placing restrictions, we increased the number of policy holders to include a broad range of people young and old.”
Ingle blames rising U.S. health care costs for making it unprofitable to provide health insurance to seniors. His company has set up an office in Florida to prevent hospitals overcharging Canadians and has negotiated deals with some hospitals for lower rates. John Ingle Travel Insurance offers special rates for seniors’ groups and gives a 10 per cent discount to members of the Canadian Association of Retired Persons.
Three years ago there were 10 companies in Canada offering travel insurance; now there are over 50.
According to Ingle, many of the neophyte companies are losing money. “I predict the whole industry will shrink because they have had high losses and can’t take care of their clients. I would advise seniors to watch out for companies that might not be around a year from now.”
Ingle says seniors should also beware of glitzy marketing and flashy pamphlets and read the fine print to make sure the policy covers their age and medical condition.
Irene Klatt of the Canadian Life and Health Insurance Association, which represents all private for-profit insurers, advises seniors to look for insurance plans that have toll-free numbers that can be called 24 hours a day in an emergency. This will cut down on hassles with American hospitals which will not admit patients without insurance. The Association also has its own toll-free advice line staffed by seniors from the insurance industry. Klatt warns that her association represents all for-profit insurers and can’t favor one scheme over another but does have a pamphlet that offers advice on choosing insurance.
Insurance, of course, isn’t enough to ensure a healthy stay. Irene Turple of the Canadian Association on Gerontology has some helpful health tips: “Discuss your trip with the family doctor. Make a list of all your medications; and remember – the names of the drugs can be different in the States. If you have an echocardiogram handy, bring it along. Make a health diary listing your medical history. Remember that physicians aren’t all-knowing and if you can provide as much medical information as possible it can make a difference.”
Turple also stresses getting immunized for the flu before going to the States and remembering to cover up from the sun.
It isn’t the nicest thing to think about, but if accident or illness strikes, you could end up receiving unwanted treatment.
But in 1994 things will change. The living will or advance directive – a document clearly stating a patient’s wishes about how they want to be treated – will become part of the doctor-patient relationship.
A trio of acts passed last December – the Advocacy Act, the Substitute Decisions Act and the Consent to Treatment Act – allow, albeit in rather vague language, for Ontarians to set out in advance which medical procedures they would or wouldn’t accept and let’s them name a proxy in case they are incapable of expressing their wishes.
This vague language – intended to allow patients to customize their wishes – means that writing a living will can prove to be a troubling and confusing experience.
To aid decision-making, the University of Toronto Centre for Bioethics is offering advice through a “model” living will.
The centre’s Dr. Peter Singer has geared the “model” to meet Ontario legislation and to offer a guide for anybody who doesn’t know where to begin.
“We put a lot of detail in the advance directive about states of incompetence people get into, and also the sorts of procedures providers might recommend in those health states.”
Singer sees living wills as an effective tool aiding patients to control their own health care.
“Unless the doctor is a longstanding friend it’s hard to know what patients want. As a practicing doctor, I have run into an incompetent person where their family member has no idea what sort of wishes the person would have wanted. The goal of a living will is to provide the personal care the patient would want.”
But there is a danger. Dr. Singer urges the need for informed and detailed language in a living will.
“If I have a couple minutes to make a decision I need a document that gives me a lot of confidence that this person wouldn’t want this treatment.”
In an emergency, the doctor might not even know of the living will’s existence. Dr. Singer advises giving a copy to your family doctor, lawyer, or proxy, and keep one with you at all times. When so-called “smart” health cards come along, Dr. Singer would like to see the living will recorded on the magnetic strip along with other health information.
Many of today’s seniors fought for Canada’s internationally-admired public health system. But more and more people are becoming worried that the combination of health care reform, funding cutbacks and free trade is fuelling the growth of a second tier of private medical services serving the well off.
The provincial government sees things differently, arguing Ontarians no longer expect government to pay for everything and rather than eroding medicare, the NDP is reinventing it.
Whichever way one looks at it, private insurance companies, homecare providers, labs and other services designed to make money are becoming more and more involved in the health care business.
Operating in the territory outside the guidelines of the 1984 Canada Health Act – which sets out the principles of medicare for the federal government to enforce – the private sector has room to expand, at the same time as OHIP coverage is scaled back from more and more services.
Janet Maher, whose Ontario Health Coaltion (OHC) represents doctors, nurses and other health care workers, worries for the future of medicare.
“A number of things like accommodation services – laundry, food services – are in the grey area of the Canada Health Act,” says Maher. “So with all these fees that are being introduced, by the strict letter of the law, there is no way to stop them. But as far as we are concerned the spirit of the Act isn’t being observed.”
In its current reforms, the government of Ontario is emphasizing paramedical professions like midwives who fall outside the CHA and aren’t covered by OHIP. The turn to community-based services means that people have to rely more on services and providers that aren’t covered under the CHA.
Maher says privatizing accommodation services is a recent phenomenon, the result of hospitals finding creative ways to trim their budgets.
“It’s a new area that hospitals are taking bids on,” she says. “The other thing around the accommodation services is that because they are not categorized, strictly speaking, as health care services, none of this is exempted in the Free Trade Agreement from U.S. competition.”
A recent report by two British Columbia researchers tries to put together this complex puzzle. Jackie Henwood and Colleen Fuller of the 7,500-member Health Sciences Association of British Columbia recently charged that a combination of free trade and budget-slashing governments is eroding the universality of medicare and ushering in a two-tier system.
Fuller and Henwood identify the Free Trade Agreement as the culprit. While the health care industry created more jobs than any other sector of the Canadian economy between 1984 and 1991, they point out the job growth has been concentrated in the private sector since free trade was implemented in 1989. And they expect worse under the proposed North American Free Trade Agreement (NAFTA).
“NAFTA will accelerate trends towards a privatized, non-union and corporate-dominated system of health care in Canada.”
One provision of the Free Trade Agreement has also made it possible for U.S. companies to compete against Canadian firms in health care. Chapter 14, “health-care facilities management services”, allows wide-open competition.
Under NAFTA, provisions will bind all levels of government to consider for-profit health care companies on both sides of the border on equal footing with public providers when bidding for services, and entitles them to compensation if they can prove to an arbitration board they’ve been wronged.
“That represents a substantial encroachment on the democratic right of local, provincial and federal governments to make decisions,” says Cathleen Connors, who chairs the national wing of OHC, the Canadian Health Coalition.
It’s this plus health care cutbacks – federal and provincial – that’s resulting in service and job cuts and bed closures in the public sector and an increase in privatization, say Henwood and Fuller. These opportunities have not gone unnoticed by private companies south of the border.
One such company is American Medical Security Inc. (AMS) of Green Bay Wisconsin. After hiring Canadian pollsters Angus Reid to do a survey, AMS saw a profitable market in offering American hospital insurance to frustrated Canadians awaiting surgery. Sixteen per cent of those polled said they wanted this service; that was enough for AMS.
“One thing that comes across loud and clear is that Canadians for the most part are happy,” says spokesperson Carrie Galbraith. “They know they are taken care of during an emergency. But they are willing to pay a little extra if they need care.”
So far, AMS offers its plan to Ontario, B.C. and Manitoba, with Toronto its best market. Galbraith says plans are in the works to expand to all of Canada except the territories.
Unfortunately, like most private health plans, AMS cuts its losses by avoiding what Galbraith calls “adverse selection” – anybody with a known serious health problem need not apply.
Here in Ontario, private for-profit home care services take in close to half of all OHIP billings. Many clients pay out of their own pockets for additional services.
The Ontario health ministry doesn’t keep statistics on the extent of the private home health care sector, says spokesperson Layne Verbeek. But the Ontario Home Health Care Providers’ Association, a trade group, estimates private homecare companies now employ 20,000 and serve more than 100,000.
“It’s a market situation,” says Henwood. “If the services aren’t available to people within the public sector, they will go outside of it. We’ve seen this in other countries like England, where they had a public system and now have a parallel private system. If you erode a system enough that people get angry, they are going to start to look for alternatives, and the people with the greatest liberty are those with money.”
But in a recent interview, health minister Ruth Grier was adamant this scenario wouldn’t be allowed to take place in Ontario. She strongly disagreed that medicare is being weakened due to recent changes, and said the government has actually “reaffirmed its commitment to medicare.”
David South Consulting 
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