Older adults navigating health care: When benefits are denied



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The purpose of this study was to explore the experiences and perceptions of elderly beneficiaries who have been denied health services by Medicare. With the adoption of devolution and a consumer driven health care system following the Medicare Modernization Act of 2003, informed consumers are essential to ensure equitable access to health care. Examining Medicare consumers’ access to care and the challenges they face is important, not only for Medicare recipients but because Medicare’s rules and payment approaches for health services are often adopted by private insurers.
Bourdieu’s theory of practice and symbolic violence provided the theoretical framework for conceptualizing the structure-agency dialectic of Medicare-beneficiary transactions. The method of this study, including sampling, interview, and analysis procedures, was guided by Interpretive Phenomenology. Semi-structured interviews were conducted with twelve individuals who had experienced denial of Medicare services (four beneficiaries, 65 years and older, and eight proxy navigators who had acted on behalf of elderly beneficiaries).
Of the five main topics and associated themes identified in the analysis, there was strong consensus among respondents in four areas. These were the perception of Medicare at the time of enrollment, the use of Medicare resources, the consequences of denial of Medicare services, and participants’ perceptions of Medicare following denial of services. Denial of services was seen by the respondents as having a major physical, psychological, and financial impact. The resulting perception of Medicare was as a cumbersome, difficult to negotiate system where the beneficiary was often the ultimate loser. Variation among participants occurred in the fifth topic area—actions taken in response to denial of services. Seven respondents told an essentially passive narrative in response to this denial, but five others took a more active, agentic stance, engaging in various ways with the medical system in an attempt to have their needs met.
Exploring lived experiences of beneficiaries and their families when beneficiaries face the challenge of not qualifying for needed medical coverage sheds light on the nature of interactions that take place between Medicare and the respective beneficiaries and their families, and the impact of such experiences. There is a need to expose pitfalls beneficiaries are likely to experience in this climate of cost containment and rationing of health care. Findings of this study and others like it can increase the awareness of beneficiaries and policy makers of the current state of equity of access to health care.