Digging into the possibilities opened up by this controversial new federal regulation, journalist Jaya Padmanbhan explores what it will mean to some immigrants and their families. This article originally appeared on the PBS Next Avenue website on Feb. 24, 2020.  Silver Century posts it with the permission of Next Avenue and the author. 

Devyani Dave immigrated from India to California in 1995 in her early 60s to live near her son and his family. Her green card was sponsored by her son (who prefers not to reveal his name), a citizen who came to the United States in 1973. When Dave arrived to start her new life, she had no health insurance and relied on her son to support her. Now, sitting on a bench at Priya Living, a senior-community facility in Santa Clara, CA, Dave said she feels fortunate to be in close proximity to her only child, especially as she ages.

But some immigration experts say the Trump administration’s new public charge rule, [which was put] into effect by the US Citizenship and Immigration Services on February 24, 2020, nationwide, will no longer welcome people in similar circumstances [to] Dave’s. That’s because, the analysts say, it will deem them likely to become liabilities for America.

How the Public Charge Test Has Changed 

Since 1999, federal immigration law has had a public charge test in place to deny people admission to the United States if the government identifies them as ones who may be “primarily dependent” on the government for support, either through cash-assistance programs or long term institutional care.

But the Trump administration is altering the definition of “public charge.” Under the new rule, any person who uses designated benefits for 12 months in any 36-month period might be considered a public charge. And the list of benefits has expanded to include Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps) and Section 8 housing assistance.

It’s nearly impossible for older immigrants to pass the “totality of circumstances” test.

A public-charge determination will be made, at the time of applying for a green card or admission at the US border, by an immigration officer after considering a “totality of circumstances,” a discretionary weighting system [that looks] at factors including age, health, family status, assets, education and skills.

The totality of circumstances test will penalize people 62 years or older, said Natalie Kean, senior staff attorney at Justice in Aging, a nonpartisan legal advocacy group addressing senior poverty, making it “nearly impossible for older adults to pass the ‘public charge’ test under the new criteria.”

Who Is Likely to Be Most Affected?

Kean and other immigrant analysts say the revised public charge rule will tilt negatively for immigrants with chronic health conditions or disabilities; those who are not fluent in English; and those earning less than 125 percent of the federal poverty limit—that’s $21,138 for a two-person household.

With these stringent benchmarks, the new rule could have an outsize impact on low-income, older immigrants of color, preventing some from becoming legal permanent residents in the country they live in or aspire to live in.

This will have “a ripple effect on their families who are here in the United States, as well as our communities in general,” said Kean.

When the Supreme Court ruled on January 27, 2020, to give the Trump administration the go-ahead for its public charge rule, a statement from the White House press secretary called the decision “a massive win for American taxpayers, American workers and the American Constitution.”

In a fact sheet promoting the new public charge rule, the White House cited a 2017 poll from America First Policies (a pro-Trump organization), saying that 73 percent of Americans favor requiring immigrants coming to the country to be self-sufficient. 

Critics of the new public charge rule, however, say older, poorer immigrants will be harmed by it. In an amicus brief filed by Justice in Aging and others to contest the new rule, one of the arguments points to the situation of five million older immigrants who “are likely to have supported their families, have contributed to our nation’s economy by, for example, paying taxes and contributing to Social Security, and have been integrated into the fabric of our country. Yet, under the Final Rule, they will be viewed as having failed to contribute to society.”

How Immigrants Are Reacting

“That’s not fair!” exclaimed Losa Petela, a 60-year-old, legal immigrant from the South Pacific archipelago of Tonga, who lives in Fremont, CA, and has worked as a home caregiver in the Bay Area for nearly 10 years. Citing her own example, Petela said that immigrants who’ve served their US community well, even if they are older, should be allowed to get their green cards.

Praveen Thakur, 79, a US citizen who came here over 50 years ago from India and lives in Santa Clara, CA, takes a slightly different view. “If the children take full responsibility [for their parents], then older parents should be allowed to come and get a green card so that they can stay with their families,” he said.

Dave makes another distinction: “Those whose children are contributing to the [United States] for so many years and who don’t have anyone left in India should be allowed to join their families,” she said.

Fear and Confusion

Fears about the implications of the new public charge rule are spreading.

“We know that health care providers and social service agencies across the country are already starting to get calls from concerned individuals, asking whether or not it is safe to remain enrolled in health, housing and nutrition programs,” said Madison Allen, senior policy attorney from the Center for Law and Social Policy, a nonpartisan nonprofit working on policy solutions for low-income people.

This chilling effect, caused by confusion as to who or what will be subject to the public charge test, has resulted in some legal immigrants disenrolling from public programs even before the February 24, 2020, official start date.

The New York City Department of Social Services has said that in 2018, roughly 11 percent of the city’s noncitizen immigrants who are eligible for and lawfully receiving SNAP benefits have either left the SNAP caseload or have decided not to enroll, at a higher rate than US citizens in the program. The agency cited a correlation between this decline in enrollment and the public charge proposals, due to a “fear of potential immigration consequences.”

Opposition to the Rule Change

Congresswoman Judy Chu, a Democrat representing communities near Los Angeles, said at a Jan. 31, 2020, press briefing, “By keeping families apart, Trump is making it harder on immigrants to succeed.” Last year, Chu introduced the No Public Funds for Public Charge Act, which would prevent federal funds from being used to implement the new public charge rule. The bill has 118 Democrat cosponsors from 34 states and no Republicans.

“We are in a wait-and-see period right now,” said Denny Chan, a senior staff attorney at Justice in Aging. Arguing that the new public charge rule unlawfully targets older immigrants and their families, five briefs have been filed in circuit courts by organizations advocating for the elderly.

“It’s going to be a lengthy process,” Chan said….

Older immigrants who are worried about the public charge rule, Chan said, should “speak to an immigration attorney to get individualized legal assistance before they make any decision to access, or apply for, benefits.”

Silver Century Foundation: The change in the public charge rule went into effect in late February, 2020, just as the coronavirus epidemic was exploding across the country. Since then, the US Citizenship and Immigration Services has agreed not to use the new rule to deny visas or green cards to immigrants who are tested or treated for COVID-19.  Advocacy groups say, however, that immigrants are still avoiding medical care because of fear and confusion.

Jaya Padmanabhan

Jaya Padmanabhan is a journalist, essayist and fiction writer. Her award-winning immigration column appears in the San Francisco Examiner, and she has also written for India Currents, Forbes, Next Avenue and other publications. In 2019, she was awarded a Journalists in Aging fellowship by the Gerontological Association of America and the Journalists Network on Generations. The Silver Century Foundation helps to support these fellowships.

Carol Kuhlman vividly remembers a weekend trip with friends about two years ago—because that’s when she started feeling dizzy. The lightheaded, unsteady sensation came on gradually and quickly got worse. 

“It was very uncomfortable,” said Kuhlman, 66. “I had to hold onto things just to keep from falling. By Monday I was so dizzy, I couldn’t go to work.”

Her physician diagnosed her with vertigo, noticing her rapid eye movements, recommended some exercises and prescribed meclizine, which didn’t prove a practical solution. 

“I took one tablet in the middle of the day and immediately slept for five hours,” she said. 

The doctor wrote a note to excuse Kuhlman from work—for just two days. She was still dizzy when she went back. Her colleagues immediately noticed something wasn’t right. “I was very unsteady on my feet and weaving all over the place,” she said. 

Many times, dizziness is caused by something benign, but it’s still emotionally and psychologically devastating. 

Kuhlman’s struggle wasn’t an atypical one for older adults. Dizziness can affect anyone, but older people are more prone—about 70 percent of adults over 65 have suffered from it in some form. And compared to younger people, dizziness in older adults tends to be more persistent, have more causes and be more incapacitating. 

“We see patients with dizziness very frequently, and we take it very seriously,” said Anupama Gangavati, MD, an assistant professor in internal medicine in the division of geriatric medicine at UT Southwestern Medical Center in Dallas. 

A patient’s experience of dizziness may come in a variety of forms: a feeling of lightheadedness or imbalance; a sensation of blacking out; or vertigo, the perception that the patient—or the surrounding environment—is spinning, tilting or moving. 

Several studies show that older people with a history of dizziness are at higher risk of falling, which is a leading cause of hospitalization and accidental death among those over age 65.

While many causes of dizziness turn out to be benign, the effects can be emotionally and psychologically devastating. Dizziness is disorienting and unnerving. Sudden bouts are frightening; chronic cases can be debilitating. 

“It’s a quality of life issue,” said Gangavati. “Dizziness can lead to a lot of psychological distress if you’re not able to control it. Patients should not let it go just because a physician has not addressed it successfully on the first try.”  

What Causes Dizziness?

Accurate diagnosis can be a challenge. Dizziness can stem from a range of issues, including problems affecting the inner ear, brain, eyes, nervous system, vascular system or heart, all of which are subject to aging-related changes, according to Kathleen Stross, PT, a neurological and vestibular therapist.

Many older adults take multiple medications; dizziness may be a side effect of one or the result of an interaction between drugs. Neurological conditions like Parkinson’s can cause dizziness. Even health issues that might seem unrelated—such as neuropathy (numbness or loss of feeling) in the feet—can cause a patient to feel unbalanced and dizzy. Stress, depression or a lack of exercise may also contribute, as can dehydration or hot weather conditions. 

Among older people, one of the most common causes of dizziness is dysfunction of the peripheral vestibular system—the inner ear and its pathways to the brain. This controls a person’s balance and spatial perception. Neurologists call the vestibular system “the sixth sense” and, just like other sensory functions, it changes as people age. 

“As we age, just as our vision changes and our hearing may be affected, the vestibular system ages as well and may not function as well as it did when we were younger,” said Stross.

Patients can help their medical providers to diagnose the cause more accurately by giving a clear description of their dizziness. Stross gives new patients a questionnaire to help pinpoint their experience—what it feels like, how often it occurs and what, if anything, seems to trigger it. 

“The way people describe it can really vary, so I ask patients to tell me how they feel without using the word ‘dizzy,’” said Stross. “For some, it’s a feeling of being lightheaded or off-balance. Some describe it as feeling ‘heavy headed’ or a sense of floating or pressure. Others say they feel as if they’re spinning or moving.”  

Steve Lavine, 65, of Plano, TX, began experiencing dizzy spells when standing up from a chair. They got progressively worse, to the point where he felt he might black out. Lavine checked his blood pressure and found it was low, almost dangerously so. After consulting with his physician, Lavine stopped the blood pressure medication he had been taking for more than six months with no problems. Lavine had since lost 15 pounds through diet and exercise. The medication was now overcorrecting and making his blood pressure too low, causing the dizzy spells. When he stopped the medicine, the problem disappeared in a few days.

A thorough medication review is absolutely important.

— Anupama Gangavati, MD

When a patient complains of dizziness, one of the first things Gangavati checks is the person’s list of medications. Blood pressure medications are common culprits, as are antidepressants, beta blockers, prostate medications and diuretics.   

“Medications are one of the most common contributors of lightheadedness or dizziness,” she said. “A thorough medication review is absolutely important.” 

Gangavati also performs an exam, reviews the patient’s medical history and asks about triggers—when the dizziness occurs and what seems to be causing it. 

Beyond drug side effects, Gangavati said she sees three common causes of dizziness among her older adult patients: benign paroxysmal position vertigo (BPPV), orthostatic hypotension and postprandial hypotension. 

BPPV occurs when tiny calcium particles (canaliths) clump up in canals of the inner ear, interfering with normal perception about head and body movements relative to gravity. Doctors diagnose the condition by observing patients’ eyes while they’re moving their heads. Patients with BPPV exhibit rapid, uncontrollable eye movements. The symptoms may be severe, making the patient feel as if the room is spinning, and may lead to nausea and vomiting. 

“BPPV tends to occur in episodic bouts of a few hours,” Gangavati said. “It’s triggered by head movement, and if you stop moving your head and keep it in one position, it subsides or goes away.” 

Orthostatic hypotension is a bout of dizziness or lightheadedness due to a lack of blood supply to the brain, typically triggered when a person stands from a sitting or lying position. Postprandial hypotension occurs when patients feel dizzy or faint after eating a meal, because their blood supply is geared to the stomach to digest the meal.

Trial and Error

Imani Calicutt, 65, of Dallas, sometimes experiences bouts of dizziness, and her doctor’s not sure why.

“Lately, it’s been constant,” she said. “It’s really limiting me because I can’t go very far without having to sit down.”

She’s working with her doctor (now via telemedicine due to the COVID-19 crisis) to determine the cause. Because Calicutt takes an array of medications for arthritis, diabetes, chronic pain and kidney disease, she’s expecting it may take some trial-and-error to find the cause.  

That’s not uncommon, Stross said. 

“In our experience, patients usually need to see three physicians before they get an answer,” said Stross. Because dizziness could relate to any number of areas of the body, finding the right specialist isn’t easy. 

After a visit to a primary care physician, the patient’s next step might be an appointment with an ENT (ear-nose-throat) specialist or a neurologist, or possibly a cardiologist (if vascular issues are suspected) or hematologist (if anemia is suspected). 

Brief moments of lightheadedness are probably not serious but do mention them to your doctor.

To treat dizziness, a physician may prescribe medications or dietary and behavioral modifications. That can include basic steps like ensuring the patient is drinking enough fluids and getting enough rest and exercise. 

For problems relating to the inner ear, including BPPV, vestibular rehabilitation therapy can be effective. Vestibular therapy ranges from simple exercises (a well-known one is the Epley maneuver, which involves positioning the head to help dislodge the tiny particles that cause BPPV) to physical therapy that helps the patient learn to compensate for imbalance and maintain physical activity. Vestibular therapy, when indicated, may provide immediate relief, or it may take some time to see results.

Gangavati added that many older people will experience brief moments of lightheadedness that likely don’t signal any serious problem. But she recommends at least mentioning it on the next visit to the doctor. “I think any dizziness should be discussed with your physician.” 

If acute dizziness occurs and is accompanied by other symptoms—like chest pain, difficulty walking or slurred speech—it could be a medical emergency, like a heart attack or stroke. In that case, Gangavati advises, head to the emergency room.  

Chronic Dizziness

Twelve years ago, as he walked out of the hospital after finishing his rounds, Tom Davis began to feel dizzy. 

“I’ve been dizzy ever since,” said Davis, 58, a physician in St. Louis, MO. Over the years, specialists have come up with different diagnoses: vestibular neuronitis, vestibulitis and Meniere’s disease, among others. None of the prescribed treatments fixed the problem permanently. Vestibular therapy made it worse. He considered surgery, which would destroy the nerve in the inner ear, but that would leave him deaf in one ear and offered no guarantees. At this point, instead of searching for a diagnosis, he’s focused on managing the symptoms as best he can. 

“It really doesn’t matter what’s causing it, because there’s no way to fix it,” he said. “You just have to work your way around that reality.” Regular exercise keeps him strong and helps reduce the risk of falls. On bad days, he takes a low-dose sedative and rests.

Unfortunately, like Davis, some people may have to contend with dizziness as a chronic or recurring issue. He says getting social support is important, especially for older people who might be tempted to isolate or become sedentary, for fear of falls. 

“If you have chronic dizziness, you’re not alone,” he said. “There are many groups on Facebook where you can get support from others.” 

Patients with chronic dizziness can also find helpful information and links to providers on the website for the Vestibular Disorders Association. Several other organizations offer support groups and other resources.   

Carol Kuhlman has been more fortunate. She did find some relief. She returned to work, still dizzy, a few days after her symptoms first appeared. She’s an administrative assistant at a medical school and, as luck would have it, an expert on vestibular disorders was visiting her department that day. 

Coworkers arranged for her to see the specialist, who diagnosed acute peripheral vestibulopathy (inflammation of the inner ear). He prescribed vestibular therapy, which helped reduce the dizziness and restored her sense of balance. Kuhlman still has flare-ups from time to time, but she’s found a way to manage them. Exercise and stress management seem to help.

“When it recurs, I go back to the balancing exercises, which help,” she said. “And when I have a flare-up, I just have to push through.” 

Mary Jacobs

Freelance writer Mary Jacobs lives in Plano, TX, and covers health and fitness, spirituality, and issues relating to older adults. She writes for the Dallas Morning News, the Senior Voice, Religion News Service and other publications; her work has been honored by the Religion Communicators Council, the Associated Church Press and the American Association of Orthopaedic Surgeons. Visit www.MaryJacobs.com for more.

When Linda Stallard Johnson’s husband had pain in his shoulder, he suspected he might be having a heart attack. His sister had just had one, with similar symptoms. The couple went to a hospital emergency room, where he underwent an EKG, blood tests, a chest X-ray and a second EKG—all, normal. As a precaution, the physician on duty wanted to admit him for a stress test the next morning. But when the couple asked how much an overnight stay might cost, nobody had an answer.

“We even called the billing office and they sent a staff person down to the room, who could not provide us with any information,” Johnson said. 

Unsure what Medicare covered and fearful the bill might prove financially crippling, the couple left the hospital, despite the doctor’s warnings. They were on edge until he finally took the stress test several days later at an outpatient clinic—also, normal. 

The Johnsons’ experience mirrors a problem faced by many Americans: a frustrating lack of transparency in the pricing of medical services and procedures.

Health care costs are not only sky-high, they’re unpredictable. There’s a wide disparity in what hospitals charge, even for routine procedures, and pricing is anything but transparent. Patients who ask for price estimates in advance often get nowhere. Insured patients must navigate a complex array of pitfalls: finding in-network providers, avoiding hidden costs or services that aren’t covered, minimizing out-of-pocket costs. Even those with good insurance may be slammed with “balance bills”—charges for services from out-of-network providers that can run into tens or even hundreds of thousands of dollars. Those without insurance can easily end up bankrupt after a single trip to the hospital. 

Faced with disease, we are all potential victims of medical extortion.

— Elisabeth Rosenthal, MD

Rosemary Hinojosa, 68, ran into that problem several years ago when she fell and injured her back while visiting relatives in another city.  She was transported to the nearest hospital, which was out of network for her employer-provided health insurance plan. When she received an $87,000 bill, the insurer refused to pay, arguing that she was responsible for the bill because she didn’t choose an in-network provider.  

“Faced with disease, we are all potential victims of medical extortion,” wrote Elisabeth Rosenthal, MD, in An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (2018).

Older adults are particularly vulnerable. Compared to younger people, they tend to need more medical care, the cost of which represents a larger portion of their overall cost of living. Many live on a fixed income and can’t manage unexpected medical bills or exorbitant drug prices. Those who are near retirement may not be able to bounce back from a big bill. And while insurance and medical billing are confusing for people of any age, they can be even more so for an older person who’s not tech savvy, or who’s dealing with memory loss, hearing loss or other disabilities or who’s reluctant to question a doctor’s authority. 

This lack of transparency in health care costs “places an unfair burden on everybody, but it’s especially difficult for older Americans,” said Cindi Gatton of Pathfinder Patient Advocacy Group, which helps patients navigate health care and medical billing. 

Perhaps the most vulnerable are those ages 50 to 64 who lost their insurance through loss of a job and can’t afford to purchase a plan, according to Lynda Ender, AGE director with the Senior Source in Dallas. Ditto for those 65 and up who don’t qualify for Medicare—for example, immigrants who have no work history in the United States or who are not citizens. 

How We Got Here

How do medical providers get away with this? 

For one thing, insurance has traditionally insulated patients from pricing. Insurance paid the bill; patients often weren’t even aware of the amount paid. 

Aside from Medicare, which sets rates for each treatment and procedure, there’s no regulation that requires doctors and hospitals to keep pricing reasonable or to disclose prices before sending the bill. 

“We always have the right to ask, but there are no laws requiring anyone to give you a price in advance,” said Gatton. 

The pricing system that has evolved in hospitals is so complex, arbitrary and labyrinthine that it’s almost unknowable. Hospitals don’t price procedures based on the actual costs to deliver them; some hospital administrators aren’t even aware of what those costs are. Instead, hospitals have traditionally set prices based on what the market will bear—while keeping pricing data a closely guarded trade secret. Hospitals maintain a retail price list called the chargemaster but, like “sticker” prices on new cars, almost no one actually pays those prices. Insurance companies negotiate lower prices. Often, uninsured patients can negotiate lower prices too, but many don’t know that. 

Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, the pilot, the copilot, and the flight attendants

— Elisabeth Rosenthal, MD

Many physicians stay out of the billing process and as a result are unaware of the costs of tests they routinely prescribe or whether they’re in-network or out-of-network for their patients. 

Sometimes, providers simply can’t predict an exact price, only a price range. For example, a gastroenterologist might charge a standard price for a routine screening colonoscopy, but if polyps are discovered during the surgery, the procedure becomes a diagnostic colonoscopy, which commands a higher price. 

Finally, billing is piecemeal. Surgeons may know how much they charge for a specific procedure but have no idea what a typical patient ends up paying after charges are added for the anesthesiologist, the hospital facility fee and any blood work, supplies and medications. 

“Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, the pilot, the copilot, and the flight attendants,” wrote Rosenthal. “That’s how the healthcare market works.” 

What’s the Solution?

Likely it’ll take a major, federally mandated overhaul of the medical system to fix this problem, but that’s unlikely, given that the medical and pharmaceutical lobbies dwarf the defense lobby. President Trump has instructed federal agencies to develop rules requiring disclosure of hospital prices in consumer-friendly, electronic form, including “list prices” as well as the discounted prices that hospitals negotiate with insurers. However, the rollout is still likely years away and is already facing challenges in court.

Some efforts are underway at the state level to improve transparency and protect consumers. New Hampshire, for example, provides an online database of quality and cost, searchable by procedure and for individual doctors and clinics, which are required to provide the information. In Texas, the legislature passed a law (SB 1264) aimed at providing relief to those slapped with balance bills—surprise medical bills that fall on patients when they have (often unknowingly) seen out-of-network providers. 

Patients can take steps to minimize their out-of-pocket expenses. However, the strategy depends on whether the patient has private insurance, Medicare or no insurance at all. 

For those covered by Medicare, price shopping generally won’t save money. Medicare sets rates for services and, in most cases, forbids providers from billing patients for additional charges. 

Uninsured patients can sometimes negotiate a lower price in advance, especially if they pay up front in cash.

For those with employer-paid or individual private insurance, price shopping becomes complicated. The objective isn’t necessarily to find the lowest price; it’s to find the provider who can provide the service at the lowest out-of-pocket cost. Typically, that means calling the insurance company (or consulting its website) to locate a doctor or hospital that’s in network, in which case the insurer will cover all, or a higher percentage, of the cost. 

Keep in mind too that even if patients choose an in-network physician and an in-network hospital, they may still see providers (such as an anesthesiologist) who are out of network, who may then charge them at the retail rate. 

For those with no insurance, price shopping is critical. Uninsured hospital patients not only get stuck paying the bills out of pocket, they’re more likely to get billed those “sticker” prices. On the other hand, it’s often easier for uninsured patients to negotiate a “cash” price in advance, especially if the patient pays up front. Also, some urgent care centers, such as CareNow, pledge to provide prices up front (usually after the patient is evaluated but before treatment begins). Cash prices aren’t cheap but are usually closer to what large insurers pay. Providers are more willing to do this with cash-paying customers, in part because they avoid the cost and hassle of obtaining reimbursement from insurers.

For those who can’t afford insurance and can’t pay cash prices, there are few good options. Many must rely on county hospitals that accept patients regardless of ability to pay. Patients with low incomes and few assets may qualify for Medicaid; states provide this coverage and requirements vary.

How to Price-Shop 

When she fell and injured her hand, Sheryl Monnier decided to call to check the price at a nearby urgent care center before going in for an X-ray. The first person she spoke to refused to provide a price. She called again, waited on hold, got transferred to a supervisor and finally got a number: $111. 

While her insurer may cover all or part of that cost, Monnier thinks it’s important for patients to insist on getting prices in advance.

“I know that the charges my insurance company pays are simply passed along as higher premiums,” she said. If more consumers insist on prices in advance, “market pressure will encourage medical businesses to make the info easily available so consumers can make wise choices.” 

But as Monnier’s experience shows, price shopping takes persistence and patience. Those who wish to price-shop a procedure can start at HealthCareBlueBook.com to get a ballpark price range for their local zip code, then call the provider’s office. The process takes persistence. If the office person says, “I don’t know,” for example, the patient may need to ask, “Who does?” 

Getting a price may also require multiple calls. “Very often, you need to talk to more than one vendor to get the whole cost of a treatment,” said Linda Beck, who provides elder and health-care advocacy. “If you need knee surgery, for example, you’ll need to get estimates from the surgeon, the anesthesiologist, the radiologist and the facility.” 

The biggest challenge for avoiding unexpected costs occurs when the patient becomes sick or injured and starts treatment. Then, it’s up to the patient to ask each provider whether he or she is in network. Even if the hospital is in network, many physicians, radiologists and other providers are contractors who may not be in that hospital’s network. 

When you’re in the hospital, keep track of every service, test and medication you receive. Errors in billing are astonishingly common.

“There may not be much you can do to avoid out-of-network care if you’re in the emergency room, because there may be no in-network providers available, but at least you’ll know the bills are coming,” Beck said.

While in the hospital, experts advise, patients should keep track of every service, test and medication received, to help later identify any charges that don’t belong on the bill. “An astonishing percentage of bills have errors,” said Beck. 

But keeping tabs on medical care isn’t easy for someone like Sophia Dembling, 61, who has undergone almost a year of treatment for amyloidosis, a rare, systemic disease—treatment including chemotherapy and a stem-cell transplant. It’s challenging enough to stay on top of her medications and doctor appointments while managing fatigue, nausea and other side effects. 

“I’m sure I should be more vigilant, but it just makes me tired,” she said. 

On top of that, Dembling occasionally receives big bills that providers claim she’s responsible for, even though she has met her maximum out of pocket and deductibles for the year. So far, she’s been able to sort them out, but only after hours on the phone with providers’ billing offices. The hassle isn’t helping her heal. 

“It’s stress on top of stress,” she said.

Finally, for patients who are slapped with a big bill, there’s almost always room to negotiate. Consider enlisting a health advocate, who can help negotiate a big medical bill, for a fee. (Some charge by the hour; others charge a percentage of the money saved.) AdvoConnection.com provides listings of certified advocates based on location.

Those with employer-provided insurance can enlist help from their human resources department. That’s what Hinojosa did after getting that $87,000 bill for the out-of-network emergency surgery and hospital stay. With help from her employer’s medical-benefits office, Hinojosa appealed the bill, arguing that she had to opt for out-of-network care, given the urgency of her injury. It took some effort, but she eventually prevailed.

“I won all the appeals that I had and ended up paying only $100,” she said. 

Mary Jacobs

Freelance writer Mary Jacobs lives in Plano, TX, and covers health and fitness, spirituality, and issues relating to older adults. She writes for the Dallas Morning News, the Senior Voice, Religion News Service and other publications; her work has been honored by the Religion Communicators Council, the Associated Church Press and the American Association of Orthopaedic Surgeons. Visit www.MaryJacobs.com for more.

Until age 45, Mary Jo Anderson says, she was a “champion sleeper.” 

“It’s like someone flipped a light switch,” she said. “When I entered menopause, I suddenly couldn’t fall asleep.” 

At age 64, she had less trouble falling asleep but couldn’t stay asleep. She woke up almost every hour of the night and felt tired much of the time during the day.

Anderson was not alone. More than half of all Americans over 65 report they have difficulty falling asleep or staying asleep, according to the National Institute on Aging.  

It’s a miserable feeling. While everyone else sleeps comfortably, you’re awake. Anxious or distressing thoughts occupy your mind. The longer you stay awake, the more you worry about not getting enough sleep. You fear you won’t be able to function the next day; you fret over how the lack of sleep may affect your health. A vicious cycle ensues: the more you can’t sleep, the more you worry about not sleeping, which keeps you awake. You start to dread bedtime and another night of trying desperately to sleep—and failing.

“It’s a cruel joke that life plays on us,” said W. Christopher Winter, MD, founder of the Martha Jefferson Hospital Sleep Medicine Center and author of The Sleep Solution: Why Your Sleep Is Broken and How to Fix It (2018). “When we’re young—working nonstop, with kids running around the house—we wish we just had more time to sleep. Then we get older and have more time, and your brain’s saying, ‘I don’t really want it anymore.’”

Plus, the media are full of alarming reports that connect sleeplessness with health problems. Chronic insomnia is linked to increased risk of developing obesity, Type 2 diabetes, hypertension, heart attack, depression or anxiety. Research also links insomnia to Alzheimer’s and other forms of dementia (although it’s not clear whether the insomnia is a cause or an early symptom). Sleep-deprived people are more prone to falls or car accidents as well as forgetfulness. And, according to the National Sleep Foundation, a lack of sleep is linked to overeating—especially the overconsumption of junk food—which can lead to weight gain. 

On the flip side, people who do sleep well are more likely to be alert, function better mentally and are even more likely to maintain a healthy weight. 

But there is hope for those of us who call ourselves poor sleepers. With a “sleep makeover”—changing habits that disrupt sleep, developing routines that promote sleepiness at bedtime—many older adults can get the sleep they need. 

The Roots of Sleeplessness

Researchers divide sleep disorders into two general categories: dyssomnias and parasomnias. Any sleep disorder that causes daytime drowsiness is a dyssomnia. That includes insomnia as well as other conditions, such as sleep apnea or restless leg syndrome. Parasomnias are sleep disorders with odd or irregular behaviors that occur during sleep, such as sleepwalking or night terrors.

People with insomnia—difficulty falling asleep or staying asleep—may experience fatigue, low energy, difficulty concentrating, mood disturbances and decreased performance at work. Chronic insomnia isn’t an unavoidable aspect of normal aging, but sleep patterns do change as we age. It’s possible to understand these changes and not let them cause unnecessary distress that keeps you up nights. 

“Among healthy older adults, the brain circuit that controls sleep just isn’t as robust compared to that of their younger selves,” said Steven Lin, MD, neurologist with Healthcare Associates in Medicine, PC, in Staten Island, NY. “Plus, older people tend to have medical or other issues that may interfere with normal sleep.”

People over 65 are more likely to suffer from chronic conditions, such as arthritis, which can cause pain that can awaken them at night. They may be more prone to bladder issues that necessitate repeated nighttime trips to the bathroom. For elders caring for a spouse or a loved one, sleep may be disrupted when they get up at night to tend to the person. Older adults are also more likely to take medications that affect sleep or cause daytime sleepiness even after a good night’s sleep.

Experts say it’s normal for older people to take longer to doze off at night, to sleep more lightly and to wake several times during the night.

The timing of sleep may change too. Older adults tend to become sleepy earlier in the evening and wake up earlier in the morning. One National Sleep Foundation poll found that about two-thirds of adults over 65 consider themselves a “morning person,” considerably more than in the general population.

Experts also say it’s normal for people to sleep more lightly as they get older. Sleep occurs in cycles that are repeated several times during the night, including dreamless periods of light and deep sleep and periods of active dreaming (REM sleep). Beginning in middle age, people naturally spend less time in deep and REM sleep. They tend to wake up more often, an average of three to four times a night. Older people also are likely to take more time to fall asleep and have more difficulty staying asleep. 

Plus, an older person who’s sedentary—due to mobility issues, for example—may simply need less sleep. Ditto for someone who is retired, who need not arise at 6 a.m. every day or face the daily stresses of a job.

For older adults, a sleep makeover can start with simply recognizing these changes that come with age—and not getting too distressed about them. Try to minimize anxiety that might trigger more sleeplessness, Winter said

“Our sleep patterns change throughout life,” he said. “I’m 47. My sleep is not the same as it was when I was seven or 17. I have occasional nights where I’m lying in bed awake up until 4 a.m. I try to enjoy the quiet time, rather than getting stressed about it.” 

Resetting Sleep Rhythms

One important step in a sleep makeover is to work with your body’s circadian clock—the natural rhythms that make us alert during the day and sleepy at night, ​and that include the waxing and waning of the sleep-promoting hormone melatonin. With exposure to sunlight during the day, the body’s secretion of melatonin tends to drop off. As it gets darker at night, melatonin secretion increases.  

To reset your sleep rhythms, you should adopt a consistent sleep schedule with an emphasis on arising at the same time each day.

In addition, these steps may help:

• Avoiding caffeine, alcohol, nicotine or other chemicals that interfere with sleep 
• Creating a comfortable sleep environment (cool, dark and quiet) in the bedroom
• Establishing a calming, pre-sleep routine
• Making an evening to-do list so you don’t fret over what’s ahead the next day
• Eliminating late-afternoon and early-evening naps
• Eating and drinking enough, but not too much or too soon before bedtime 
• Exercising regularly but not right before bedtime
• Taking melatonin supplements under a physician’s supervision

An effective sleep makeover should also involve using light to your advantage. Get plenty of exposure to sunlight. Avoid electronic devices (e-readers, cell phones, tablets, TV or computer screens) that emit blue light, which can delay or disrupt sleep, in the hour before bedtime. 

Incorporating relaxation techniques, such as meditation or yoga, as part of your bedtime routine may help too, Lin said. Similarly, it’s a good idea to avoid anything too stimulating (a tense or engrossing novel, a violent film or the TV news if that upsets you) at bedtime. 

But how do we stop thinking about those news reports about the dangers of poor sleep? They can trigger anxiety. And anxiety is the enemy of good sleep. 

It’s easy to underestimate the number of hours you slept. Pay attention instead to how you feel the next day. 

“Unrealistic expectations about sleep that are not helpful can add to a patient’s stress, and that can lead to chronic insomnia,” Lin said. Because older people sleep more lightly and wake more often, or simply need less sleep, they may worry about a lack of sleep even when they’re actually getting enough. That leads to more stress, which leads to more trouble falling or staying asleep, triggering a vicious cycle. 

Experts advise against getting too hung up on how many hours you’re asleep on a given night. Sleep needs are individualized. There is no “gold standard” for how much sleep an older person needs; rather, it’s based on how people feel and how well they function on the amount of sleep they get. It’s more important to pay attention to how you feel during the day rather than how many hours you slept.

Adding to the anxiety, people can also easily misjudge the number of hours they are actually sleeping. Sleep medicine specialists call that paradoxical insomnia, according to David Luterman, MD, medical director of the Sleep Center at Baylor Scott & White in Dallas. For example, patients in the sleep lab—where sleep is monitored during an overnight stay—may report they didn’t sleep at all. 

“Yet the measurements taken of their brain waves showed they were asleep for at least four hours,” he said. “The patient’s perception is ‘I’m up all night’ but that’s not really the case.”

If you’re feeling anxious about how little sleep you’re getting, try wearing a fitness tracker (such as a FitBit) that monitors sleep. These wristband devices may not differentiate precisely between REM, deep and light sleep, but Winter said they do tally the total number of hours you’re asleep with reasonable accuracy.

“If a patient tells me he’s sleeping only an hour or two a night, and the device is saying he’s sleeping six hours and 13 minutes on average, I believe the device,” he said.  

Don’t Lose Sleep Over a Little Lost Sleep

We all experience sleeplessness at times. You may feel tired and worried about it, but it may not actually be worrisome. 

Winter cautions against equating insomnia with sleep deprivation, especially occasional insomnia. Those studies that warn against the dangers of too little sleep, he said, relate more to people who never get enough rest: the single mom working two jobs who can manage only four hours of sleep a night; the hard-charging executive who gets up at 4 a.m. to work out; the person with chronic sleep apnea who awakes four to five times an hour at night. 

It’s normal for people to experience insomnia for short periods after a stressful event, such as a divorce or the death of a loved one, Luterman said. During very stressful periods, he recommends considering the option of sleep medication, which may help avoid short-term, stress-related insomnia that turns into chronic insomnia. However, because older people respond differently to medicines than younger adults, sleep medication should not be taken except under a physician’s supervision. 

“It’s a careful balance,” Luterman said. “You don’t want to rush to prescribe patients a sleeping pill when the root cause of insomnia may be something else.” 

He added that the American College of Physicians recommends that, for patients of any age with chronic insomnia, the first line of treatment should be cognitive behavioral therapy (CBT) rather than medication. CBT is solution-oriented psychotherapy that treats specific problems by modifying dysfunctional thoughts and behaviors. Behavior modification might include simple steps like going to bed an hour or two later if you’re not feeling sleepy or devising a helpful routine for times when you can’t sleep. (When that happens, experts advise against staying in bed and tossing and turning; instead, get up and do something quiet, like knitting or reading boring materials, until you start feeling sleepy.)

In general, sleep medication is recommended only for the short term—several weeks at most. After a longer period, patients can build up a tolerance to sleeping pills (needing increasingly higher doses for the same results) or become psychologically dependent so that the idea of going to sleep without a pill causes anxiety. Follow your doctor’s instructions and stop taking the drug as recommended.

“When you compare the two—sleep medications vs CBT—research shows the results are the same, or CBT is a little better,” Luterman said. 

When to See a Doctor

Anyone experiencing trouble sleeping that lasts more than a few months should consult a physician, to eliminate underlying emotional or medical conditions that may disrupt sleep, such as depression or restless legs syndrome, a condition that causes a twitching or tingling sensation and an uncontrollable urge to move the legs at night.  

If insomnia persists, your doctor may prescribe a visit to a sleep clinic. That involves spending the night sleeping in a private room, with equipment that can help detect sleep problems by monitoring brain activity, eye movement, heart rate, snoring, body movements and more. 

Before you go to the clinic, the doctor may ask you to keep a sleep diary for a few weeks, noting how much sleep you got, when you went to bed and how many times you woke up during the night. That information will be compared to the results in the lab. 

Don’t Get Discouraged

While there are indeed many ways you may be able to improve your sleep, there is no one-size-fits-all answer. You’re going to have to experiment to see what works best for you. The solution may involve doctors and sleep clinics, or maybe simple changes in your routine will work wonders. 

Vickie Parker, 67, was waking up every morning at 4:20 a.m. and couldn’t easily fall back asleep, even though she was still tired. So she developed a routine that seems to work: a trip to the bathroom, a heating pad to relieve pain in her shoulder, and turning down the thermostat in her bedroom by a degree or two. If that doesn’t work, she takes a low-dose sedative prescribed by her doctor. 

And Mary Jo Anderson eventually found an unconventional solution that helps her fall and stay asleep: a podcast called Sleep with Me, which the New Yorker described as “the podcast that tells ingeniously boring bedtime stories to help you fall asleep.”

“The host talks in this lull-y, drone-y voice,” Anderson said. “He’ll tell a story or recap a popular TV show. On one, he narrates while he’s putting together an Ikea bed. It helps shut down your mind but it’s not interesting enough that you stay awake to hear the end. It’s been the best thing for me.”

Mary Jacobs

Freelance writer Mary Jacobs lives in Plano, TX, and covers health and fitness, spirituality, and issues relating to older adults. She writes for the Dallas Morning News, the Senior Voice, Religion News Service and other publications; her work has been honored by the Religion Communicators Council, the Associated Church Press and the American Association of Orthopaedic Surgeons. Visit www.MaryJacobs.com for more.

An older couple put aside some of the food delivered by Meals on Wheels in order to have enough to feed their dog.

A widow delays an important visit to the doctor, fearing no one will care for her cat if she is hospitalized.

An older man living alone with a sick pet agonizes over a terrible choice: incur vet bills he can’t possibly afford or have his only companion euthanized.

Heartbreaking stories like these point to a difficult reality. While pets can benefit older adults’ health and happiness, they can also lead to financial burdens, near-impossible decisions or devastating grief.

Do the benefits of pet ownership really outweigh the risks?

Weighing Benefits with Costs

For many older adults, animal companions can make a huge difference in quality of life.

“People with pets in general are happier and healthier,” says Nicki Nance, a licensed psychotherapist and associate professor of human services and psychology at Beacon College in Leesburg, FL. “Pets require a structured schedule and daily exercise. They provide a sense of purpose, constant companionship, physical contact and humor.”

Those benefits can boost mental and physical health. An American Heart Association research review concludes that “pet ownership, particularly dog ownership, may be reasonable for reduction in cardiovascular disease risk,” with the most significant benefits associated with owners who walked their dogs regularly. The Human Animal Bond Research Institute (HABRI), a nonprofit, research and education organization, cites research that points to the benefits of therapy animals: they can calm older people with dementia and alleviate anxiety and distress for those undergoing cancer treatment.

Doctors often encourage their older patients to adopt a pet. But psychologist Hal Herzog, author of Some We Love, Some We Hate, Some We Eat: Why It’s So Hard to Think Straight About Animals (2010), questions whether the data is strong enough to warrant a doctor’s recommendation. While some studies point to health benefits, others show little or none. He also notes that studies show correlation but don’t prove causality: it’s not clear whether pet ownership makes people healthier, or healthy people are more likely to have the energy, motivation and financial resources to take care of pets. Most analyses, he adds, don’t factor in the lifetime cost of owning a pet in the United States, which can run upward of $10,000.  

The hardest part of my job is having to tell an older adult that a beloved pet needs to be euthanized.

—James Moebius, veterinarian

The downside of pet ownership should not be underestimated. Pets pose a significant risk of falls. A cat underfoot, a dog that pulls too hard on a leash, or pet toys on the floor can cause a person to stumble and fall. A 2009 Centers for Disease Control analysis estimated that more than 86,000 injuries due to falls each year were related to cats and dogs, with the highest rates of injury occurring among people 75 and up. For older adults, a fall can have devastating health consequences; a hip fracture, for example, can lead to long-term impairment, nursing home admission or death. 

Dogs need to be walked, all animals need to be fed and most must be groomed at least occasionally or have cages that should be cleaned regularly. These tasks are time consuming and can be hard for someone with limited mobility. Pets need trips to the veterinarian for routine wellness visits and illness. That can be traumatic, as well as costly, and difficult for a person who doesn’t drive. 

Then there’s the trauma of losing a pet. 

“The hardest part of my job is having to tell an older adult that a beloved pet needs to be euthanized,” says James Moebius, a veterinarian in Sachse, TX. “It’s even harder when it’s an older gentlemen who lives alone and who’s part of that generation that doesn’t express feelings. You watch him walk out alone, silently, without his little dog, and it just pulls your heart out.” 

Making It Work

Barb Cathey, CEO and founder of Pets for Seniors, an adoption program in Illinois, admits there are ups and downs and often, unexpected outcomes. She helped a client named Betty to adopt a rescued dog named Zoe, and the match was a happy one. However, Betty’s family returned Zoe to the shelter a year later. A fall had forced Betty to move to rehab for several months, and no one could care for the dog. The shelter agreed to keep the dog until her owner recovered. 

Meanwhile, Betty wasn’t doing well, refusing to even try to cooperate with her rehab therapist. Then her daughter brought Zoe for a visit. Delighted to see the dog, Betty immediately moved in her bed to make room. The therapist encouraged the family to bring Zoe back regularly to keep Betty motivated. 

“Betty ended up getting better, with Zoe’s help, and eventually was able to take her back home,” Cathey says. 

Before adopting a pet, a person should carefully consider all potential challenges as well as ways to minimize problems. A key first step: choosing a pet that’s a realistic match for an older adult’s physical capabilities and energy level.

“The worst mistake a senior can make is getting an energetic puppy or young dog,” Cathey says. Ditto for a dog or cat that requires lots of expensive grooming (such as a breed with long hair) or a young pet that’s almost certain to outlive the owner by many years. 

Shelters have a hard time finding homes for older animals, but they’re often a good match for older adults.

Cathey worked with an older woman whose family gave her a Jack Russell puppy, a breed known for its high energy level.

“She would call me in misery because the puppy was too much for her and she did not want to hurt their feelings,” she says. “I convinced the family to let me find a new home for the Jack Russell pup and found an eight-year-old Pomeranian that was housebroken and just wanted to lay in her lap all day—just what she wanted.”

Shelters have a hard time finding homes for older animals, but senior pets often make a good match for older adults, according to Linda Ross, a retired counselor who worked with aging populations. Ross and her husband are in their 70s and are both healthy and active, yet they chose to adopt an older dog after theirs passed away in 2010. 

“Older pets tend to be housebroken, quieter and less energetic,” she says. “And if they’re rescued dogs who’ve been homeless or in a shelter, they are just so grateful to have a soft bed and a good routine. We just love on them and they love on us.”

Finding Solutions

Those heartbreaking stories—the older couple who put food aside for a pet or the widow who postponed medical attention—were the impetus for the founding of the Seniors’ Pet Assistance Network (SPAN) in the Dallas area. Caseworkers for local aging-related agencies had noticed the challenges of elders living alone with pets, and how a little help might go a long way. 

Now, SPAN serves low-income older adults in the Dallas area with regular deliveries of pet food as well as help with veterinary-care costs. Grant money pays for food for about 75 animals; volunteers deliver it once every other month and spend a little time checking on each client. SPAN’s clients also receive an allotment of up to $300 per year to cover routine vet care, including immunizations, heartworm medication, and flea and tick prevention. 

“That’s significant, given that many live on as little as $1,200 per month in Social Security benefits,” says Laurie Jennings, SPAN’s co-founder.

For others, potential problems in pet ownership can be addressed with a little advance planning. Some veterinary costs, such as immunizations and spaying or neutering, can be minimized by taking advantage of low-cost clinics offered at animal shelters and pet-supply stores. For those who can afford it, pet insurance offers a way to help owners avoid wrenching decisions about vet bills. Owners pay a monthly premium but may be covered (depending on the type of plan) if pricey treatments are needed. 

To prevent falls, the CDC recommends that pet owners consider obedience training, installing night lights on walkways, moving the animal to another room or a crate at night, or even choosing a light-colored pet rather than one with dark fur. 

And in the event that an older pet owner loses a beloved animal, veterinarians can often help with the grieving process by pointing them to a pet-loss support group. 

Making Arrangements for Future Care  

Jennings often hears from family members who tell her, “That animal is keeping my parent alive.” But on the flip side, it’s a source of worry.

“We have a client, a 97-year-old widow, who has a very ornery, 9-year-old poodle,” she says. “She lives for that dog and frets over who will care for the dog if something happens to her.”

Some older adults want to provide for their pets in their wills, according to Lori Leu, an elder law attorney in Plano, TX. She recommends checking with a friend or family member first to see if they’re willing to take the pet after the owner dies or becomes incapacitated. That arrangement should be put into a will, along with (if possible) a small bequest to help cover the pet’s expenses. 

Although they are careful to avoid making promises, the people at SPAN try to help clients “rehome” pets if they can no longer care for them. It’s not always possible, but they do have success stories.

Jennings recalls Bobo, the beloved pet of an elderly woman who lived alone and was dying of cancer. Family members wouldn’t take Bobo, a pit bull mix, and because he was a little aggressive, Jennings despaired of ever finding a home for him. But a rescue group took Bobo, helped socialize him and found him a home.

When the young man who adopted Bobo learned of his previous owner, he offered to bring the pet to visit her one last time, just a few weeks before she passed away. 

“So, we have this photo of Bobo, this massive pit bull, lying on top of her in her bed,” Jennings says. Now SPAN receives a holiday card each year from the young man, with a photo of Bobo sporting a Santa hat.

“You make wonderful human connections doing this work,” says Jennings. “It’s beautiful.”

Mary Jacobs

Freelance writer Mary Jacobs lives in Plano, TX, and covers health and fitness, spirituality, and issues relating to older adults. She writes for the Dallas Morning News, the Senior Voice, Religion News Service and other publications; her work has been honored by the Religion Communicators Council, the Associated Church Press and the American Association of Orthopaedic Surgeons. Visit www.MaryJacobs.com for more.