We need a Marshall Plan in the US for the aging and elderly
Senior residents at Horace Nye listening to the debate over the future of their nursing home, which was privatized this year. (Photo: Brian Mann)
A couple of months ago, I was sitting n a press conference where Chandler Ralph was talking about big changes at the Uihlein nursing home in Lake Placid. Ralph is CEO of Adirondack health, which operates nursing homes, hospitals and clinics in the northeastern Adirondacks.
“The state does not have a firm public policy on how we’re going to treat the elderly and service the elderly in the future, in my humble opinion,” Ralph said.
It’s an astonishing idea, given that we live in a society being reshaped by the aging of the baby boom generation.
The population of Americans over 65 grew 15% over the last decade alone. The population of young workers, age 18 to 44, grew just .6 percent.
These trends, combined with the troubled economy and the trainwreck national debate over the future of entitlement programs, make it more and more urgent that policy-makers begin to hash our a kind of Marshall Plan for America’s seniors.
We know that the old system of guaranteed-payment entitlement programs probably isn’t affordable. Already, even solidly “blue” Democratic states are squeezing Medicaid reimbursements so hard that nursing homes and hospitals are struggling to survive.
Simple economics dictate that more and more nursing homes will turn away the poorest seniors, who rely solely on Medicaid.
As state and Federal officials move to tackle the astonishing levels of debt we have accrued as a society, boosting those payments will be all but impossible, particularly at a time when more and more seniors are entering the system.
It’s also a simple fact that the marketplace isn’t solving this problem. Many seniors have been hurt badly by the stock market’s gyrations, by the collapse in the value of their homes; and by the decision by private companies to cut or curtail pensions.
And there is simply no way that two-worker families, or traditional groups like churches, can care for the millions of old and very old Americans who will be added to the population over the next couple of decades.
At risk here are the enormous moral gains that we have made a society since the 1940s. Before that time, dire poverty was a normal state of affairs for the elderly. Old people starved or froze to death, or died for lack of basic medical care.
So what’s the answer? I’m guessing that it will take a complex, multi-faceted and non-ideological approach to create the next generation of safety nets for seniors. We will have to raise taxes. We will have to make painful decisions about what kinds of end-of-life care are affordable.
But we should also be far more creative.
One troubling aspect to this is that, so far, leaders at all levels have approached the question of senior care as a zero sum game, asking only what burdens their budgets can bear.
I would suggest that it’s time to turn the conversation around. Let’s ask first what that safety net should look like. What is the most basic network of support programs for seniors that would fulfill the requirements of dignity, respect and care?
What are the services that an ethical society simply must provide?
From that answer, we should work towards finding the most efficient, cost-effective and creative approaches possible.
A first step might be to create an “aging czar” in Washington, someone who can pull together all the thinking and resources from balkanized bureaucracies ranging, from the VA to the Administration on Aging to Housing and Urban Development.
Begin working with the states to foster experiments in creative elder care. Look to churches and NGOs for their best ideas.
The first baby boomers are now hitting 65 and people who look at the fate of nations say demographics is destiny. If we handle this change well, we could emerge with a more logical, affordable and decent safety net for our most vulnerable people.
This challenge could make us a better, more caring nation.
If not, if we shirk the tough decisions or simply turn away and leave more and more people to the Darwinism of aging, I suspect we will wind up with a humanitarian crisis among the very old not seen in the US since the 1930s.
Tags: aging, elderly, health, medicaid, medicare, politics, social security
The present system allows some dying people to have almost infinite amounts of money spent to try to keep their body part alive a little longer. Others can’t afford nursing home care. There needs to be a more rational/moral way to spend our limited resources.
Start with the fact that 96% of the population does not need or will ever use a nursing home. Most of those in nursing homes only spend about a year there before death.
That model is pretty much over. Seniors are going to be healthier and live longer and be productive longer. Finding ways to fully engage seniors in productive work and finding alternative living arrangements and options for seniors in their living will be key. Most senior care will happen in their own home and how do we do that in the most effective way?
Anyway I agree we really need to think about this. We will always need a form of defined benefits though in my opinion. We could start with fully funding Social Security, and right now show we are serious about it by raising the Social Security tax up to where it was two years ago before Obama and the Congress lowered it.
Mervel said: Start with the fact that 96% of the population does not need or will ever use a nursing home.
” … 96%”
That puts things into perspective. The thought of “millions” of seniors not being cared for suggests a crisis.
“… does not need.”
More families could take in their elderly parent(s). I know of such people who do it – and one is a two-worker family. It is difficult in some situations but it is do-able.
How about a conversation about voluntary euthanasia? One of the biggest fears I’ve heard from the healthy elderly is ending up in a nursing home. Many of them claim they would rather be dead. Same from those suffering from nontreatable, terminal diseases.
Can’t speak for anyone but myself.
For me, I am now 69, employed and plan on working until I die.
I don’t like doctors, hospitals or anything related to the health care system but nothing personal.
I think Medicare is a cruel joke. Yes, I do have health insurance.
If I get sick and can’t work, I intend on doing nothing that would provide an income in the medical profession. I would consider suicide.
To me, life is about living and living is about working.
By the way, I do take SS since I paid into it for years and continue to pay into it since I continue to work. I view it as my part-time job.
To me, retirement is simply waiting at the bus stop for the death bus to arrive.
Kathy – that model where more family members help take care of the elderly is probably the way we have to go. But they (the family members) are going to need help – home care nursing and hospice care that would still be far far cheaper (as well as more humane) than having the elderly end up in intensive care units for extended periods with all sorts of tubes and machines hooked up to their failing organs.
4% of the US population is still 12,463,677 people. For most of those twelve and a half million people and their families, the lack of affordable nursing or day care is very likely a crisis.
Once my grandmother was no longer able to live on her own, she moved in with my family and lived with us from the time I was 12 until she died on my 16th birthday. She had a variety of medical issues that made it difficult, but not impossible for a two-income family to handle. That I was a teenager at the time and able to help out certainly helped.
I hope to be able to provide the same support for my parents if and when the time comes. But there are cases where the situation goes far beyond difficult and truly becomes impossible. As life spans increase and modern medicine keeps bodies going longer, the incidence of dementia and Alzheimer’s have climbed. When you can’t leave grandma alone for an hour for fear she’ll walk outside in her bathrobe and freeze to death, living with a two-income family is no longer an option. When 85-year old grandpa starts waking up in the middle of the night trying to strangle 84-year old grandma because his shriveled brain is convinced she’s cheating on him, moving in with a two-income family with kids isn’t an option. (Both are real situations, not fantasy “what ifs”, by the way.) My father has Parkinsons. Will I be able to carry him up the stairs or lift him into our only shower on the second floor when his body gets so locked up he can’t do it himself? (Don’t think I haven’t already spent hours thinking about how to make it work.)
It’s easy to say more people “could” take in their elderly parents and grandparents and point out a few examples where it works. But its just as important to recognize that a lot of people “can’t”, even when they want to.
I don’t think suicide is really part of this discussion and is a major sideline issue. Certainly suicide, depression and mental health treatment are major societal issues that we need to address and provide support and help with, but I don’t think it really relates to how we embrace aging one way or the other.
Well Pete we are ALL waiting on that bus stop.
But the solutions to those very real situations and issues laurie does not have to be a nursing home, not even close.
There is a huge range of in home care, senior apartments, assisted living and so forth. This is the future. We will always need nursing homes I am not saying get rid of them, my point was that they will not be the cornerstone for how we address aging, they will be one small part of a much broader continuum.
Mervel – I totally agree that traditional nursing homes aren’t the only solution. But all those options you listed come with costs too. While they might not be as pricy as traditional nursing home care, they’re services that are going to have to be funded and/or provided by somebody. I think that’s the point Brian was trying to make.
Brian,
I find your take on this very real problem somewhat astonishing. It seems your approach would include increased government bureaucracy and increased taxation and spending beyond the wasteful levels already established. Why not approach the problem at it’s origin: out of control costs, insane spending and a medical establishment that encourages the warehousing of the elderly so that they can suck every last nickel out of them? The train wreck isn’t in the debate, it’s in the entitlement programs themselves.
The truly astonishing thing is that there sems to be no limit to the problems you think can be solved by raising taxes. Throwing money at this problem has been the consistent approach since the 1930s, so I have to ask: How’s that working out?
One last comment. You said, “Before that time, dire poverty was a normal state of affairs for the elderly. Old people starved or froze to death, or died for lack of basic medical care.” Seriously?
C’mon Larry – most of us can probably agree with your first paragraph up until you get to the rant about entitlement programs. Before social security and later medicare, the elderly lived frequently in dire poverty without access to health care. Thats why those programs were started. As to “how’s that working out?” the answer is pretty well so far (not perfectly), but probably needs some serious tweaking for the boomer generation. Is it going to take more tax money, simply because the percentage of elderly is going to increase, at least temporarily as the boomers pass through old age. Thats not throwing money at a problem – its recognizing that costs go up sometimes.
But everyone agrees that health care costs are ridiculously out of control. there is just no agreement on even the broad outlines of how to go about controlling costs.
Kevin Drum has a good post on why our healthcare system costs so much. We pay too much for doctors, drugs, and administrative overhead.
http://www.motherjones.com/kevin-drum/2012/08/american-doctors-hospitals-and-pharmaceutical-companies-are-overpaid
“A first step might be to create an “aging czar” in Washington”
Yeah. That always works. Tell me again one problem that an appointment of czar ever solved?!!
This is a job for the family to solve. Not the government version of families, either. Real families with dad and mom and kids taking care of their own.
laurie,
Yes I totally agree. Those solutions are ALL pretty expensive.
Just in general we have an expensive system for providing care even at the most minimal levels.
JDM you know yes it is better to have family support. But that is not always possible, its not just that people don’t want to take care of their family its that they physically, financially or skill wise, just can’t do it.
If you have to work and your elderly parent needs to be checked on four times a day, you have to find a way to make that happen, not everyone can afford to do that. But even more of an issue would be things like losing the ability to do things like bath and go to the bathroom by yourself, well not everyone is strong enough to lift their parents to be able to do that. So this is an area that society has to step in and help with, its a basic safety net issue.
I think we can and should find ways to do it for much less cost than the options currently available though.
I think we all agree there are situations when family support is not always available or competent.
It’s worth noting, however, many are able to offer family support and look to nursing homes out of convenience.
Mervel: “its not just that people don’t want to take care of their family its that they physically, financially or skill wise, just can’t do it.”
Then we need to incentivize it. Anyone taking care of an elder blood relative pays absolutely no taxes. No income tax. No property tax. No capital gains tax, nuthin.
I think we can convince people to give it a try.
If you are 63 and are taking care of your 89 year old parent who is incontinent and needs to be lifted onto the bathroom stool and lifted from his wheelchair into the bathtub and lifted from his chair into his bed, and although does not have alzhiemars does not really know what is going on a lot of the time; incentivizing you to do that won’t matter, you simply can’t do it by yourself. Paying no property taxes would help, but lets say you are not working and living on social security yourself? What are you supposed to do?
There are going to be many many cases that require the help of our society and yes that means the government, to find a way to help this family. It may simply mean help paying for some in home nursing care or it may mean more.
I find it hard to believe that very many functional families put their parents in a nursing home out of convenience. For one thing, the cost is tremendous. If the person is going to pay for it through Medicaid they must first qualify, which means that they have to be basically poor.
While I agree that many people can take care of loved ones at home, and there are many people doing just that, there are also many cases where it really is simply impossible to do at home even with the help of professionals checking in on occasion. It can be dangerous to try to care for a parent with dementia. You have to sleep sometime and during your sleep they can put something on the stove, forget it and cause a fire. Or they could be a danger to themselves or others because of their dementia. Look out when grandma starts hiding scissors and knives to have for “defence” in the middle of the night. My parents spent tens of thousands of dollars to build an apartment in their home for my grandparents to live in only to find that they simply weren’t capable of providing the necessary care. And they are both retired with no other commitments
Pete Klein, some people have been raised to find suicide impossible, but many of us know we have the right to make the most important decision in our life on our own…when and how to die. Unless of course it doesn’t get us before we’re ready.
“Throwing money at this problem has been the consistent approach since the 1930s, so I have to ask: How’s that working out?”
The standard of living by pretty much any measure is exponentially higher than it was in the 1930s. So my answer to your query is: imperfect but reasonably well.
One way of reducing costs is in end of life care. Under Obama’s plan doctors would have spent time discussing those issues with patients to determine their wishes so that people wouldn’t end up in a hospital unable to communicate and their kids would have to try to make those decisions for them.
Those were the so-called “death panels” and they could have been an important part of providing good care while saving money.
if things are working “reasonably well” why did Brian Mann call for increased bureaucracy and increased taxation to address “a humanitarian crisis among the very old not seen in the US since the 1930s”? Somebody got it wrong.
Speaking of throwing money at a problem, isn’t that what we are doing when it comes to defense? How about all the money we give to businesses in the hope they will use some of the money to hire workers?
How much money do we throw into the criminal justice system to keep us safe from someone who smokes a joint?
As you may have deduced, I’m not a big fan of throwing money at anything via the government, but I will say that the enormous amounts spent on Defense have at least kept us from another 9/11 style attack.
Yes, but how much of it was waste?
And you could equally say that the enormous amounts spent on social welfare have kept us from widespread starvation.
It’s always hard to guess what would have happened if things had been different.
I’m not a big fan of nursing homes. It seems that the average resident is so ill that their quality of life is quite low with usually very little chance of getting better. I’ld prefer that the money spent on nursing homes instead be used to cover those who currently don’t have insurance.
Larry – let me get This straight. You don’t think government should spend any money to keep the elderly from starving or freezing to death, but any amount spent to keep some Muslim religiious fanatics from bombing some New York City workers is money well spent?
Don’t be ridiculous, Peter, nobody wants the elderly to starve or freeze to death and that is not even close to what I said. Do you think money spent keeping us safe from terrorist attack was well spent? Maybe not in the case of New York City?
Larry, how much of the money that we spent on the Department of Defense was necessary to keep us safe from terrorist attack? Seriously, what would you guess?
And how much of the money that we spent killing people in Iraq and Afghanistan made us less safe, serving as an effective recruiting tool for our enemies?
Walker,
Seriously, you can’t isolate money spent on different aspects of Defense. Bottom line: no terrorist attacks in the US since 9/11. As for making our enemies angry at us, what then was the reason for 9/11? Did we upset someone?
Most elderly care is not happening in nursing homes. I think we all focus on them and they need to be supported but the future of the traditional nursing is that we will need fewer and fewer of them and we need fewer of the today than we did 20 years ago because there are so many other options.
The problem in a rural area and a poor area like the North Country is that those options are more limited than in other areas of the country and they are still very expensive.
My parents are in their mid-80’s and are graced with good health, however they have now bought an assisted living apartment that is connected to higher and higher levels of care as they may or may not need it. The apartment they have now is just an apartment with no services but they can access services as they need more care. But I know I don’t worry about them nearly as much. They could live with us, BUT they want more independence and they would have to uproot and move across the country. They had to sell their home to afford to buy into this.
The range of issues we will address as a society is very large as this will be a healthier generation of retirees than in the past, they are an asset to society not a burden. A society that views the old, the poor and the young as burdens, is not one that I would want to be part of. I think we have to think about this and deal with it, but I also don’t see this as a problem but an opportunity.
There is just many many options outside of a nursing home, the key is paying for those options and how to best finance them.
“Seriously, you can’t isolate money spent on different aspects of Defense.”
Why not?
Larry – I said you don’t want to spend tax dollars to support the elderly to keep them from freezing or starving, but you do Want to spend tax money to prevent Fanaticskilling tracking new York city. That’s notnsaying you want them starve or freeze.
Fanatics attacking. This spell checker …..
Well, it is nice of Larry to admit that Obama has kept us safe from Muslim extremists!
Here’s an interesting piece from the NY Times: Rationing Health Care More Fairly
It argues that rationing, especially for health care for the elderly, is going to become increasingly necessary, and faults both party’s plans for addressing the issue.
Walker, go right ahead if you think you can.
Although I am sure there are isolated cases of elderly people freezing or starving to death, I am equally sure this is not a widespread problem. I also don’t think it was widespread in the 1930s. It is, however, a great piece of melodramatic, liberal misinfomation that has obviously gotten everyone ready to raise taxes yet again to solve a problem that really doesn’t exist.
Well Larry, you’re in luck! There seems to be almost no reliable data on people starving to death during the great depression, though I keep hitting a report that in NY City in 1932 there were 29 deaths from starvation and 110 deaths from malnutrition.
That was not the information-saturated age we live in today. But think about it– at its height 37% of all non-farm workers were unemployed and there was no unemployment insurance or food stamps, no social security for the elderly, nothing but the county poorhouses and churches to fall back on at a time when the whole nation was in economic turmoil, while the dust bowl was wiping out a generation of mid-western farmers.
You’ll find figures on the web ranging from zero to 12 million deaths due to starvation and malnutrition in the US during the depression. I think it’s ridiculous to assume that deaths due to starvation and malnutrition were anything but rampant during the depression, but you can believe what you like.
As for the present, according to one source, 2,000 to 3,000 people a year die due to malnutrition-related causes in the U.S.”
We have rationing now, all societies have some form of allocating limited resources.
In health care some people get better access than others, some get much better access. I mean we can turn on Dalllas and watch a regenerated Larry Hagman with a transplanted liver after losing his first one to booze, kind of funny how that worked out for him, while many younger healthier people who were not alcoholics died waiting for a liver the same year he got his.
That is just life. The question is how to provide a minimum of care that we all can live with and not becoming a brutal society ignoring those most in need.