Wednesday, April 14, 2010
Today's post was delayed as I researched the most current trends in using reverse mortgages as a strategy for aging at home, instead of in an institution. The housing catastrophe of the past 30 months changed much of what I had originally written in the early drafts of the book. I am still waiting on Medicaid to provide some updates but decided to post this entry now, even if the final version of the book is somewhat different, based on those updates. Medicaid is currently overwhelmed with adopting changes related to the new healthcare legislation and my request for interviews and information are likely a low priority.
Chapter 3 (Part 2)
A PLACE CALLED HOME
The Reverse Mortgage
In 2030 the youngest boomers will be 67, the oldest 84. The homeowners in this group--eight of every ten boomers are homeowners--will be perched atop a home equity money mountain worth $8.1 trillion. Unfortunately, unless current efforts and policies are improved, many of these house-rich and cash-poor seniors will struggle to find the money they need to pay for the help that would allow them to remain at home. Failing that, they will be forced to sell the house in order to pay for alternate living arrangements.
A reverse mortgage—and there is currently only one type available—can unlock much of a home’s equity value, putting cash in the homeowner’s pocket immediately, without putting the house at risk. The cash can be used to make staying at home possible.
A reverse mortgage is a relatively new, creative and promising financial service. Those seniors who need help at home but find themselves house-rich and cash poor deserve a reverse mortgage option that is affordable, well-designed, carefully monitored and delivered by trustworthy professionals. The roadblocks for making this happen on a large scale are apparent: (1) $8.1 trillion piled up in one place will attract a lot of additional flies and as seniors lose their mental acuity, advantage can be taken; (2) the lending industry has proven that it cannot effectively police its own; (3) policy-makers do not understand the service and its potential positive impact on lowering Medicaid costs; (4) seniors do not understand the service benefits and believe many negative myths and (5) the product could get expensive again.
First, let’s understand the service. Below are the basics of the one service currently available, the Home Equity Conversion Mortgage (HECM, “heck’um”). This service was co-designed by AARP and The Federal Home Administration (FHA) and is underwritten by The Department of Housing and Urban Development (HUD):
1. Every HECM applicant receives mandatory professional information counseling to insure that they understand the service.
2. Available to those 62 or older, the homeowner gets the equity advance (loan) but maintains title to the home.
3. There is no time limit on how long the homeowner can then stay in the home.
4. The loan is not due until the home is sold by the homeowner or his or her heirs.
5. The homeowner’s heirs will never be responsible for paying any part of the loan. Any negative gap in home sale price to loan value is insured by HUD. A positive gap goes to the estate.
6. The loan proceeds can be used for any purpose.
7. Loan proceeds are not income and therefore, not taxed.
8. The homeowner must keep the home maintained, pay the real estate taxes and keep the home insured.
9. A homeowner’s other assets, income or credit score play no role in qualifying for the loan.
10. The amount of the loan is based on a formula that includes the appraised value of the home, the homeowner’s age and current interest rates.
11. Currently, there is a cap of $625,500 on the appraised value of the home, an amount that includes the vast majority of American homeowners.
12. Interest on the loan is a tax deduction expense in the year the loan is repaid.
13. The older the borrower, the greater the percentage of equity value he or she can free up.
Here are three simplified examples:
Home Value: $200,000
Mortgage Owed: $0
Cash to homeowner: $101,600
Interest Rate (2010): 5.7%
Home Value: $200,000
Mortgage Owed: $0
Cash to homeowner: $117,000
Interest Rate (2010): 5.7%
Home Value: $200,000
Mortgager Owed: $0
Cash to homeowner: $134,000
Interest Rate (2010): 5.7%
In the past, based on the $200,000 appraised value, each borrower would have paid $4,000 in mortgage insurance, $4,000 in origination fees plus title, closing and appraisal costs; likely about $10,000 in all. However, due to recent changes in the value of HECM-backed securities, the prices from some lenders have dropped dramatically, by as much as 70%. The actual out-of-pocket costs are relatively small because most of the fees are incorporated into the loan. The borrower could choose to take the loan proceeds in one of several ways: a lump sum, as a set monthly distribution, set up as a line of credit or some combination of those three.
So, in a country where several million retirees could benefit from this service, why are there only about half a million of these loans in force? More importantly for baby boomers, how can the percentage of users increase dramatically over the next 20 years?
In 2005, the National Council On Aging (NCOA), with the support of the Robert Wood Johnson Foundation and the Centers for Medicare and Medicaid Services, published a study entitled “Use Your Home to Stay at Home: Expanding the Use of Reverse Mortgages for Long-Term Care: A Blueprint for Action”. The study pointed out that one of the ironies of our current situation is that at a time when millions of impaired older Americans are financially struggling to maintain their independence at home, their homes could be the source of the money needed to stay in their homes.
Currently, there are four major barriers to a more robust and successful use of home equity to help seniors remain at home and pay for appropriate support services: (1) The uncertainty of reverse mortgage costs and features, (2) consumers’ negative attitudes, (3) government policy and (4) the fraud potential.
Historically, compared to other home mortgage products, the HECM has not been cost efficient. Interest rates, servicing and origination fees and mortgage insurance were markedly higher than conventional mortgages. Recently, however, these cost differentials have begun to moderate, making the costs of a HECM much more attractive. There is a role for federal government regulations to play in encouraging the mortgage industry to keep these costs competitive. Doing so would encourage millions of retirees to include reverse mortgages in their long-term financial planning.
Even among seniors who are familiar with reverse mortgages (and most are not) many are reluctant to consider one because they think that they are putting their home at risk; in fact, they are not. Many believe that this type of loan is only appropriate for the financially desperate.
One of the biggest negative perceptions is caused by semantics. The term “reverse mortgage” immediately brings to mind the 30-year mortgage debt of which most homeowners could not wait to be rid. The notion of taking on substantial debt late in life, using the home as collateral, seems an anathema. But--and this is key--as long as the borrower is alive and able to live in the home (and this provision extends to the borrower’s spouse and certain other qualified dependents while they remain alive), they can remain in their home. This financial product should probably have been initially labeled something like “cash leverage service” or “liquidity generator account” so that consumers would perceive it in a more positive light. Maybe it’s not too late to re-think the label that providers put on this service.
Yet another perception problem is tied to the desire to “leave something to the kids”. This often means the home. Nearly 80% of home owning seniors view their home as a primary asset for bequest. Many children, however, have a decidedly different view. Fewer than 15% express any interest in retaining their parent’s home, either as a residence for themselves or as a rental asset. Adult children are much more amenable to seeing the equity value of their parents’ home used for their parents’ long term care needs, especially when the money helps the parents stay in their home.
Currently, some state Medicaid policies work at odds against the broader use of reverse mortgages. For instance, because reverse mortgages are required to be first mortgages, if the state has placed a lien against a home when one of the residents goes on Medicaid, and this is often the case, the spouse who is not on Medicaid is not qualified to get a reverse mortgage to help pay for any at-home care as long as the state lien is in the primary position. This policy increases the likelihood of one or both of the elders being forced into a nursing home where Medicaid picks up the entire cost of their care.
There is also a problem when states define reverse mortgage proceeds as “income or assets” in their calculations for Medicaid eligibility for poorer citizens. Reverse mortgage proceeds are loan proceeds, not income and should have no impact on determining eligibility just as the value of the home plays no role in eligibility. Unfortunately, many states have failed to see that this policy is working against the best interests of the state’s taxpayers. It discourages poorer homeowners from obtaining a HECM for fear of losing their Medicaid eligibility. Thus, cash strapped for private pay help at home, they end up, at state expense, in the local nursing home.
For elders who qualify for Medicaid nursing home services, several states have developed waiver programs that pay for some in-home services; that’s good. However, the current limitations of these programs still make it difficult for many elders to remain at home. One such benefit exclusion is “room and board” or the cost of maintaining a home, groceries and utilities. In addition to excluding these day-to-day expenses, there is a limited set of authorized in-home medical and support services for which Medicaid will pay. This limited set does not include home modifications, companion care, house keeping, shopping services, meal preparation or most transportation. By requiring that homeowners pay out-of-pocket for these in-home services, while not encouraging the use of reverse mortgages—indeed, even discouraging their use by threatening the loss of Medicaid eligibility—Medicaid prematurely funnels millions of elders into the more costly nursing home alternative. Sometimes the government’s left hand needs to have a conversation with the government’s right hand.
The increased use of reverse mortgages is not a cure-all for what ails the Medicaid funding crisis but it can be an important part of the overall fix. Reverse mortgages hold the realistic potential to increase private sector (homeowner) funding for in-home support services which could save Medicaid about $4 billion each year, or roughly 10% of its annual budget for long-term care for the elderly. As the baby boom closes in on its dependence years, the comparable illiquid housing wealth will escalate because we have been better educated and more financially successful than our parent’s generation and much of our wealth has been poured into housing stock.
Medicaid policy change will also have to address the issue of reverse mortgage proceeds use, which currently has no restriction. For those who would otherwise be destined for a nursing home at Medicaid’s expense, reverse mortgage money must be dedicated to in-home care expenses meant to replace the nursing home alternative. This requirement likely means that a specific HECM product be developed for those homeowners who are already—or soon to be--Medicaid qualified, to insure that HECM proceeds don’t end up paying for things unrelated to in-home care.
Finally, and also related to the current issue of “no restrictions on HECM proceeds use”, is the specter of fraud. The immense liquidity value of baby boomers' home equity coupled with rules that put no restraint on what the HECM money can be used for and the mental deterioration that will be visited on too many as they age, is a recipe for fraud on a massive scale. The flies aren’t just circling; they are already feeding on the exposed cash. The current fraud activity associated with reverse mortgages is, in a major way, tarring the HECM service with the brush meant solely for the unscrupulous and outright dishonest. Once again, government policy and oversight are required to address this issue.
If, as a nation, we truly intend to resolve the cost challenges associated with the long-term-care of the country’s largest ever generation, then creatively using the generation’s own wealth as a foundation is a necessary (but not sufficient) prerequisite.
Observoid of the Day: Bikers who wear a helmet look silly. Bikers without a helmet look like organ donors.
Wednesday, March 10, 2010
Today's post begins an in-depth look at the five overarching issues confronting the nation as a result of the Baby Boom's march towards old age. This chapter addresses the alternatives of how and where best to live dependently.
Chapter 3 (Part 1)
A PLACE CALLED HOME
“Can a man put on his socks? If not, he will soon
need someone to dress and bathe him.”
Frederick T. Sherman, M.D., Instructor
need someone to dress and bathe him.”
Frederick T. Sherman, M.D., Instructor
Mount Sinai Hospital Cont. Ed. Seminar.
Here is a common Baby Boomer Delusion: growing old and needing help with things that are now taken for granted will never happen to me.
For about 20% of boomers, this belief will be true because they will die before becoming significantly infirm. Deborah Chase’s husband will be in this category; healthy enough to go on a golfing holiday but beset with the high blood pressure that will do its damage in a massive and immediate way. The rest of the generation will benefit from improved medical care, survive into advanced old age and eventually suffer the indignities of various physical and mental impairments.
To determine whether or not a patient is “at risk” when living without help, clinicians observe a patient’s ability to accomplish five Activities of Daily Living (ADLs). When these activities become problematic, living without assistance is dangerous, unhealthy or both. Here are the things that an independent person must be able to do for themselves: (1) get dressed and undressed (Dressing), (2) transfer food to one’s mouth, chew and swallow (Eating), (3) walk around (Ambulating), (4) get to the bathroom in time, take care of business and clean oneself afterward (Toileting) and (5) keep oneself clean and relatively sanitary (Hygiene).
There you have it, Dressing, Eating, Ambulating, Toileting and Hygiene or, as the clinicians mnemonically and ironically remember them, DEATH. If you lose the ability to do one of these activities, you need a little help. Lose several and you need a lot of help. Either way, a person with one or more of these deficits has entered the realm of dependent living.
Currently in the U.S. there are four basic dependent living alternatives, not counting the dangerous, but oft chosen, alternative of toughing it out alone.
(1) Stay at home. This is almost everyone’s preferred alternative and there is much to recommend it. First, some relatives are likely nearby. Also, you know and are known in you community and deep social roots are important. Staying put is less stressful than moving. And, there is compelling medical evidence that, done right, staying at home will add to the length and quality of your life. When you are dependent at home, you will rely on your mate, other family members, friends or someone responsible and trustworthy to come in and provide the required help. Unless the caregiver is a family member or close friend, you will pay for the cost of these care giving services privately. If the ADL challenges are in their earliest stages, the amount of necessary paid help could be just a few hundred dollars a quarter. If you are eventually so impaired that you need 24/7 skilled care, privately paid assistance at home currently costs about $15,000 per month. It is a safe bet that costs will be a good bit more in 2031. As Deborah Chase’s family learned, this “at home” alternative is often complicated, aggravating and expensive. Medicare will not help, unless the in-home care is associated with a short-term medical problem. With a few pilot program exceptions, Medicaid will not pay for these types of in-home care services; not at all if you have assets. Long-term care insurance may pay, if you had the foresight to be one of the very few who bought such a policy when it was affordable. Even then, the home care benefit is likely to be only a portion of what private insurers pay should you move into a nursing home.
(2) Move in with family or friends. To a lesser degree than staying at home, living with those who truly care about you has many positive aspects. However, there is no substantive monetary relief for the care giving household in the current tax code. Neither is there much, if any, monetary assistance from Medicare, Medicaid or the private insurance sector. There may be some tax relief for the hosting household if you can be qualified as a penniless dependent and, in that case, Medicaid may help a little. Clearly, this alternative poses some challenges to the established routine and budget of the hosting household. It also requires that you adjust to living in someone else’s home and the reality of being a minor or major burden. There is a nascent but very small movement called senior co-housing (sharing a modified residence with friends or colleagues), a variation of home-based living which will be discussed later in the chapter. However, the financial and social cooperation requirements for this approach will restrict its availability to a very small slice of the aging population.
(3) Buy or lease an apartment in an Assisted Living Facility (ALF) or Group Home. These institutions are designed for those whose ADL deficits are mild to moderate and who do not require all of the clinical skills available in a nursing home. Here, communal meal service, laundry and private apartment or room maintenance are usually part of the paid package. Assistance with ADL deficits is available for additional fees. The expenses at an ALF are private-pay. The average monthly cost, not including routine assistance with daily activities, is currently $3,200. Prices vary widely across the country, however, from $1,900 per month to $5,600. Help with ADLs usually costs $15 to $30 per hour depending on the level of clinical skill required to provide the assistance. If we assume that you move to the ALF because you need some daily assistance, say two hours per day at $20 per hour, it would add another $1,120 per month in out-of-pocket expenses for a monthly total of $4,320 in 2007 dollars. If inflation averages just 2% per year, the yearly out-of-pocket expense will be almost $72,000 in 2031. And, this calculation assumes that the amount of paid care remains constant at two hours a day, a risky and likely unrealistic assumption. The downscale version of the ALF is the Residential Care Home or Group Home, a version of dependent living that has been around for generations. Small, independent, for-profit and often run by families, these are basically rooming houses for the elderly. It is estimated that half of them are not licensed and therefore fly under any regulatory radar. Very little national data is available about the overall quality of these small operators. The conventional wisdom suggests that some of them are pleasant and responsible and others far less so. Take your chances.
(4) Move into a Nursing Home. A Skilled Nursing Facility (SNF) is an institution for many who need constant hands-on care. (However, many U.S. nursing home residents are there only because it is the only alternative in their market, even though their ADL deficits are mild to moderate.) Unless you are verifiably destitute, you or your family will pay the SNF out-of-pocket. The current average monthly tab for a semi-private room is a staggering $6,025. If you want privacy, the rate escalates to $6,782. Adjusted for a theoretical 2% inflation rate, the monthly cost in 2031 will be north of $11,000. Should you go broke paying these costs, Medicaid is the social safety net that will pick up the tab. However, many SNFs accept only a limited number of Medicaid patients because of lower benefit payments (compared to private pay). So, you may eventually be moved to another SNF where there is room for lower-revenue generating Medicaid patients. For many reasons beyond just the financial, the SNF is almost everyone’s option of last resort. If you reach 85, however, the data indicate that you have an 80% chance of spending some time--recuperating from an illness or injury, or living permanently--in such an institution.
Each dependent living alternative presents unique emotional, financial, physical and psychological implications for the frail elderly and their family. When one of these alternatives become unavoidable, families often experience confusion, frustration, heartache, anger, despair, guilt, denial, remorse or even trauma. With few exceptions, transitioning from living independently -- after having done so for six or seven decades -- to any one of these four alternatives is difficult and, a blunt reminder of our mortality.
I’d Rather Stay at Home, Thank You
Nearly everyone (93%) wants to age-in-place and then die at home; at least that’s what the data indicate. However, it may not always be the best alternative and certainly not always the most affordable. Our current long-term care policies, funding mechanisms and support systems don’t often encourage this option when help is needed. Changes will have to be made to make the “at home” alternative easier, more financially sensible and less traumatic for all involved.
For those experiencing the steady erosion of their ability to be independent, a much-loved home eventually becomes an unsafe environment. Throw rugs and loose carpet menace the less than sure-footed. Hot water heaters direct scalding water to skin that no longer always senses heat and cold as it once did. Medicine cabinets and counters are filled with powerful prescription drugs for multiple ailments and often there’s the cognitive challenge of remembering which drugs to take, how many and when. Just to round out the potentially dangerous chemical cocktail are all those over-the-counter supplements, vitamins, minerals and remedies that the doctors and pharmacists rarely know about.
Getting into and out of the bathtub or shower provides an adventure of slick surfaces and missing handholds. Burned out light bulbs darken the hallways and stairs because replacing them is problematic. Repairs and maintenance to loose steps, railings or floor tiles are postponed until someone else can get to them. Meals become a succession of microwave or TV dinners because the spouse who once cooked is no longer around or because preparation of fresh food is simply too difficult. There’s also the problem of remembering to turn off the stove or oven when meal is finally prepared. And, even if the oven timer goes off, there’s the problem of hearing deficits. Adding to these lesser indignities is the embarrassment and hygiene issues resulting from the occasional or constant problem of incontinence, one of the primary reasons that the elderly end up in an institution.
And, there are those mailings and phone calls from friendly strangers announcing that you are a winner in that rich Canadian or Nigerian sweepstakes. These elder-targeted offers become more and more attractive as the senior becomes lonelier and less skeptical of such scams. Ah, home.
Clearly, not every person attaining their 85th birthday and living in their own home suffers from even one of these problems, let alone all of them. Those hail and hardy few with no deficits at 85 are a very small minority however and, unless they then die suddenly after being the picture of health into their ninth decade, they too will experience the frustrations of decline for some period of their life prior to death. When this occurs, staying at home without assistance becomes a personal safety and health gamble.
Prior to WWII, 65% of adult children lived within five miles of the place where they were raised and where their parents yet lived. When mom and/or dad became infirm, there was family nearby with whom they could live or from whom they could get assistance. Particularly in rural America, this generational family care giving still occurs, but it is far less common than it was 60 years ago. This cultural sea change is attributable to an American society and workforce that became mobile and restless in the latter half of the 20th century. There were two driving factors: (1) adult children began moving away from hometowns to further their careers and (2) many retirees migrated to warmer climates across the Sunbelt, leaving family and friends behind. Today the percentage of adult children who remain in the same general location as their parents has flip-flopped and now only 35% live within an hour’s drive.
When we look at this particular issue in the retirement destination geographies, what we see is a 65+ population, 85% of whom have no local family support.
The problems associated with the “at home” alternative have several sources. First, there is the denial factor. Frail elders are rarely the first to volunteer that they need assistance. The weekly phone conversation wherein the senior responds that he or she is “doing fine” is often a pale imitation of reality. Second is parent/child role reversal. Many adult children are uncomfortable taking the lead and many aging parents refuse to relinquish their leadership. Third is the reluctance of the elderly to pay the going price for assistance. Fourth is the confusing and fragmented nature of the local community-based care providers. Fifth is most family’s lack of clinical expertise to determine the elder’s actual assistance needs. This lack of expertise leads to reactive solutions instead of planning. Frustration ensues.
In spite of all of these potential negatives, about 2.7 million of America’s 4.7 million 85+ population continue to live in their own homes (1.7 million alone and 1 million with spouses). Over 80% of these elders are struggling with one or more of the quality of life or safety challenges mentioned earlier. By 2031 the number of frail elderly trying to live independently in their home will balloon to over 6 million. And, because the trend of adult children not living close to their parents is not likely to reverse, the “at home” alternative has the potential to become one of the nation’s leading social and health care problems.
There is nothing to suggest that we Baby Boomers will be any less stubborn about aging at home than our parents have been. If anything, given our reputation for independence and disdain for authority, the trend is likely to intensify. Therefore, America’s policy-makers must look at long-term care funding issues with a keen sense that aging safely at home is at least as big a concern as fixing the institutional problems of nursing homes or ALFs.
To be sure, aging at home is not the best alternative for some elders. Those who have ADL deficits and/or dementia issues that require 24/7 nursing care or monitoring are faced with enormously expensive paid care giving options or overwhelmingly difficult family burdens. However, millions can live very safely and contentedly at home with the appropriate support. But what is appropriate and who should decide? Most family caregivers are not clinicians or care giving professionals, nor are their elders. As a result, the care giving tends to be based on reactive and defensive perceived need, some real, some not.
Family caregivers face one or many of a myriad of tasks in support of the elder: scheduled and emergency trips to doctors, health care benefits management, insurance and payment questions, financial management, fraud prevention, home safety challenges, nutritional issues, medication management, grocery and other personal shopping, meal preparation, housekeeping, home maintenance, toileting, bathing, dressing, grooming, companionship and socialization.
The fragmented nature of the community-based services that could support a family caregiver makes it very difficult to organize and execute an effective plan for aging-at-home. This is especially true for those elders who don’t live in the same community as their family. As discussed before, this long-distance care giving scenario is the rule in American today, not the exception. As a result, support and service opportunities are missed, money is ill-spent and frustration grows as solutions are created after problems develop.
Where there is a need there is a market opportunity and, indeed, a small industry has emerged in the U.S. to address this need. The service is known as Geriatric Care Management, although it might better be described and understood as Assisted Living at Home. Consisting primarily of clinicians (nurses and social workers) the role of this small industry is to provide families with a knowledgeable representative in the community where the elder lives. The care manager’s job is to evaluate the real assistance needs of the senior, create a care plan, arrange for appropriate help, using community-based providers, monitor the quality and effectiveness of that help and generally be a quality-of-life ombudsman for the elder and the family. There are only a few thousand of these independent practitioners in the U.S. and they tend to be concentrated in the destination retirement communities of the Sunbelt where there are many frail elderly who have aged-in-place but not near their families.
For their services these practitioners charge a fee, which varies widely across the geographic markets of the U.S. The industry has a professional organization headquartered in Tucson, Arizona, The National Association of Professional Geriatric Care Managers. The association provides a certification process for practitioners but, to date, there are no state or federal licensing requirements, which means that care manager knowledge and quality can differ dramatically from one practitioner to another.
Nonetheless, with appropriate funding support, stricter competency requirements and wider consumer awareness, this Assisted Living at Home industry is destined to grow, especially if it links itself to the ALF industry where 92% of the prospective clients visit the ALF and then return home to try and “tough it out” on their own. As a better and safer at-home living option and/or an interim step to institutional living (if that becomes necessary), having a geriatric care manager who can help assure safer aging-at-home, which is more satisfying and affordable for all concerned, should be on our national policy agenda now not later. (To find a care manager in your particular area of the country, go to www.caremanager.org. and click on “Find a care manager”.)
Aging-at-home is what most Americans prefer. This alternative could be improved dramatically with common-sense policy decisions that encourage tax benefits that are beneficial to dependent elders and their informal unpaid caregivers and Medicare and Medicaid rules that encourage care at home and not in an institution. We don’t need further national debate, we need policy change.
Tuesday, March 2, 2010
With today's post, Chapter 2 is complete. Chapters 1 and 2 have set the stage for the remainder of the book; a close look at the five challenges and their potential solutions. While some of my solutions may prove controversial, their debate, final form and transition into policy and law cannot wait another generation.
Chapter 2 (Part 3, Final)
A GREATER GENERATION?
4. Demand Knowledgeable and Sufficient Care
Here’s a fact that many in the medical community would rather you not know: they don’t know much about treating the elderly. Unless a medical student or resident is planning on being a geriatrician, the American system of training doctors almost completely ignores the unique needs of the elderly. If your reaction to this fact is “So what, I’ll just get a geriatrician when the time comes,” you are in for an unpleasant surprise. Geriatricians are a rare and shrinking breed in America. You are unlikely to find one. This situation is a result of relatively low pay for geriatricians, ageism and the issue of professional status.
Compared to their specialist peers, who routinely earn $500,000+ per year, the geriatrician, similar to the family doctor or pediatrician, can expect to earn only about 1/3 as much. When many young MDs emerge from med school owing hundreds of thousands in student loans, there is little monetary incentive in becoming a geriatrician. And, our medical students and residents are not immune to the issue of ageism; old people with multiple complaints are just going to get older and develop other complaints. Then, there is the issue of professional status, where the pecking order surely does not begin with doctors whose specialty is geriatrics; it doesn’t sound glamorous and, relatively speaking, it doesn’t pay that well. Deborah Chase’s internist was not sufficiently schooled in geriatric depression and his ignorance ruined at least a year of her life.
The demographic realities of America indicate that all physicians should be schooled in the basic aspects of health care for the elderly. Geriatric medicine is different in the same way that pediatric medicine is different. The training issues and pay disparities must be addressed through policy solutions.
Broadening geriatric medicine expertise will reduce health care costs by reducing the current mistakes in diagnosis or treatments that occur because a clinician doesn’t know that the aged often present symptoms and react to treatments quite differently than younger patients. At the very least, all 131 American medical schools should include an expanded, recurring and required geriatrics curriculum, regardless of the student’s declared specialty. For most of them, treating elderly patients will be a given not an option. Such schooling would also have a moderating effect on the issue of professional status as clinicians come to appreciate the complexities of dealing with the health issues of aging.
America already has a nurse and nurse’s aide shortage, especially for those serving the dependent elderly. The trend of producing qualified new ones is down and we’re only 22 years away from the first of the Boomers turning 85. Without a measurable reversal in this situation, there won’t be enough qualified caregivers (RNs, LPNs and nurses aides) available to provide the help many Boomers will need to live dignified lives when they are dependent on help. This shortage will mean rationing of assistance and/or care provided by the inept and ill-trained.
Although better than the geriatric educational in America’s med schools, the amount of geriatric training in America’s nursing colleges falls short on two fronts: (1) the shortage of classroom space and instructors to train nurses of all types, including geriatric nurses and (2) the same issues of ageism and professional status that plagues the med schools. Creating classroom space for the 92,000 qualified nursing school candidates who are turned away every year will be easier than training the trainers to teach them. The latter will require changes in policy and the creation of financial incentives for some nurses to teach rather than to nurse, a decision that is often driven by pay differentials.
While there are enough candidates for nurse’s aide jobs now--as there will be in the future--the poor working conditions in which aides are often asked to build a career, for meager pay and low professional status, attract only the most altruistic or desperate. If this were not so, the average annual turnover rate for nurses aide workers in geriatric settings would not be 85%, a number that does not reflect career satisfaction. The solutions for this particular problem involve issues of more and better candidate screening, working environment improvements, training, job status, career path and pay, and immigration policy.
5. Eliminate Lingering, Lonely and Painful Dying
The irony of the incredible advances in medicine in the past century is that these advances have turned death into a medical failure, even for the very old and very sick. With one or two arguable exceptions, for every recorded human birth in history, there has been a related human death. Up until about 1950, old age was but one of many causes of death, e.g. child birth, heart attack, pneumonia, cancer, stroke, the flu, the plague, polio, accident, ruptured appendix, infection, et al. Today, old age and its related vicissitudes—which, individually, get the credit on the death certificate--dominates the “cause of death” paradigm in America. Sure, the other causes of death still remain but the bulk of Americans now die because their systems simply wear out with age.
The human body can now -- with mechanical and chemical aids -- continue the processes controlled by the lower brain stem; respiration, circulation, digestion and elimination, long after the higher brain functions of communications, memory, emotion, muscle control, senses, etc. have disappeared, never to return. The fact that 80% of Americans now die at an advanced age, in small undignified steps, in institutions surrounded by well-meaning strangers (instead of at home, where over 93% of Americans claim that they want to die) illustrates the problem. What we want and what we get at life’s final milepost are completely different.
Today, once the old and terminally ill enter the health care system, the choice about the nature of their care is usually out of their hands. The end-of-life health care choices are complicated by the following: confusion about who is to make decisions on behalf of the incompetent dying patient, newly available medical alternatives, ethical dilemmas, religious beliefs, cultural taboos, legal precedent and, most importantly, ignorance of the patient’s wishes.
Perhaps the biggest reason that the very old have such a low chance of experiencing the dying process they might want is the distancing between physicians and their patients. This disconnection means that many physicians, particularly specialists, don’t know the patients under their care very well. If a family doctor is involved but hasn’t had a specific “end-of-life” discussion with the patient, their end-of-life care input is trumped by the specialists. Deborah Chase’s internist is a case in point. This situation has been created by the emergence of specialized and more complex medical alternatives, Medicare’s cure versus care bias and woeful confusion or ignorance regarding the nature and intent of living wills, health care surrogates, Do Not Resuscitate orders and Advanced Medical Directives
If Boomers want better options for their own end-of-life care, whether it is “Do everything possible to keep me breathing regardless of the consequences” or “Let me be comfortable, unafraid and at peace with the outcome,” then Boomers need to help create and support sensible end-of-life health care policy, greatly expand and refine the use of advance care directives, demand better end-of-life health care training for clinicians and promote insurance reimbursement for care expenses not just cure expenses. These changes should come from a recognition by the public and the health care system that dying is eventually a natural process for the very old, not an enemy to be vanquished. The real villain is a dying process that needlessly prolongs suffering and/or robs people of the dignity each deserves.
Having a national policy that encourages citizens to consider these issues and talk with their physician about their end-of-life care wishes is the antithesis of the notion of “death panels”, a patently ludicrous fiction promoted by the hopelessly paranoid.
Becoming a Great Generation
The five challenges outlined are daunting. It will take wisdom, courage and strength to take them on. There will be sacred cows to herd. Large and moneyed lobbies will rear up to oppose the process. Some influential but cowardly politicians will regard power as more important than the common good. There will be well-meaning but wrong-headed opponents and proponents clouding the issues with their own religious, spiritual or personal objections. There will certainly be defeats, self doubts, contentious viewpoints, heated debates and strange bedfellows along the way. What, you thought this would be easy? Well, it’s easier than wading ashore under withering fire at Omaha Beach on the morning of June 6, 1944.
And, should the Baby Boom take up the call and succeed, it would not be classy to seek accolades. We should take on these challenges simply because they desperately need to be done; right now. Someone has to take the lead and it is our turn.
In the following chapters I will elaborate on the nature of the challenges and suggest solutions, but mine aren’t the only ones. My goal is to give you ideas about how you can help move the agenda for change along. We must act now or the necessary changes will not happen. Unless you and I and Deborah Anne Chase individually decide now to put our support and influence into improving the systems, institutions and attitudes related to dependent living alternatives, entitlement programs, unnecessary costs, geriatric health care and end-of-life care in America, the same dysfunctional system is awaiting our arrival. Considering how much of our lives has already been lived, that future is very close.
Observoid of the Day: Freud said, "We cannot imagine our own death." Nevertheless, Freud is dead.
Thursday, February 25, 2010
Today's post highlights the first three of five policy issues confronting and/or caused by the Baby Boom. These issues will significantly impact all 77 million Boomers, their children their grand children and the fiscal viability of the American Republic.
A GREATER GENERATION?
(Part 2) See previous posts for background
In brief, here are the challenges:
1. Completely Re-Think Long-Term Care
Putting mom or dad in a “home” after they have lived a lifetime at home is a decision that usually causes immense family heartache, anger, guilt and division. Do you want to live in a nursing home? Deborah Chase certainly didn’t. Statistics indicate that you and Deborah probably will spend some time there at the end of your life—unless we begin changing policy and nursing homes now.
There is a reason that nursing homes are so universally feared; it’s because they are rarely good places to finish out a meaningful life. Nursing home owners and managers will likely take exception to this viewpoint. Many of these professionals are devoting their careers to making their nursing home(s) the exception to the rule. However, you know what is said about pigs and lipstick. You can gussy up an institution with flowers, homey furniture, sun rooms or allow pets and it’s still an institution. It is not and will not feel like home.
America’s institutional nursing homes develop rapidly in the mid-20th century in response to the fact that Americans were beginning, in large numbers, to live beyond their ability to live independently. Not only was advanced old age a new norm for America, it was new to mankind, thanks to better health care and new medicines. American politicians did their best to resolve this challenge and passed appropriate legislation to encourage (through financial incentives) the creation of beds to serve this growing infirm population. In the 1950’s this new industry borrowed the clinical hospital model as the template for building. There was no other model that seemed to fit.
Today there are better alternatives (many involving staying at home or moving into a truly home-like setting) and, here’s the promising part, these alternatives are budding just as the old institutional nursing home infrastructure is aging and crying out to be replaced. However, without the right incentives and public demand, the private sector will likely just tear down the old nursing home and put up a new, bigger institution. If so, one of those oxymoronically named “semi-private” rooms will be waiting for you and Deborah Chase, whether you want to live there or not.
Creating ways for people to age in-place--in their homes, or in a home-like setting--requires that we (1) provide more substantive support and tax relief for family caregivers, (2) re-direct public funds from institutional care to in-home care, (3) be creative and sensible in using the equity value of home mortgages so that the costs of in-home care do not translate into a higher tax burden for subsequent generations, (4) provide incentives for long term care facility providers to expand on a building model that mirrors a home environment and (5) insist that long term care insurance (including Medicaid) not be skewed toward institutionalization, as it is today.
2. Re-Design Social Security, Medicare and Medicaid
Any talk of trimming the big three entitlement programs makes politicians grow pale and wet themselves. They react thus because, once a benefit is established, it’s political suicide to suggest taking any of it away, even if the original benefit no longer makes any sense in a dramatically changed demographic and financial environment. As a result, we now have a Social Security system designed to serve the conditions of a 1935 America when there were 16 wage earners supporting one pensioner. Today, the ratio is about 3 to 1 and about to get worse.
Politics has generated a popular Medicare system that focuses on cure but shifts the cost of long-term care to the family. It is a program that is an unwilling and unhappy passenger on a run-a-way health care cost inflation bus. And, although it is arguably the nation's most efficient and fastest payer of claims, it is rife with fraud primarily because of this efficiency. No good deed goes unpunished.
Politics has also given us a Medicaid system that steers elders to nursing homes in many states (once beneficiaries can prove themselves penurious) and too often discourages care solutions that favor aging at home. Medicaid is another unhappy passenger on the health care cost inflation bus.
The conventional wisdom is that if law-makers tinker with the nature and intent of these entitlement programs, voters will relieve them of their power. Touch the entitlement “third rail” and you will be political toast. George W. Bush tried to tweak Social Security during his second term and was resoundingly booed off the stage. Although, he did manage to add an unfunded drug benefit to Medicare while big pharma cheered and waved pom-poms on the sidelines. Adding stuff is way more popular than subtracting stuff.
The consequences of maintaining the status quo of these programs makes for a grim financial picture. In fact, the status quo is unsustainable; period. No kidding. If the Baby Boom wants to make a reasoned and reasonable sacrifice for the common good of the country, amending these entitlement programs is the opportunity. If, however, the entire Baby Boom demands these entitlements in full, as currently constructed, the Boomers will eventually be hoist by their own petard. If Boomers fail to help adjust these programs now, their children and grandchildren will have less reason to remember “Grammie” fondly.
The fixes for these entitlement programs require political will, an attribute currently in short supply in Washington and State Houses around the country. Boomers must provide the backbone and leadership on these issues because the politicians have proven themselves unable to lead, time after inglorious time. We must insist that lawmakers grab the “third rail” and make sure that the entitlement train is headed in the right direction, not just in our direction. The fiscal viability of America depends on it.
3. Expose and Eliminate the Hidden Costs of Growing Old
Fraud. Unless you have had first-hand experience or have made it your business to explore the ways in which the unscrupulous relieve the elderly of their money, you probably have but a cursory idea of the problem. The scamming of the elderly has become--thanks to sophisticated data base mining, improvements in telephone technology and the Internet--an international industry. The perpetrators are often beyond the reach of local law enforcement, highly mobile and relentless. Deborah Chase meant well, “Dr. Someone” did not.
Even more frequently than strangers, known caregivers financially abuse the elderly. These caregivers are often relatives but also include hired help such as aides or professional advisers. These financial losses often go undetected and/or unreported. It is a difficult problem because of privacy and autonomy issues. This hidden cost will significantly balloon with the aging of the Baby Boom, a generation that has more assets than any before it.
America needs to put a much higher priority on catching and meting out deterring punishment to those who take financial advantage of the vulnerable elderly.
Medication Mismanagement. Another cause of unnecessary spending can be found in the medicine cabinets of the elderly: rows of medications, some current, many out of date and most of them potent. Without a reliable means of assessing the possible interactions or a foolproof way to manage their proper use, the aged too often end up in the emergency room because of over dose, under dose or drug interaction.
Beyond the problem of medication mismanagement, medication overload becomes problematic as the elderly expand their coterie of medical specialists, many of whom have neither the time nor inclination to conduct a thorough inventory of their patient’s medication regimen. In addition, few of these medical providers have even basic training in geriatrics. Boomers should take the lead in demanding that the health care industry find a workable solution to medication management, a problem that silently leeches away billions in private and public funds every year.
Corporate Inefficiency and Family Costs. According to a 2006 MetLife study, the annual inefficiency cost to American businesses for the “under the radar” elder care responsibilities shouldered by employees was $33 billion. These corporate costs come from (a) unexpected turnover, (b) absenteeism, (c) workday interruptions and (d) diverted attention on the job because of the employee’s need to provide care for an elderly relative. It’s conservative to estimate that this inefficiency cost now exceeds $40 billion every year.
These figures do not include the out-of-pocket expenses incurred by employees, which, especially for the long distance caregiver, can easily be thousands of dollars per year. Deborah Chase’s children spent thousands for travel alone. Layered on to these dollar costs are the emotional and physical tolls that elder care can extract from family caregivers, most of whom have jobs and many with children still at home. American business leaders and government policy makers need to bring elder care out of the shadows, relieve it of its stigma in the workplace and help caregivers find affordable solutions. Not only is it the right thing to do, it is the economically sensible thing to do.
Observoid of the Day: 43.7% of all statistics are made up on the spot.
Monday, February 22, 2010
With this post begins Chapter 2 of Baby Boom Delusions and Solutions. This chapter focuses on five demands that the Baby Boom must make on our policy and law-makers. If these demands are not realized, the negative experiences visited upon Deborah Anne Chase and her family--as recounted in Chapter 1--will be visited upon millions of Boomers and their families.
A GREATER GENERATION?
Tom Brokaw’s 1998 book, The Greatest Generation, tributes his parent’s cohort, the one that mobilized, fought and helped the Allies win the Second World War. Millions of relevant examples can be recounted that illustrate the effort and sacrifice of the American generation born between 1910 and 1924. They rose to the challenge of a world threatened by the ideologies of fascism and militarism. Many did it enthusiastically. Others grumbled and groused but did it anyway. The overarching reality was a national effort and sacrifice in blood, money and deprivation. The Greatest Generation’s contribution from 1941 to 1945 was primarily as the military muscle. When blood was spilled, it was mostly theirs. They didn’t choose to play this role but they did it when history brought it to them.
Here are a few examples of that effort. Deborah Chase’s father piloted an Army Air Corps C-47 Skytrain and ferried airborne troops to North Africa, Sicily, Italy and France. He was wounded by flak fire on D-Day just after he had dropped paratroopers behind German lines. Deb’s grandparents, her mother and the others on the American home front endured shortages of critical raw materials, lived with rationed gasoline and foodstuffs, tended “victory gardens”, gathered scrap metal and bought War Bonds. It was a brief time of effort and sacrifice for the common good. Brokaw has a case.
When the war was over, the Greatest Generation then produced Deborah’s generation, the Baby Boom. Using Brokaw’s yardstick to compare the Baby Boom to the Greatest Generation, how do we Boomers measure up?
In terms of sheer numbers there is no doubt that the Baby Boom can claim the title of America’s biggest generation. Those of us born between January 1, 1946 and December 31, 1963 make up the largest generational cohort in American history: 77,000,000. Raised and educated in a prosperous post war society, the Baby Boom is the bull in America’s demographic China shop. Being big, however, doesn’t mean being respected and it certainly doesn’t mean general popularity.
Even a cursory review of things written and said about the Baby Boom will often include such descriptions as: “selfish, self-absorbed, entitlement mentality, navel gazing, irresponsible, immature, self-important, smug, frivolous….”, you get the drift and may agree. As a Baby Boomer, I squirm a bit considering that these descriptors could be more right than wrong. But are we as bad as our general reputation?
Very few voices have risen to defend us. One of those voices is sociologist Leonard Steinhorn whose 2006 book The Greater Generation, In Defense of the Baby Boom Legacy, suggests that the Baby Boom is generally getting an unfair evaluation. Steinhorn says that Boomers “created, reinvented, invigorated or sustained the great citizen movements that have advanced American values and freedoms” since the mid 20th century. Among these movements he includes environmentalism, consumerism, women’s rights, civil rights, gay and lesbian rights and openness in government. Well, maybe.
To be sure, Boomers took up many of these causes and provided the ground troops and some ballot muscle to change America for the better. However, in virtually all cases, the visionaries who first stepped out of line to challenge society on these seminal issues were from the generations that preceded the Baby Boom; Martin Luther King, Jr. (civil rights), Gloria Steinem and Betty Friedan (womens’ rights), Aldo Leopold, Rachel Carson, Bob Hunter (environmental awareness), Franklin Kameny and Barbara Gittings (gay rights) were all born before 1946. To claim that that the Boomers created these movements just doesn’t match the calendar.
The Baby Boom’s contribution to these social sea changes has more to do with lucky timing than with pioneering vision. The social movements of the 60’s and 70’s occurred when Boomers were very young adults, teens or adolescents, the perfect rebellious age for latching onto causes that parents and society were resisting. Unlike China’s Cultural Revolution, which harnessed the same age-related energy for destructive social upheaval, America’s turbulent 60’s and 70’s were fueled by the participation of Baby Boomers for the common good. But the leaders and visionaries behind these movements came from the ranks of the Boomers’ parents or older brothers and sisters.
Steinhorn also asserts that Boomers had an important influence on remaking the American workplace as soon as they began to enter the job market. “In the seventies,” he says, “at the precise moment that a critical mass of Boomers was entering the workforce, it became painfully clear to them that the economy was collapsing under the weight of shortsighted management decisions that protected the status quo at the expense of investments needed to keep our economy a step ahead. As Boomers saw it, the dinosaur organizations their parents embraced stifled not only creativity but fulfillment on the job.” (Italics, mine)
I was one of those early Boomers entering the workforce in 1972 and I can assure you that I was not thinking about any of those things and I doubt that very many of my contemporaries were either. We barely knew what an organizational chart was. We were just happy to have jobs. Granted, as our careers and business savvy matured and as younger Boomers entered the workplace behind us, we changed the American workplace, but then each new generation does, whatever its sensibilities. I don’t think that this makes the Baby Boom special, except for the sheer number of plum jobs that we now occupy. Deborah Chase attained one of those good jobs.
While Baby Boomers might want to take credit for most of the cultural good that has emerged in America since the 60’s, I think it's a stretch for Steinhorn to label it the “Greater Generation” in pointed comparison to the Greatest Generation. To quote Brokaw’s book, “In the World War II generation, ordinary people found common cause, made extraordinary sacrifices and never whined or whimpered.” To date, we Baby Boomers may have found several good common causes to rally around but the quantity of self-sacrifice has been measurably less than experienced by the Greatest Generation and we have not developed a comparable reputation for stoic acceptance of whatever burdens we have assumed. We tend to be a bit whiny.
Whether you agree or disagree that the Baby Boom has earned the appellation of “greater generation” based on its vision and sacrifice for the common good, I believe that there is one final chance for the cohort to truly earn (or burnish) such a reputation. This chance comes with the aging, decline and eventual death of the Baby Boom itself. It is an eventuality that is only now dawning on Boomers; a process and finality that most Boomers would rather not ponder. Many boomers are under the delusion that they will be spared.
The Baby Boom has prospered and the great majority of us will live long. History, therefore, has presented our generation with a monumental challenge based on our newly experienced longevity. Living long has some down sides.
America’s current social service policies, entitlement programs, health care systems, end-of-life care standards and support structures are ill-prepared for the onslaught of Boomers as they age beyond good health and independence. These shortcomings are plaguing the very old in America today, but the dependent elderly are, as they have been for many decades, not a powerful voice for change. Even now, millions of Baby Boomers are observing the challenges discussed in this book because they are grappling with the frustrations of care for their own parents. It’s amazing that this experience hasn’t already created a loud and long outcry for change.
If the Baby Boom wants better and more effective policies dealing with their own care, decline and death than are currently in place, the changes must begin now, not in 22 years when the oldest Boomers will be 85. Boomers should want to tackle these challenges for three reasons: (1) for their own good, (2) to save their children and grandchildren from a support system that, if not broken, is certainly dysfunctional, and (3) to allow America to regain budget sanity.
These systemic changes will impact how Americans are cared for as they decline and die for generations to come, not just the Baby Boom. And, some of the needed changes will ask for real but reasonable sacrifice from many Baby Boomers, lest the burden fall on their children and grandchildren. So, the changes are for the common good, many of them will require measurable self-sacrifice from Boomers and they need to be done with stoic awareness that they are necessary. Given these elements, it can be argued that if the Boomers take up the challenge and succeed, then the claim to be a great generation has traction.
Observoid of the Day: Anywhere is within walking distance if you have the time.
Wednesday, February 17, 2010
Final Installment of Chapter 1, "A Baby Boomer's Life and Death". See previous posts for Parts 1 and 2.
One morning the other bed in Deborah’s room was empty and neatly made. She haltingly asked an aide where the other woman was; the aide said that Deborah “needn’t worry about it” and quickly left the room. Death was not spoken of in this place, although it occurred regularly. Two days later, another woman moved into the room with Deborah. The new roommate was ambulatory, talked incessantly about the same topics over and over and pawed through Deborah’s chest of drawers when she thought that no one was looking. She took clothing and small items. The aides recovered most of Deb’s stuff but it was a constant activity. Deb had never suffered fools gladly but here, she was forced to endure them; and, to endure this place along with them. They were all inmates.
Because Deb’s step-daughter made regular and unannounced visits, Deb was kept relatively clean and dry. When the daughter considered her mother’s care unacceptable, she made a fuss. The aides soon learned that Deb’s daughter could be a problem if they didn’t attend to her mother’s needs. Since there were too few aides for this 120 bed facility, taking good care of residents-- especially those who had regular visitors--meant that those residents with no one routinely stopping in for visits received less care. Often, when being wheeled past particular rooms along the long linoleum corridor, Deborah could smell the residents who were left to marinate in their own filth until the aides could find time to clean them up, sometimes hours later; too much work, too few workers.
In mid-September of 2035, Deborah developed an infection in an ankle wound suffered when an aide accidentally banged into her with the footrest of a wheelchair. The infection spread up her leg and proved resistant to the regime of antibiotics. After years of taking antibiotics for various infections, Deborah’s bacteria were well armed to resist eradication. The infection turned ugly and her leg gangrenous. Deborah was sent to the ICU at a large Atlanta teaching hospital. Her leg was amputated at the knee. The surgery site contracted another and different infection, a bug from within the hospital. The new infection spread to her lungs and they quickly declined in function. The medical team, none of whom her family had known prior to this hospitalization, recommended that Deborah be placed on a ventilator to “ease her breathing”. What they did not tell the family was that it was very unlikely that Deborah would ever breathe on her own again, ever.
Deborah’s kidneys began to fail. A young resident arranged for her to be gurneyed to the dialysis three times a week. Her daughter agreed.
The amputation site was painful and Deborah often teared silently and furrowed her brow when the doctors or nurses asked her how she was feeling. Pain medication was administered but never enough to do the job.
The wounded stump required another surgery to clean up additional gangrene. Deborah’s eyes were now sunken hollows, seeing little but still registering pain and misery. Her med-student grandson argued with one of the residents about failing to provide sufficient pain medication. The resident insisted that to give Deborah more drugs would make her dependent on the morphine; he said that she would become addicted. The grandson also argued with his own mother about her decision to allow Deborah to have dialysis. His argument was based on the medically obvious; Deborah was dying; doing anything to prolong that process was simply extending her suffering.
The daughter called Deborah’s doctor for his advice. He deferred to the hospital’s medical staff. It was clear, he felt that his role as a healer was over because Deb couldn’t be healed. Cure trumped care.
Deborah had never filled out an advance medical directive, although such forms were readily available. She had not discussed her end-of-life wishes with anyone, including her doctor. She had given her daughter a medical power of attorney but she never talked with her daughter about her wishes for care when her condition became terminal. Perhaps Deborah wanted every treatment available regardless of the expense, discomfort or likely outcome. Or, perhaps, she wanted the dying process to be comfortable, without intrusive and futile medical interventions. Her family was left to guess, because Deborah was no longer able to communicate.
As it was, Deborah experienced the first kind of dying; lingering, painful, undignified, fearful and lonely, in spite of the best intentions of the medical staff and family.
Dozens of friends, former employees, business associates and family members attended her memorial service. She was fondly remembered by these people. Most, except for the immediate family, were unaware of the details of Deborah’s life during those final few years.
No one from the hospital team attended nor did her family receive notes from any who had served her in the medical or care community.
Deborah’s rich and meaningful life spiraled into ignominy during her final four years. When she lost independence, she was swept into an elder care, health care and dependent living systems that were fragmented and awash in state and federal policies that frustrated proper and affordable care for the dependent elderly. In general, it was a dysfunctional, multi-layered system, ill-prepared for the tsunami of dependent elderly still known in 2035, ironically, as the Baby Boom.
Health care professionals, politicians, federal and state bureaucrats plus the voting public had seen the elderly tidal wave coming years before but, for various and not always altruistic reasons, had chosen to avoid big fixes. Instead, there was patching here and there hoping that it would somehow all work out. It didn’t. It was a delusion to think that it would work itself out.
The biggest delusion was that of the Baby Boom. They allowed themselves to believe that they would never grow old and dependent.
By 2064 there were but a mere handful of centenarian Baby Boomers left. The majority of the cohort had already experienced much the same kind of physical decline, sub-optimal care and poor dying process that Deborah had experienced. Their education, money and reputation didn’t alter the nature of the outcome. The Baby Boom failed to take control of its own inevitable future back when it still had political and financial clout. The generation’s lack of political will and action sealed its fate. It should have been different. It could have been different.
Coming next: Chapter 2 "A Greater Generation?"
Observoid of the Day: Growing old is an accumulation of small indignities.
Monday, February 15, 2010
See previous posts for background.
Deb’s daughter and stepdaughter arranged for a series of private duty in-home helpers. The first woman was good for the first few months and then began to skip days, show up late or leave early; but, she was always sweet to “Miz Chase” and Deborah liked her. The woman asked Deborah for a loan of $10,000, claiming that her husband “needed emergency surgery”. Deborah wrote her a check. The woman cashed the check but never returned.
The second woman lasted one week. The third, referred by an employment agency, turned out to be in the country illegally, had a drug habit--which she partially funded by fencing Deborah’s jewelry--and left the country before she could be arrested. Frustrated, the family hired bonded help through an in- home companion service agency. As Deborah’s confusion mounted and her memory slipped, the tag-team of companions had to be with her nearly 24/7 and the monthly bill exceeded $15,000. Because Deborah’s care needs were not directly related to medical treatment, Medicare paid not a penny. While well-to-do by most standards, Deborah’s nest egg could not stand a nearly $200,000 per year tab for trustworthy in-home assistance.
Her children might have pooled resources to keep her at home but they were already paying over 22% of their incomes to fund Social Security, Medicare and Medicaid. Their generation was financially struggling to fulfill the government’s entitlement program promises now that the entire living Baby Boom was over 65. It was rumored that FICA would increase another 2% in 2030.
After much rancorous family discussion, Deborah moved to an Atlanta assisted living facility. She left behind her spacious home with its beloved art collection, her craft studio, beautiful kitchen and peaceful screened deck. She gave her cat to her granddaughter because pets were not allowed at Heritage Gardens. She moved into her new small apartment an unhappy camper.
She hated the community dining room with its cliques of “ins” and “outs”, social butterflies and overly attentive gentlemen. She despised the cafeteria-style food. She wanted nothing to do with the group outings to local attractions, all of which she had seen before and several for which she had served on the boards or fund-raising committees. She only admitted it to herself, but the thought of returning to those local attractions as just another senior citizen shuffling off of the van was humiliating.
She made one or two friends, was attended to by the facility’s health and daily care staff and life for her scattered family returned to nearly normal. It wasn’t normal for Deborah and she developed clinical depression, a condition that went undiagnosed for over a year. Her doctor had no training in geriatrics. He mistook her symptoms as the natural state of the elderly. The woman that her children, grandchildren and friends visited and phoned during this time was a heart- breaking shadow of the vibrant woman Deb had been for nearly eight decades.
In March of 2030, Deborah’s daughter, by then living in Santa Fe, received a call from Deborah’s tax attorney. The attorney, a long-time friend was in the process of preparing Deborah’s 2029 return and had come across some banking transactions that were problematic and of no small consequence, nearly $80,000. She suggested that the daughter come to Atlanta right away.
Within the week it came to light that Deborah had been contacted via untraceable wireless phone by “Dr. Someone” (she just couldn’t remember his name) in Nigeria. He claimed to have gotten her name from the director of Deborah’s favorite charity, one that indeed did good work in Nigeria. The ”Dr.” indicated that there was a very large pool of money—Deborah thought it was $4 or $5 million, or maybe he said $45 million--available there, left over from an unfulfilled Nigerian government contract. If Deborah would just help free up this money he promised to give one quarter of the millions to the favorite charity.
Over the course of the next four months, Deborah wired $5,000, then $12,000, followed by $8,000, $35,000 and finally, $19,000. Each transfer was preceded by a call from the friendly “Dr. Someone” who assured Deborah that these additional payments were needed to take care of unforeseen bribes, a bureaucratic snafu or tax payment and that soon the charity would have its grand gift, thanks to her. He also assured her that she would soon get all of her money back with interest. Deb told her trust officer that these large checks were cash gifts for her grandchildren and children. Deborah had once been one of the most respected financial executives in Atlanta.
The money was never recovered; Deborah continued to insist that “Dr. Someone” was “such a nice man” and would never cheat her and she was livid when her daughter had Deborah’s phone number changed. For security reasons, the tax attorney was added to her checking account and did a daily on-line review of transactions. This trusted professional charged a pro-rated $250 hourly fee for this service. None of the government entitlement programs paid for this type of oversight or could provide someone who could do it cheaper.
The brain aneurysm did its damage late in 2030, just before the holidays. By this time, only one of her children remained in Atlanta. After the initial hospitalization, Deborah’s daughter and stepdaughter searched for a skilled nursing facility (nursing home). Deborah was now almost totally dependent. She could no longer communicate clearly, dress herself, go to the toilet on her own or transfer from wheelchair to bed. She was once a woman who ran 10Ks in support of local charities.
After a sobering tour of several facilities, the daughters selected the one that didn’t smell of disinfectant and urine. This “home” had the fewest residents aimlessly parked in front of common area TVs. The institution was pleasant looking from the street with well-maintained grounds and walking paths. Inside there were live plants in the sun rooms and common areas and the semi-private rooms had floor to ceiling windows that looked out onto small patios and gardens. Deborah’s roommate was bedridden and talked to unseen visitors while awake and even during her dreams. She had no idea who Deborah was day-to-day.
A nurse’s aide awakened Deborah each morning at 6:30. With nearly 100% of the nursing home’s aide staff turning over every year, the person who woke Deborah was often a new face with a new accent. Some aides were more patient with Deb’s physical deficits than others. All of them called her “Debbie” or “Darlin’” or “Honey” or “Suga”. None of them called her Ms. Chase and they spoke to her as if talking to a child. When they were angry, like when she soiled herself after they had just changed her into something clean, they spoke harshly. On these occasions, Deborah was frightened and cried. Some of the aides called her a “big baby”. During her career, Deborah had a reputation for speaking truth to power, it was one of the attributes that made her successful, but none of the aides knew of her personal history and they had all the power now.
In her one-piece shift with Velcro fasteners and her skid-grip socks, Deborah was wheeled to the dining room every morning at 7:00 a.m. She sat beside another woman in a wheelchair and both were fed oatmeal, always oatmeal, by one aide who spooned first to one and then the other. There were not enough aides to feed the residents who needed eating assistance one-on-one. Deborah hated the oatmeal. It was tasteless, always nearly cold and nothing like the delicious oatmeal that she used to make with a touch of brown sugar, wheat germ, fresh berries and a splash of half and half.
The aide who fed them talked to the aide at the next table and Deborah ate very little. Most of the gruel slid out the side of her mouth that drooped. Nevertheless, the aide was instructed to feed [them] “all of the oatmeal” and so the feeding charade continued until the bowl was empty. Much of the food slipped down the neck of Deborah’s shapeless dress. She had once been a superb cook and she still knew what good food was. What was shoveled at her three times a day in this fluorescent-lit, loud and confusing place was certainly not it.
On Tuesdays, Fridays and Sundays, Deb was wheeled to the shower room where someone would remove her skid grip socks, help her stand, strip off her dress and underwear and ease her onto a wet plastic bench where she steadied herself as the aide shampooed her snow white hair and washed her down. There was no dignity in this routine but it was efficient. Once, many years ago, Deb had redone her master bath with a large walk-in shower. She could still recall the pleasure of the slate tiles under her feet and the hot water coursing from two shower heads. In those years, showering efficiency was not a goal.
To be continued.
Observoid of the day: A nursing home bears little resemblance to your home.