Wednesday, July 19, 2017

Throw Mama from the Train: Why Medicaid Cuts Will Destroy Long-Term Care

One of the good things about the otherwise distressing health care drama in Congress is that people are becoming aware of the fact Medicaid is important to everyone.  As Ron Lieber wrote in the New York Times, the Medicaid debate is important to everyone who plans to grow old.  That’s because Medicaid pays for much of the nursing home care in this country.  That’s right—Medicaid, not Medicare, which pays very little toward nursing home care. 

According to a Kaiser Foundation study, 1 in 3 people will spend some time in a nursing home.  That could be you or me.  Since the United States alone among economically advanced countries has no national long-term care insurance program, you will have to pay for care, which can run $100,000 a year or more.  If you run out of money or can’t pay when you are admitted, that’s where Medicaid comes in.  Currently, 62 percent of nursing home residents are on Medicaid.  Medicaid also pays for home and community-based services that are increasingly being used to help people stay at home longer.

The proposed cuts in the hopefully defunct House and Senate bills to replace the Affordable Care Act would have taken a huge chunk of federal dollars from Medicaid.  The federal government pays 62 percent of Medicaid, and states pay the rest.  Currently, the amount paid by states represents 19.5 percent of state budgets nationally, although the percentage varies by state.  Can you imagine your state increasing substantially the amount that it pays for Medicaid?  Our state legislature can’t pass a spending bill to fund the budget they already passed for the fiscal year beginning July 1.   It’s more likely that states would go along with most of the cuts and reduce spending on all of the Medicaid programs.  Inevitably, that would mean fewer nursing home beds and less funding for home and community-based programs that keep people out of nursing homes. 

Along with Medicare, Medicaid was part of President Johnson’s Great Society Program.  It was designed to provide health care for poor people, but has become the de facto method for paying for nursing home care.  This stretches the already limited resources allocated to Medicaid.  It has also allowed politicians to ignore the fact that many people become infirm and need assistance near the end of life.  The need for long-term care is one of the costs of a longer life expectancy and we need to find a better way to pay for it.

What would that involve?  Many countries use portions of general tax revenue to pay for long-term care.  In Japan and South Korea, a tax comes into effect when people are 40 to pay for long-term care.  That is a clever approach, because by 40 it begins to dawn on many of us that we will need to care for parents and may need care ourselves. 

Of course, given the deadlock in Congress, it is hard to imagine new taxes to cover long-term care, when they can’t even agree on health care.  The problem is not that a long-term care program would lead to higher taxes, but that many Republican politicians are fundamentally opposed to government programs and would be glad to get rid of Medicaid, Medicare and Social Security.  

So even if you are experiencing Trump-fatigue from responding with letters and emails and hopefully some actions to defend against each new outrage, keep your eyes on health care reform and what could happen to Medicaid and Medicare. You may be part of the 1 in 3 who spend time in a nursing home, and even if that’s not the case, it’s still the right thing to do.

The photograph was taken in Stockholm.  The shop combines two favorite things of our Swedish friends—coffee and a good bargain.  Swedes also enjoy some of the best long-term care in the world.  You can read about how the Sweden does long-term care in our series of blogs from May, 2016.   Brew a cup of strong coffee, sit back and read what a country can do with the determination to get supports for older people right.

Also, look at the excellent columns by Ron Lieber about Medicaid in the New York Times:

Thursday, June 8, 2017

Lessons from Sweden

Sunset over Lake Vättern near
Jönköping, Sweden

As you probably know, I have spent considerable time in Sweden over the years, working with colleagues at the Institute for Gerontology at Jönköping University.  There is much to be learned from Sweden about how to provide care for older people and I wrote about some of those issues in detail in May, 2016.  But I recently came across something else of note involving Sweden.

In last Sunday’s New York Times, columnist Nicholas Kristof wrote about inequality in society.  His column had the provocative title, “What Monkeys Can Teach Us About Fairness.”  The part of the column about monkeys and fairness was quite interesting, but I want to focus on another point. 

Kristof described a study in which people in the US were shown two pie charts that displayed the income distribution of residents of two unnamed countries, one with relatively equal distributions and the other with more pronounced differences between rich and poor.  When asked which country they would rather live in, 92 percent of Americans said they would prefer to live in the country with the more equal distribution of income.  That country was Sweden.  The country with the large gap between rich and poor?  The US.

Inequalities are problematic for many reasons.  Some observers say that the growing gap between rich and poor contributes to the harsh tone of our political discourse and to the sense of alienation of many voters. 

Inequality may also affect aging.  I have been reading papers recently by Jay Olshansky, who is a professor of public health at the University of Illinois—Chicago.  He documents that while life expectancy in the US has continued to rise, the increases are greatest among more highly educated people, who also tend to be the most economically advantaged.  The gap in life expectancy between whites and African Americans has grown.  Among white Americans with the lowest education, life expectancy has actually been decreasing.  One reason for this growing gap is that people with low income and education tend to have poorer health habits and inadequate access to health care.  They also have higher levels of chronic stress.  Chronic stress leads to increased risk of illness, but as Olshansky points out, it may actually speed up the aging process.   He cites growing evidence that markers of aging such as telomeres are affected by stress, which may contribute to the increasing gap in life expectancy.

Maybe it’s no wonder that Swedes live longer than we do.

Here is a link to the Kristof column:

And references to Olshansky’s work:

Olshansky, S. J. (2015). Has the rate of human aging already been modified?  Cold Spring Harbor Perspectives in Medicine, 5, a025965

Olshansky et al., (2011) Differences In Life Expectancy Due To Race And Educational Differences Are Widening, And Many May Not Catch Up, Health Affairs, 31, 1803-1813. doi: 10.1377/hlthaff.2011.0746

Sunday, May 28, 2017

A Farewell

A little over a month ago, Steve and I were driving up to Amherst to visit with family, and about five hours into the trip, we got a phone call from a very polite police officer who told us that my mother had pushed her Medical Alert button, and that they were at our house, but there was no answer at the door.  We gave him the code to the garage door, and he and the EMTs went in and found her on the floor in her apartment.  She had fallen and could not get up (just like in the commercials).  So they took her to the Emergency Room.  In the mean time, I was able to contact our wonderful Geriatric Care Manager, Deb Soltis, who met her at the ER, and stayed with her until we could get there.  She also texted me and let me know that the X-rays showed left hip and left elbow fractures.  

When we got there, the Emergency Room doctor had already asked her about surgery and she had refused, and I confirmed that she did not want surgery.  The truth is that for the previous six months she had been on a steady downward trajectory due to increasing sciatic pain.  She had tried medication and physical therapy, but had gotten no relief.  She was more and more dependent on a walker, and in the month prior to her fall, she was really only comfortable in bed or in her recliner.  For an active, social person, this was not the life she wanted.  She also had stated on many occasions that she did not want surgery, specifically for a broken hip, because of her experience with her own mother.  

So our goal was very clear:  to get as much pain relief as possible so she could be comfortable.  Because of the two fractures, our original plan, which is that she would return home with home health care, was no longer took two and sometimes three people to move her.  Luckily, Deb found out that two of our local Continuing Care Retirement Communities had available beds in their nursing home units, and since I knew that both provided excellent care, we chose one of them.  She spent four days in the hospital, and during the first two it seemed that she might rally.  She talked about having her card-playing friends in for games, and she knew people at the Community she was going to.  However, as the reality sank in that she would never walk again and that she would be totally dependent on others for personal care, she began to withdraw into herself.  We also suspect that she may have had a stroke around this time.  She had a history of small strokes, and this time her speech was slurred and she was very disoriented.  At this point she stopped wanting to talk to anyone who called, and she was very clear that she did not want visitors.  She directed me to tell them that she did not want them to see her the way she was now, and that she wanted everyone to remember her the way she was the last time they saw her.  

She was transferred to the nursing home, where we tried therapies, but in the end they were discontinued because she really did not want to do anything except lie in bed.  Over the next ten days she gradually slipped away, finally succumbing to pneumonia.  

While this has been a very difficult time, I feel good about the planning we had done, as well as about my ability to grant her wishes.  In her last months, as her pain and disability increased, she talked more and more about being ready to die.  When the fall happened (which may well have been the result of a small stroke), she knew and I knew that this might well precipitate the end for her.  I won't pretend that made it easier to watch, but it made it much easier for me to be certain that I was carrying out her wishes.  In the end, she had about six months of declining mobility, and two weeks of letting go of life.  She was 91 years old, and she had a long, full life.  Now I'm glad she's at peace.

Tuesday, April 18, 2017

Play It Again!

 A classic Renault belonging to our friend Gerdt Sundstrom.  
The translation of the bumper sticker is "Old but vital."

My college friend, Anne Lefkovitz, recently sent me a copy of We’ll Always Have Casablanca, Noah Isenberg’s book about the making of the movie Casablanca and its enduring popularity.  When we were students at the University Michigan in the mid-1960s, we regularly went to the makeshift theater in the Architecture building where we were introduced to classic films.  Movies with Humphrey Bogart were a particular favorite, perhaps because as Isenberg writes Bogie captured what we were feeling—suspicious of authority but ultimately idealistic and wanting to take a stand.

It is pleasant to indulge in nostalgia as we grow older, but nostalgia can be a trap that leaves us looking backward.  We’ll Always Have Casablanca evokes nostalgia, but also something relevant and important for today. Most people remember Casablanca just as a love story.  It is also about refugees seeking to escape the terrible events sweeping Europe at that time. As Isenberg points out, European refugees had a major part in making the film.  The director of Casablanca, Michael Curtiz and almost all of the 75 actors in the film had fled the Nazis in Europe, including 11 of the 14 actors who received a screen credit.  Just like the characters in the movie, many of the actors in the film escaped just ahead of roundups that would have landed them in concentration camps, and some even had experiences of waiting for papers to be able to travel on to the United States.

The door was open for these refugees.  Their presence in the US did not generate hysterical fears that we might be letting in saboteurs or terrorists, though after the war there were demagogues braying about communists in our midst.  And while some refugees were let in, too many others were turned away.  The refusal by the Roosevelt administration to admit more Jews trying to flee Europe was a terrible act, as was the internment of Japanese Americans. 

The recent use of chemical weapons in Syria brought home to many Americans the horrific conditions in the Middle East that have led to the current refugee crisis.  Rather than opening the door to more refugees, we bombed an airfield instead.  Sweden, a country of 10 million people, took in 270,000 refugees in the past 3 years, but we have frozen immigration from countries where people face the gravest danger.  Our current government’s xenophobia represents one of the foulest strains in American culture.

So watch Casablanca, not for the nostalgia or for the romance that, as Bogie says, doesn’t matter a hill of beans.  Rather, watch Casablanca because it reminds us of our best qualities, the willingness to stand up for what is right and the generosity to take in refugees and make them part of our country. 

Here’s lookin’ at you, kid.

Monday, March 27, 2017

The Best Advice about Aging Is to Live Well

An article today in the New York Times proclaimed that the recommendation that everyone walk 10,000 steps a day is no longer sufficient.  Instead, we now should walk 15,000 steps a day. 

Why the change?  It is based on a new study of 111 postal workers in Scotland.    It turned out those workers who walked the longest routes, over 3 miles a day, had the best metabolic and body mass scores, compared to workers who walked shorter routes or those who had desk jobs.

The flaw, like many studies of this kind, is that the health differences among workers may be influenced by factors that led to selection into jobs that involved different amounts of exercise in the first place.  It’s possible that the people who were not in good shape and didn’t like to exercise in the first place took desk jobs or moved to desk jobs because of health issues, while the most hardy postal workers opted for the longest groups.  In fairness to the author of the story, Gretchen Reynolds, she did mention the possibility that selection into these different roles influenced the findings

There is no question that exercise is good for us, but claims that certain types or amounts of exercise are better usually are based on small samples or weak inferences from the data, as in the Scottish study.  Likewise, the claims that one type of diet or any other magic bullet will prevent aging and disease are overstated.  As we saw last year with butter, recommendations that something was bad for us can change.  Likewise, we can find that recommendations of a health-promoting food, supplement or type of exercise ultimately prove to be wrong.

For a long time, one of the most prominent theories of aging was that molecules called “free radicals,” which were by-products of metabolism, caused damage to body tissues and could lead to disease and frailty.  We were advised to take supplements or eat foods high in anti-oxidants, “superfoods” like blueberries, goji berries or dark chocolate to help bind with free radicals and prevent them from doing any damage. 

Now it turns out evidence from animal studies suggest that certain free radicals are associated with longer life, and that lowering levels under some circumstances might be a bad thing to do.

So what should you do?

First, continue to eat dark chocolate.  Whatever it may or may not do at a physiological level, it tastes good and makes us happy.

Seriously, the answer is to ignore all the crazy advice.  Aging is determined by multiple factors and no one thing is going to prolong life or prevent Alzheimer’s or any other disease. 

The best strategies for living to a good old age involve moderation.

·      Regular, daily exercise is good.  Doing too little or too much is bad.  Our joints, feet and back are vulnerable and can wear out with high impact and high intensity exercises.  What’s the right amount?  Work up to a reasonable amount but don’t do anything that causes pain or discomfort.

·      Controlling weight is good.  Too much or too little is bad, although the latter does not get enough attention.  One of the best ways to control the amount you eat is to eat food that tastes good.  It’s satisfying and you don’t then eat too much or feel like snacking.  A desert made with real butter and dark chocolate, for example, will taste great and be satisfying in a small amount.
·      Cognitive stimulation is also a good thing.  You don’t have to buy the computer programs that train cognitive skills.  Just challenge yourself to do new things.  Don’t fall into a rut.  As our long-time friend Margy Gatz said, “Be an interested person.”

·      Do things you enjoy.  You can do more of the things you like if you are not preoccupied about whether you are eating the right foods or getting the right kinds of exercise or stimulating your brain in some optimal manner. 

·      And don’t pay too much attention to politics.  It’s OK to do things, like call or write your Congressman or Senator, but don’t dwell on the craziness.

These steps do not guarantee a long life free from disease.  Nothing does.  But these approaches put us on the right track.  And they allow us to enjoy each day.


“Should 15,000 Steps a Day Be Our New Exercise Target?”

"The Myth of Antioxidants" Scientific American