Tom Rider's Reviews

By the year 2030, seventy million Americans will be over sixty-five. And a growing portion of those older Americans will live into their late 80s and 90s. Susan Jacoby asks us to think about how we are going to finance the health care bill. And how can we help them lead the good life given the contingencies of the aging process? Jacoby laments that a good old age is presently the exception not the rule, and that will continue to be the case.

Our rendezvous with the Grim Reaper is not, of course, our choosing. We need to get over the idea that if we live a healthy life-style, we’ll have a good, long old age. It is true, Jacoby concedes, that we can improve our chances if we avoid overweight, quit smoking, and exercise regularly. But much of the pathologies that plague the aged –and particularly diabetes and dementia – are not to be avoided by our leading a life of virtue.

Jacoby is amused with the idea that the aging process can bestow on us such things as wisdom, common sense, other worldliness, and selflessness. Hopefully we shall carry these virtues with us into old age, but there is no evidence that we’ll be better at much of anything.

Jacoby also has her doubts about the social usefulness of research on longevity. Should we consider aging to be a disease that needs to be conquered as we do cancer and HIV? It would be a gold mine for the health-care industry, but a diversion of resources from other social purposes. On the other hand to decide collectively not go after old age is a form of (gasp) health care rationing.

Jacoby believes that there is a growing rift between old people and the younger generations concerning the particulars of our future health care system. She argues that part of the opposition to Obamacare was because people in their 60s and older believed that extending health coverage to younger Americans would jeopardize their health care. They are probably correct. Health care may become a given pie of resources, and the expansion of health care to younger folks may mean less for those on Medicare.

What about various kinds of repairs to the aging body like joint replacement surgery, organ transplants, cosmetic surgery? Should a man in his seventies with a history of heart disease be given a donor heart?

How will longer retirements be financed? We are admonished to save for our old age and depend less on Social Security and Medicare. But even those who have been able to stash away money in IRA and 401k accounts were shaken by what happened to those savings with the financial crisis in 2008. And in any case, Jacoby is not convinced that most Americans can save sufficient amounts to finance their old, old age.

This is particularly true of older women, Jacoby points out. Women live longer and so outlive their husbands on average by many years. The death of that husband has put a substantial dent in their joint savings. And for most Americans, there is no chance of a financial windfall after 65.

There is much talk about extending the work live beyond 65. For many of us that has been a choice that we have made voluntarily. But in many instances, extending retirement significantly will be resisted; many have worked for many years in jobs that, if continued, would be detrimental to their health. Or they are very tired of their job.

Jacoby believes that we must consider whether the present paradigm for health care for the dying is sustainable. Currently a large portion of an individual’s health care costs occur in the last year of life. Decisions about what you want done to you have to be made before you reach that year. Jacoby points out that only 30% of all Americans have living wills and most of them are probably obsolete, not keeping up with the medical technology.

One practice that would save Medicare a lot of money would be to make palliative care home based. Today 80% of all Americans die in the hospital, but 90% indicated that they would prefer to die at home surrounded by family. Medicare coverage should respect their wishes wile saving money.