In the film industry, when a new movie flops, the studio often responds with layoffs, in part to cover the stiff losses. Thus, in spring 2015, after 39 years with Columbia Pictures—by then Sony Pictures—I found myself with lots of free time at my disposal.

I decided to use that time in part to volunteer; I felt too work-oriented to abide being put out to pasture. While tutoring with the adult literacy program at my local branch library, a flyer for a neighborhood group called Westchester Playa Villages, later renamed Westside Pacific Villages (WPV), caught my eye. “Neighbor Helping Neighbor” and “Serving Your Community” and “Become a Friend”—the upbeat, dynamic, and thoroughly sociable tone intrigued me.

I learned that WPV matches aging neighbors (who pay a small fee) with local volunteers who help them in a number of different ways: making short visits, being a walking buddy, or driving to doctor’s appointments and the like. WPV is based in L.A.’s Westside but is part of a national “village movement” to help people age in place.

I knew the neighborhood well and enjoy in-city driving. Before long, I was signing into the Assisted Rides software that WPV uses in order to drive around my neighbors who no longer are able to drive themselves.

I am happy to offer myself as a responsible person and a comfort to someone who is nervous about their appointment and concerned about getting there promptly and safely. I’m usually available to stay with the person I’m driving during their visit and accompany them back to my car for the ride home.

These drives also can be ideal times for relaxing conversation. I’ve had many substantive discussions, discovered many common interests, and heard numerous extended stories of past travels and family histories.

I’ve even discovered that some neighbors have a connection with the early glory days of Hollywood. One, a soft-spoken grandmotherly sort, shared with me that she played a flower girl in the wedding scene in the movie Camille. She didn’t want to tell me how long ago that was, but since I knew that the film came out in 1936, I could easily do the math. Her other proud accomplishment: teaching English lessons to the actress Leslie Caron at the school for child actors on the MGM lot.

Another neighbor related to me her experience at the Japanese American internment camp at Heart Mountain, Wyoming in the 1940s. She had an incredible recall of the daily routines of camp life. One powerful recollection: getting a day pass to go into the local town to do shopping and seeing stores with “No Japs” signs in the windows.

Sometimes it’s challenging to make conversation, but for the most part I’ve found that my neighbors enjoy the opportunity to have a rich, unexpected, one-on-one discussion about a range of topics.

And I feel I’ve gained insight into how to listen to personal sharing, and how to share about myself in response to the openness neighbors show to me. Some folks are very expansive when talking about their family, and seem eager to share even casual details. Other members are more outward-oriented and want to discuss current events—in which case I prepare myself in advance with the latest breaking news and the political scene in general—which can be very challenging but does keep me on my toes.

There’s also the emotional state of the passenger to contend with. I often begin rides by reassuring a nervous neighbor by calmly saying, “I know where we’re going, the most direct route, and the best place to park. You’re in good hands with me.” But one day, I was driving someone for the first time, in a rush to see her doctor because she had run out of pain medication. She was in something of a nervous frenzy and stayed in an agitated state after she got into my car. I allowed her nervousness to make me nervous. In my haste, I scraped the side of my car against a water spigot jutting out from the back wall of her home. Nothing else went wrong that day—and my driving record (and car) have been pristine ever since.

These driving experiences also have afforded me opportunities for reflection and insight. I had always associated trips to doctor appointments, hospital check-ins, and lab testing with sick people or being sick myself. But after countless drives, these destinations have become normalized. They feel as natural as going to the library. Well, almost.

I’ve come to feel a oneness with the neighbors I have come to know, and a keener awareness of the aging process we all share. In living through so much time with them, I realize I’m going through the same stages. It’s the sensation of “We’re all in this together.” What an empowering realization, but it’s also a humbling one.

A final irony for this movie aficionado is that I no longer need to go to a darkened theater and gaze at a big screen in search of high drama. Whether it’s a World War II-era family story or anxiety about current events or good news from a doctor, I experience it all from a decidedly front row seat.

The post Where I Go<span class="colon">:</span> Your Doctor, My Car, Our Neighborhood appeared first on Zócalo Public Square.

Then you are dead wrong.

Because our very senior senator, more than any other political leader in the state, actually represents California’s future. And while those political insiders campaigning to force her retirement may be correct about her diminished capacities, they fail to recognize just how much she resembles who we Californians are, and what we are becoming.

California’s future, like Feinstein, looks old. Californians are increasingly the sort of people who are well past their prime but don’t know it. We forget other people and even ourselves. Once among America’s youngest and fastest-growing states, California is now losing population and aging faster than the rest of the country.

Both trends should make us cherish our senator, who is 88, even more, because she represents a rare and precious demographic success story: People over age 85 who, through their longevity, are preventing a California population collapse.

This rising Feinstein Generation is by far the fastest-growing and most rapidly diversifying age group in California; by one estimate, it will grow 489 percent from 2010 to 2060. State analyses suggest that the post-85 group will dominate the 2030s, as the first Baby Boomers enter what you might call the new prime of California life.

Younger people, by contrast, show nothing but ingratitude for this cohort’s largesse, choosing to leave California (85 percent of departures are among those 25 to 64), or failing to move to the state in the first place.

Instead of whining about DiFi and her ilk, why don’t young people and younger politicians devote themselves to building up the younger generations they claim to champion? They could get busy having more children and enticing others to procreate, thus reversing declines in the number of California kids and increases in closures of schools (some of which will probably be repurposed for senior living). Incentives to have children might well be combined with greater investments in public education to extend school days and school years, improve instruction, and raise standards.

Another strategy would be to push harder to reverse the restrictionist immigration policies of our last three presidents—Obama, Trump, and Biden—that have contributed to a decline in international migration to California. Still another pro-youth strategy would be to build more and cheaper housing, so more young people could afford to settle here.

It’s hard politically to expand new public investment in California, particularly when it benefits young people who represent a declining share of the population. But it would be easier if politicians pursued more money for schools or child care in combination with more care for the growing population of the elderly. Investing in seniors is popular, with support for the governor’s Master Plan for Aging, which has five big goals around improving care and housing for the oldest Californians, recorded at around 80 percent.

Feinstein could help the cause by being less defensive about her decline. Indeed, her staffers and supporters, instead of disputing press reports about her lapsing memory or diminished cognition, should embrace her faltering. They make her a better representative of her state.

The senator, on her good days, might talk more often, and in public, about the needs for forward-looking investments, even if she experiences senior moments in the process. She should present herself, and her good fortune in having plenty of money to pay for care-giving, as examples: Every Californian should have as many people to keep an eye on them as Feinstein does.

It’s tempting to want someone younger and more energetic for the job of being one of two senators for nearly 40 million people. I myself recently accused Feinstein of stubbornly holding on, in a certain San Francisco fashion. And it can be unsettling to see one’s elected representative seem confused in public.

But take a step back. Who isn’t confused by the strangeness and pressures of American life these days? And to her credit, Feinstein hasn’t created nearly as much confusion as her much younger friend, Gavin Newsom, has done with ever-shifting COVID restrictions and policy announcements.

It may be time—as her hometown paper, the San Francisco Chronicle, is now arguing—for Feinstein to step aside. But the reason for retirement would not be that she is failing to represent our state. To the contrary, in one very important respect, every day Feinstein remains in office, she provides Californians with an indispensable example.

When we look at our senator, we are looking in a mirror.

The post Dianne Feinstein Is California’s Future appeared first on Zócalo Public Square.

The extraordinary circumstances of pandemic life had altered my role in the units, too. In normal times, my work as a geropsychologist—a mental health provider who specializes in treating older adult patients—involves conducting therapy sessions to help patients manage depression, anxiety, changes in health and ability status, and other medical and mental health conditions. Usually, I help patients, family members, and staff better tailor care of the residents in our skilled nursing environment, and make safe plans for discharge.

But as our long-term residents missed out on visits from loved ones, and had fewer social outlets and activities to enjoy, part of my job became providing companionship, entertainment, and comfort. In a way, the change provided a salve for my own pandemic anxieties—my mother was out of work and newly diagnosed with lymphoma; we had two deaths in the family (one due to COVID, another likely due to pandemic-related isolation); and I was carrying the weight of many struggling patients. The combined pressure and isolation felt unbearable at times. The work helped me through.

For the first weeks of the pandemic, the silence in the corridors remained. The intern and fellow I supervised were sent home to telework from new laptops. Most of my fellow psychologists in the hospital worked from home offices, too. Even I had a brief telework spell, after the first residents and staff tested positive for COVID in early April 2020. But a few weeks later, I returned to the hospital. There was only so much teletherapy my patients could do.

Returning felt like a trip down Alice’s rabbit hole into a new world of masks, gloves, and face shields, restrictions on group activities and visitors, throat and nose swabs (at first once, later twice a week), and a permanent cloud of ennui among residents and staff alike. My former office, where I used to see patients, had become a COVID overflow hospital room. So I worked out of a trailer-like edifice across the street, making quick runs to the hospital to do bedside psychotherapy with residents in their rooms.

When I started visiting the patients in person, I resumed the usual therapy duties, providing cognitive-behavioral work for depression and chronic pain; reminiscence and life review for patients at end-of-life; and caregiver support sessions. But I was aware that business as usual would not be enough. Researchers know that loneliness and social isolation have detrimental effects on individual health—as detrimental to health as smoking; new studies of COVID isolation suggest that older adults suffered even greater loneliness over the course of the pandemic.

With the patients so painfully impacted by prolonged isolation, I needed to step up my role as friend and confidante—it was the only way to alleviate suffering in the increasingly confined environment. My job had always focused on short-term patients receiving rehab or hospice services; during the pandemic, I started more actively following long-term residents, many of whom were suffering from new bouts of depression, loneliness, and anxiety. For example, Ms. Carlisle, the feisty and creative centenarian on our hospice wing, had always turned down psychology services in the past. To help pull her from her depression, I began reading her poems and Beatrix Potter, and helping her write letters to her many friends at the independent living facility where she used to reside.

Pre-pandemic, Mr. Baker, a patient in his 70s who suffers from PTSD and dementia, happily spent his days in the common room, greeting passersby and engaging in group games and activities as best he could. He was not a good candidate for therapy, as his conversational abilities were fairly limited. My weekly visits became an important point of contact in the absence of the recreational opportunities he once had loved. I’d sit by his side, feed him Cheez Doodles, talk with him about his service in Vietnam and his nights stateside going to “liquor houses,” and groove along with him to Jimmy Reed and Fats Domino.

Music became an essential tool in my work. Per COVID guidelines, we weren’t allowed to sing, but we could listen, and music was a vehicle for reminiscence, communication, and connection. Spotify on my phone’s tinny speakers served as a jukebox for my patients: the man at end-of-life on hospice, hugging a posterboard photo of his late wife as we listened to Roberta Flack’s “The First Time Ever I Saw Your Face”; the long-term resident who was unable to leave his bed and could speak only faintly, drifting off the otherworldliness of Pink Floyd; the agitated younger resident who would briefly relax if Tupac was playing.

Over and over again, the new order of closed doors opened my therapy practice to increased spontaneity, and opportunities for connection. In graduate school, we were taught to provide talk therapy as a means of alleviating distress, meted in 50-minute sessions in neutral outpatient spaces. Now here I was, running around a half-empty hospital facility, doing things I never thought part of my job: bringing a dying man the Dr. Pepper he craved, playing chess with a long-term resident with dementia, offering coping skills and support to nurses and nursing assistants, and helping train an intern and a postdoc sitting at workstations in their homes. Even though I transitioned this past summer into a largely outpatient role within palliative care, those formative early pandemic experiences have made me a more flexible, adaptable, and generous clinician and co-worker.

Reflecting now, in the wake of so much loss and tragedy, the joyous moments stand out. I’ll never forget a rainy afternoon when I made a visit to a resident during one of the most desolate days of the pandemic. As the precipitation beat down, I had an idea: “Ms. Dubois, would you like to hear the rain?” Ms. Dubois could barely see or hear, and she’d typically spend the day listening to CNN on her hearing aids.

In my weeks sitting with her during the pandemic, I had learned that she was a lover of nature and all things poetic. I opened the door from her room onto the water-logged courtyard, and cranked up her pocket talker to its highest volume. As the downpour reached a crescendo, I saw her smile beaming through the pouring skies.

*All names and identities in this essay have been altered to protect patient confidentiality.

The post The Weird, Wonderful Work of Pandemic Geropsychology appeared first on Zócalo Public Square.

Seniors might start by learning a word: “prosumer.” This means we are not just producers or not just consumers, but rather both. Seniors increasingly serve as both caregivers and care receivers at the same time. This new reality is taking shape right in front of our eyes—and faster in Hawai‘i than elsewhere.

We—yes, I am a senior citizen too—are bombarded by advice and scattered information from drug companies, internet providers, and more web pages than we have time to search. There is too much advice to be helpful, and few guides. In spite of well-intentioned efforts of government and nonprofits, we are too often confused and disoriented. If you are in a family crisis, there is no time to sort it all out.

This situation, my situation, will only get more difficult. In this decade alone, the percentage of Hawai‘i residents who are 65 and older has jumped more than three points, from 14 percent in 2010 to more than 17 percent today.

Since the government outsources so much, the unstructured and competitive world of small business and nonprofits will primarily drive aging-related service delivery. This change, in turn, will redefine our idea of the aging system into one that is less like a hierarchy and more like a horizontal web. Government is becoming less of a policymaker and more of a partner.

Navigating such a web will be harder; the network of nonprofits serving aging people must answer to small boards of directors and must be creative to raise funds from multiple sources to sustain operations. Often payments to providers are delayed, and they are always at the mercy of the latest legislative appropriation. For providers of services to the aging, public information, education, empowerment, collaboration, and volunteerism are overlapping concentric circles of daily reality.

At the same time, the people who work in institutions for the aging, and those institutions themselves, will have to reinvent themselves to survive over time. Those dependent on the fickle changes in government appropriation, grants, and hot topics are forced to accept “mission drift” to chase the money.

Ultimately, my generation of aging people will have to take more ownership over the institutions that serve us. I can already see this at work on the islands, where there are different groups on Maui, the Big Island, Kauai, Oahu’s windward side, and in other small communities that are affiliated with a small local health clinic or senior center.

Working in this way will ask more of people, but there are advantages. Groups that are tied closely to community may be better equipped to speak to individual needs.

Much of what I’ve said to this point is true of many places. But Hawai‘i has its own micro-trends that will complicate the transition to a new era of aging.

Hawai‘i has a high cost of living and is far from easy access to neighboring states or services. We import all of our food and everything else. Housing costs intensify the income gaps. New generations often leave for greener opportunities. Too many families are one minor crisis away from homelessness.

Already, families and their networks are stressed. In Hawai‘i, there are over 150,000 caregivers helping family members. This sort of arrangement may not be sustainable. Increasingly, extended families don’t live in the same house, or even on the same island. And after attending college on the U.S. mainland, many set down roots elsewhere, and are thus unable to respond to an emergency. The ability of the family to help with the health and well-being of elders is disappearing.

The cost of housing limits our ability to safely and affordably house aging, vulnerable, and frail elders. Widows live in isolation in condos, with no one to check on their welfare. Many are too rich for Medicaid and too poor to afford high-end senior residential facilities—where “buying in” may cost hundreds of thousands of dollars for peace of mind as one grows frailer.

What Hawai‘i needs, then, is a middle zone that meets the needs of elders within a fraying system. Where will the income come from to support such an infrastructure? In the future, a growing percentage of retirees will not even have retirement benefits.

The ability of government to provide safety nets is on shaky ground. American culture, ideology, and politics may make it harder to guarantee existing benefits such as Social Security, Medicare, and Medicaid. Long-term care insurance for the middle class is not on the health care agenda. The role of the federal government is diminishing, with political polarization creating a narrative that views every essential service as an unnecessary and undeserved entitlement. Each state is on its own.

At the same time, a trend towards decentralization is overtaking many of our services and quickly exceeding the ability of government to regulate them.

Everywhere in Hawai‘i, we see this decentralization of organizations as former employees are becoming self-employed. Employed and licensed cab drivers are becoming Uber contractors. Taxed hotels are becoming untaxed bed-and-breakfasts hidden within a larger house or even an apartment. Care homes that were once regulated, inspected, and licensed are becoming alternative living arrangements beyond the reach of government oversight

Consider a new trend in Hawai‘i, so-called Aging in Place (AIP) facilities. Traditionally, a state-regulated care home was clearly defined by the law. The operator of such a care home could receive both private pay and public Medicaid residents, and would provide health benefits, social services, meals, and other assistance for people who had difficulty with activities of daily living. In addition, a small number of unrelated residents might share a home, which was inspected for compliance with basic safety features, like larger doors and ramps for wheelchairs.

Now enter the new, unlicensed, private-pay AIP entrepreneurs—claiming to be only landlords providing bed and board under a rental agreement (often for $6,000 or more a month!). They say each “renter” has his or her own arrangement with support systems provided by independent home health or home care agencies. They say the state has no right to knock on the door and inspect the facility or its residents.

Because this does not fit the government’s previous definitions of care facilities—indeed the AIP was invented precisely because it could evade them—these facilities are poorly regulated. Government has been slow and unable to change its industrial-style consumer protection and quality-control approach to this new world, where innovative legal and financial arrangements appear outside the scope of regulation.

There’s a tendency to think that this time of confusion—for aging individuals, for government regulators, and for society at large—will soon pass and we’ll be back to some kind of predictable normal. I do not see it that way at all. The most consequential social change of our times has been the shift from the industrial culture and society to the information age. This is the Third Wave, as futurist Alvin Toffler titled it in a book suggesting that human history could be understood as three major waves of change.

The First Wave of change—the agricultural revolution—took thousands of years to play itself out. The Second Wave—the rise of industrial civilization—took a mere three hundred years. Today, in the Third Wave, history is moving even faster, making most factory assembly lines obsolete; fragmenting families; and radically changing governments and corporations.

For aging and specialized communities, the Second Wave gave us large hospitals, mental health institutions, public health and sanitation, orphanages, large homes for the disabled—all tightly controlled and isolated from the general public. But the Third Wave pulls apart and decentralizes everything we do. The consumer has more choices—and more difficult responsibilities and decisions.

When those choices involve aging, as they so often do in Hawai‘i, this change should make you think of small, flexible nonprofits serving seniors in their homes rather than government-run facilities. Or think of nonunion workers rather than civil servants with pensions. Or think of government funding through contracts to Meals on Wheels, home hospice care, home chore services, or adult day care.

If the Second Wave was a mass society, with mass media, and mass production, the Third Wave is a fragmented society—multimedia internet rather than three big networks, small musical groups versus orchestras.

The future of Hawai‘i’s seniors depends on our ability to craft appropriate, affordable support and oversight systems for such smaller operations, and for the new realities and the special challenges of the Aloha State.

The post Why It’s So Tough to Grow Old in Hawai‘i appeared first on Zócalo Public Square.

Each of these first two chapters of boomers’ lives (while allowing for other ethnic, gender, and socio-economic determinants) forms a relatively straightforward narrative that, in many ways, was quite representative of previous generations of Americans. Declaring independence from one’s parents and their respective values in an attempt to create something different actually goes back a couple of centuries in this country, as does the subsequent settling into the domesticity and maturity of midlife.

This is, however, where it gets interesting. Rather than embrace their parents’ model of seniority defined by retirement, baby boomers are now considering or pursuing many different options, a version of life I call Boomers 3.0. Instead of heading en masse to retirement communities much like “Del Boca Vista” (the fictional condominium complex in Florida of Seinfeld fame), 60-somethings are going back to school, starting new relationships, exploring their creativity, taking new spiritual paths, embarking on “encore” careers, forming new communities, fighting for causes in which they believe, giving their time and money away, and yes, bucket listing. For financial and other reasons, a good number are working and staying in their current homes as long as possible, seeing no compelling reason to do otherwise.

Much is being made about how many baby boomers are financially unprepared for retirement, something all too true for a sizable segment of their generation. But boomers are collectively the richest generation in history and, even though a good number have already scaled back their careers, they are getting still richer. The (currently) strong stock market is making affluent boomers wealthier, with those additional financial resources being used to pursue alternative, sometimes very costly third acts.

Sixty-five million (of the original 76 million) in the boomer population are still alive and kicking. They range in age from 53 to 71, and each one is approaching or already engaged in his or her third act. Some baby boomers, unwilling or unable to accept that their bodies and minds have gotten older, are clinging desperately to their remaining youth by investing in the wide array of “anti-aging” therapies to be found in the marketplace. But even most of these folks don’t take these alleged fountains of youth too seriously.

Still other boomers are admittedly lost when it comes to planning for their third act; they are not interested in the traditional model of retirement, but not at all clear on which path they should take. Interestingly, in my research I’ve found that it is the financially secure who are most likely to be directionless, a result perhaps of having too many options available.

What happened to the very pleasant idea of spending one’s third and final act of life enjoying what one had worked so hard and long for during the first and second acts? Why is there no longer a central narrative to Americans’ last quarter-century or so of life (roughly age 55 to 80, on average)—replaced by a postmodern jumble of stories going in all sorts of directions? Are baby boomers, as some observers have claimed, the first “ageless” generation in history, rejecting the rules of society as they famously did in their idealistic younger days? Is creating a new paradigm of aging their final hurrah, something perhaps greater in scope and longer-lasting than their countercultural dream of universal peace and love?

In retrospect, the baby boomers’ impulse to toss out the Greatest Generation’s interpretation of older age makes perfect sense and was entirely predictable. Boomers (the “Me Generation,” remember) were and remain resistant to social norms and expectations, their individualism and anti-authoritarian ways perhaps being their most enduring legacy. It would be easy to suggest that as boomers plunge headfirst into their 70s they are suffering from an acute case of Peter Pan syndrome, refusing to grow up even as their physical selves experience decline and as they more often forget exactly why they came into a room. The looming threat of becoming a victim of Alzheimer’s disease or another form of dementia is incentive enough to pretend that older age is something that only happens to other people.

Overall, however, I believe that baby boomers’ inclination to take on new challenges and “act young” later in life is a very good thing. Studies show that there is much truth to the cliché, however trite, that one’s age is “just a number” or a “state of mind,” and that one is “only as old as one feels.” (Don’t even get me started on the “70 is the new 50” adage, or other such silly twistings of chronology, not to mention basic biology.) But sitting down to dinner at an “early bird special” to save a couple bucks, or whiling away afternoons playing mahjong, are simply not boomers’ style. (To be fair, retirement communities are a lot more active than they used to be.) Boomers’ third acts of life may indeed be scattered, disjointed, and personally defined, but as a whole they offer an attractive alternative to the going-off-into-the-sunset model that was so popular in the latter half of the 20th century.

Finally, given the widespread ageism in our youth-obsessed society, it’s no surprise that baby boomers will do pretty much anything to avoid being branded as irrelevant and over the hill. It’s also important to note that boomers’ insistence on trying to keep their jobs despite lucrative early retirement offers is actually in the best interests of the country. Millennials may wish boomers would get out of the way so they could take over their prestigious jobs and fat salaries, but millions of 60-somethings delaying Social Security and Medicare payouts is, for the moment at least, averting the economic and healthcare apocalypse (and “generational war” over resources) that many experts are predicting.

Continuing to find meaning and purpose in life is the real goal of Boomers 3.0—a less coherent story than version 1.0 or 2.0, but certainly an intriguing one that will have major social, economic, and political consequences over the next few decades.

The post Why Boomers Need a New Script for Life’s Third Act appeared first on Zócalo Public Square.

That’s the big question Wall Street Journal reporter Anna Wilde Mathews posed in her opening remarks to a Zócalo/Health Futures Council at Arizona State University event last night, held at the Arizona Science Center in Phoenix. With America’s elderly population on a path to nearly double by 2050—up to 83.7 million—and health costs only rising, the country is charging headfirst toward the biggest strain its health care system has ever seen.

“Will we be able to get the care when we need it?” Mathews, who covers health insurance and policy and moderated the evening’s discussion, asked. “And how much will that cost?”

On hand to tackle this daunting topic were four panelists: ASU economist Marjorie Baldwin, CEO of Arizona Integrated Physicians Keith Dines, executive director of Long-Term Quality Alliance Lawrence Atkins, and CEO of the National Coalition on Health Care John Rother. While they debated what specific kinds of interventions would ensure that future generations have reliable access to care, they fundamentally agreed on the big picture: There’s trouble ahead, and the more we can do today to prepare for the coming challenges, the better we’re going to be able to prevent an all-out crisis.

On one level, some of the largest changes our society needs to embrace are conceptual, the panelists suggested. From carefully reconsidering spending strategies to get more from the dollars that already go into health care (by some estimates, up to 30 percent of the money we spend on health is wasted, Rother pointed out) to reconceiving our relationship with care providers (we need to “look at health care as consumers,” Dines suggested), there’s a lot of work to be done to improve the current system. And seniors can no longer expect for every aspect of care to be paid for. “We can’t afford to have it all,” Baldwin said.

On a nuts-and-bolts level, how would these changes actually happen? How do we ration care, balance deductibles, manage out-of-pocket caps on insurance costs, and reduce the often-devastating expense of long-term care? To address these complexities, Mathews steered the conversation toward three major issues: drug costs, end-of-life care, and payment models for care providers.

On soaring drug prices, Atkins said “the problem is we have a lot of expensive drugs but not the mechanisms to get value from them.” He called this a matter of “opportunistic pricing”: The pharmaceutical industry charges high prices for its products when it can, without regard for the people who are dependent on them, as opposed to making its money from providing much-needed drugs that have the greatest best effects and largest social impact. “We have to get much better at really measuring the value of drugs and pricing them [accordingly],” Atkins said.

Baldwin doesn’t think the drug industry—one “we love to hate”—is the main culprit. She argued that focusing on reducing hospital and physician costs is more important in the overall effort to save money. Even if expensive, Baldwin added that “when drugs keep people out of hospitals, they’re actually lowering the costs of treating specific conditions”

She pointed to Germany and Australia, both of which have imposed price restrictions on their pharmaceutical industries and, in her view, suffered from a lack of innovation as a result. She mentioned one expert’s take: “If you slap price controls [on the pharmaceutical industry], you better like the drugs you have, because you’re not going to get new ones.”

On end-of-life care, Mathews pointed out that a disproportionate amount of Medicare spending comes at the very final stages of life, when expensive technology is used to try to prolong life—though not necessarily at the will of everyone involved in medical decisions, including the person suffering. As Dines explained, “up to 50 percent of health care expenses are spent in the last nine months of a patient’s life, and often interventions expedite end of life instead of expand it.”

The topic is so challenging, he continued, because for decades death has been taboo. Many active physicians were never trained in how to discuss end-of-life options with patients, so people aren’t aware of palliative care and other ways to deal with dying besides fighting it with all technology available, regardless of cost—both economic and in terms of quality of life.

Payment models for providers are perhaps the most complex challenge of all. “Data shows that how you pay providers affects the quality of care they give,” Mathews said. The Centers for Medicare and Medicaid Services have been looking for ways to improve how doctors are paid, so how can we best incentivize quality care?

The panelists talked about the benefits and shortcomings of different models, most notably “capitation,” in which doctors are paid a set amount of money to provide all the care for certain patients, regardless of how many procedures these patients receive. No one system is perfect, they agreed—which makes any route a challenge, especially when it comes to finding actual ways to measure the quality of care provided.

“How do you get these measures?” Baldwin asked. While in part it’s simply a matter of improving digital records, “in part it’s subjective,” she said. “The fundamental problem is the person who receives the care—the person who really knows the value of it—is not the person paying the bill.”

In a lively question-and-answer session following the discussion, the panelists tackled the arguably larger issue of how to convince people to live healthier lifestyles so that care isn’t so direly needed and expensive in the first place. “We’ve been talking about health care as if the medical system is the answer,” Rother said, “but if we really wanted to change things and drive down costs, we need to be talking about population health”—issues like smoking, drinking, lack of exercise, and other unhealthy habits weighing Americans down both physically and financially.

On this topic, the four panelists agreed that doctors, hospitals, and government can’t solve our health problems alone. In addition to institutional innovation, everyday Americans are going to have to take responsibility for their own health, too, though there was some disagreement over the extent to which insurance pricing should take into account a person’s pre-existing behaviors. The consensus on stage was that Americans wouldn’t accept what could be seen as a punitive approach, but Baldwin noted that it seems to be accepted in other insurance arenas. If you’ve had a number of accidents, for instance, you will likely pay more for your drivers insurance than someone who hasn’t.

If there is good news to report, the panelists agreed it may be the fact that there is a great deal of data-driven experimentation going on that could lead to innovation, some of it driven by the much-maligned Affordable Care Act. But all the answers cannot come from Washington or policymakers, as some of the thorniest issues remain cultural.

“The sooner we do something, the sooner we can fix things,” Baldwin said. “We can make some fundamentally easy fixes now. If we wait, it’s going to be surgery.”

The post If We Want to Fix Health Care, It’s Now or Never appeared first on Zócalo Public Square.

In advance of an April 26 Zócalo/ASU event on the future of our health care system—”Will the Aging of America Bankrupt the Healthcare System?“—we posed that very question to people who think a lot about how the Baby Boom will impact us overall.

The post A Silver Tsunami Is About to Hit U.S. Health Care appeared first on Zócalo Public Square.

“Maybe it would help if I looked at the set list,” the 70-year-old joked.

For rock legends that have been around as long as Blue Öyster Cult, going into autopilot on occasion is certainly understandable. BÖC released their best-known song—the cowbell-heavy paean to death and eternal love, “(Don’t Fear) The Reaper”—in 1976. They stopped putting out new albums in 2001, and rarely perform anything that was composed after 1983. But they still tour heavily every year, even though the current lineup is down to just two of the original members. In 2014, the band played 55 gigs. This year, they’re slated to play even more.

More than ever, rock bands that saw their heyday decades ago are strapping on their guitars and squeezing into their leather pants in order to strut back on stages around the world. Groundbreaking British punks The Damned just completed a trek across America, playing to packed houses of rabidly moshing fans. Diehards Motörhead are powering their way through a U.S. tour (to be followed by a European one), when they’re not canceling shows due to their bassist’s health issues. Aging hair-metal godfathers Mötley Crüe are currently in the final legs of a swan-song tour, and the Canadian trio Rush just completed a 40th anniversary tour.

Often, these bands seem to approach nostalgic tours as the most expedient way to make bank; choice seats for top acts—Fleetwood Mac, Elton John, the Rolling Stones, and Stevie Wonder—can run in the hundreds of dollars. For every rock-togenarian flush with cash, there are plenty who genuinely need concerts to eke out a living. (With digital music so freely and widely available, hardly anyone makes money off sales or royalties these days.) Consider the sad case of Dick Dale: The guy who practically invented surf guitar has a myriad of serious health issues, including renal failure and the aftereffects of two bouts of rectal cancer, and has to tour relentlessly in order to cover the $3,000 he needs each month to pay for his medical supplies. He plays in excruciating pain while wearing a colostomy bag.

After reading about Dale’s plight, I might make the extra effort to see him when he passes through the Bay Area, where I live—and not just because I feel sorry for him and think that he needs my money. No, in reading reviews of the guitar legend’s recent shows, it sounds as if he’s literally giving it his all, resulting in some truly incendiary performances from the 78-year-old. And that’s the thing: Most aging artists still seem to genuinely enjoy trotting out their old hits for audiences, who are thrilled to relive the music of their youth and pay a premium for the pleasure.

Back on the beach at the Blue Öyster Cult show, the audience was an eclectic crowd of summer fun-seekers of all ages, skewing toward the well-over-40 set. Younger audience members who might not know BÖC beyond “Reaper” were maybe just catching a break from the cotton candy and roller coasters on the adjacent boardwalk. Graying t-shirted dudes ensconced in beach chairs, meanwhile, were clearly longtime fans of the band. One intoxicated biker-mama wobble-danced on a hill and kept shouting “Godzilla!” before every song.

So what’s in it for them? I’m not quite in the demographic of the “Godzilla” screamer, but I’ve attended hundreds of concerts, as a lifelong music fan and a freelance journalist since the mid-’80s. And while I certainly go to my fair share of performances by current artists, I find myself often drawn to rock revivals—shows put on by rock stars who are just a few years younger than my dad.

Partly the reason I go to these shows is to call back my earliest days as a music lover. Rock icons like Rush, the Who, Kiss, and the Rolling Stones provided the foundation for my lifetime of music fandom, and the chance to revisit such formative faves is often irresistible. I’ve since moved on through punk and post-punk into more esoteric and experimental realms, but I still vividly remember purchasing my very first albums by those groups, and the countless hours I would spend happily listening to them, bouncing around my parents’ basement rumpus room in full-on teenage air-guitar geekdom.

Recently, I revisited Rush’s A Farewell to Kings, a 1977 album I hadn’t heard in decades. What a flashback it was: the chiming chorus-laden guitar chords, audaciously complex drum workouts, sci-fi sound effects, and epic progressions on tracks like the 11-minute “Xanadu.” Even the cheesy state-of-the-’70s synths sprinkled throughout and Geddy Lee’s high-pitched vocals brought back warm memories of raptly listening to the LP via headphones jacked into my ’70s-vintage Sears combo stereo. It was like time-jumping back to re-encounter my teenage self. The house and the world I inhabited in Massachusetts at the time. The friends I would voraciously listen to records with, back in a pre-earbud era when we actually did that. The nerdy rock-star aspirations the music would soundtrack. It all seems so distant now, but it was a vital experience that molded who I am today.

Big names in rock have been packing it in or shuffling off mortal coils for decades, but I now find something especially poignant about watching the heroes of my youth approach their expiration date. Perhaps the fact that groups I called my favorites as a teenager are nearing their demise invokes my own mortality. Or maybe I’ve just arrived at a nostalgic time that happens in everyone’s life, when artists they loved all seem to be approaching their final victory lap. I feel compelled to see those bands I grew up with one more time, in part because there’s that nagging fear it might be the last opportunity. But seeing these bands also fills me with genuine joy. I can honestly say that some of the best shows I’ve seen in recent years were courtesy of bands I loved ages ago.

In the end, perhaps that’s all that truly matters—that the performer and the audience have a mutually beneficial experience, an ecstatic event that both parties can revel in. I sometimes wonder if it’s time for me to say enough already, to focus on seeing younger artists and stop going to watch my teen idols gradually ossify onstage. But then I think of the several minutes of six-string pyrotechnics Blue Öyster Cult’s 67-year-old guitarist unleashed at that beach show, just before they played “(Don’t Fear) The Reaper.”

If the grizzled warhorses keep mustering up something I enjoy, I’ll continue to give them my time and money. As some wise old men once said, “it’s only rock and roll—but I like it.”

The post Rock on, Grandpa appeared first on Zócalo Public Square.

A growing number of senior citizens—both permanent residents and part-time “snowbirds”—have settled in neighborhoods and mobile home parks across Phoenix, Arizona. All of these out-of-state transplants and seniors have created a growing demand for alternatives to traditional funerals.

When I was 23, I started working for one of several whole-body donation organizations that serve the region. When someone dies, his or her family has several options for the body: a viewing and burial, cremation, embalming, or donation. Donating tissue, like organs, corneas, and skin, can also take place.

My time in the whole body-donation industry began on Craigslist. The help wanted ad didn’t list the organization’s name. When my future boss called to set up an interview, I thought she was a telemarketer. I could’ve hung up then, missed the opportunity, and been none the wiser about the death industry.

Instead, I stayed on the phone, and she ended up hiring me for the receptionist position.

I answered phones, typed up letters, and ran to the post office. It was a normal office job, except for the cadavers less than 100 feet from my desk, sealed away in the laboratory.

Soon I was promoted and began taking “notification of death” calls. Some people signed up to donate their bodies to science. Family members or a hospice nurse called to inform me of the donor’s passing, and I arranged for mortuary transportation. Other times, people called in dazed. Their father or mother or sister or spouse had died, they told me, and they didn’t know what to do.

I couldn’t do much. I couldn’t undo their loved one’s death or say something wise to make everything better. But I could give them a to-do list: call this person, sign this, fax this, and answer these questions.

It was an industry I hardly knew existed until I was part of it. Soon, I started picking up on references to donation on television shows like Bones and Law & Order: SVU. The storylines usually involved a nefarious character in a suit, stolen body parts, or a funeral home with a hidden autopsy suite.

These plotlines are not baseless. The reputation of the body- and tissue-donation industry as a whole has been damaged by the actions of dishonest hospitals, funeral homes, and doctors. Less than a decade ago, the CEO of a tissue recovery firm was arrested for selling illegally harvested body parts. Funeral homes, donation companies, and hospitals have also been exposed for forging consent forms and unlawfully obtaining tissue. In 2013, I watched as FBI vans and news helicopters swarmed a nearby tissue donation firm. Our phones began ringing off the hook. I assured panicked callers that no, that was not our organization on the television, and that yes, we could help with arrangements for their loved ones. I feel lucky to have worked for an ethical business in such a loosely regulated industry.

My supervisor required us to inform people fully of the nature of full body donation, answer all questions, and only proceed with witnessed, written consent. Not all religions and communities support donation. I made it clear that people should only donate if they were 100 percent comfortable with the process.

Whole body or anatomical donation places organs, body parts, and other tissues with medical facilities. The tissue is then used for training doctors, developing new treatments and medications, and researching diseases, from breast cancer to dementia. What is not used for research is cremated and returned to the family.

Death is expensive. Traditional funerals cost upwards of $6,000, and even simple services can force families to choose between paying rent or paying for a cremation. The organization where I worked covered the cost of mortuary transportation, cremation, and the return of ashes to the family. We took care of all the necessary paperwork and tried to whittle down any other costs. Usually families were just left with paying the county for a death certificate, which are about $20 apiece.

Some people decided to donate because of financial hardship. For most people, the decision to donate was not a financial choice. I saw people who had suffered for years from cancer sign up for donation because they thought it was one final way to fight the disease.

Sometimes, especially when the person died in hospice, a nurse or social worker would step up and help the family plan for a funeral home or alternative service. Other times, it was a family member who called. They found us in a Google search or were referred by a friend and were fumbling through a bewildering situation.

If the deceased was registered to donate, I started the transportation and donation process immediately. If they were not, I ran through a list of questions. Depending on the answers, I either carefully told the next-of-kin that their loved one did not qualify for whole body donation or informed them that they were accepted. Hepatitis C or HIV/AIDS rules out donation of any kind.

The majority of my workday consisted of filling out medical questionnaires. I called the family sometimes within hours of the passing and asked questions ranging from routine medical questions to intimate social history. As an introverted child and teen, I was too shy to call in a pizza delivery order. In this job, I was on the phone calmly inquiring about drug use, tattoos, and sexually transmitted diseases.

With the phone cradled on my shoulder, I frantically typed and Googled unfamiliar medical conditions. I memorized the correct spellings of aneurysm, Levothyroxine and myelodysplastic syndrome.

The most surreal part of the job was when the donation was done, and I personally delivered the ashes back to the family. I logged thousands of miles on my VW station wagon. The other coordinator and I drove so much the owners eventually bought a company car that was much nicer than either of our vehicles. I traveled to every corner of the valley to multi-million dollar homes, gated suburbs, and rusted trailer parks.

Some days were good. The families were in mourning but thanked me profusely. I could tell they were content with their decision. People invited me into their living rooms. They showed me photos of their loved ones and detailed their plans to spread the ashes on the beach or in the forest or in the Colorado River.

Other days, not so much. I visited hoarders with houses so crammed with card tables, boxes, and cat food that I had to come in through the garage. I delivered to homes in the empty stretches of Apache Junction that gave off a distinct meth-house vibe, complete with cardboard jammed over the windowpanes and a television set smashed on the lawn. After delivering the ashes of a 20-year-old to his grieving mother, I sat in the car for 20 minutes and tried to shake off a wave of sadness.

People expressed shock to see me, a person in her 20s, on their doorstep, holding their loved one’s ashes. They remarked on how young I was. (I think they expected a gaunt-faced, middle-aged man in a gloomy suit.)

“How’d you end up in with this kind of job?” they’d ask.

The death industry is not an easy business to work in. You carry the sadness and anger of your workday home with you. Sometimes you have nightmares. After reading too many medical examiner’s reports, you create a mental list of ways you do not want to die.

I still didn’t come any closer to understanding death. I couldn’t ever define what I wanted after my death, but I realized that talking about it was the best way to prepare for it. Ignoring death just leaves empty spaces and gaps for the survivors to guess their way through.

One thing that struck me was how the reports always describe the state of cleanliness of a residence where someone dies. Now I find myself making a point of keeping my home neat, because you never know when death might visit. And I’d like to avoid the judgment of the medical examiner.

My time in the industry gave me endless anecdotes and cautionary tales. With my boss’s encouragement, I re-enrolled in school and accepted a journalism internship. I left the job after three years, but felt a decade older. I knew my time in the death industry was over.

The post Want to Donate Your Body to Science? Call Me appeared first on Zócalo Public Square.

Californians like to think of this state as a place defined by endless youth and growing diversity. But the biggest transformation in California is the breathtaking speed with which our population is aging. So instead of just measuring ourselves against oil-rich Texas or Wall Street-dependent New York, we should be focusing more on Florida as our competitor.

While Californians 65 years or older represent just 12 percent of the state’s population today (a figure slightly below the national average and well below Florida’s rate of 19 percent), the number of 65-plus seniors is projected to nearly double, representing 20 percent of the population by 2030. That rate of growth is roughly the equivalent of adding one new Rossmoor—the 9,000-strong senior community in Walnut Creek—twice a month for the next 15 years.

But even that may not be enough geezers to meet our needs. Other sources of new Californians are drying up—immigration is flat, the birth rate has dropped below replacement, and too many young families are leaving the state because of the high costs of living. Our state’s budget system—by limiting education spending and relentlessly forcing cuts and higher tuition at our universities—and our politics— which are increasingly dominated by older voters—all but preclude investments to attract more young people. So if California wants to grow, and find new buyers for our homes and new shoppers for our retail corridors, our best option may be to convince more people to spend their golden years in the Golden State.

U.S. economic surveys show that the fastest-growing American regions are the most successful in attracting retirees. Yes, seniors come with high health care costs. But federal programs cover many of those costs. And, California already must make hundreds of billions of dollars in public and private investments just to serve our own aging population. So why not make a virtue of necessity?

Yet California has built very little of the senior-oriented infrastructure that makes Florida such a magnet for the old. Instead, we have spent the last generation cutting back, in the name of budget austerity, services upon which they depend—from health and housing to culture and transportation. Too many California communities are chasing the same younger, highly educated, and creative people with the same menu of attractions—bike paths, downtown lofts, any development that can be labeled “sustainable”—even though the young are declining as a share of the state’s population. Meanwhile, the state has too narrowly focused its self-promotion on attracting trade and tourism rather than luring snowbound seniors from Back East.
Here’s one example of our narrow vision when it comes to the possibilities of the old: The biggest California debate involving seniors right now is over proposed legislation to make it easier for them to end their lives when they’re terminally ill.

State Senator Carol Liu, one of the few state leaders focused on the opportunities and challenges of a rapidly aging California, told me that when she put forward a bill to require adult bicycle riders to wear helmets, she was inundated with media calls and public questions. After her special legislation committee put forward a comprehensive report and ambitious legislative package on aging, she said, “No one is paying attention.”

That report, from the state Senate’s Select Committee on Aging and Long-Term Care, is worth reading. In more than 200 pages, it recounts yet another state governance mess—California’s collective failure to plan properly for old age. Programs on long-term care are scattered across six different state departments. There are no clear safety and access standards, and precious little data, for home-based and community-based senior services. Despite model senior centers around the state—in reporting this column, I heard a lot about the West Senior Wellness Center in San Diego—there is little effort to build statewide on such successes.

Liu’s report is at its most depressing when it quotes decades of previous reports that offered the same warnings—and produced little progress. This new report offers 30 recommendations, the headliner being the appointment of a California aging czar. It also suggests more forceful advocacy for seniors and framing aging investment as a women’s issue, since women live longer and thus represent large majorities of the senior population.

California may never be able to compete with Florida on income taxes (ours are high, theirs are nonexistent), but our climate is more comfortable, and, as anyone who has visited the Coachella Valley knows, we have lots of things to offer seniors. (Maybe some Californian could pitch Governor Scott, who will be termed out of office in Florida shortly after his 66th birthday in 2018, on buying in La Quinta.)

With the cost of living so high in coastal California, it would make sense to focus senior recruiting efforts on lower-cost communities inland. UCLA Anderson School of Management economist Jerry Nickelsburg has argued that the Central Valley would have much to gain by focusing on seniors. That would require governments and private companies to build improved health care facilities and train more people to work in professions serving seniors. The good news is that those are low-risk investments that would raise education levels and produce badly needed jobs.

Liu’s report notes that California’s seniors will be highly diverse. And therein lies more opportunity. According to the United Nations, the worldwide population of older persons—age 60 or over—is expected to more than double to 2 billion by 2050. If California can develop senior infrastructure that can serve people of many cultures and languages, California could pitch itself as a global destination for retirees.

Go West, old man.

The post California Needs More Old People appeared first on Zócalo Public Square.