I am at the age where my family and friends all seem to be coping with aging
relatives. And I can tell you that something has gone terribly wrong with both the
health care system and the system of nursing care.
People in their 80s and 90s, when their health starts to deteriorate, tend to have multiple things
wrong with them. From a doctors point of view, they are very time consuming to treat. They
often tend to be fearful and forgetful.
All of this means that either a family member, or a very conscientious doctor, needs to be
carefully coordinating their care, or disastrous mishaps will occur. But middle aged sons and
daughters are nearly all in the workforce, without much time to spend with frail and aging
And despite the promise of managed care, they one thing doctors are not paid to do is spend a
lot of time with patients or on the phone.
Indeed, managed care has become a parody of its original aspirations. Back in the days when
HMOs were nonprofit, prepaid group health plans, the idea was that paying doctors salaries to
treat a fixed number of patients would reward prevention and remove any incentive either to
undertreat or to overtreat.
In the 1990s, after most HMOs had become for-profit, shareholder owned corporations, they
tried to make money signing up Medicare patients. The government encouraged HMOs to serve
seniors, on the theory that this would cut costs. HMOs targeted relatively healthy oldsters, in
the hope of making a bundle.
But it mostly didn't work. For one thing, old people gradually become older people. Even
healthy ones eventually get sick. For another, the Medicare payments to HMOs weren't
adequate to the need. So most elderly people, especially the sickest ones, went back to
The Medicare program, though reformed to discourage overly long hospital stays, is still
basically a fee-for-service program. That means it rewards intensive medical interventions, such
as surgery, but doesn't reimburse enough money to compensate doctors for the careful case
management that older people require. The more that Congress cuts the Medicare budget, the
more money comes out of hands-on care.
One member of my extended family has been shuttled from specialist to specialist, while his
case falls between the cracks because his overworked primary care doctor fails to adequately
coordinate the whole enterprise. After many months, nobody knows what's wrong with him.
Another, in her mid-80s, was barely spared unnecessary and dangerous open heart surgery,
only because her daughter had the wit and the energy to ask impertinent questions and seek a
The mother has multiple conditions. The daughter is spending half her time on the phone doing
what her mother's primary care doctor should be doing.
The managed-care system is saving money by displacing the burdens of caring back onto
families. Those who don't have families available to accept such burdens risk becoming
casualties of the medical system. When it comes to people in their 80s and 90s, especially those
without close relatives on the case, the system can simply bury its mistakes.
The story is, if anything, worse when it comes to nursing care. Most nursing home care is paid
by Medicaid. The reimbursements are inadequate, so nursing homes tend to recruit help from
the very bottom of the labor market.
Assisted living is an attractive alternative to nursing care, but is costs far more than most
elderly people typically can afford usually $2,500 a month and up. And Medicaid won't pay
any of its costs.
Both parties are crowing about the huge and growing budget surplus, as if it were a costless
boon to the economy. But the fact is that a big chunk of the surplus came out of cuts in the
budget for Medicare and Medicaid.
Our society is demanding that everyone work, but ignoring the cost to the enterprise of
caregiving. We are becoming a richer economy, while we impoverish those most dependent on
the care of others.
So the wondrous budget surplus is anything but costless. As anyone who has lately helped an
elderly friend or relative navigate hospital care can tell you, the costs are coming at the expense
of our own parents.
This is a political failure, because these are mostly public dollars. But somehow, the voters
aren't connecting the dots and demanding better of our elected officials. If we fail to make this a
public issue, our families will suffer the consequences.