As a result, old people are being asked if we would be willing to give up some expensive, life-sustaining treatment so that our grandchildren can have health care. This is a bogus question, and a bogus “choice.” The real question, as I say in the article, is whether we should give up the treatment “so some WellPoint executive can take another expensive vacation, so Pfizer can book $3 billion in annual profits instead of $2 billion, or so private hospitals can make another campaign contribution to some gutless politician.”

It’s a long article, and I’m including just the opening here, with a link at the end to continue reading at the Mother Jones web site. Or you can read the whole thing at MotherJones.com by clicking here. And if you’re one of those geezers who still likes reading print and turning pages, the July/August issue is on newsstands now.

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From Mother Jones, July/August 2010

There’s a certain age at which you cease to regard your own death as a distant hypothetical and start to view it as a coming event. For me, it was 67—the age at which my father died. For many Americans, I suspect it’s 70—the age that puts you within striking distance of our average national life expectancy of 78.1 years. Even if you still feel pretty spry, you suddenly find that your roster of doctor’s appointments has expanded, along with your collection of daily medications. You grow accustomed to hearing that yet another person you once knew has dropped off the twig. And you feel more and more like a walking ghost yourself, invisible to the younger people who push past you on the subway escalator. Like it or not, death becomes something you think about, often on a daily basis.

Actually, you don’t think about death, per se, as much as you do about dying—about when and where and especially how you’re going to die. Will you have to deal with a long illness? With pain, immobility, or dementia? Will you be able to get the care you need, and will you have enough money to pay for it? Most of all, will you lose control over what life you have left, as well as over the circumstances of your death?

These are precisely the preoccupations that the right so cynically exploited in the debate over health care reform, with that ominous talk of Washington bean counters deciding who lives and dies. It was all nonsense, of course—the worst kind of political scare tactic. But at the same time, supporters of health care reform seemed to me too quick to dismiss old people’s fears as just so much paranoid foolishness. There are reasons why the death-panel myth found fertile ground—and those reasons go beyond the gullibility of half-senile old farts.

While politicians of all stripes shun the idea of health care rationing as the political third rail that it is, most of them accept a premise that leads, one way or another, to that end. Here’s what I mean: Nearly every other industrialized country recognizes health care as a human right, whose costs and benefits are shared among all citizens. But in the United States, the leaders of both political parties along with most of the “experts” persist in treating health care as a commodity that is purchased, in one way or another, by those who can afford it. Conservatives embrace this notion as the perfect expression of the all-powerful market; though they make a great show of recoiling from the term, in practice they are endorsing rationing on the basis of wealth. Liberals, including supporters of President Obama’s health care reform, advocate subsidies, regulation, and other modest measures to give the less fortunate a little more buying power. But as long as health care is viewed as a product to be bought and sold, even the most well-intentioned reformers will someday soon have to come to grips with health care rationing, if not by wealth then by some other criteria.

In a country that already spends more than 16 percent of each GDP dollar on health care (PDF), it’s easy to see why so many people believe there’s simply not enough of it to go around. But keep in mind that the rest of the industrialized world manages to spend between 20 and 90 percent less per capita and still rank higher than the US in overall health care performance. In 2004, a team of researchers including Princeton’s Uwe Reinhardt, one of the nation’s best known experts on health economics, found that while the US spends 134 percent more than the median of the world’s most developed nations, we get less for our money—fewer physician visits and hospital days per capita, for example—than our counterparts in countries like Germany, Canada, and Australia. (We do, however, have more MRI machines and more cesarean sections.)

Where does the money go instead? By some estimates, administration and insurance profits alone eat up at least 30 percent of our total health care bill (and most of that is in the private sector—Medicare’s overhead is around 2 percent). In other words, we don’t have too little to go around—we overpay for what we get, and we don’t allocate our spending where it does us the most good. “In most [medical] resources we have a surplus,” says Dr. David Himmelstein, cofounder of Physicians for a National Health Program. “People get large amounts of care that don’t do them any good and might cause them harm [while] others don’t get the necessary amount.”

Looking at the numbers, it’s pretty safe to say that with an efficient health care system, we could spend a little less than we do now and provide all Americans with the most spectacular care the world has ever known. But in the absence of any serious challenge to the health-care-as-commodity system, we are doomed to a battlefield scenario where Americans must fight to secure their share of a “scarce” resource in a life-and-death struggle that pits the rich against the poor, the insured against the uninsured—and increasingly, the old against the young.

For years, any push to improve the nation’s finances—balance the budget, pay for the bailout, or help stimulate the economy—has been accompanied by rumblings about the greedy geezers who resist entitlement “reforms” (read: cuts) with their unconscionable demands for basic health care and a hedge against destitution. So, too, today: Already, President Obama’s newly convened deficit commission looks to be blaming the nation’s fiscal woes not on tax cuts, wars, or bank bailouts, but on the burden of Social Security and Medicare. (The commission’s co-chair, former Republican senator Alan Simpson, has declared, “This country is gonna go to the bow-wows unless we deal with entitlements.”)

Old people’s anxiety in the face of such hostile attitudes has provided fertile ground for Republican disinformation and fearmongering. But so has the vacuum left by Democratic reformers. Too often, in their zeal to prove themselves tough on “waste,” they’ve allowed connections to be drawn between two things that, to my mind, should never be spoken of in the same breath: death and cost.

Click here to the rest at MotherJones.com.

The advertisements for retirement investments and hair color keep telling you that 70 is the new 40, that you’re only as young as you feel. AARP’s magazines say the same thing–but the world they depict seems unreal and, to tell the truth, somewhat revolting. Because you don’t feel young–you feel old. And in today’s America, that’s hardly a happy feeling. You feel shoved aside, irrelevant, a relic waiting to hurry up and die. You realize you can’t remember things as well as you once did, have more and more of the proverbial “senior moments,’’ and start wondering how long it will be until you sink into dementia, maybe Alzheimer’s, at which point your life will really be over.

There’s precious little in our society that acts as an antidote to any of these thoughts. But for the last half-century, there has been one man: Dr. Robert N. Butler. A psychiatrist, activist, and visionary, Butler died on Sunday at the age of 83, and is being eulogized in the obituaries as the founder of modern gerontology, the man who coined the word “ageism.’’ Butler founded the National Institute of Aging at the NIH, and helped found the American Association for geriatric Psychiatry and the Alzheimer’s Disease Association; he also launched the first medical department devoted to geriatrics at Mount Sinai Hospital in New York.  He wrote influential books, advised politicians, counseled the World Health Organization, and he founded and ran the International Longevity Center in New York. 

Through all of this work, Butler inspired thousands, perhaps millions of people to think differently about growing old, and to treat aging and the aged differently. For old people, that transformation is even more profound, because it means thinking differently about yourself. I am one of those people whose thinking was changed, in some significant way, by Robert Butler and his work.

I was lucky enough to meet Butler a few weeks ago at a week-long series of seminars his International Longevity Center put on annually for a small group of journalists, called the Age Boom Academy. That one week produced some of the most astute briefings on every aspect of health policy and the challenges ahead that one could hope to take in–from research on Alzheimers, to the political assault on Medicare and Social Security currently underway in the administration and Congress, to the day-to-day work on the ground across the City of New York. What I had feared might consist of a bunch of self-serving medical and psych professionals was instead an immersion into the real world of the politics and economics  of medicine, tempered always by Butler’s vision. Despite his concerns for the scandalous lack of funding for research on Alzheimer’s and the aging brain, as well as the growing shortage of doctors trained in gerontology or even general practitioners, he approached his work with unyielding  optimism. I had no idea he was battling a life-threatening illness.

On Monday I was on a train on my way to New York, where I had an appointment this week to sit down with him to further discuss his ideas, when I received an email and learned that he was gone. Although he had acute leukemia, Butler reportedly had been working until three days before his death. At 83, he had seemed like he was in the prime of life–not because he acted like he was 40, but because he had succeeded in redefining 83 as a different kind of prime, for himself and for others.

 In a speech not long ago at the American Academy of aging, Butler quoted Proust from In Search of Lost Time, “If we mean to try to understand this self, it is only in our innermost depths, by endeavoring to reconstruct it there, that the quest can be achieved.” He saw that quest as part of the journey into old age, and gave it significance and dignity. He said in his speech:

In the 1950s, psychology, psychiatry and gerontology textbooks devalued reminiscence and memories. Reminiscing was condescendingly called “living in the past,” and phrases like “wandering of mind,” “boring” and “garrulous” were used to describe elders who looked back. Actually, reminiscence was thought to be an early diagnostic sign of senile psychosis–what is known today as Alzheimer’s disease. However, I was seeing a different picture in vibrant, healthy individuals who were engaging in a fascinating inward journey.

More than fifty years later, Butler’s ideas are widely respected by psychologists and social workers, many physicians and research scientists, and even some policymakers. As far as they have caught on at all with the general public, it is thanks to his tireless work. He like to point out that demographics was on his side: More and more, elders will outnumber youth, and the voice of the geezers will grow stronger and stronger.

I was pleased to see, this morning, an eloquently written obituary in the New York Times by Douglas Martin. Fittingly, it included some remembrances of Butler’s past. As Martin notes, “Dr. Butler’s mission emerged from his childhood.” His parents split up less than a year after he was born, and he went to live with his grandparents on a New Jersey chicken farm. 

He came to revere his grandfather, with whom he cared for sick chickens in the “hospital” at one end of the chicken house. He loved the old man’s stories. But the grandfather disappeared when Robert was 7, and nobody would tell him why. He finally learned that he had died.

Robert found solace in his friendship with a physician he identified only as Dr. Rose. Dr. Rose had helped him through scarlet fever and took him on his rounds by horse and carriage. The boy decided he could have helped his grandfather survive had he been a doctor. He also concluded that he would have preferred that people had been honest with him about death.

From his grandmother, he learned about the strength and endurance of the elderly, he wrote. After losing the farm in the Depression, she and her grandson lived on government-surplus foods and lived in a cheap hotel. Robert sold newspapers. Then the hotel burned down, with all their possessions.

“What I remember even more than the hardships of those years was my grandmother’s triumphant spirit and determination,” he wrote. “Experiencing at first hand an older person’s struggle to survive, I was myself helped to survive as well.”

Butler spent his life passing on that painful but profound gift to thousands of other people. I feel fortunate to have been one of them.

There’s a good chance this commission will end up proposing cuts in Medicare, along with steps towards privatizing  parts of Social Security. These have been heartbeat issues for conservatives running all the way back to the creation of Social Security in the New Deal, and has only grown since Congress created Medicare in the 1960s, after some arm twisting by LBJ. Doing away with these entitlement programs has been a cherished conservative idea, right alongside ridding the nation of  ties to the UN, ending the income tax, and abolishing the Department of Education, to name but a few.

In addition to destroying the social safety net, the war on entitlements serves to distract attention from the real causes of the inflated deficit. Elizabeth Rogers suggests some other sources of deficit-reduction that our politicians might want to consider before they start dipping into our Social Security checks. 

Retired Senator Simpson must travel in a very different crowd of older Americans than my husband and I do! We live in a compact 2 BR condo in the Pacific Northwest. Yes, there’s a gate, but our complex is very definitely occupied by middle class workers and retirees like us. At 73 I’m still working part time and thank my lucky stars that I have a job. My husband, now 80, worked until four years ago (he started working at age 14).

Lexuses? I don’t think so. Our small SUVs are over 10 years old and we hope they last as long as we do. Fat cats? Not exactly, although we do have an overweight feline in our family.

Seriously, although we have some additional resources, Social Security is a significant source of income for us, as I suspect it is for most recipients. That said, we get that the nation’s huge budget deficit is a serious problem.

We’d be willing to pay more taxes if the amount is fair and reasonable, but FIRST, how about: (1) pursuing the offshore bank accounts of billionaire tax evaders, (2) allowing the Bush tax cuts for the wealthiest 2% of Americans to expire, (3) ending the UNfunded wars in Iraq and Afghanistan that are now costing in the trillions; (4) changing our culture’s views on end-of-life care so that Medicare doesn’t continue to spend huge sums on “heroic” measures to “save” those in their last 6 months of life. I have multiple advance directives in place because I have no desire to fall into the hands of the medical-pharmaceutical complex at the end of my life, but even so, I can’t be certain that I won’t. We need to get real about this issue!

On one side, we have pundits like David Brooks babbling on about old people stealing the nation’s wealth, and billionaire geezer-basher Pete Peterson bankrolling a campaign for an “entitlement commission” to cut Medicare and Social Security. Why should we expect a government handout just because we’ve worked and paid taxes all our lives? (Never mind that Wall Street has already decimated our retirement savings and home values.)

On the other side we have the champions of age-based health care rationing, led by “ethicists” like Daniel Callaghan, trying to convince us to go gently into that good night, while our corrupt system of medicine for profit goes on unrestrained. How would you like to be denied a kidney transplant or even a new hip, on the grounds of enlightened “cost-benefit analysis,” while the drug and insurance companies continue to rake in their profits?

It’s no wonder elders around the world are taking matters into their own hands. The only thing that’s surprising about the German geezer gang described in yesterday’s post is that it doesn’t happen more often. You hear about other incidents every now and then: an oldsters’ crime wave in Japan, or an octogenarian bank robber with an oxygen tank in San Diego. Maybe soon we’ll be seeing more elderly sapper gangs in action.

In the meantime, a reader dropped me a line last night with a reminder that there is indeed a precedent for all this, deftly portrayed by Monty Python. Seems to me that it might be time for Hell’s Grannies to ride again.

For years prison rights organizations and families have sought to persuade states and the federal government to free elderly  terminally ill inmates into the care of family or friends. But prisons and politicians have generally deemed such compassionate release programs too “high risk” because of the possible security threat to the general populace–in other words, they worry grandpa might get out and go berserk, and they’d be left holding the bag if he committed a new crime.

Places like Angola, the giant Louisiana state prison where most inmates have such long sentences that they are destined to die inside, have dealt with this situation by setting up their own hospices. Now, Penn State has received a $1.27 million grant from the National Institute of Nursing Research to develop what Susan Loeb, an assistant professor, described to the student newspaper the Daily Collegian as a “comprehensive toolkit of tailored resources for end-of-life care in prisons.” The article continues:

Leaders of the program plan to apply study findings at six different prisons state-wide in an attempt to improve care for inmates reaching the end of their lives, wrote Loeb, the principal investigator for the study.

“Since prisons are among the most restrictive, most complex organizations — prisons are the best context for this study,” Loeb wrote. “Our hope is that findings will benefit not only dying inmates but also others who spend their final days in a complex organization.”

Though the study is still in the early stages, researchers are quickly learning, said Christopher Hollenbeak, associate professor of surgery and health evaluation sciences and an investigator on the study. “The real goal of it is to come up with a tool in prisons to improve the quality-of-life care,” Hollenbeak said. “We want to provide a toolkit that would be cost-effective as well.” Current end-of-life prison programs only offer limited low-cost medications. One proposed change is the “buddy system,” where healthy inmates are paired with a terminally ill inmate to help look out for them, Hollenbeak said.

I suppose it’s a worthy effort, given the current situation. But none of it would be necessary if American society could get over its desire for punishment and revenge just enough to let these inmates die in the free world.

Congress raised estate-tax exemptions, culminating with the tax’s disappearance next year. However, due to budget constraints, lawmakers didn’t make the change permanent. So the estate tax is due to come back to life in 2011–at a higher rate and lower exemption.

Frank Soffen, now 70 years old, has lived more than half his life in prison, and will likely die there.

Sentenced to life for second-degree murder, Soffen has suffered four heart attacks and is confined to a wheelchair.  He has lately been held in the assisted living wing of Massachusetts’ Norfolk prison. Because of his failing health and his exemplary record over his 37 years behind bars—which includes rescuing a guard being threatened by other inmates—Soffen has been held up as a candidate for release on medical and compassionate grounds.

He is physically incapable of committing a violent crime, has already participated in pre-release and furlough programs, and has a supportive family and a place to live with his son. One of the members of the Massachusetts state parole board spoke in favor of his release. But in 2006 the board voted to deny Soffen parole. He will not be eligible for review for another five years.

The “tough on crime” posturing and policymaking that have dominated American politics for more than three decades have left behind a grim legacy. Longer sentences and harsher parole standards have led to overcrowded prisons, overtaxed state budgets, and devastated families and communities. Now, yet another consequence is becoming visible in the nation’s prisons and jails: a huge and ever-growing numbers of geriatric inmates.

Increasingly, the cells and dormitories of the United States are filled with old, often sick men and women. They hobble around the tiers with walkers or roll in wheelchairs. They fill prison infirmaries, assisted living wings, and hospices faster than the state and federal governments can build them—and since many are dying behind bars, they are filling the mortuaries and graveyards as well.

The care these aging prisoners receive, while often grossly inadequate, is nonetheless cripplingly expensive—so much so that some recession-strapped states are for the first time seriously considering releasing older terminally ill and mentally ill prisoners rather than pay the heavy price for their warehousing. It remains to be seen what will happen when such fiscal concerns run head on into America’s taste for punitive justice. A recent report by the Vera Institute made this clear.

Politicians no doubt did not imagine this Dickensian landscape of the elderly incarcerated when they voted to lengthen sentences and impose mandatory minimums three or four decades ago. But their actions are yielding an inevitable outcome.  While the graying of the prison population to some extent reflects the changing demographics of the populace at large, it owes considerably more to changes in law and policy. And this is likely to continue into the foreseeable future.

According to the Sentencing Project, the United States imprisons five times as many people as it did 30 years ago and more than seven times as many as it did 40 years ago. Our criminal justice system now keeps 2.3 million people behind bars—about half of them for drug offenses and other nonviolent crimes. Twenty-five years ago, there were 34,000 prisoners serving life sentences; today the number is more than 140,000. The fact that each person is spending a longer stretch behind bars means that the falling crime rates of the 1990s do not translate into fewer inmates. It also means that more and more people who committed offenses in their 20s or even their teens are growing old and dying in prison.

The situation is particularly stark in California, Texas and Florida, which have large prison populations with cells crammed to overflowing because of harsh sentencing laws. In California, the population of prisoners over 55 doubled in the ten years from 1997 to 2006. About 20 percent of California prisoners are serving life sentences, and over 10 percent are serving life without the possibility of parole. Louisiana’s prison system now holds more than 5,000 people over the age of 50—a three-fold increase in the last 12 years.

While 50 or 55 may not be old by conventional standards, people age faster behind bars than they do on the outside: Studies have shown that prisoners in their 50s are on average physiologically 10 to 15 years older than their chronological age. Older prisoners require substantial medical care, because of harsh life conditions as well as age. Inmates begin to have trouble climbing to upper bunks, walking, standing on line, and handling other parts of the prison routine. They suffer from early losses of hearing and eyesight, have high rates of high blood pressure and diabetes, and are susceptible to falls.

A recent study by Brie Williams and Rita Albraldes, published as a chapter in the book Growing Older: Challenges of Prison and Reentry for the Aging Population, found that in addition to the chronic diseases that increase with age, older offenders have problems such as paraplegia because of the legacy of gunshot wounds. Many have  advanced liver disease, renal disease, or hepatitis. Still others suffer from HIV-AIDS, and many more from drug and alcohol abuse. Living under prison conditions, they are more likely to get pneumonia and flu.

Many prisons are notorious for not taking their inmates’ health complaints seriously, and there is anecdotal evidence this problem may be compounded when prisoners are elderly. A doctor under contract in one southern prison told me in a recent interview how a diabetic man’s illness was misdiagnosed, resulting in months of excruciating pain and the amputation of toes and part of one foot. Back in prison, the man asked for prosthetic shoes so he could get around by walking; his request was denied.

Another elderly prisoner complained of an earache which went untreated for months.  When it became unbearably painful, the prisoner was shipped to a local hospital emergency room, under contract to the prison. There the doctors found the earache was brain cancer—by then, too advanced to treat.

The exploding prison population has further undermined the already questionable quality of inmate medical care. In California, which has the nation’s largest number of state prisoners, a panel of federal judges earlier this year found that the state of medical care was so poor that it violated the Constitution’s ban on cruel and unusual punishment, and was in danger of routinely costing prisoners their lives. The only solution, the judges said, was to reduce prison overcrowding caused by the states draconian mandatory sentences. The court recommended shortening sentences and reforming parole, which they believed would have no impact on public safety; it has given California three years to comply.

To come in Part Two:  Challenging the status quo for geriatric prisoners

The U.S. 9th Circuit Court of Appeals on Friday sent the case of Arizona Death Row inmate Viva Leroy Nash back to a lower court to determine if he is mentally competent to assist in his appeals.

Nash, who turned 94 last week, has a criminal record that goes back to the 1930s.

He spent 25 years in prison for shooting a Connecticut police officer in 1947, and he was sentenced to life in prison for shooting a man to death in Salt Lake City in 1977. But he escaped from a prison work crew in October 1982, and a month later, already 67 years old, he shot and killed a Phoenix coin shop sales clerk named Greg West. He was sentenced to death for that murder.

But Nash’s attorneys argue that his diminishing competence hampers his ability to communicate on legal matters. And on Sept. 11, a panel of judges at the 9th circuit ruled that he was entitled to a competence hearing. The case was remanded to the U.S. District Court in Phoenix