Dealing with health means dealing with health care. The older we get, the more we’ll be dealing with both of them.
For most Americans over 65, health care depends on Medicare. Sadly, Medicare is a mess. It’s been shaped by the competing priorities of insurance companies; pharmaceutical and medical equipment companies; hospitals and other venues for providing medical services; organizations representing doctors, surgeons, nurses, and other providers; politicians; religious leaders; and last, and least, we the “consumers.” Key aspects of Medicare are frozen in 1965, many needs aren’t covered (like dental care, hearing aids and long-term care), and choices are governed by byzantine rules and processes.
Still, for relatively healthy people between the ages of 65 and 85 (or so), Medicare works as well as or better than any other health insurance plan in America.
Medicare is good at preventive care, knee and hip replacements, cataract surgery and other limited fixable problems. It provides effective management for high blood pressure, acid reflux, high cholesterol, even arthritis. Faced with a virtual epidemic of diabetes among elders, Medicare is encouraging best-practice approaches to managing diabetes. If you have a heart attack or a stroke, Medicare will be there for you (up to a point).
But Medicare fails to ensure good care for those who need it most – old people with multiple chronic ailments, who have frequent health crises and mini-crises, and who may be impaired by dementia, arthritis, blindness, deafness and other conditions causing them to need help with the most basic activities of life. This growing population is poorly served by Medicare or anything else.
Just ask family caregivers! A Life Worth Ending, by Michael Wolff, is only one example that details the multiple obstacles making it harder to get good care for his mother. In many cases, our health care procedures seem like the opposite of good care.
Medicare’s goal is laudable – to provide old people the same health benefits available to other adults. But old people with multiple worsening ailments are not like other adults. Mainstream medicine, so successful at combating disease and prolonging life, is unsuited to managing those prolonged lives.
Like pediatrics for children, there’s a specialized branch of medicine for old people – geriatrics. But geriatricians are in short supply. There are currently fewer than four geriatricians per 10,000 citizens over 85 and the number is dropping. Most physicians who see old people in emergency rooms and urgent care centers are unschooled in geriatrics. They respond to incentives for aggressive treatment as well as their own desire to “do everything possible.”
It’s usually a good idea to look ahead, especially if there’s no one to fall back on. If we understand the options, we can make our wishes as widely known as possible while we’re still competent. (Preparing for the Inevitable). Then we can pray that health professionals don’t override our wishes in their eagerness to save us.
Since people are living longer in states of incompetence, health surrogates will be making medical decisions not usually considered part of end-of-life planning. For our wishes to be followed when we’re beyond self-advocacy, to avoid imposing a terrible burden on surrogate decision-makers, and to avoid decisions that result in treatments we wouldn’t want, we need to look ahead and start planning now.