October 24, 2021

It’s been six days since I wrote a long piece. In my head, it’s coming out in Gloria Stuart’s Old Rose voice along the lines of ‘It’s been 85 years’ as if there’s something seriously wrong if I don’t churn out some piece of gentle wisdom a couple of times a week. Nothing’s wrong. All is as well as can be expected within the borders of Andydom I just went to the theater and the movies this weekend rather than staying home and writing a think piece. That’s the problem with writing a book that people are actually buying and enjoying. There’s a certain amount of energy unleashed back at you that seems to demand that you come up with a new project. And, if that’s going to happen, I have to keep writing. Someday I may even figure out what it is I’m writing about. I’m uncertain if I’m currently still writing a plague diary or if it’s morphing into something else as the Delta wave recedes and we can all continue to pick up the pieces of health care and keep moving forward.

Local numbers continue to decline. The number of hospitalized patients at UAB this weekend is down to a couple of dozen, about the same as it was early in the summer before the numbers began to skyrocket with increasing Delta variant infections. I am under no illusions that we’re done with Covid though. Vaccination rates remains significantly below where they should be and, with that remaining the case, we’re still sitting ducks for the next variant that Improves transmissibility or causes more serious illness than those that are currently circulating. I don’t know if the health system can survive another major wave or two. The majority of practitioners of my generation are making their exit plans, burned out by the experiences of the last eighteen months and the younger ones, who still have time to revamp careers, are starting to look at less stressful ways to make their living. I don’t think we’re going to run out of doctors in the near future and medical school class slots are hardly going begging; it’s the positions that allow doctors to actually do their jobs that are becoming harder and harder to fill – nursing, medical assistants, nurse’s aids, and all the other support staff. Finding quality candidates for good jobs at both UAB and the VA is starting to become more and more difficult and I’ve had some conversations with health care entities outside of my big systems and they’re having an even tougher time finding the staff they need.

This is going to create a major issue in the next decade as the aging baby boom, whether they believe it or not, is going to start having to deal with the chronic illnesses and infirmities of age and are going to start requiring professional assistance to maintain their lives (the advanced and instrumental activities of daily living as those of us in the biz call them – these are the things you have to have a system in place to live as an independent adult in our society. There are various lists, but the big four for aging are meals, wheels, bills and pills – this is what I teach my residents to check into when they have an older patient). The basic activities of daily living are those you have to be able to do to maintain your own body. Most of us have been pretty good with these since about age five – anyone who gets out of bed in the morning, heads into the bathroom and gets ready for the day on their own has got them covered.

Twenty years ago, there were roughly 30 million Americans over 65. Of these, about five million required assistance from someone to maintain in the community and another one and a half million lived in a nursing facility. These days, we’re at about 50 million Americans over 65. They’ve actually become more functional with nursing home residents down to about 1.3 million and a smaller percentage depending on help at home. However, the rise in population has drowned out thes percentage gains and we’re up to about seven and a half million needing help at home. In 2030, eight years from now, these numbers will go up substantially as the older boomers start to ender their latter 80s and the great boomer die off of 2030-2050 begins. They’re likely to need more and more in home workers due to cultural shifts of the last half century. More boomers are entering elderhood single than in previous generations. (Something like 60% of women over 80 live alone). Children are fewer and more apt to live in a different geographical area than their parents. Informal networks like clubs and churches are less strong as people have withdrawn into suburban cocoons. This means the demand for paid help in the home is going to grow exponentially just at a time when the industry is shedding workers due to the changes wrought by Covid.

And these are the kinds of side effects of the pandemic that those who are blithely ignoring public health measures or who have chosen political stances incompatible with good social order are not considering. when they make their defiant proclamations. Their decisions which allow for a deadly virus to keep circulating and stressing the health care system will keep the health care system from functioning as it should. It’s had serious issues for decades due to its business models and if the people who keep it propped up abandon it for easier careers or for retirement or just because of plain old burnout, what then? If the number of skilled providers of in home support and health services declines as the population ages, Adam Smith’s laws of supply and demand suggest that these services will only be available to the wealthiest. If nursing homes cannot hire staffs and are cited by governmental regulators, the corporate owners will close them as bad investments and no one will want to open new ones. Governmental entities could potentially close the gap but there’s no interest these days in raising taxes to enhance social services. The current infrastructure bill is in general funded in ways other than tax increases and that sort of slight of hand can’t be kept up forever. If we returned to the tax schedule of the 1970s, pre Ronald Reagan, we would have collected 26 trillion dollars over the last forty years for the common good that went instead into private hands. (Staying out of disastrous military adventures would have garnered us another fifteen trillion or so…) We the people decided to go a different way so we the people must live with the consequences of those decisions.

Most of us do not have the resources we will need for old age. We can usually thrive if our bodies and brains will allow us to remain independent, but for those of us where that is no longer possible, the costs of long term care are astronomical (and not covered by Medicare – they are covered by Medicaid if you are impoverished, at least on paper but as these costs are rising rapidly in state budgets, states are actively looking at how to shift them back on the population at large). If you want someone to come into your home and assist, figure $15-25 an hour for non skilled care. If it’s a skilled nurse, double that. If you want to live in a senior community with assistance, figure $3,500-5,500 a month plus buy in fees for the more upscale. If you need to live in a nursing home, figure $5-7,000 a month. The average liquid asset life savings for an American retiring today is just over $100,000. That’ll buy you about fifteen months of nursing home care. The average person who enters a nursing home for long term care is there for between four and five years. I have a lot I could say about nursing home care. There are a lot of wonderful people dedicated to the field who do the best they can, but the way the industry runs is not friendly to innovation or support of good employees. But that’s a subject for a different rant on a different day.

I didn’t have any idea when I began this piece that it was going to be about long term care. It’s just what came out this evening. All I can hope is that those, especially those in significant positions of power, who continue to defy public health and logic are going to be prepared to deal with the mess when the other dominos start to fall. The attorney general of Alabama has been grandstanding again that Alabama won’t let employers or those offering services to the public mandate vaccination. He and the governor can posture all they want but UAB, the largest employer in the state, is mandating vaccination. They have to. It’s a requirement for all federal contractors via executive order and UAB isn’t about to leave tens of millions of dollars on the table so some yahoos in Montgomery can bloviate in front of television cameras. My other major employer, the VA, is also mandating vaccination as the same executive order is requiring it of all federal employees. I’m glad I can go to work and not have to worry too much about whom I am passing in the halls. Governor DeSantis is trying to get a $5,000 bonus payment to hire out of state police officers who refuse vaccination and have them come work in Florida. I’m not sure that filling the police departments of Florida full of the sorts of folk that are vaccine deniers is the wisest of ideas, especially in this time of increased public scrutiny of bad behavior by the police – but that’s just me. I have a feeling that the state of Florida will end up paying some very large settlements after a certain type of bad apple moves in and goes to work. The voters of Florida are getting what they voted for. It’ll be interesting to see if they keep voting that way in the future.

I could keep on with this drivel for a few more paragraphs, but I’m due at a birthday celebration so I’m going to sign off. Yes, I’ll wear my mask, wash my hands, and I’ve had my booster.

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