June 24, 2022

Another work week over. This one punctuated by the collapse of Roe vs. Wade in the official release of the Supreme Court’s vote and opinion in the Dobbs case. This is where we are: a political system in which the minority party is busy dismantling the election apparatus in plain sight and a judicial system where the supreme arbiters are hell bent on imposing the world views of a particular religious minority on the majority. I can’t fix any of it so I’m not going to let any of it ruin my life. It will be interesting, however, to see what happens when there is no longer the unifying force of ‘overturn Roe’ keeping all of the disparate groups and agendas on the conservative side of the political agenda pulling together. Will they now start turning on each other over finer points of theology and doctrine? Will the money behind them whip them into a frenzy over a new target? (If this is what’s next, I’m likely to have a large bullseye on my back). Time will tell.

My friends in the local emergency departments are reporting a sharp uptick in people with Covid related illness over the last week. Most are not ill enough to require hospital support and are sent home with comfort meds and prescriptions for antivirals if warranted but the number of inpatients are creeping back up again. The bigger issue for the health system currently isn’t the patients but the workforce. When one of us catches it, we’re out for five to ten days on quarantine and as the case numbers climb, the number of nurses and doctors and therapists and pharmacists and housekeepers and billing clerks going out climbs putting additional burdens on those who remain to close the gaps. It’s leading to more and more erosions of care. There isn’t a specialty service I’ve called with a referral this past month that doesn’t have a six to twelve week waiting list for appointments. If I pull in favors and it’s urgent, I can sometimes get that down to a couple of weeks but forget getting someone in the next day or by the end of the week. Anyone I think’s emergent generally has to go to the ER if I’m going to have a prayer of getting it looked at in a timely fashion. It’s not a great use of ER resources but my hands are tied and my first responsibility is to the needs of my patients.

We’re seeing this play out in another industry, travel. I’m very glad that I decided to forego booking a significant vacation this summer (a combination of needing new kitchen appliances and expenses around the 60th birthday bash took care of that). The news from the front lines of travel, especially by air, is shall we say, chaotic at least and its a world wide phenomenon. It’s driven by a couple of things. The first is an inadequate workforce and understaffing (this one sounds familiar). The rapid fall off in travel in 2020 due to the pandemic led to the airlines hemorrhaging money and, like any for profit business they did what they could to shore themselves up. They offered early retirements and buyouts to senior staff to save on salaries and trimmed their work force. Now, everyone wants to travel again and the airlines just don’t have the flight crews – and it’s not like they can create a pilot from a willing applicant with a couple of weekend seminars, an on line training course and a couple of YouTube videos. Then there’s the lifting of the universal masking mandate on transport. Masking only really works properly when everyone does it and, in the airline industry, it helped keep the chances of flight crew getting ill and out on quarantine lower. Without it, the pilots and cabin crew are more likely to get sick, go out on quarantine and there you have it, not enough on the duty roster for all the scheduled flights to take off. The same thing is happening in medicine, just replace flight with elective surgery or MRI scan with contrast or rheumatology appointment.

The piece of the health system that looks like it’s going to collapse the first is the long term care industry. By the latest numbers, 98% of nursing homes and long term care facilities are understaffed and 73% are in the red as they have to spend additional dollars on agency staff to make up for additional employees coupled with inflation in food and energy costs. The pandemic also has made families rethink when to use group living for elders and a lot of the patients who would have been relatively easy care as their needs are fewer are being kept at home making the per capita acuity of those that remain higher, and therefore more expensive. In the middle of the last century, long term care was mainly a not for profit sector with the nursing home generally reserved only for those who could not be cared for at home by family and often subsidized by either a governmental or religious entity. As the industry was transformed with advances in medicine into more of a step down hospital role, and with more certainty of payments with the introduction of Medicaid for the indigent, for profit corporate entities began to buy up nursing homes as revenue generators and put processes in place to allow for economies of scale. For profit operators aren’t going to want to carry chronically money losing businesses on their books and I foresee a rash of closures coming over the next few years.

Closing nursing homes are going to run into smack dab into several other trends which are pushing the opposite direction. The first is the continued aging of the Baby Boom generation, that huge cohort of individuals that’s just starting to age into the chronologic band where long term care becomes necessary for a portion of the population. The lead edge is 76 this year. They’ll be 80 in four short years and with that, the number who will not be able to care for themselves due to physical and or cognitive decline will start to increase exponentially. The second is the financial strain that Medicaid places on state budgets. Medicare, which is a federal program and solely consists of federal dollars, does not pay for long term care. It will pay for brief stints in a nursing home for rehabilitative purposes to recover from illness or injury if certain conditions are met. If you require a permanent stay, you are on your own (unless you have private long term care insurance – a product that as now near impossible to obtain as it’s actuarially unsound). If you have either exhausted or cleverly hidden your assets from the state, than Medicaid, a joint federal/state program steps in to pay the bill to maintain you.

We don’t tend to think much of nursing home residents as they are a hidden population from society. You don’t see them walking down the street or out to dinner or at the football game but there are about one and a half million nationwide. Roughly 40-50% of a state’s total Medicaid budget flows to nursing homes annually. Medicaid is about 20% of the average state’s general fund spending so nursing homes take about one dollar in ten of a state’s discretionary spending. If nursing homes start to close, there’s going to be an enormous financial pressure on states to try and get out of future nursing home payments as most state budgets are pretty cash strapped. There’s not going to be a lot of push for the public sector to step in with new beds. I think there’s going to be pressure instead to get families to step up and house and nurse their own elders as in times past. There will likely be promise for new pots of public money to provide assistive services to make that more successful but the reality is likely to mirror the deinstitutionalization of the mentally ill some years ago. The mental hospitals were closed but the promised community based programs and funds that were to replace them somehow never materialized.

If you’re in my peer group and contemplating retirement and the unknown country of age and infirmity, it’s a good idea to sit down and make some plans and talk to the kids now. The old models aren’t likely to last. It’s one of the reasons I made my decision a couple of years ago to downsize to this condo. It’s a space I can age in with minimal supports. Take it from the geriatrician. Your golden years are coming, like it or not. Unless, of course, you skip your vaccines, expose yourself to sick people and don’t wash your hands.

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