January 22, 2023

I’ve been thinking a lot about death. Not in a particularly morbid way and I’m not especially concerned about my own, despite the fact that I am now on day number twelve of the never ending respiratory viral illness, but in a more existential way. We live in a death denying society. The sometimes messy and painful processes of the winding down of our biologic selves had been removed from sight and as part of private family life into the alien world of hospitals and nursing homes. By the last quarter of the 20th century, fewer than 15% of US deaths happened at home. Shifting public opinions regarding end of life and the rise of the hospice movement began to change this and through the first two decades of the 21st century there was a steady rise of home deaths to something between 25 and 30% of deaths by the end of 2019. The world turned upside down in the spring of 2020, of course, and the 1.1 million US deaths caused by the Covid virus over the next three years occurred predominantly in hospitals and home deaths were very uncommon from this disease, reversing this recent trend.

We’re heading into a new equilibrium. It’s too soon to tell what the pandemic may have done to the American way of death. My guess is we’re going to see a major rebound towards home death, driven by the reduction in capacity of the nursing home sector (pandemic job market changes are making it nigh on impossible for nursing homes to staff and stay profitable and they are closing rapidly, especially in rural areas), and by the personal economics of families who just don’t have the financial resources for long term care. Remember kids, nursing home care is not a Medicare benefit. It may be a Medicaid benefit but Medicaid is different in every state with very different eligibility requirements and payment systems and alternatives. In Alabama, Medicaid only pays for nursing home care, not for assisted living or for in home care to prevent nursing home placement (with limited exceptions under a program known as Medicaid waiver). Other states use their Medicaid dollars in other ways or may have a larger tax base to offer more generous programs.

There is private long term care insurance which will pay for these costs but, for the most part, these products have proven actuarially unsound and are no longer sold so if you haven’t already bought a policy, you may be out of luck. There are still some on the market but the premiums are extremely high and they are pretty unaffordable to all but the highest socio-economic strata. Consequently, as the Boom generation starts to enter it’s dying off years, most of them will die at home cared for and observed by their families, biologic or of choice, and this is likely to cause some significant changes in how our society views mortality over the next few decades, especially when added on top of the somewhat shell shocked state we find ourselves in as the pandemic continues to percolate along in the background, always threatening to explode once more.

The Boom generation is enormous. 76 million babies were born in the US during the boom years. Accident and bad luck has carried off some at early ages but about 60 million of that cohort remain living. And then they’ve been joined by another 10 million in that age group who immigrated to the US at some point so there’s about 70 million in the demographic band between 58-76 today. The lead edge of the boom, born 1946, is busy turning 77 (think Dolly Parton, Sylvester Stallone, and Cher). US life expectancy is now currently 76.1 years (having dropped significantly from 78.9 a few years ago due to Covid and the opioid crisis). The unstoppable force and the immovable object are just about to collide…

Now it’s a somewhat specious argument as life expectancy is a calculated statistic that suggests the average length of life of a baby born today and really has nothing to do with the health and senescence of older individuals. The rapid drop is because of the number of young people who have died recently of Covid and overdoses. The younger a death, the more impact on life expectancy. Life expectancy for a 75 year old in the US is roughly 11 years so most of the boom is going to be around for another couple of decades. If you look at the projections, and we assume that there isn’t a new pandemic or major climate alterations that cause famine, Boomer deaths really start to take off around 2030 when the oldest boomers are in their mid 80s. 40% of the boom population dies in the 2030s. 45% dies in the 2040s. They’re demographically irrelevant after 2050 even though the very last member of the US boom cohort won’t die until sometime around 2080.

What’s going to happen first, and is already happening and you’ve begun to notice if you’re paying attention, is the death of the cultural figures who created the pop culture of the 1960-1985 from which the boom takes its identity. They tend to be a few years older than the boom, young adults when the early boom was still in its adolescent phase. The most recent is David Crosby who died this past week at age 81. Paul McCartney is 80. Francis Ford Coppola is 83. Robert Redford is 86. As the boom has been such a force in American culture for so long, its icons have remained constantly with us for five, six and seven decades in the public eye. They’re mortal. They’ll start falling and over the next decade or so the pace is going to accelerate. American culture has, in some ways, been in stasis for some time to boom norms with younger generations not really being able to make significant impact on our understanding of the world.

That’s about to change. The old will die to make room for the new. That’s how nature is designed to work. My favorite symbol of this rebirth and renewal is the phoenix, made hip again by Harry Potter a few years ago. Because of my arts work and my teaching, I mix with Millennials and Gen Z all the time, They’re bursting with ideas and with life, and with new perspectives. I’m looking forward to seeing what all they come up with and, if I have to get out of the way to let them do it, fine with me. We’re going to see some battles though. I can’t help but think that, at its core, the current fuss regarding transsexuals and drag queens is a generational battle. Generation Z has decided to toss old ideas of gender expression out the window in favor of freer and more human ways of experiencing the world. Boom and Gen X politicians and religious figures, raised with tight binary views of gender are digging in their heels and, as they control the levers of power, we are where we are. They won’t always have the control they have now. Change is inevitable. You can either accept it and ride it or you can be left whining and irrelevant. Death, life. Just points on the ever turning wheel.

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