CHAPTER FOUR
Navigating the Baby Boomers’ Perfect Storm
The baby boom generation has always felt secure, knowing that our last chapter will be longer, wealthier, healthier than our parents’. Imagine our surprise when we arrive to find the eldercare infrastructure overwhelmed and crumbling.
—Carlos, physician and focus group participant
If you’ve read this far, I’m hoping you are now intrigued by what the Other Talk can offer you and your family: a chance to discuss with your kids the various issues and options that arise in the last years of life; an opportunity to create a road map for decision making during the inevitable role reversal that will occur as you get older; and an occasion for you to teach, probe, think about, and share ideas with your kids about the end of life—not only dying but also coping with the aging process.
And if you are in this generation, the Other Talk you have will be uniquely your own because you will experience your last years in ways previous generations never did, as you have with every other stage of life.
The good news is, of course, that you will be able to enjoy a longer, healthier, more active lifestyle in your senior years. And with the unprecedented wealth accumulation piled up by this generation, according to Fidelity Investments, you can expect to have a whole lot more fun.
The flip side of these happy circumstances is what makes the Other Talk not just an opportunity for you to bond with your kids but also an imperative if you are to have any hope of managing the rest of your life. The reason, quite simply, is that a “perfect storm” has been brewing in geriatric care in recent years, and it will wreak increasing havoc as more and more of us reach 65. This means that you and your family are going to need a real sense of urgency to plan and prepare for a whole new set of challenges when you enter your last years.
Here are the three phenomena that power this generation’s perfect storm: an escalating demand for resource-intensive healthcare, greater longevity, and a declining supply of medical practitioners.
An Escalating Demand for Resource-Intensive Healthcare
Starting in 2010, the 77 million baby boomers began our march into retirement. This unprecedented demographic movement will continue to have a profound impact on U.S. society and its healthcare system for generations to come.
In 2011 alone, the number of people in the United States celebrating their sixty-fifth birthday jumped 21 percent, from 2.7 million to 3.3 million, according to 2010 U.S. Census Bureau projections.
The ranks of Americans aged 65 and older are projected to more than double by 2050, from 40.2 million to 88.5 million. They’ll comprise 19 percent of the population in 2030, compared to 13 percent in 2013. The 85-and-older population will be our fastest-growing segment, projected to grow from 5.8 million to 19 million by 2050, according to the U.S. Administration on Aging.
The implications of this tidal wave of new geriatric patients are momentous in part because of the sheer numbers alone but also because of the type of healthcare involved: the average retiree requires healthcare that is many times more resource intensive than the average American. In fact, the 13 percent of our population over 65 today uses a disproportionate amount of services, according to a 2009 study by the American Hospital Association:
38 percent of emergency medical service responses
35 percent of prescriptions
26 percent of physician visits
Finally, it’s worth noting that in general, the number of family caregivers is dwindling, for several reasons. First, Americans are having smaller families than generations have had in the past. Second, Americans’ greater geographical mobility means your kids may be dispersed across the country and less available for caregiving. And third, dualcareer households mean that the traditional stay-at-home wife taking care of Mom and Dad is often no longer an option.
While the ramifications of the baby boomer takeover of the retirement segment may be multilayered, complicated, and daunting for the healthcare community, they are quite simple for you and your family as you enter your final years: from now on, the competition for geriatric healthcare resources will become fiercer with each passing year.
You and your kids need to start preparing.
Greater Longevity
The duration of the “elderly” years has mushroomed over the past three decades, as life expectancies have increased for older Americans. In fact, an American who reaches age 65 can expect to live on average another 18.5 years (16.8 for men, 19.8 for women), according to the National Center for Health Statistics.
But there is a downside to all those extra years. The fundamental drivers of this increasing longevity are the groundbreaking medical advancements that have been made in the detection, diagnosis, and treatment of health issues, along with a more concerted commitment to healthy living. The result is that people are dying gradually rather than suddenly, which was the norm in previous generations. For example, according to an annual study by the Centers for Disease Control and Prevention, deaths from heart attacks have dropped 61 percent from the rates of 30 years ago. Stroke fatalities have declined even further, 71 percent, over this same period.
Of course, people are still dying; they’re just taking longer to do it. In recent years, “incremental killers” have become much more common. Deaths from chronic respiratory disease have increased 77 percent in the last 15 years. Deaths from Alzheimer’s disease increased 68 percent between 2000 and 2010, and the number of global cancer deaths is projected to increase 45 percent from 2007 to 2030.
The upshot is that the cost implications of living longer lives are significant. As older Americans make up a larger proportion of the population, the resulting increase in the numbers of people with chronic health conditions like Parkinson’s disease, arthritis, diabetes, heart disease, and almost all types of cancer will create a huge demand for healthcare and social services.
To add to the strain on an already challenged medical care delivery system, as of 2014, approximately 30 million more Americans than in the past will have access to health insurance under the Affordable Care Act.
The implication for you and your family is that longer life will very likely mean a greater need for the family to cover assisted-living and medical expenses.
You and your kids need to start preparing.
A Declining Supply of Medical Practitioners
What ultimately whips the world of geriatric care into a perfect storm is that the exploding demand is about to run into faltering supply.
Over the next 30 years, our sheer numbers and the extent and duration of our medical requirements will drive up the need for quality healthcare exponentially. Yet practitioners who deliver geriatric medical care—primary care physicians, nurse practitioners, and geriatricians—are already in short supply, and their numbers are projected to fall further behind exploding demand, as can be seen in this illustration.
The Declining Supply of Medical Practitioners
Primary Care Physicians
Primary care physicians are critical to the care management of the chronic conditions that older Americans will inevitably face. Yet, just as we baby boomers are entering this phase of our lives, medical students have been opting for the specialties.
In 1960, half of all physicians in the United States were in primary care. By 1978, the percentage had fallen to 36 percent, and in 2010, it was down to 33 percent. The root causes for this migration appear to be a combination of lifestyle and compensation. Specialists generally have shorter hours and limited on-call schedules. Yet their median income sits at $384,467, versus $212,840 for primary care physicians, according to a 2012 survey by the Medical Group Management Association.
So it should be no surprise that, as reported in a 2013 study by the National Resident Matching Program, only 39 percent of the graduating classes of medical schools are entering residency training in primary care.
To make matters worse, the number of federally funded residencies has been frozen since 1997. (Residencies are the three to seven years of on-the-job training in the United States that medical school graduates must complete before they can practice independently in this country.)
Medicare funds most of the residencies, paying $9.5 billion a year to subsidize 94,000 positions at teaching hospitals. Medicaid and other sources fund about 10,000 more. But as baby boomers and new beneficiaries of the Affordable Care Act flood the market and demand accelerates, government support for residencies (future doctors) remains static.
But there’s also a qualitative challenge that this generation will need to confront, as described by an internist in one of my focus groups:
Because fees are fixed by Medicare and insurers, the only way primary care doctors can generate more revenue is to take on more patients, which means spending less time with each one. Yet the most common complaint you hear from patients is, “I don’t have enough time with the doctor.”
They’re right. You can’t take good care of your patients with chronic conditions in less than 15 minutes.
Nurses
The picture is equally dire in the nursing profession. Today, more than 8 percent of nursing positions nationwide are vacant.
To make matters worse, dramatic technological improvements in healthcare in the last 20 years mean even more nurses are required, especially those with comprehensive training, because there are more diagnostic tests to run, more medications to administer, and more machines to monitor. Demand for registered nurses is expected to grow 26 percent from 2010 to 2020, according to government statistics.
Geriatric Specialists
Then there are the geriatricians—that is, doctors who have taken an additional year of training after a three-year residency in family or internal medicine. In many ways, this practitioner group is uniquely qualified to treat older Americans because, rather than just focusing on cures, they also spend time helping patients to maintain their independence and to age as well as possible.
Yet perhaps because geriatricians average $240,000 a year in salary, about half of what radiologists, gastroenterologists, and cardiologists make (according to the American Medical Group Association), their numbers have fallen by one-third in recent years. In fact, today there are only 7,600 geriatricians nationwide—not enough to meet current demand and far below the 36,000 needed by 2030, according to the American Geriatrics Society.
Home Care and Nursing Home Aides
Finally, there is a growing shortage of support staff in this field. Just as my generation heads into retirement, reports an April 2013 Wall Street Journal article, “nursing homes and operators providing home-care services already are straining to find enough … care workers.” This is a particularly acute problem because most of the demand in geriatric care is for one-on-one custodial care. These workers help with things like bathing, grooming, dressing, meal preparation, transportation, social services, and shopping—help that can’t be automated as the demand for these services escalates.
The clear implications for you and your family are that the days of your doctor providing continuity of care and guiding you through the complex medical system are most likely numbered, leaving you to navigate on your own.
Available Public Resources
Starting in 2010, an enormous segment—43 percent—of the working population began to retire and transform from taxpayers to government beneficiaries, according to the Census Bureau. Because the next generation is 34 percent smaller than my generation, the workforce will grow more slowly, as will tax revenues to finance Medicare, Medicaid, and Social Security. At the same time, healthcare inflation, which is driving up the bill for Medicare and Medicaid, could send the federal budget deficit skyrocketing.
While we won’t know the outcome of the current debate about medical spending priorities and budget deficits raging in Congress and across the country, perhaps for years to come, it’s obvious that changes to the delivery of medical care to older Americans will occur.
One thing we do know for certain: the rules of the game and public resources available will look vastly different than they do today.
Clearly, you and your kids need to start preparing.
You should have the Other Talk now—then keep on talking!
You need a game changer if you are to successfully navigate the medical and many other challenges that you will face in your later years.
The Other Talk is one important tool to help you achieve that because you need partners (your kids) and a plan that prepares you and your family for the roles you all will play in your later years.
And because you can’t know how things will turn out, you’ll need to have the Other Talk on an ongoing basis. The next two parts of the book will show you how.