WHAT DO WE OWE TO THE ELDERLY? The graying of America raises hard questions about who will pay, in time and money, the rising bill for the old. Everybody's in a bind -- taxpayers, the aging, their children.
By Lee Smith REPORTER ASSOCIATE Jennifer Reese

(FORTUNE Magazine) – THE FUTURE has arrived and is available for viewing in Florida, where 18% of the residents are over 65. That's what the elderly population of the whole U.S. will amount to in 30 years; it's 12% now. Much of what's on display in the Sunshine State is agreeable: fit, well-heeled retirees enjoying themselves. But it is also worrisome. As the legions of the very old and sick grow, their care becomes more and more costly. The inexorable demographic march to a much older America presents intense practical and ethical questions. How much of the country's resources -- time and money -- do the elderly deserve? What personal sacrifices should be made to ensure their comfort, to keep them healthy, to prolong their lives? Americans confront these issues every day, whether as taxpayers, as concerned citizens, as children of aging parents, or as the elderly themselves. Those over 65 now consume about one-third of the federal budget, including Social Security. Medicare, which pays hospital and doctors' bills for the elderly, is swelling so fast that President Bush will consider it a victory if he can hold spending to only $93 billion next fiscal year, almost 10% more than this year. A third of the $55-billion-a-year budget for Medicaid, which helps the poor of all ages, goes to those over 65, primarily to support them in nursing homes. Under current law, the elderly will account for at least 36% of all federal outlays when the baby-boom generation starts to retire around the year 2010. By then Medicare will cost more than defense, and the number of ''old old,'' men and women over 85 and most in need of help, will have doubled to six million. By 2030, a staggering 45% of the U.S. budget will go to the old. Clearly that would devour funds for other worthwhile projects, like cleaning up the environment, educating children better, and extending health insurance to younger people with none. Crassly put: Are the elderly worth it? They're already more prosperous than ever, with more discretionary income than any other age group. Each year the inflation-adjusted Social Security benefits paid to new retirees are higher than those for the entering class of the year before. As they age, cost-of- living adjustments protect their benefits from erosion. The growing ranks of the elderly are putting pressure on government to assume more and more of their costs. But in an era where budget deficits are the overriding problem, where will the money come from? For the Social Security system to continue as it is, the payroll tax rate might have to rise from 15% to 25% by 2020 or so, and to an almost unbearable 40% by the middle of the next century. The issues are not merely budgetary. They are complicated, wrenching dilemmas that tell what kind of nation the U.S. is and what kind of society it will become. With 28% of Medicare's budget going to patients in their last year, are Americans paying merely to extend life without making it more worth living? Will the U.S. ultimately have to ration health care and deny it to the very old? Do children have the right to dump elderly parents in a nursing home and expect the state to pay? How do families and government balance compassion for the old against concern for the young? TO HELP AMERICANS think through the pressing questions of the elderly's rights and society's obligations toward them, FORTUNE interviewed doctors, medical ethicists, demographers, Jewish and Christian thinkers, and philosophers for this report. The surprising findings: The U.S. should move toward lightening the burden the elderly place on the taxpayer and restoring more of it to the aging themselves. The message society now gives the elderly is that they have paid their dues and no longer owe anything to anyone. Says the Reverend Dr. Willis Elliott, 71, a minister of the United Church of Christ who is still active as a Biblical scholar: ''The whole retirement pitch is, 'Have fun in the sun, buy into a narcissistic dream.' It robs us of the dignity of service.'' The only way to support the expanding heft of the elderly is a three-legged stool: government, children, and the leg that in many cases could bear more weight than it does -- the old themselves. Here's how they could divide the burden: -- THE GOVERNMENT. It will have to continue paying hospital and doctors' bills -- an assignment so expensive that it won't leave money for much else, like the reimbursement for nursing home and home-care expenses that Senator Edward Kennedy proposes. While pressing hospitals to be more efficient and physicians to settle for smaller fees will help slow the growth in Medicare spending, it will not halt it. Daniel Callahan, 58, director of the Hastings Center, a research institute that puzzles over issues of science and ethics, has upset the geriatrics establishment with a radical argument: Maybe the U.S. ought to ration health care and deny it -- at least in its more heroic forms, like major surgery -- to those over 80, say. Medicare shouldn't pay for big-ticket items past a certain age, he says. If the patient can foot the bill himself, however, Callahan would let him. Over the past decade the average age of people who have coronary bypass surgery has jumped from 55 to 61. Thousands of patients in their 70s have undergone the $25,000 operation. When surgeons began to master the art of transplanting hearts two decades ago they limited the procedure to patients under 50. Now they sometimes sew hearts into people in their 60s. A transplant costs $75,000 to $140,000, and as with coronary bypasses Medicare pays the bill for those over 65. NO OTHER COUNTRY goes to nearly such lengths to preserve life. Japanese surgeons perform no organ transplants. In Britain kidney dialysis isn't generally available to anyone over 55 through the National Health Service. Medicare subsidizes dialysis for more than 100,000 people, half of them over 60, at a cost of more than $2 billion a year. Should the U.S. restrict care along the lines Callahan suggests? Medicare probably ought to draw the line on organ transplants at around age 70, certainly by 75. That kind of money is too much to spend on someone who has already had seven decades of life and may have only a few dreary years remaining even with a new heart. Because coronary bypasses are cheaper, and don't require the donation of scarce hearts that could go to younger people, the government probably should continue to pay for bypasses without an age limit. Callahan's critics complain that he uses age alone as a criterion for rationing. One of them, Dr. Robert N. Butler, 62, head of geriatrics at New York's Mt. Sinai School of Medicine, raises a poignant question: ''What would it mean to my 9-year-old daughter if her 84-year-old grandmother didn't matter?'' Why not ration medical care in other ways, the critics say, if using costly resources most effectively is the object? Maybe extraordinary measures should be denied first to the 10,000 patients of all ages who are in a ''persistent vegetative state.'' Or to premature babies weighing little more than a pound, who may require $100,000 worth of care in just their first few months -- and much more if their brains are damaged. In any case, state courts and legislatures should make it easier for the old to die when they or those they have designated as their proxies recognize that an illness is terminal and that life has become unbearable. Thirty-eight states have laws recognizing living wills in which patients list the circumstances under which they want medical treatment stopped. And in other states judges' rulings have upheld the same right. What remains murky in most states is whether, in the absence of written instructions from the patient, relatives can have intravenous feeding halted along with extraordinary medical measures. Last year the highest court in New York ordered a hospital to continue to feed by tube a 77-year-old woman whose brain had been severely damaged by a series of strokes, even though her two daughters pleaded that she had often told them she didn't want to go on living under such circumstances. The courts, backed up by clear, specific legislation, should allow such requests. -- THE CHILDREN. Most cultures impose a moral obligation to care for aging parents. Both Christianity and Judaism make it plain that a child's responsibility to a parent is fundamental, maybe even greater than his duty to his offspring. As Rabbi Wolfe Kelman, 65, executive vice president of the international Conservative rabbinical assembly, observes, ''The commandment says, 'Honor thy father and thy mother.' It doesn't say anything about honoring children, military officers, rabbis, or anyone else.'' Teachings of the major Western faiths do not specify how to carry out the Biblical order. Kelman would rather have the elderly cared for at home than in nursing homes -- a preference shared by a sampling of thoughtful Christian clergy. A Roman Catholic theologian, the Reverend James Tunstead Burtchaell, 55, of Notre Dame, insists that a child should welcome the burden of an infirm parent: ''We need to be stuck with some people, even sick people. It matures us because it forces us to rearrange our lives, and in doing that we become more generous.'' In fact most of the elderly are cared for at home. Only about 20% of those over 85 are in institutions. Carrying out the Fourth Commandment generally falls to middle-aged daughters and other female relatives. Many families are pressed from both sides. A large slice of the middle-aged population is a ''sandwich'' generation, caught between the demands of college-age children on one side and ailing parents on the other. Author Ken Dychtwald (see page 62) predicts that with grandparents and often great-grandparents living on and frequently needing care, the small, child-centered nuclear family will decline, to be replaced by adult-centered multigenerational groups. Representative Claude Pepper would like government to assume much of the cost of caring for the invalid elderly at home by reimbursing families for medical equipment, nurses, and other help. Compassionate, but recklessly expensive. By a Health and Human Services Department estimate, so many would apply for help that Pepper's proposal would cost $20 billion annually by 1991, about as much as the entire farm subsidy program in a typical year. Pepper also failed to include a means test, ignoring the fact that not all children need financial help to cope with aging parents. Looked at from the other direction, government cannot compel family members to take responsibility for their old. But morally, how much should children have to sacrifice? Father Burtchaell has a point about the spiritual rewards of caring for the helpless. American society probably overvalues those who are productive, or at least busy, and fails to cherish those who are dependent through no fault of their own. But families can take only so much. Not all have the endurance to live with an advanced Alzheimer's patient around the clock. IF MOTHER has to be sent to a nursing home, how much should the family cut back other expenses? Clergymen are inclined to argue that if the price of sending granddaughter away to college, rather than to a less expensive local school, is to put grandmother in a nursing home that barely clears minimum standards, granddaughter ought to stay home. Says the Reverend Martin Marty, 61, a leading Lutheran scholar at the University of Chicago: ''Youth can take care of itself better. Old people alone are vulnerable.'' But when the trade-off is between a top-of-the-line nursing home (up to $60,000 a year) and, say, Harvard ($18,000 a year), the answer changes. The elite nursing home is not essential. Says Burtchaell: ''We tend to spoil old people the way we spoil children. We ignore them and then out of guilt lavish extravagances on them.'' In this case the high-priced college probably has the better claim on family resources. The rewards of a first-rate education last a lifetime, while the aged don't necessarily live better or longer in luxurious nursing homes than in those that are simply good. -- THE ELDERLY. No one owes the old more than the old themselves. In almost every sense the elderly have never had it so good. The notion persists that in preindustrial America the old were more secure because the young honored them as masters of ancient crafts and interpreters of the communal past. Not exactly. After poring over records from colonial New England, Yale historian John Demos, 51, concluded that the old were prized according to the amount of land and money they controlled. So at the Hampton, New Hampshire, meeting house in 1650, for example, the town's oldest citizen, William Cole, 79, a man of little property, sat in the back row. Thomas Ward, 31 and a comer, sat up front. The old now have more rights, which is as it should be, but few more responsibilities, which isn't. Those over 65 are healthier than ever and can work longer. If the age of eligibility for full Social Security benefits were moved up to 70 in gradual steps over the next 20 years, millions more would stay in the work force -- which would come in handy, since the U.S. is heading into a period of labor shortage. At present Social Security income is taxed at no more than half the ordinary rate. Because the better-off elderly can well afford it, for people with incomes over $30,000 or so Social Security payments should be taxed at something near the full rate for other income. The major sacrifice the elderly have been asked to make has enraged many. Since the start of the year those with bigger incomes have been required to pay higher premiums, up to an additional $800 a year, for Medicare so that everyone over 65 can be covered for catastrophic illnesses that require long hospital stays. That seems fair. Wealthier retirees should also have higher deductibles for Medicare: They now pay only $75 a year, regardless of income. Some corporations require higher deductibles from upper-income employees for private health insurance. The healthy old, rich in time, could volunteer their labor to the frail. To be sure, thousands of elderly people take on all kinds of useful projects, but not nearly as many as there are opportunities. Lots of Florida's two million residents over 65 live in ''adults only'' communities. As uninviting as such places may seem to those who prefer heterogeneous company, they at least offer a convenient meeting ground where the old can take care of one another. Unfortunately, they rarely do. A barrier of understandable anxiety separates the able from the helpless. At Lakeshore Villas in Tampa the fit and tanned retirees at the mobile home park stay away from the health care center, which is a nursing home for Alzheimer's and stroke victims, among others. ''They like to know we're nearby in case they need us,'' says Jack Freeman, 41, the center's executive director. ''But they don't want to visit, because that means facing up to the greatest fear in their lives.'' FREEDOM SQUARE is a somewhat fancier community in Seminole, but attitudes are much the same. The hardy avoid the nursing pavilion, where at least some of them will ultimately wind up. The pavilion employs about one staff member for each of its disabled residents, which helps explain why the rates are a stiff $78 a day. Some 14% of the patients get Medicaid. With a little training, volunteers could take over much of the semiskilled labor such as feeding and washing, the core work of a nursing home. No doubt it will be tough to overcome the resistance of vigorous retirees and turn them into elder-care volunteers. Says a nursing home director: ''They'd rather work at McDonald's and hire a kid to work for them in the nursing home.'' Well, why not? Another solution might be to offer retirees an insurance policy of sorts. For every hour they work in a nursing home, or take care of someone confined to her own home, they would get credits entitling them to free care should they need it. Aging is a difficult, disturbing idea for most Americans. Perhaps that's because the society has so long focused on youth, or because the U.S. is so prosperous and medically sophisticated that anyone's inevitable decline is seen as some kind of failure. Even with the best of wills, there are limits to what the rest of society can do -- either publicly or privately -- for its aged citizens. Dylan Thomas had some good advice about not going gently into that good night. If the elderly can take that to heart and stop thinking of the burden of old age as somebody else's problem, there's no telling what imaginative remedies they will produce.


Families scout for the right college for the children at their leisure. When they hunt for a nursing home for the parents it's generally in a crisis. Here are a few guidelines: -- The U.S. Department of Health and Human Services publishes a 75-volume, state-by-state listing of 15,000 nursing homes that it has spot-checked on such items as whether the residents' hygiene needs are attended to. (About 25% flunked that particular test.) The directory is available at some senior citizens' organizations and public libraries. -- The American Association of Retired Persons publishes, free, Nursing Home Life: A Guide for Residents and Families, which suggests some questions families should ask the director. Example: If the resident is rushed off to a hospital for emergency care, will her room at the home be reserved for her return? -- Before Mother moves in, the family should ask to have a meal at the home with the residents. How is the food? How are the residents' spirits? -- Pick a home that family and friends can get to easily. Cherilyn Poulsen, administrator of Manor Care Nursing Center in Potomac, Maryland, says staffs generally pay more attention to residents who have frequent visitors.