- BIOETHICS FORUM ESSAY
When I’m 64 (and Then Some), Who Will Care?
The recent report from the United States Census Bureau, 65+ in the United States: 2005, brought welcome news. The population of Americans over 65 is healthier and less burdened by disabilities than earlier generations of older Americans. The improvement in health expectancy is attributed to greater prosperity and higher levels of education among today’s elders – trends that will continue, the study’s authors speculate. The trend is heartening not only for this burgeoning population and their families, but also for local, state, and federal officials fearful of what is often described – in the words of one National Institute of Aging official – as a potentially “devastating drain on government coffers.”
Yet as good as the news seems to be, we should not exhale yet. When it comes to aging in America and public policy, there is still a lot to worry about.
The United States is facing what some describe as a “care gap” and others call a “care crisis.” It is estimated that the nation will need three times the number of “formal” caregivers – nurses, nurse assistants, nurse aides and home health aides – now employed to meet the needs of an aging population. Given the census data, this need may not be as great as was predicted, but it is still substantial, especially when we take into account existing shortages, and the fact that it is the population of Americans 85 and above that will see the most dramatic increase. The turnover rate in direct care work, which is done mostly by women (many of them women of color and an increasing number of them immigrants), is at an unprecedented level, and some positions now go unfilled. Nor should this be surprising, given that it is strenuous, even hazardous, and for nurse aides and home care aides also pays poorly (often barely above minimum wage), frequently lacks health insurance, and has limited opportunity for professional advancement. By all accounts, too, these problems are expected to worsen unless we take steps to address them.
“Informal” caregivers, too, are mostly women. Although they tend to be in the paid labor force (which is a shift from earlier eras), they still tend to take on the role of caregiver in families – to be pushed into it by gender norms, inequitable pay, and a health care system built around acute care and early discharge. They too face considerable social, economic, and health consequences as a result of taking on this work, the estimated value of which is over $250 billion. Many leave the labor force, or work fewer hours and take unpaid leaves, making them financially vulnerable over the long-term. Leaving jobs or working less often means losing health insurance. At the same time, a significant number of family caregivers face chronic stress and are at heightened risk for poor physical health, depression, and death. Even if the years ahead do see a drop in the percentage of older people with disabilities, and a shift toward a later onset of disability, these problems will remain. Indeed, it may be that the greatest problems we face when it comes to aging in America concern the scarcity of caregivers, the scant support they receive, and the implications of this state of affairs for the quality of care given to the elderly and dependent, however many there are.
It is also worth remembering that the current and soon-to-follow populations over 65 have been the beneficiaries of generous corporate health and pension plans, as well as expansive government programs in public health, education, health care for the poor and disabled, and occupational health and safety. But these programs have been on the chopping block. Given the retrenchment in such programs and ongoing pressures to cut costs, not to mention the mounting federal deficit, it is far from clear that future generations of older people will experience the same high quality of life as many of today’s aging Americans.
Instead of breathing easier, then, and using the report to justify spending cuts, we ought to be thinking about how can meet our obligations to the aging population and to those who care for them. We need to be thinking about strategies that will encourage people to enter and stay in the professional fields of caregiving. We need to be thinking about greater incentives for education in geriatrics and nursing, equitable pay, worker safety and career advancement, and more protections for immigrant caregivers. For family caregivers, we need to be thinking about workplace reforms, including more meaningful family leave policies, work at home options, and flex time. We need to be thinking more about strategies to support those who give care full time – stipends, tax credits, and credit time for Social Security, for example. We need to be thinking more about respite care and increased funding for caregiver support programs. And we need to be thinking about access to quality, affordable health care for all people, and transforming the health care system to allow for greater integration and coordination of services for caregivers and the elderly.
This is the least we might do for the aging population – our parents, grandparents, and great-grandparents, the people who have made us the people we are and who have built the country we inhabit – and for those who do the work of caregiving, the most important work in any society.
Lisa Eckenwiler teaches philosophy at Old Dominion University and is a visiting fellow at the Center for American Progress in Washington, D.C.