Gray is In

This past week, the Wall Street Journal ran an article titled, “The Hottest Hair Color of the Moment is…Gray.” Granted, it was in the “style and fashion” section (who knew there was such a thing?). Presumably, the WSJ was interested primarily because the market for hair dye is enormous. What is the significance of this trend? 

The article raises the possibility that the development represents a changing view of beauty, and perhaps even more fundamentally, a changing view of aging. Change in societal attitudes towards aging would be most welcome—and with the proportion of the American population that is over 65 now 15 percent, and expected to rise to 24 percent by 2060, overdue.

It would not be the first time that attitudes underwent a profound shift. In colonial America, historians David Hackett Fischer (Growing Old in America, NY: Oxford University Press, 1978) and W.A. Achenbaum ("Old Age in the New Land," Baltimore: Johns Hopkins University Press, 1980) both argue, most older people received “deference and respect [although] little love or affection.” This attitude reflected the Calvinist tradition, which venerated old age as “proof” of God’s favor. In New England, the choicest seats in the meeting house were accorded the oldest members—not those who made the largest donation. Distinguished statesmen wore white wigs as a mark of sagacity. 

George Washington on his horse

But the view changed by the post-Civil War period: Fischer says the transition to a youth-biased culture occurred between 1770 and 1820; Achenbaum places it in the 1860s, but somewhere during that time, old people fell out of favor. Arguably, things got worse in the twentieth century, with social security resulting in resentment towards older people.

But whether it was a social revolution (the rise of egalitarianism after the French Revolution) or the industrial revolution (the decline of agrarian paternalism and the demise of primogeniture that had kept the young under their father’s yoke) that triggered the shift, there is no doubt there was a shift. Today, by contrast, the major change is demographic (in 1700, an estimated 20 percent of the population could expect to live to age 70; today, 80 percent can) and medical (today, many older people remain vigorous for many of their post-retirement years). The social reality is that older people in the workforce limit the possibilities of the young—the most egregious example is the university tenure system, which can literally fossilize an entire department. And while physical function often remains good as Americans age, the scourge of dementia remains, especially among the oldest old, or those over age 80.

It’s hard to be sure what the interest in gray or silver hair dye signifies. My suspicion is that gray is just another color on the palette and thus represents a new market opportunity. Just as the past few years have brought us pink hair and purple hair, orange hair and blue hair, so now we are adding shades of gray to the list of options. There is no evidence presented in the article that a larger number of older people are opting to stay gray—evidently, they continue to dye their hair blond at the same time that younger people choose gray. 

At the heart of the issue is whether people are willing to accept themselves, and others, as they are. As long as older people opt in large numbers to dye their hair, we can be pretty sure that attitudes towards aging remain unchanged.

Me

Rescue and Reform

A new poll conducted by the Kaiser Family Foundation found that nearly 80 percent of Americans want Congress and the President to modify the Affordable Care Act to make it work. They don’t want repeal and replace. 
       The numbers are impressive: 95 percent of Democrats and 52 percent of Republicans favor a legislative fix to the current law. Even among Trump supporters, an absolute majority (51 percent) support such an approach. In fact only 17 percent of the public (although 40 percent of Republicans) believe the Trump administration should act to initiate the infamous “death spiral” by taking such steps as eliminating the universal mandate and withdrawing subsidies to poor people. Taking Medicare as a model of sweeping, comprehensive health care legislation, we can look at just how much the program was reformed by Congress in the first 15 years after the law went into effect.
       Passed by Congress in 1965, Medicare first became a reality on July 1, 1966. In 1972, Medicare eligibility was extended to people under age 65 with long-term disabilities as well as to those with end-stage renal disease. This was no minor tweaking of the program: today 9.1 million people out of the 55 million on Medicare are in the under-65-with-disabilities category. In the last year for which data are available, Medicare spent a whopping $30.9 billion on end-stage renal disease out of total expenditures of $646 billion. 
       In 1973, “Medicare HMOs” were introduced. The federal government established standards for what benefits had to be provided, but basically outsourced plan design, management and marketing to private insurance companies. The name of this program has evolved over time, from Medicare Choice + to the current Medicare Advantage plan, but the idea remains unchanged: instead of enrolling in Medicare Parts A, B, and now D with deductibles and co-pays, Medicare enrollees can opt for one-stop shopping. Today, a record 17 million people, or 31 percent of all Medicare beneficiaries, are enrolled in a Medicare Advantage plan.
       Jumping ahead to 1980, the decision was made to broaden coverage of Medicare home health services, allowing more people to stay out of hospitals and nursing homes because they received physical therapy and occupational therapy, as well as visiting nurse services at home. At the same time, supplementary Medicare insurance plans (“Medigap”) for those people not enrolled in an HMO, came under federal oversight to cut down on all too common abuses found at the time. 
       And then in 1983, in what was perhaps the most far-reaching reform of the Medicare program ever instituted, prospective payment was introduced for hospital care. What this meant was that instead of hospitals charging whatever they wanted—with Medicare dutifully paying soaring bills—Medicare set rates that were based on the expected length of stay for a given condition. The hospital got paid that fixed amount (adjusted for co-morbid conditions and geographic variation in the cost of living) regardless of how long a patient was in the hospital. In other words, patients with an unusually long length of stay cost the hospital money and patients who were discharged unexpectedly early generated revenue for the institution. The result of this innovation, in addition to controlling how much money Medicare spent on hospitalizations, was to shorten length of stay, moving much “post-acute” to the home or the skilled nursing facility.
       Reforming Medicare didn’t stop in the 1980s. But my point is not to present an extensive history of the Medicare program (though if your interest is piqued, you might like my forthcoming book, Old and Sick in America: the Journey through the Health Care System); rather, it is to emphasize the complex, innovative, health care legislation seldom bursts onto the scene fully and impeccably formed. It usually needs to be fixed. The ACA is no exception.

       After chanting “repeal and replace” for so many years, the Republican majority needs to save face. But the way to do t do that is not to sabotage what we have, a compromise bill designed to save private health insurance rather than jettisoning the industry in favor of single payer coverage. The Republican Party should appropriate the idea behind the ACA as its own, acknowledging its true founding father, the extremely conservative Heritage Foundation. Maybe what’s needed is a new mantra. How about “rescue and reform?”

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The Worthy and the Unworthy

One of the most illuminating and insightful articles I ever read was written by historian of medicine David Rosner. Entitled “Health Care for the ‘Truly Needy’: Nineteenth Century Origins of the Concept.” I read it when it was first published and I’ve remembered it since—and that was 35 years ago. The nineteenth century concept of the “worthy poor” or “deserving poor,” and its Reaganesque reformulation is sadly reflected in the Republican health care bill revealed today.

Rosner points out that at a time of relative ethnic homogeneity in pre-industrial, pre-Civil War America, the poor were often seen, in the light of Christian teaching, as individuals who would be rewarded with salvation. As an added bonus, the presence of poor people gave the wealthy an opportunity for charity, which would likewise be rewarded. But then, in the second half of the nineteenth century, millions of destitute immigrants arrived on American shores. At the same time, Americans suffered from tremendous economic dislocation related to urbanization. As a result, “a general consensus developed among the native-born equating poverty...sinfulness, and individual failure with foreign birth. Conversely, wealth, American nativity, and material success were equated with righteousness and moral behavior.”

The Surgeon General of the US in 1891, Dr. John Shaw Billings, remembered for introducing the collection and maintenance of “mortality and vital statistics” records, also accepted the notion of a meaningful distinction between the worthy and unworthy poor saying “there is a distinct class of people who are…almost necessarily idle, ignorant, intemperate, and more or less vicious, who are failures…and who for the most part belong to certain races,” by which he meant Catholics, Jews, Irish, Italians, and Eastern Europeans. He accepted the need to provide medical care for this group—but only to prevent the spread of infectious diseases to the remainder of the population.

And then we have Dr. Stephen Smith, another public health giant, who cautioned that medical charity can be “the inlet through which the habit of pauperism first creeps into the poor man’s house.” That is, helping people who are poor fosters dependency and is to be avoided. Remember Romney’s 47 percent? The people who are “dependent on the government” and who should simply “take personal responsibility” for their lives?

After discussing the way that concepts of the worthy and unworthy poor evolved in tandem with the growth of the hospital in the early part of the twentieth century, Rosner concludes by arguing that “although the language used today is significantly different from the angry, moralistic, and class biased rhetoric of the nineteenth-century debates, there is a similarity of meaning and analysis in arguments over definitions of the ‘truly needy, over the proper eligibility criteria for a variety of health programs like Medicaid and Medicare, and for the scope of other social service programs such as food stamps and welfare.” He was writing in 1982, but he could equally well be writing today, as we learn who it is that the Republican senators, or at least those who crafted the latest version of the health care bill, deem worthy. Full-time employees of well-heeled companies are worthy and older people, provided they don't live in nursing homes, are worthy. It's unclear if fetuses are worthy: health plans may be excluded from the insurance exchanges if they cover abortion, but health plans may also be allowed (through a waiver) although they fail to cover maternity care. Everyone else, the senators assume, could purchase health insurance—or better yet, not get sick—if only they had the necessary moral fortitude.

This isn’t how any other democratic nations in the world view health, medical care, or their citizens. They assume that everyone is "worthy" of basic medical care. They regard it as the responsibility of government to promote the health of their citizens, just as it government's responsibility to keep them safe and educated. Tell your senator that  enshrining archaic concepts of worthiness into law by severely restricting access to medical treatment is not the way to keep America great.