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Yep, I'm going to be really peeved if I retire, and then find I can't paddle a canoe or drive a car any more, just when I have the time to do them.

With luck you'll have a massive heart attack and die instantly after a long hard day of canoeing, a steak cooked over an open campfire, a glass of red wine and a smoke.

Great post, and one that touches home. It reminds me of my maternal grandparents. She had a stroke in her late 70's which left her with progressively worsening dementia. For the better part of a decade my grandfather (who had previously been the typical male of his generation) learned to cook, clean and generally care for both her and himself. She outlived him by two years, but he was the caregiver for the last decade of his life.

I was at an epidemiology conference this fall where some strong evidence was presented that socio-economic factors have more influence over chronic illness morbidity in women than in men (and, speaking of preventing snap judgments, nobody really knows why); the HALE costs you note are largely in chronic/degenerative disease. I wonder if there is a cohort effect in those HALE numbers, regarding female income, and hence whether women working today face a better fate.

It is hard to see a happy outcome for either party. As you note, Frances, married women will have more mateless and prolonged morbidity than men. On the other hand...being relieved at dying because I'll cease to be a burden, or regretting being at the end because it will leave my spouse alone and perhaps vulnerable...those are not good options.

Bob, thanks for sharing that story.

Shangwen - I was just chatting with a friend the other day whose father is dying of lung cancer caused by working as an accountant for an asbestos manufacturer back in the 1950s or early 60s. As workplaces have become safer and the percentage of people working in risky conditions has decreased (simply because there are fewer manufacturing and industrial jobs) we're going to see fewer men exposed to workplace toxins. But it will take years and years for these effects to show up in life expectancy stats. So, for now, all we have is, as you say, socioeconomic factors matter but we don't really know why.

I don't know of any study that finds positive impacts of paid employment on women's physical health, do you?

The Canadian insurance market has recently started to offer "Long-Term Care Insurance". It pays for the difference between LE and HALE. The main claim is Alzheimer's, followed by strokes, but it's dementias that are the real cost by a country mile.

I keep telling economists there is a free lunch here. The Canadian group benefits market makes disability insurance (against loss of income due to accident or sickness) standard. There is no tax break for this insurance, it's just standard in all group benefits contracts and easy to offer.

It ends at 65, some companies already offer a rollover into a Long-Term Care policy.

Sometimes the free market does work.

"Sometimes the free market does work."

On the other hand, I was reading something in the Times last year about US insurers taking it in the teeth because of long-term care insurance policies that were offered years ago and which were, in retrospective, ridiculously underpriced. Apparently a number of insurers are getting out of the market, while other are looking for loopholes to try to increase premiums/terminate coverage.

Frances - other than general findings on the income gradient and health, I'm not familiar with any, but that's pretty far outside my area. As you probably know, most work on income health focuses on low income populations.

Having made my earlier comment, I wonder on the other hand if the specific issue in your post--partnership--may actually see worse outcomes in future generations. Those entering nursing homes now are part of the generation that knew rising rates of divorce, and after that we have growing numbers of the never-married; many people now enter fragile old age while their own children are busy with young children of their own, something previously rare. Anyone who has ever worked in a long-term care facility, or had a family member in one, knows just how huge a difference the involvement of a family member makes in the quality of care.

Hot health care tip of the day: retire in a rural area and get admitted to a small-town nursing home. You'll get better care there than in a city.

Shangwen "partnership--may actually see worse outcomes in future generations"

This is one reason why my caller is trying to find someone to write on gender and population aging. I wouldn't say actually that those entering nursing homes now are the rising rates of divorce generation. Let's call 80 the start of "old-old" age, when the risk of needing long term care really rises. People who are 80 now were 40 in 1972. They're a bit old to have experienced the big rise in divorce rates. Sure, there is some divorce in that cohort, but not a huge amount. It'll be in 15 to 20 years time, when the first baby boomers start hitting old-old age, that we're going to start seeing the big impacts of falling fertility and rising divorce rates.

Tomorrow's old will be different from today's old, but people have a really hard time thinking this through and imagining what it means.

Shangwen made a good point about nursing home care in rural areas where jobs are more scarce, and therefore nursing home jobs are more "special" than in cities, where job seekers have greater choices. I've read other articles recently that pointed out how nursing home jobs in general are more "special" to job seekers in tough economic times, which actually creates greater longevity for older women who come to these homes in larger numbers.

It was hard to imagine anyone making a choice to live in a nursing home when I was young, but my grandmother made that choice after an accident, as it was just too hard to give up autonomy to family members. That is oh so true for elderly who want nothing more than to take care of themselves long after they are actually able, and oddly enough, a good nursing home environment can help to perpetuate that illusion in a sense better than family.

It may be that those who are in nursing homes today are really in a golden age of care for the elderly. They are of the generation that mostly remained married, and had lots of kids, and there is still a large proportion of people available to provide paid or unpaid care to them. One of the big dilemmas in future health care delivery is the decline in the number of people able to provide it, or at least the decline in the professionals-to-patients ratio. Maybe Nick has some useful info on robots who can wipe our rears or coax our children into visiting us. This is another one that few people want to contemplate.

Shangwen - "a golden age of care for the elderly"

That's not unlikely. Earlier generations had a greater likelihood of reaching old age as singles because of the greater probability of becoming a widow or widower.

On the patients to professionals ratio - to some extent that can be solved by de-professionalization, e.g. having people go to the pharmacy for their flu shot and having the flu shot delivered by a pharmaceutical technician. But we've talked before about the special interest group politics that come into play in these kinds of situations.

Robotic caregivers are under development in Japan, as I'm sure you know. People probably wouldn't mind them as much as one might think.

Frances, a few years ago I was involved as a consultant in some of the robotics research for the elderly, and have seen some of it at work in North America and Asia. It is pretty limited with respect to augmenting or substituting; there is not a lot of investor interest either. The underlying issue is that care of the elderly is more about social systems and the quality of human (team) capital in institutions.

It is also of course not glamorous. I don't think most people and even many policy experts realize just how much geriatrics as a medical specialty is imperiled. For the past several years, the average number of geriatrics residents in training at any given time in Canada was exactly five. Compare that to dozens or even hundreds in surgery, psychiatry, endocrinology, etc., and you can see the problem. As a result it is very unlikely that the fragile elderly receive good specialty care (in the sense of having a geriatrician). Most likely they will be cared for by hospitalists or others who rely more on outdated ideas and stylized facts. The inability to induce more people into it is going to remain a policy problem that no one wants to touch, because the idea of a shortage of surgeons or oncologists can always be used to scare the public more.

Shangwen -
- do you have a cite on those geriatrics #s?
- do you have a good reference off the top of your head on gender differences in risk for chronic disease? (I can do a lit survey easily enough, but figured you might know who's working on this right now).
- have you seen these studies which find that people, e.g., walk more slowly and generally act like an older person when exposed to older people, or even old-people things and images?
- do you think the lack of people going into geriatrics is a pricing problem (it's more lucrative to treat old people for skin cancer as a dermatologist than as a geriatrics person), an issue of psychology/preferences (babies are cuter than old folks, being with old people makes you feel old) or an information problem?

- I heard those residency numbers over the summer from a couple of geriatricians, will dig around.
- Off the top of my head, no.
- I haven't seen those studies. But there was Ellen Langer's research in the 70s where elderly people were put into a museum-like environment that recreated life as they lived it in their 30s (music, design, etc), and they thrived; and there is an experimental village in Holland built along those lines.
- The NHS tried a supplementary payment system for geriatricians some years back; I don't think it slowed the lack of interest. There is probably a good empirical answer underlying this, but for now all one ever hears are sloganesque denunciations like you hear about the "underfunding" of mental health: society doesn't care for the elderly, doctors only care about technology and drugs, we all hate old people...blah blah blah. I don't think that's it. The fact that the field is inherently less dynamic is probably more salient. I also suspect that, while doctors can still do well as individualists in other specialties, geriatrics demands heavily that clinicians be team players, and that may be less appealing to ambitious people in their early 30s. Sure, geriatrics is not the highest-paid speciality. But there are still plenty of people going into family medicine, pediatrics, and other specialties that aren't eye surgery or tummy tucks.

On Shangwen third -
There is at least one care center in Montréal wha has this approach, including a tavern. On top of my head, can't recall the name, but either the Agence de la Santé or Radio-Canada, who did a piece on it, may have it.

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