A Final Word


On an ill-advised rafting trip several years ago, I was bruised and battered after tumbling into the raging waters. I found myself scrambling onto a rock in the middle of the river–my raft and mates ahead, all of us trying to hold steady. The last thing I wanted to do was to jump back in. My initial relief about the safety of my rock was doomed to be temporary. I had to plunge into the dangerous current and swim, hoping for the best.

That’s how most people feel about navigating the increasingly difficult currents of living to be very old in America. We cling to a fragile and temporary security created by personal savings and family, and public programs like Medicare, Medicaid, the Older Americans Act, which, along with charitable social services, have kept so many afloat in the past. But the situation is becoming much more hazardous—one full of dangerous and deadly undercurrents of rapidly increasing numbers of frail elders with thin savings and poorly funded supportive services, medical overtreatment, and multiplying health care costs. We need to confront the inevitability of change.

We simply cannot keep the future working like the past. If some of us insist on clinging to that rock, hoping for a miraculous rescue from an unknown source, millions of our fellow travelers will experience devastating consequences, as services become unavailable while suffering and costs explode. The political power of the elderly might then shred the fabric of society, as essential investments in healthy children and a healthy economy become impossible.

Even worse, if we fail to tackle the challenges of right-sizing services for a much larger population of very old people, we are likely to be forced to choose who to pull from the river, and who to leave behind. We could attempt to sustain the illusion of helping by providing the existing supports and services to an ever-shrinking proportion of those in need, while learning to accept that others will not have adequate housing, food, and health care, or simply finding ways to be blind to their plight.

That path is unacceptable. Who among us wants to be saved from suffering and destitution while our friends and loved ones are not? Who wants to risk being among those abandoned? Tradition and culture guarantee that we are all in this together. We will have to take our chances, jump in, and swim to an uncertain future. Planning ahead, testing the options, and putting better arrangements in place now will make us much more likely to succeed, and building MediCaring Communities through PACE expansion is a comprehensive, practical model that can get us started toward a much better place.

We did not, of course, plan for this journey with the idea that we would wind up stuck on a rock in an increasingly threatening environment. Decades ago, we funded a health care system that was well-suited to the needs and realities of those times. But circumstances have changed, and our systems must now change, too.

The essential first step is to understand our new set of facts and to develop a new set of insights. This book has shown that we can build our future in a way that treats us all fairly as we age, and achieves reliability and efficiency. Success is possible. We can get through the next fifty years of a rapidly aging society, having cared well for one another, and having avoided slowing our overall economic development. We do need, though, to be honest about the facts and willing to work with reality.

The journey will entail some risks, and failing to get underway will only make it harder to succeed. When I plunged into the rapids, I had some strengths to build on. I could swim; I wore a helmet; and my comrades were ready to try to help. So too, our society will improve our chances of building the care system that delivers what we most need in frail old age if we build on our strengths, marshall our resources, deliberately plan for what’s ahead, and encourage and support one another along the way. We may occasionally wash up in a spot that turns out to be disappointing, but we will learn from that, and move on.

Doing nothing, we can continue to hang onto our metaphorical rock a while longer. But eventually, even that hard work will fail and many of us will face grim futures of disability without essential services.

We have a long national tradition of joining forces to solve seemingly intractable problems and challenges. We can encourage innovation, learn from experience, abandon outmoded practices, and embrace a worthy future. The time has come to jump in and solve the problems, and this book charts the course.

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