death and dying in the 22nd century

In 1969, Elisabeth Kubler-Ross wrote a book on death and dying.  I had to read it for nursing school a few years later.  People still use her steps of grief and read her book.

This is not about her book.  It was a good book; a valuable book. 

But, this is about death and dying now.

So let's get some context--because this is not a short trip--its a journey. 

In the early nineteenth century, and for more than a century to come, most Americans gave birth and endured illness and even surgery at home.  They mostly died at home.  They belonged to a largely rural society, and few among them would ever have occasion to visit a hospital. Hospitals in the United States emerged from institutions, notably almshouses  (the proverbial poorhouse we were all supposed to avoid through hard work), that provided care and custody for the ailing poor. Rooted in this tradition of charity, the public hospital traces its ancestry to the development of cities and community efforts to shelter and care for the chronically ill, deprived, and disabled. A six-bed ward founded in 1736 in the New York City Almshouse became, over the course of a century and more, Bellevue Hospital. The predecessor of Charity Hospital in New Orleans opened its doors the same year. Today’s Regional Medical Center in Memphis, the oldest hospital in Tennessee, was founded in 1829. Similar origins exist for other public hospitals—places where the “care of strangers” grew from modest origins into multifaceted municipal institutions.

During the Civil War, the first versions of health insurance came about.  Everyone couldn't afford it and there weren't many hospitals.  But war frequently causes strange change.

In 1883, the first European nation developed the precursor of a social medicine system as a safety net hospital system that later became their universal healthcare system.

The United states has been working on that since that same time--but with no results.  In the United States, we now have at least 245 healthcare systems and an a smattering of rural and urban unaffiliated hospitals---all competing with each other for the patient dollars.  (no one is competing for the opportunity to care for the individuals without patient dollars, if it wasn't for EMTALA they would mostly be out of luck.)

https://essentialhospitals.org/about-americas-essential-hospitals/history-of-public-hospitals-in-the-united-states/

The unregulated Wall Street business world, shades of the ever popular Laissez Faire  (abstention by governments from interfering in the workings of the free market  which has been altered slightly--we don't interfere with much they do and then we subsidize and bail them out when they take us down the toilet--I know a few smalltime business people that would appreciate that type of interference--but they are not wealthy enough to buy their own congressman) led to the 1928 fall--for years I assumed fall was referring to the rich folks suddenly made poor that jumped off the tall buildings.  (who can explain the oddities of children's minds)

The social security program began with the Social Security Act of 1935, originally titled the Economic Security Act. The term Social Security was coined in the United States by activist Abraham Epstein, who led a group called the American Association for Social Security.  For the first time, older people without "means" or family could retire when they were no longer able to work.  This alone probably increased the life-expectancy of people tremendously, as working as a washer woman with heart failure at 72 was not likely to increase one's health.

We then had WWII, which created quite a few changes, including the reticent recognition that women had held the country together in the work field while the men were at war.  The depression was over.  Factories were busy.  People headed off the farms and into the cities.  Cities had hospitals.  WWII had made changes available in medical care---one benefit of war is always an increase of technology and knowledge from the sheer number of young people needing help in the field.  We now had penicillin, anesthesia that was better than whiskey and a rawhide strip, germ theory to prevent infection, and more regulations of what it meant to be a physician.  We had regulation of medications decreasing the number of alcohol or poison based syrups dispensed willy-nilly. And we had hospitals.  More hospitals.  Hospitals with emergency departments.  And for those with money or insurance, getting care at those facilities could prevent death from simple injuries and basic infections. 

People without money or insurance were not so fortunate--an abcessed tooth or a broken leg was as likely to kill you as not.  Back then, first aid and herbal medicine by the old herb person or vet was frequently as good as it got.

And no insurance company offered coverage to people over 65.  The actuary tables called that a bad risk.  Old people got sick, a lot, and died, often slowly.  They would either have to have money or die fast.

Medicare was created in 1965 when people over 65 found it virtually impossible to get private health insurance coverage, in one of those many attempts to create a universal healthcare system. Medicare has made access to health care a universal right for Americans once they reach age 65. This has helped improve the health and longevity of older Americans. 

Hospitals  were becoming the norm.  While very poor people and black people and native people and those early immigrants that are now called undocumented couldn't yet go to the hospital, the middle-class born of the 1950's could and did. 

By the 1980's, most people considered the Nursing home to be an expectation in later years instead of a horrible possibility (more poorhouse than retirement home--as it had been viewed previously).  Only those with experience with those fine facilities understood how many are actually still mostly poorhouse.  Private money paying for a Nursing Home always bought a better experience.

DRG's, created in the early 1980s, was an attempt to prevent the outrageous costs medicare was covering .  A huge number of egregious offenses by physicians, pharmacies and hospitals created the need.  Medicare stopped the previous cash payments and chickens and blackberry pies for that pneumonia treatment, appendectomy or broken leg and upped the number of preventative medicine procedures, and the number of questionably helpful procedures and visits in general.  Physicians became wealthy almost immediately after finishing school.  Pharmacists gained money--as did pharmaceutical companies, nursing pay went up, driven by supply and demand--now, making less than your average marketing rep, but more than most teachers below professors at college level.

https://www.bls.gov/oes/current/oes_nat.htm#29-0000

Healthcare was the number 2 employer in the country, topped only by government.

Home health and hospice appeared in response to Medicare changes and were seen by healthcare administrators as an opportunity to increase money that stopped flowing due to DRG's and new rules of participation--both directly aimed at those medicare dollars--and while neither are perfect, both can keep people at home where they want to be at least for a good while.

And, now here we are with the Affordable Care Act; with a watered down version of the type of universal coverage most other countries have AND about to vote in a piece of legislation--the American Health Care Act to replace it that will undo what the previous did, i.e., give more people coverage and give more people fuller coverage at a better price only to return us more closely to the frontier days when "only the rich will survive". 

The various laws, like EMTALA, which aim to prevent hospitals from turning away the critically ill and injured,  and laboring mothers due to lack of money is all poor people, undocumented people and people without access to coverage will have--take that away, and we can return our country to a much smaller size--life expectancy will go down.  Mother deaths will go back up.  Baby deaths will go back up.  And only those with money will survive past that first bad pneumonia, early cancerous tumor, diabetes or obstructive sleep apnea.

If Social Security and Medicare are altered or eliminated,  Average age of retirement will go up---way up, as in homeless when no longer able to work and dead if you get sick--unless you have kids that can afford another mouth to feed and have the room and time and inclination to deal with you.

Many of us have 401k's and IRA's and Roth's, there are other variants also, but they are tied to bonds or stocks or interest rates, and those are not without risk, ask the folks that lost their retirement in 2007-2009.  A few have pensions from their employer or annuities.  Bad things have been known to happen to those also.  Our future savings has become the target of embezzlers, hucksters, shoddy investment strategies and fees, more fees than a cell phone contract or cable TV.

I'm not here to recommend a return to the stuffed mattress of old---think about India's method of suddenly making the cash worthless and giving everyone a short period to trade it in--but you might want to pay attention, call a lawmaker, stay informed.  We, the people, need our Social Security and Medicare.  We would mostly love to join the rest of the civilized world with a good Universal healthcare plan. We need laws to protect us from the harshness of a world about only money.

And read the Kubler-Ross book--second hand copies are cheap.  It won't help with healthcare cost and retirement finance, but we should all know more about what to expect in any circumstance.