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Photograph by Michael Amsler Fixing the Age Gap: Shirlee Zane of the Council on Aging stands in front of a portrait of a client by Harvey Henningsen. Same Old Problems As our population ages, the healthcare system struggles to catch up By Joy Lanzendorfer Roy and Ivera Cobb can't even remember how long they've lived in Sonoma County. The couple lives in Burbank Heights Apartments, a retirement community in Sebastopol. Like many older people, they subsist on a fixed income that includes Social Security--a hard enough feat as it is considering the ever increasing cost of living. A few years ago, health complications led to some new medical bills for the Cobbs. They had Medicare, but that didn't help when it came to the cost of prescription drugs, which the program doesn't cover. Pushed to make choices between their health and food and shelter, the Cobbs decided to declare bankruptcy. "I didn't like it very much, myself, " says Ivera. "But we're not the only ones we know who have had to take out bankruptcy to pay for our bills. I know other people who did it. At least four or five people I know took bankruptcy out because of healthcare." The Cobbs continue to struggle with their medical bills to this day, which they say are hard to manage. But when it comes to paying for their prescriptions, they have no choice. "I just go and get the prescriptions anyway, even when we don't have the money," says Ivera. "I have to have it." While the healthcare system poses a challenge for most people these days, for the elderly the problems are more pressing, especially in light of the closing of Sutter Medical's Senior Health Center this month. The center was the only program in Sonoma County that specialized in geriatric medicine. With its closure, it will mean one less option for seniors when it comes to their healthcare. If this trend continues, their only option left will be to not get sick. An Aging County Chances are, the healthcare of the elderly population will affect you at some point, too. Sonoma County's population of 55 and older grew by 21 percent from 1990 to 2000, and 12.6 percent of the county is over 65 (slightly higher than the state average), according to the 2000 census. More remarkably, the number of people aged 45 to 54 grew 82 percent during the same time period, compared to an increase of 49 percent nationally. That age group will continue to grow, as the largest segment of the U.S. population, the baby boomers--those born between 1946 to 1964--marches toward retirement. As that group ages, the healthcare system will be increasingly strained, and small problems that exist now may become serious later. While Sonoma County's largest population is still a young one, with the age 35-44 population barely edging out the age 44-54 population at 16.5 percent to 16.1 percent, younger generations will also be affected by senior healthcare. As parents and grandparents deal with large bills or neglect their health problems because they can't afford to see a doctor, the younger generations may end up paying for care or giving the care themselves, at great burden and personal sacrifice. "We're an intergenerational society, whether or not we want to pretend that the market is king," says Carol Estes, professor and founding director of the Institute for Health and Aging at UC San Francisco. "It's just not the case when we're in a family. These problems can't be solved separately." The Senior Center's Demise Healthcare is in bad shape in Sonoma County. Among other problems, costs continue to rise, doctors and other medical professionals are in short supply, and healthcare providers are closing down or restricting services. Since most of the elderly are on a fixed income, and since they have the biggest need for medical care, changes in the medical system hit them the hardest. "If I were going to pinpoint one issue that is affecting the elderly, I would say access to care," says Shirlee Zane, executive director of the Council on Aging. "Medicare is not widely received by doctors anymore, and the cost of prescription drugs are high, especially for people who only have Medicare." Nearly 700 patients were served through Sutter's Senior Health Center, though CEO Mike Cohill estimates that there are probably closer to 530 repeat patients. Sutter has been undergoing major restructuring. It laid off over 70 employees and closed its pediatric intensive care unit in December. "We implemented the overall hospital breakthrough plan in an attempt to stem the significant financial losses we were taking of around $2 million a year," says Cohill. "The senior section was also losing money, about $200,000 per year." Though only one-third of the center's patients had Medicare, it was losing money because the government does not reimburse equal to every dollar of Medicare spent. When the center opened, reimbursement was based on the cost of operating. Over time, the reimbursement changed to a flat per-visit charge, which was not enough to cover the cost of operating, explains Cohill. The closing of the Senior Health Center has been met with opposition from senior groups, who feel that Sutter Medical could maintain the center if it were made a priority. "Sutter is doing what a lot of healthcare organizations are doing right now," says Zane. "They are saving the sexy programs, the ones that are going to pay. They are keeping the heart program open, which has nice coverage, but they are closing the geriatric center, which wasn't really losing that much. But Cohill sees that though it's not losing much now, it won't make a lot of money in the long run." Sutter is required by law to find its patients new doctors or risk accusations of patient dumping. As of this writing, Sutter still needed to find doctors for 240 patients but was confident it would be able to do so before the end of the month, despite the fact that fewer doctors are taking Medicare. Critics admit that while it is likely that Sutter will find the doctors, the move will be hard on older patients, who often have long-standing relationships with their doctors. "I've had to change doctors three times, and I'm 43 years old," says Zane. "Imagine what's that like for someone in their 70s or 80s to make that change, especially when they have a long health history with a doctor." The center was also the only one specializing in geriatric medicine. Seniors have more complicated health needs requiring attention, such as emotional and cognitive problems. And while a family practice may be equipped to deal with most health problems, seniors can sometimes get lost in the shuffle. Generally, seniors can find technologies like voice mail intimidating and confusing. They can also have a hard time adjusting to the more streamlined, efficient doctor visits designed for younger patients who understand modern approaches to medicine, such as group classes and shorter visits. In fact, research shows that elderly people get less time with a doctor on average, only about seven minutes compared to about twice that for younger people, according to Estes. "Young people get more time with your average doctor, while at the same time, the elderly need more care and have more complex needs," she says. "That's how they end up taking a bag of 30 drugs. The doctors don't have the time to check them out properly." With the closing of the Senior Health Center, Kaiser's Senior Advantage Program becomes the only Medicare program of its kind still operating in Sonoma, Napa, and Marin counties. While healthcare providers of all kinds struggle, Kaiser continues to do well financially because its costs are all contained in one system. Still, the North Bay Kaiser operations received only two out of five stars on a survey this spring by the California HealthCare Foundation. The survey rated HMO plans for seniors by looking at premium costs, co-payments, plan benefits, and prescription drugs. But even the survey admits that most of Kaiser's faults were related to the low reimbursement rate from the government for Medicare patients, something that has taken quite a toll. Last year, Health Plan of the Redwoods went under, leaving 78,000 patients with new doctors and higher rates. Five other medical groups also collapsed, all due in part to low reimbursement from the government for Medicare. Simply put, the cost of healthcare has greatly increased while reimbursement rates haven't kept pace. Sonoma County has an additional problem because the government has classified it a "rural" rather than an "urban" area. The rural designation means that healthcare providers receive 15-20 percent less than urban areas. "There have been a lot of changes in Sonoma and Marin counties with groups collapsing," says Karen Weddle, project director of the Health Insurance Counseling and Advocacy Program. "As things continue in this direction, physicians will limit their practices even more to Medi-Cal and Medicare patients. It will exacerbate an already serious problem." Medicare and Prescription Drugs Another problem for seniors is that Medicare doesn't cover prescription drugs. In fact, Medicare has never covered drugs since it was formed in 1965, yet drugs have become central to medicine since that time. Biopharmaceutical advances have led to drugs that can mean the difference between life and death, prevent serious surgeries, and improve quality of life for a patient. And there are hundreds of other new drugs in the FDA pipeline waiting to be released to the public. While many believe seniors are overmedicated as a whole (a problem more likely caused by multiple doctors and short visit times), there's no denying the importance of drugs in modern medicine. One prescription can cost several hundred dollars. And 67 percent of seniors on Medicare have multiple chronic illnesses often requiring multiple prescriptions. Paying for all those prescriptions can quickly become unmanageable. Seniors deal with this problem in different ways. Those with low incomes can go on Medi-Cal, which does cover prescription drugs. Others use organizations like the Health Insurance Counseling and Advocacy Program to help sift through complicated supplemental Medicare programs. Still others use HMOs to cover the difference, and many simply try to get by with paying out of pocket for their medicine. Roughly 20 percent of the average senior's income is spent on out-of-pocket healthcare expenses, usually for medicine. For the low-income population, about 40 percent of income is spent on prescription drugs and other healthcare expenses. It's easy to see how seniors can get in situations where they are faced with choosing between their healthcare needs and their bills. It's also easy to see why so many declare bankruptcy, like Mr. and Mrs. Cobb. Some say drug companies are taking advantage of the fact that Medicare doesn't cover prescriptions by making money off of a captive market. "There is a lot of profiteering in pharmaceuticals," says Estes. "Our whole healthcare system is built on a profit motive, which has distorted the incentive for care. It makes care less accessible to the population. For-profit HMOs and for-profit pharmaceuticals and for-profit long-term care just raise costs and don't have a uniform set of benefits for everyone." Others, however, feel that the market is the best way to regulate the cost of healthcare. President Bush is pushing through a bill that would add drug benefits to Medicare. He is urging Congress to vote on it by July 4. Under the bill, drug benefits wouldn't be doled out through a complex formula of reimbursements, as is the rest of Medicare. Instead, private insurance companies would start government-subsidized prescription drug plans for the elderly. The bill would also encourage patients to get their healthcare through Preferred Provider Organizations, or PPOs, which would push them toward specific providers. Republicans feel that using private insurers this way will create competition and drive prices lower, thereby giving seniors more choice. Democrats, however, say this is the Republicans' attempt to privatize Medicare and to scratch the back of the pharmaceutical and insurance industries. "Bush's plan is a step in the wrong direction," says Congresswoman Lynn Woolsey. "Privatization works wonderfully to maximize profits but falls short of providing the healthcare that American seniors need. Healthcare is a public necessity, and it must not be left to the whims of market forces, profit margins, and private business concerns." Many liberals support building on the existing Medicare program and moving toward universal healthcare. Rather than watering down the system through involving the private sector, proponents want to see additions to the system so that eventually all people will be able to access healthcare. But universal healthcare has its detractors, too. "Universal healthcare eats at the gross national product and offers far less care than privatized insurance," says Doug Williams of Santa Rosa's Heritage Financial Services, which brokers insurance for businesses. "There are long waits for services, especially for specialized care. And the taxes are horrible in countries that have a single-payer system." Long-term Care Seniors also lack long-term care, a term that used to mean nursing care but now covers a variety of services, including in-home, mental health, physical therapy, and even food and shopping. While it's difficult for older people to pay for medication out of pocket, it's nearly impossible to pay for long-term care. Many people who need long-term care end up in nursing homes. While only 5 percent of the elderly live in nursing homes, 45 percent may spend some time there for various reasons, such as rehabilitation from surgery or to recuperate from a stroke. In recent years, many nursing homes have come under criticism for abuse or neglect of the elderly. Some cities have begun policing nursing homes for this very reason. Redwood City just launched a program where local police make random checks in nursing homes to check for mistreatment. San Francisco may soon follow suit. The California HealthCare Foundation also created a database ranking the safest and best nursing homes in the area. But the lack of long-term care is just part of the overall picture. In a time when one uninsured hospital stay can devastate a family financially, the need for healthcare reform is more important than ever. Ignoring prevention or not getting follow-up care is not only more painful to the patient, it's more costly to everyone involved. Because many older people are ashamed of their situation and don't want to cause embarrassment to their families, they are reluctant to talk about their experiences with healthcare, which makes it hard to know how bad this problem really is. "It's penny-wise, pound foolish to ignore this problem," says Zane. "We are so enamored with youth in this culture, we have to change the attitudes beneath the lack of care. Seniors need to get angry about this. They need to organize and stand up for their rights." 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