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July 22, 2004

AGING: What the Future Holds

Since 1900, average life expectancy in the United States has risen from 47.3 years to the current 77.4 years, based on figures released this spring by the federal government.

Advances in medicine over the past 50 years include virtual eradication of certain diseases such as polio and smallpox, the evolution of viable organ transplantation and, more recently, the burgeoning field of stem cell research.

Americans are living longe. That’s the good news.

The bad news is that the aging population – 77 million baby boomers will begin reaching Social Security eligibility age in 2011 – already has strained the U.S. health care system fiscally and introduced new and complicated medical, ethical and legal issues such as advance-care planning and end-of-life decisions.

In anticipation of growing aging-related concerns, Provost James Maher and Senior Vice Chancellor for Health Sciences Arthur Levine convened a council on aging here in 1999, bringing together experts from all 16 of Pitt’s schools. The council became a working group of researchers representing interdisciplinary approaches to aging-related problems.

In fall 2002, Pitt opened the Institute on Aging to coordinate the University’s research efforts, to link clinicians, educators and researchers and to attract grant money. The institute’s web site ( is an on-line repository of information and links that bring together experts, from within and outside the University, from a wide variety of disciplines: physicians, psychologists, nurse practitioners, social workers, lawyers and others.

This is the second in a series featuring some Pitt experts’ predictions on “Aging: What the future holds.”


“One thing that will not change in the next 25 years is the desire people have to secure an income for life and still have some money left to pass on to their children,” said Lawrence A. Frolik, professor and expert in elder law and the law school ‘s representative on Pitt’s 1999 council on aging.

With that caveat, Frolik pointed to three areas where the law must evolve to accommodate anticipated changes in the health care system and a growing elderly population: refinement of Medicaid law and development of alternative payment systems for long-term health care; property and asset management for the aging population, and end-of-life legal and ethical considerations.

“The Medicaid program, which in this country pays for most of long-term care, is too complex: There are complicated economic issues, including who qualifies for Medicaid, and end-of-life medical issues and legal issues. What exactly Medicaid pays for also is not entirely clear,” and can vary widely between the states, which set the guidelines for eligibility, Frolik said.

“Some level of wealth will continue for many of the baby boomers. So a significant number of the population will probably be okay. And I think the government will take care of the very poorest. I don’t believe we’ll ever get away from that. Still, it’s a ‘haves and have-nots’ situation and that gap is likely to widen.”

People with modest financial resources who won’t qualify for Medicaid increasingly will have problems paying for their long-term care, especially in nursing homes, Frolik said.

According to a 2003 survey by Metropolitan Life Insurance Co., the average rate for a private room in a nursing home is about $66,000 a year. By 2021, when millions of today’s 55-60-year-olds are likely to need such care, the average rate will have risen to more than $175,000 annually, the survey said.

“People are looking for alternatives that don’t include moving in with their relatives,” Frolik said. “I can see [an emphasis on] assisted-living, for example, coming out of the woodwork in the next few years.” But with wide varieties of assisted-living and corresponding levels of required care that need to be catered to the individual, no formula yet exists to subsidize this alternative. “The point is: We need a system to provide long-term care,” he said.

American also need advice on planning their estates so their money doesn’t just run out. But, Frolik said, currently there aren’t enough options.

One option that dates to the mid-1980s is long-term health insurance. Such insurance has a number of deficiencies, Frolik said, including that benefits may cover only a portion of the total expense; that many policies are loaded with clauses to prevent holders from collecting, and that the insurer’s financial viability may not last for the duration of the policy.

“In this country, long-term health insurance has been getting little traction,” Frolik said. “That may change some, but not enough planning advice is available, and the insurance companies themselves, from the legal perspective, have come under fire for whether these policies are delivering as promised. We can expect increasing litigation about what these policies mean.”

Buying long-term insurance also is a big gamble for the individual, he added. Premiums are much lower for younger people, but the average age of people admitted to a nursing home is 83. “If you’re 40 now, depending on your policy, it might get you money 20-25 years before you need it, or you might be paying for more than 40 years before knowing whether you’ll need to use the policy at all.”

A second major issue confronting the legal system over the next generation or so is property and asset management for the aging population, Frolik said. “What do we have to do to help people with diminished capabilities to manage their finances and assets and protect their interests and desires? Traditional notions of legal guardianship are cumbersome, inconvenient and costly. What’s more, the courts are not set up to deal with [formal guardianship],” Frolik said.

Society is wrestling with who owes the citizen guardianship – the family, the place of employment or the government, Frolik said.

In many, if not most, cases, asset management for the elderly involves a private solution. “Most often it’s an adult daughter who lives in the same area, who is involved with a parent’s or parents’ life and helps out and, eventually, secures the power-of-attorney,” Frolik said. “The danger in this is that power-of-attorney is often misused. To put it bluntly, children steal from their aging parents. So the private solution is not ideal. What we need is a system with a third party who understands the individual circumstances of both the elderly person and the family members.”

Such a system would require continuing oversight to control abuse and ensure that an individual’s wishes are honored. “But the real question for legal institutions is: Is this a practical solution? Can developing a third-party system of oversight handle the numbers of people and their individual needs?” Frolik said.

Other factors inhibiting a third-party system include lifestyle preferences, family in-fighting and lack of adequate financial planning.

“If you look at the baby boomers with money, the legal situation is often exacerbated by today’s mobility,” Frolik said. “It’s also complicated by the break-up of families by divorce and the expansion of families through marriage, and the [geographic] dispersal of the family. It has created, for example, legal responsibility for property management across great distances, sort of a new breed of absentee landlords.”

Over the next 25 years, the issues of end-of-life rights and treatment alternatives will loom even larger for legal institutions.

Many people in the last two years of life end up in an intensive care unit, a particularly costly proposition, Frolik said.

Sometimes this is inevitable, and can even coincide with a patient’s wishes, but much more often it’s the lack of legal forethought that forces the health care system to take in intensive care patients and keep them alive as long as possible, Frolik said.

“The family wants to know: How can we provide the elderly with care at home? The health care system has the same question,” he said, so there should be a meeting of the minds that encourages alternatives.

“With more people living longer, we will see a continued increase in right to die legal cases, assisted suicide and other related cases that require legal interpretation,” said Frolik, who also teaches courses in the legal specialization track of Pitt’s new interdisciplinary gerontology graduate certificate program, one of the first of its kind, offered through the College of General Studies.

“[Lawyers] are not trying to solve whether it is better to be old or to die. The question we ask is: What is fulfilling for the individual?” Frolik said. “All you have to do is see one relative through a dying stage to learn how difficult it is. I think more and more Americans are coming to the conclusion that delaying death is not always a victory. Sometimes picking death is a victory. It’s a culture problem we’re trying to deal with. Whether we’ll ever come to a national consensus is anybody’s guess.”

-Peter Hart

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