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Some birthdays are cause for celebration. I didn’t consider my 75th birthday to be one of them. Aside from my radical amazement that I’m still walking the planet after three-quarters of a century, it didn’t strike me as an occasion worthy of summoning friends and family to offer toasts, present gag gifts, and deliver snarky birthday cards poking fun at my whitening brow and steadily crumbling infrastructure.

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Consequently, there was no party, and I observed an untraditional birthday signing copies of The AfterWork: Finding Fulfilling Alternatives to Retirement in a delightful Rehoboth Beach, Delaware bookstore. The bookstore was jammed with customers (drawn not by me but by a torrential downpour), and I sold a few books. So happy birthday to me.

But while my 75th was not a worthy occasion for celebration, I do think other significant milestone birthdays are. For example:

Memorable Milestones

1st – I don’t remember my own, but as a parent I adopted the widely observed ritual: Sit the birthday baby in their high chair, place a chocolate cupcake or a slice of chocolate cake on their tray, and laugh raucously as the baby slams their tiny fist into the cake and smears chocolate all over face, hands, hair, and floor.

13th – in Jewish tradition, the child celebrates a Bar or Bat Mitzvah and is treated like royalty for a day, followed immediately by a torturous six-year journey through darkest Adolescence.

21st – This is the date on which you are legally permitted to do what you’ve been doing illegally for years.

30th – This marks the moment you realize you are no longer just pretending to be an adult. A 4-day-old baby in my arms brought that reality home.

39th – On this day, I called my father and said, “I’m not sure how it happened, but now you and I are same age.”

52nd – Not normally a landmark, but it was on this birthday that I received a note from my son that read: “Congratulations! If you had received a card for every year you’ve lived, you would finally be playing with a full deck.”

60th – A small celebration marked the day I became a sexagenarian. It sounded a lot more exciting than it turned out to be.

65th – Until recently, this milestone represented the advent of retirement. Now it only means you can enroll in Medicare.

There is a clear pattern here: The older I get, the less thrilled I am by the prospect of cake and candles. As another writer puts it, birthdays become less like milestones and more like millstones.

Gaining Perspective

But what a milestone birthday is good for, if not embarrassment among friends, is for taking a step back, breathing deeply, and putting some perspective on life to date.

The ambitions of my youth were grand. Like Clark Kent, I wanted to be a newspaper reporter fighting for truth, justice, and the American way (or was that Superman?). I wanted to be an acclaimed figure in the world of books. I pictured myself writing in an upstairs garret of a townhouse overlooking a beautiful park.

I didn’t achieve those ambitions, but it doesn’t matter. Life took me in other directions I had not even dreamed of. In my first 75 years I managed to get an education, support myself, enjoy a 50-year partnership with the love of my life, raise two well launched and reasonably well adjusted children, make good friends, make stupid mistakes, and come out smiling. I have enough to eat and a roof over my head. My bottom line is that I feel satisfied and content. I have no regrets.

I have no clue what awaits me on the downhill side of 75, but I look forward to being surprised. I plan to stay curious, keep writing, nurture loving relationships, and encourage laughter. Especially laughter. We all need more laughter. If I can go out smiling, that will be something worth celebrating.

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Odds are, you have heard someone toss off the remark, “You can never be too rich or too thin,” as if it were true. Some people must believe it’s true, to judge from the images of impossibly trim young darlings bombarding us from movies, television, telephones, and Instagram sites. As a former beauty editor observes, “Some of our most visible celebrities have gone from merely thin to gravely gaunt.”

In fact, I would argue that “Never too rich or too thin” so brilliantly captures the spirit of our age that it should be printed on our currency, in place of “E pluribus unum.”

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Regardless of contemporary ideals of beauty, “too thin” is terrible health advice at any age, but especially for older adults, where it can lead to frailty. Frailty in a clinical sense means you are less resilient to health events such as falls or surgery and more vulnerable to bad health outcomes. Researchers at Johns Hopkins University report that frailty doubles the risk of surgical complications, lengthens hospital stays, and increases the odds of landing in a nursing home or assisted living.

Frailty happens when our bodies lose muscle mass, our bones become less dense, and our cells experience more inflammation. All these are normal effects of aging, but frailty results when these changes occur at an accelerated pace.

Frailty will be the death of us all, eventually. We would be wise to forestall it for as long as possible.

What Counts as Frail

A large global review in 2020 estimated that frailty affects about 11% of adults aged 50-59, while about half of all adults aged 50 and older were “pre-frail.” Interestingly, and contrary to popular belief, only 25% of adults aged 84 and older are considered frail.

Diagnosing frailty and pre-frailty used to be strictly a matter of how a patient appeared. Today doctors use one of two different methods to make a determination. The first assesses five physical abilities: weakness (in grip strength, for example), slowness of gait, exhaustion, physical inactivity, and unintentional weight loss (10 pounds or more in a year). A patient with one or two of these conditions is pre-frail; three or more qualifies as frail. The second tool, called the deficit accumulation model, rates whether the patient presents any of about 30 different symptoms, including high blood pressure and cognitive decline, and their ability to perform everyday tasks. The more conditions, the more likely the patient is frail.

Hold It At Bay

If you are not frail now and don’t plan to be frail in the near future, several actions will help you remain strong and vital.

Eat well. People who faithfully follow the Mediterranean diet – fruit, veggies, protein, good fats, whole grains, and low-fat dairy – are 74% less likely to become frail.

Get your protein. Vegetarian and vegan diets require extra effort to get sufficient protein, which is necessary for building up muscle. Protein is most abundant in meat, fish, poultry, and dairy. Dried beans and yogurt (especially Greek yogurt) can make up some of the deficiency.

Work those muscles. Walking is nice, but not enough. Working out with weights is highly recommended, if not exactly popular (only an estimated 10% of women age 75 and older engage in strength training, despite their higher risk of falls). Practicing Tai Chi and doing resistance exercises are another alternative. Aerobic exercise helps build endurance.

Think positive. An upbeat attitude about aging has been linked to a lower risk of frailty. As the oft-cited study by Becca Levy of Yale University has shown, adults with positive views about their age outlive their negative contemporaries by an average of 7.5 years.

I avoided weight training for my first 72 years, but fear of falling finally forced me to overcome my own resistance to weight-bearing, balance, and aerobic exercises. The results aren’t obvious on the surface, but my incidences of tripping and falling have declined about 90%. It’s never too late to start taking action to postpone the inevitable. And anything you do is helpful. A little bit is better than nada.

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No. 108/May 27 , 2026

NewScan is a biweekly briefing on news relevant to readers of The EndGame. NewScan is a premium feature exclusively for paid subscribers.

Few Retirees Work

Although 75% of American workers expect to supplement their retirement savings with paid work, only 27% of retirees actually do, according to EBRI’s 2026 Retirement Confidence Surv…

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Note to Readers: Today, May 23, is my father’s birthday. (It is also my birthday, and my grandfather’s birthday, but that’s another story.) In his honor, I am reprinting this post from the archive.

Life dealt my father a pretty lousy hand at birth. As an infant he had asthma so severe that he almost didn’t make it. His parents had to drive him to a hospital in another state to bring the illness under control. When he was not quite 3 years old, his mother committed suicide. That left him with his father, an immigrant from Latvia, and his 11-year-old sister, who reluctantly babysat him while the father worked as a traveling peddler. About a minute after the sister graduated from high school, she left home. With no other options, his father sent the 8-year-old to an orphanage.

As orphanages go, it was better than average. The children were enrolled in a top-flight private school. In the summers, my father returned home to his father, who took him along as he sold goods and collected payments in poor city neighborhoods and rural communities. He was only 17 when his father died (at age 53). Thus ended childhood. My father entered adult life virtually alone in the world.

These experiences did not embitter him, but they did kindle a deep desire to have a family – to ease his own loneliness, certainly, but also to see that another generation would not have to begin life as he had. At the age of 24, he married my mother, whose positive attributes included membership in a large extended family.

From Orphan to Father

Then he became a father of four. Considering that he had no model of what a healthy, happy family should look like, I stand amazed at how much he got right. His marriage was not idyllic, but it lasted 48 years, right up to the moment that his death did them part. And it succeeded in creating a stable, secure, and safe home environment that launched the four of us into our own adulthoods.

My father was a salesman, sometimes at retail furniture stores, sometimes on the road. He changed employment frequently, but his job hops never seemed to lead upward. He also tried a number of entrepreneurial adventures: Selling fallout shelter supplies, franchising, home repair, property management, turnkey bridal trousseaux. All of his ventures lost money, and most added to his debts.

He was never a success by the standards of American culture. Unfortunately, he believed that was the standard that mattered most, and it grated on him that he was falling short. He understood his male role as the family provider. When he wasn’t providing, and my mother had to work to pull us through, he felt ashamed.

But as a father, he was top-notch. He taught me to throw and catch a baseball. He taught me to drive. He taught me to shave. But most of all, he taught, by his example, values I have incorporated into my own life.

• He taught me to give of myself. My father volunteered his own time readily, to us and a variety of community causes, from synagogue activities to high school clubs.

• He taught me to be generous in spirit. My father knew what loneliness felt like, so he was quick to befriend the friendless, the newcomer, the acquaintance down on his luck. He was even quick to lend money to people he believed in, regardless of whether he had it to give.

• He taught me to love justice. By his actions he demonstrated his conviction that African Americans were being denied the fair chance they deserved. Today that sounds obvious. In Louisiana in the 1950 and 1960s, it was virtual heresy.

• He taught me courage. He knew it was not easy to be in the minority religiously, politically, or ethnically, but he showed me there were values worth standing up for.

Asthma and Depression

Only later in his life did I come to understand something else about my father’s courage. He had two serious, lifelong medical challenges. Asthma was the one I knew about. It had hospitalized him more than once, and it flared up to dangerous levels at irregular intervals. What took me longer to understand was his severe depression. In retrospect, it is clear that he was bipolar. At the high end, bristling with self-confidence, he would launch into a new job or venture that was sure to bring him riches. These were always followed by a crash and a descent into a dark place where he could hardly speak or bear to be seen on the street.

The depression (but not the bipolar component) is part of my inheritance from him. For me, it was a simple matter to seek help and treatment. My father did not believe he had that option. In his mind, if he told a psychiatrist about his thoughts, he would be hustled away to an institution in a straitjacket , leaving his family destitute. So he kept it all inside and dealt with it as best as he could. Through years of despair, he found the courage to go on living because it was the best thing for his family.

Two years before he died at age 72, he found the courage to seek help for his mental health. I thought it was incredibly brave of him.

Forty-five years ago I became a father. I tried to pass on the values I had learned to my children. I passed along bits of wisdom my father had shared with me, and I tried to add what I had learned. I don’t know what took. To be a father, I believe, is to light fuses each day that are 25 years long, and you live in suspense about which will fizzle out and which will detonate someday. But what can you do? You work with the hand you’re dealt, and you do your best.

My father did his best with a terrible hand. That took tremendous courage. I am proud to be his son.

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Many years ago, The Different Drum, a book on building community by M. Scott Peck of The Road Less Traveled fame, made a huge impression on me. Peck described creating intentional community as a four-step process. In the first, “pseudo community,” people are polite and congenial and avoid saying anything controversial. In the second, “chaos,” conflict rips off the mask of camaraderie and leaves it in tatters. The third phase is “emptiness,” a troubling, uncomfortable state when participants are forced to let go of their expectations and preconceptions, prejudices, easy solutions, and desire for control. In the final phase, “community,” participants emerge from emptiness by reaching out to others with openness, honesty, and vulnerability, creating the basis for a peaceful community that can last.

This description, especially the part about emptiness, has remained with me through the years. Peck saw emptiness as a necessary pre-condition for reaching the desired outcome. Because it is so uncomfortable, it also happens to be the stage we stubbornly try to avoid.

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I speak from personal experience. The emptiness is terrifying. Yet whenever I have made a major life change, the process of my own journey closely mirrors Peck’s process. The emptiness always comes before the resolution, much as “the darkest hour is just before the dawn.”

The emptiness stage also shows up, with different names, in other scholarly descriptions of how human beings change. In William Bridges’ seminal book Transitions: Making Sense of Life’s Changes (1980), the formula for transition is a three-step process: the ending (of one reality), a neutral zone, and a beginning (of the new reality). The neutral zone, the in-between stage comparable to emptiness, is the necessary bridge that makes the journey from ending to new beginning possible.

In less clinical language, the emptiness is often labeled “the messy middle.”

Avoidance

Whatever you call it, it is a state of mind that most of us avoid like the Plague. It’s painful. It’s that point when all our previous assumptions – about what’s happening, about our own abilities, about what we want – have been stripped away, leaving us on shaky ground.

Here’s how it often plays out in the transition I know best: the move from full-time work to no work at all, which once was called retirement but I call The AfterWork. At work we know where we stand in the hierarchy. We have calendars and appointments to organize our days, assignments to undertake with deadlines to meet. We have clients, work associates, vendors, and others we see often enough to consider friends.

Then one day we leave the work world and find ourselves in a liminal state with no assignments, no deadlines, no appointments, no contact with people, no structure, and for many of us, no clue to what comes next. All assumptions about a typical day are off the table. Nothing is certain, least of all our future.

That’s the messy middle. And it is not a place most of us choose to be.

Perhaps it is most aptly described by Tibetan Buddhist master Chogyam Trungpa. “The bad news is you’re falling through the air, nothing to hang on to, no parachute,” he observed. “The good news is, there’s no ground.”

A little Buddhist humor there.

A Necessary Step

Uncomfortable though it may be, psychologists say we need to spend time in the messy middle to find our way out of our stuck places and into somewhere new and better. Just as emptiness was a pre-condition for true community, the messy middle is a pre-condition for personal growth.

Psychologist Cara Gardenswartz suggests a change of mindset would be valuable in navigating transitional states. “What if we viewed these transitions not as disruptions but as opportunities for significant personal growth?” she writes. “What if the very moments that challenged us most were the ones that helped us grow?” If we embrace the unknown and allow space to process our emotions, she adds, we can develop resiliency and other personal skills that can move us to the next stage.

The author and popular podcaster Brené Brown puts it this way: “The middle is messy, but it’s also where all the magic happens.”

So when you find yourself facing the prospect of change, don’t try to sidestep that feeling of being unmoored, unsure, and unclear. Sit with it, accept that it’s an unavoidable part of the process, and rejoice! It means you have a chance of moving into something far, far better.

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No. 107/May 13 , 2026

NewScan is a biweekly briefing on news relevant to readers of The EndGame. NewScan is a premium feature exclusively for paid subscribers.

Long-Term Care Drains Middle Class Wealth

A new report from the Roosevelt Institute, a New York think tank, finds that the costs of long-term care put a significant dent into middle-income household…

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Photo by Isaac Quesada on Unsplash

Reader Alert: I’m going to be signing copies of my book The AfterWork: Finding Fulfilling Alternatives to Retirement at Browseabout Books in Rehoboth Beach, DE on Saturday, May 23 from 11 am to 1 pm. So if you’re going to be danny ocean (as we say in Balmer) drop in! The book is also on sale at Amazon.

The fact that there are so many of us chronologically gifted adults is being framed as a perplexing problem for society. (And what could be more thrilling than being told your existence is a social problem!)

Yes, there are millions of us in the U.S. who are over 65 years of age. Some of us refuse to stop working. Some of us refuse to leave our mortgage-free houses. Some of us require extensive and expensive medical attention. Some of us refuse to die in a timely fashion.

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To hear some people talk, you might think that older lives don’t matter, or at least, are worth less than other people’s lives. Some might go one step farther and suggest that our lives are worthless.

The most egregious example is an essay in the New York Times by Samuel Moyn entitled “Older Americans Are Hoarding America’s Potential.” Moyn, a 54-year-old professor of law and history at Yale University, argues that it is terribly unfair for older adults to control so much power and wealth. They hold some of the best jobs and refuse to budge, and they own “much of the most desirable real estate in the country’s best cities,” he claims. Because a higher percentage of older adults vote regularly, they have a disproportionate impact on elections. While older people do deserve health care, he writes, “they also need incentives to give up accumulated housing, jobs, and wealth.”

Moyn, by the way, has a book coming out next month called Gerontocracy in America: How the Old Are Hoarding Power and Wealth – and What to Do About It.

The Aging Strike Back

If Moyn’s purpose was to stir up controversy, he succeeded. Janine Vanderburg, CEO of Encore Roadmap, led the charge with a fiery rebuttal. “You read that right. A professor of law and history at an elite university is arguing that older people participate too much in democracy,” she wrote. “Let me be very clear about something: This is ageism.” Vanderburg argued that the wealth inequality isn’t about age, but about class. “The real concentration of wealth in this country sits with the top 1%.” She summed up the article as “a book promotion dressed up as policy analysis.”

“The real conversation we should be having,” adds podcaster and pro-aging advocate Ande Lyons, “is about why we’ve designed systems that pit generations against each other instead of asking who actually benefits from that narrative.”

Meanwhile, at the other end of the spectrum, economists contend that because of a shortage of younger workers, older adults must stay longer in the job market to keep the economy humming. To them, we have worth – as long as we’re economically productive.

“There is nothing wrong with supporting people who want or need to work later in life,” writes psychologist Denise Taylor. “The problem arises when employability becomes the dominant lens through which ageing is understood.”

Jane Barratt, a globally recognized advisor and advocate on aging and social policy, also objects to policies that tie aging to usefulness. “Longer life is welcomed because it can still perform,” she writes. While this view opens opportunity for those who in good health who have the “right” work experience, “it has far less to say about those whose lives do not fit that script.” Many older adults contribute by caring for partners and holding families together on reduced income, “yet our redesign efforts continue to center on capacity…. Longer life is supported, so long as it looks purposeful in the right ways.”

And it’s not just economics. On the health care front, the Journal of the American Medical Association published in April a study concluding that there’s no point in screening adults aged 75 or older for colorectal cancer, as there’s a higher risk that they’ll die from some other disease first. Another study in the same issue looked at whether adults aged 60 and older could discontinue treatment for thyroid disease.

There’s nothing quite like the feeling of being on the losing end of a cost-benefit analysis, when all you’ve done to deserve it is live longer.

What It’s Really About

Ageism is a common thread in all these intellectual cross currents, certainly. But there is something else going on. Each of these examples is evidence that our longer lives don’t fit neatly into the systems and structures of contemporary society. In short, we are here today, and the systems that were built decades ago have no idea what to do with us. Our existence does not compute.

(Is it just me, or does this remind you of growing up in the ‘60s and ‘70s and not fitting neatly into 1950s-era structures of school, work, family, and dating?)

We have a few choices. We can roll with systems as they are. We can rant about the inadequacies of those systems. Or we can replace those systems with new ones more appropriate to the longer lives that we are experiencing now, today.

Having tried rolling and ranting, to no avail, I’m ready now to work on replacing. How about you?

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The word “longevity” is having its 15 minutes of fame these days. It shows up in serious journals. It also shows up in pitches for unproven treatments designed to beat back the ravages of time.

Let’s talk about what’s real and what’s hokum.

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What’s very real is the fact that populations around the world are getting older. Thanks to medical breakthroughs and more attention to healthy lifestyles, people are living longer than they once did. In 1935, when Social Security was established, life expectancy for males was 58 years. That number has risen to 76 years today. And those statistics include people who die young. If you live to age 60 today, you have a good chance to live well into your 90s.

That, combined with the population bulge fondly known as the “Baby Boom,” to which I and many readers claim membership, has changed the traditional balance of old and young. For the first time, there are as many people 60 and older as there are people under age 20. Instead of the typical age pyramid, with a large number of young people at its base and fewer older folks at the peak, populations of many nations look more like squares, with roughly equal numbers across all ages.

Serious Science

So this is the longevity social scientists talk about, and it is a real thing.

Another real aspect of longevity is the serious scientific research taking place in universities and private industry, supported by an influx of capital from tech billionaires Jeff Bezos, Peter Thiel, Sam Altman, and others. The billionaires seem to be obsessed with cheating death and enjoying eternal life with their inexhaustible resources. Even Vladimir Putin and Xi Jinping were caught on a hot mic speculating about ways to reverse aging and perhaps avert death altogether. Another happy thought – autocrats ruling in perpetuity.

Meanwhile, back on Planet Earth, we non-billionaires are bombarded with “dramatic breakthroughs,” “miracle treatments,” and “scientific answers” for beating back the forces of aging. We have high-tech gadgets to monitor our steps and our blood sugar, supplements to correct dietary deficiencies, special creams to erase wrinkles, exercise equipment to build strength and melt away fat, radical diets, cold plunges, and pills that promise 70-year-olds they’ll feel like 40 again. This aspect of longevity, needless to say, is highly suspect. It’s a direct descendant of the Wild West medicine show, patent medicines, and similar all-American quackery.

It’s also big business. Feeding on the current enthusiasm for wellness and fear of dying, the longevity industry raked in $192 billion in 2024. Much of its momentum is fueled by social media influencers and podcasters who are handsomely paid to promote wellness products.

Beware of this manifestation of longevity. And remember: Not everything you see on social media is a lie, distortion, half-truth, or exaggeration. Only 90% of it.

No matter how science-based these longevity products sound, none of them – so far at least – has been proven to deliver the results they promise. Most “bio-hackers” grab onto studies that suggest possible benefits, but don’t wait for proof of effectiveness.

Personal disclaimer: For the record, I take nine supplements daily, all recommended by a wellness practice and based on detailed testing of my blood chemistry. None of them is a proven cure for anything, but some functions have improved. I’m not saying avoid all supplements, but do be skeptical of miraculous cures. If it sounds too good to be true, it probably is.

What Does Work

While science has yet to find the Fountain of Youth, there is broad scientific consensus on measures that do tend to increase longevity. They are boring, but proven effective:

• Regular exercise

• A nutritious diet

• Adequate sleep

• Abstinence from tobacco

• Limited alcohol

• Nurturing meaningful relationships

Just because you’ve heard it all before doesn’t make it any less true. If you’re serious about longevity, do the boring things, and ignore the clickbait.

And, as my favorite Vulcan used to say, live long and prosper.

No. 106/April 29, 2026

NewScan is a biweekly briefing on news relevant to readers of The EndGame. NewScan is a premium feature exclusively for paid subscribers.

Letting Go of Who We Were

One hard part of aging is saying goodbye to our former, younger self. Two writers reflect on the emotional struggle. Rebecca Gummers finds that you can have a positive out…

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Photo by Takuya Nagaoka on Unsplash

Monday was the day of reckoning, I was certain.

My latest lab results were back, and my glucose score was not looking good. My doctor had been warning me for two years that my score was on the high end of the normal range and on the verge of crossing into the pre-diabetic stage. Now my score had crossed the line. From there it was a hop, skip, and a jump to … DIABETES!

I knew what that meant. No ice cream, ever again. No sweetener in my tea. No cookies. No mini-chocolates. And most devastating of all, no daily chai latte to start my day - a morning delight that acts as my coffee surrogate.

That was the line I was not ready to cross.

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In a classic comedy sketch, Jack Benny (remember him?), whose character was legendary for being tight-fisted with a dollar, is approached on the street by an armed robber. “Your money or your life!” shouts the robber. There follows an uncomfortably long silence. “Come on, you heard me — your money or your life?” To which Benny replies, “I’m thinking it over.”

Life or Sweets?

That’s exactly how I feel when confronted with the prospect of forgoing the sweets forever. Life is not meant to be joyless, colorless, bland, and deprived of sweetness. There is pleasure to be had in life – in moderation, of course – and for me, one of life’s greatest pleasures is consuming sweets. It is reasonable to ask whether a life without sweets is even worth living. I’m still thinking it over.

I am not over-indulgent. I don’t insist on a dessert after every meal. I don’t munch on candy bars or snack on M&Ms between meals. But I do enjoy the occasional ice cream and I am physically unable to restrain myself when placed within reach of a cookie tray. Also, I would have to be near death to turn down a slice of pecan pie.

But these very occasional indulgences could hardly explain the steady rise in my glucose numbers, so I considered what might. I dismissed the chai latte – it was off the table and would not be sacrificed. I thought of another suspect, and one I could live without: Throughout the day I flavor each glass of water with a jigger of lemon juice and a packet of stevia, turning water into quick-and-dirty lemonade. This is how I keep hydrated and meet my minimum daily requirement of water. I find lemonade far more appealing than plain water. But perhaps those stevia packets add up to a problem. Under protest, I suppose I could drop the stevia and just drink lemon-flavored water. In any event, it could be a useful chip.

Those familiar with the Kubler-Ross formulation of the five stages of grief will recognize that I had moved past denial and anger and was ready for bargaining, as I prepared to face my doctor on Monday to get serious about glucose.

But the meeting did not go as anticipated.

The Reckoning

My doctor noted the rise in glucose, as expected, but she did not immediately demand a total blockade on all sweets, as I had feared. We talked about what foods might be causing the glucose surge, and whether the cause might actually be a deficiency in another body function, such as insulin production.

When I mentioned the stevia in my ersatz lemonade, she said, “That wouldn’t be causing it.”

Instead of clamping down on all sugar, she prescribed me a continuous glucose monitoring device. Once it has been installed, she said, “Keep a food diary, so we can figure out just what’s causing the spike.”

What a relief! My chai latte is safe for the moment, I’m still on the low end of pre-diabetic, and we have a plan for lowering my score that doesn’t involve coming off all sweets cold turkey.

By the way, another thing that can elevate glucose is stress. The kind of stress that might be generated by anxiety over being deprived of sweets for life because of DIABETES! And I know just what to do about anxiety.

I will chill out and enjoy a refreshing chai latte. For my health, of course.

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I admit that when I learned the so-called One Big Beautiful Bill was going to cut $911 billion from Medicaid over 10 years, my first thought was, That’s really cruel, but at least it doesn’t affect me.

And if Medicaid were, as it was intended to be, a program strictly for older adults in poverty, I might have been right. But Medicaid has become something else in recent years that does affect middle-income families – any family that would be severely challenged to pay $100,000 or more annually for long-term care. Medicaid has become the payer of last resort: If you can’t afford a nursing home, your only recourse is to spend down all your cash and assets until you’re broke enough to qualify for Medicaid coverage.

(You knew that Medicare doesn’t cover nursing homes, didn’t you?)

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But soon, it appears that we won’t have Medicaid to kick around anymore. Partly that’s because middle-income families glommed onto it, partly because of chronic underfunding, but ultimately because of a political failure to address the ruinous cost of long-term care.

“The real story,” writes Kathy Heery, a nurse and writer, “is how a program designed as a narrow safety net for low-income families was slowly stretched into the country’s primary payer for dementia care, custodial care, and the daily support millions of aging adults now need.” Medicaid now pays for more than half of all long-term care in the U.S. The reason is also clear, Heery adds. “It happened because no other federal program stepped in.”

Breaking Point

It has brought Medicaid to the breaking point. As Heery writes, “The idea that Medicaid will ‘step in when you need it’ is no longer a plan. It’s an illusion.” That’s bad news for every household that doesn’t have several hundred thousand dollars squirreled away for long-term care.

In other words, the safety net has a gaping hole in it. While Medicare and Social Security have made great strides in battling old-age poverty, the U.S. has never developed a policy about long-term care. A report from the Bipartisan Policy Center notes, “Although policymakers have recognized this complex challenge for decades, they have yet to sufficiently tackle it, and the cost of continued inaction is unsustainable with the aging of the baby boomer generation.”

In the absence of policy, the burden of care falls on older adults and their families. Most of us hope to avoid the prohibitive cost of long-term care by aging in place. However, a study last year from the Johns Hopkins Bloomberg School of Public Health observes that “without a national long-term care insurance system in the U.S., most services, which are often expensive, must either be paid out of pocket or be provided by unpaid family members.”

How expensive? Here are annual costs today:

• home health aide to assist with daily activities: $80,080

• adult day care, five days per week: $24,700

• assisted living community: $74,400

• nursing home, semi-private room: $114,975

These costs explain why three-fourths of older adults in the U.S. with functional or cognitive impairments rely on unpaid family members for support. But that “free” care comes at a cost to the caregivers, who reduce their work hours or leave the workforce entirely, putting intense financial strain on their families.

Until two decades ago, long-term care insurance policies existed to soften the financial blow. But the market has shriveled as annual premiums skyrocketed and most insurers dropped out of the market.

What may be the death blow to Medicaid is the passage last year of the One Big Beautiful Bill, with its nearly $1 Trillion in cuts to Medicaid over 10 years and new rules, such as work requirements for some enrollees. Those cuts mean less money flowing to the states, which administer the program. This year, states must enact policy changes to keep their programs running with less federal aid. Those changes, according to current estimates, would add 7.5 million people to rolls of Americans without health insurance by 2034.

Revising Priorities

What can we do about this sad state?

The costs of government-funded long-term care are staggering, and, many would say, prohibitive. Certainly there is no room in the present federal budget for it.

But budgets are moral documents. They accurately convey our priorities and our values. Congress has no trouble allocating $893 billion for defense – a sum that is the highest on the planet and more than double the military expenditures of all 30 NATO nations combined – while slicing $911 billion (over 10 years) from Medicaid.

If you are unhappy with these moral choices, consider replacing your elected representatives with people willing to set different priorities.

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No. 105/April 15, 2026

NewScan is a biweekly briefing on news relevant to readers of The EndGame. NewScan is a premium feature exclusively for paid subscribers.

Retirement in U.S. Earns Mediocre Score

Compared to retirement systems in other nations, the U.S. system is in the middle of the pack, according to the Mercer CFA Institute Global Pension Index 202…

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Image created by Chat GPT

This post marks the beginning of Year 6 of The EndGame.

Yes, difficult though it may be to imagine, I’ve been posting weekly (with brief lapses) about aging for five whole years!

No one is more amazed than I am. Amazed that I have stuck with it, week after week, for this long. (In a career marked by many job changes and pivots, five years approaches a personal record for tenacity.) Amazed that hundreds of subscribers read these posts and dozens respond and comment every week. Amazed that I still find new and interesting things to write about.

My objective when I began was to write about all aspects of aging with an emphasis on finding the positives. The negatives, I feel, are already well-documented.

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Over five years, I’ve written about aging in place and senior living communities, depression and resilience, retirement and semi-retirement, grief and hope, identity and identity theft, mental health and physical therapy, loneliness and social connection, tech innovations and tech shortcomings, health insurance and the health care system, brain science and dementia. Other topics included higher education for adults, feeling invisible, fighting ageism, and avoiding scams.

Several weeks ago, when I mentioned to someone that I had been writing about aging for five years, they asked, “What have you learned?”

The question stumped me. I have certainly learned plenty (as, hopefully, have you), but how could I sum it all up in a coherent way?

After several weeks of pondering, here is my first attempt at answering her question. Here is what I have learned.

1. Aging is not a bowl of cherries.

It comes with inevitable losses – of friends, of loved ones, of memory, of bodily functions. It comes with doubts about whether we serve a purpose any longer – doubts fed by a youth-worshipping culture that is eager to declare us obsolescent. It comes with unwelcome thoughts about regrets and might-have-beens, and often-difficult thoughts about mortality and legacy.

2. But aging is not all pain and loss. And it beats the alternative.

Medical advances, along with the advantages of living in affluent societies, have gifted us with longer lives. Once we reach 60 years of age, we have an even chance to live into our 90s. This is unprecedented, and it is up to us to use these gift years to our benefit.

3. You need a reason to get out of bed – something or someone to live for.

We take for granted all the structure that working for an organization provides. We’re assigned tasks. We work toward established goals. We’re invited to meetings. We chat with colleagues. You only notice the structure when it disappears from your life – at retirement – and you wake up in the morning with nowhere to go, no one to see, nothing to do. Once you’re done celebrating your liberation – the typical honeymoon is about six months – you come to realize that you need to replace the organization’s structure with one of your own.

Some call that capital P Purpose. But even a little p purpose will do – a fix-it project at home or chauffeuring the grandchildren. And it’s up to you to find it.

4. The American “healthcare system” is an unspeakable mess.

This is not to slam physicians, nurses, researchers, and others who dedicate their lives to helping people achieve better health. It is to say that the “system”
in which they must operate is hopelessly complex, needlessly expensive, and delivering less than optimal outcomes for patients. It’s not impossible to do better: Other countries have created systems that guarantee access for all citizens at considerably less cost. But our jerry-rigged mishmash of highly trained professionals, privately and publicly supported research, state and federal regulation, a private insurance industry, a private pharmaceutical industry, and for-profit and nonprofit institutions manages to create high incentives for profit and less compelling incentives for excellent patient care. And no group spends more money on health care, and suffers more harm from its failures, than older Americans.

5. Retirement was an interesting idea whose time has passed.

Longer lives are a mixed blessing. While we can be grateful for more years of living, it’s hard to feed and house yourself on no income. The original concept of retirement was a short span of leisure at the end of a career. When fewer people lived long enough to retire, and retirement typically lasted 5-15 years, the math worked. When the period after working is 25 to 35 years, only the wealthiest 10% can afford it.

6. The AfterWork (my term for the state formerly known as “retirement”) is a new stage of life.

The old configuration for a normal life was roughly 20 years of education, 40 years of work and family, 5-15 years of retirement and failing health, and death. Today the configuration looks more like 20 of education, 40 of work and family, and 20-30 years of The AfterWork preceding the Afterlife. The AfterWork is our longevity bonus, too lengthy to spend entirely in leisure but long enough to build a second career or pursue a personal passion. We can use these years to solidify personal relationships with friends and family, or for that matter, to seek enlightenment – whatever brings us satisfaction.

7. Perspective lengthens with age.

With six decades of living behind you, your thoughts and concerns change. Short-term ambitions in the present moment take a back seat to seeing life as a sweeping panorama encompassing past and future. You’re slower to judge, more accepting of what is. Less inclined to fight, more eager to find resolution.

Some even call it wisdom.

8. No one’s journey is identical.

They say when you’ve met one old person, you’ve met one old person. As we have aged, our lives have taken different paths, so that we are actually more different from one another than when we started our lives. And that means sweeping generalizations about older adults are nearly always untrue. Be wary of them.

Now, it’s your turn.

What have you learned in your years on the planet? Do the things I’ve learned fit your own experience? What aspects of aging have I left out? I’m curious to know. Feel free to share your thoughts in the comments.

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Image by Valeria Nikitina for Unsplash

“If it makes you happy,” Sheryl Crow sang, “then why the hell are you so sad?”

Good question, Sheryl. I wish I knew the answer. Because I’ve had a bad case of the sads for weeks, for no obvious reason.

Or maybe a better descriptor is the blahs. Not much catches my interest or arouses my curiosity. This is a distinct problem for someone trying to come up with something fresh to write about every week. Nothing I read grabs me. No movies appeal to me. No books demand that I read them. Spring is bringing more pleasant days, perfect for a walk, but why bother?

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Last week, I got a clue to what may be at the root of this pervasive downer. Linda Melone, who writes about fitness and health at midlife, wrote a compelling piece about her own low mood in which she states, “I discovered that dopamine – the brain chemical that lights up when we feel rewarded – is fading into the sunset. It’s not gone completely, but is no longer at the robust levels of my younger years.”

Dopamine! Who knew?

Latching onto this important clue, I took a deep dive down my own personal rabbit hole and returned to ground level with more surprises. It’s not just dopamine, it’s a whole set of changes in brain chemistry, brain mass, and brain function. They’re a normal facet of aging – not that that’s any consolation.

Didn’t Get the Memo

It turns out our brains begin to shrink in our 30s. The shrinkage accelerates by the time we reach our 60s. But no one tells us this is happening. We don’t get a memo. It happens so gradually that we scarcely notice. Aging skin is obvious. Aging brain happens on the QT.

But eventually, we observe symptoms. We can’t remember names. We take longer to process information. We find it harder to pay attention. We can’t multitask as we used to. None of these symptoms is a precursor to dementia – they’re all normal byproducts of aging.

The brain is constantly changing as we grow and develop. Neuroscientists at the University of Cambridge have concluded that the human brain goes through five major epochs over a lifetime. The childhood brain begins at birth and concludes about age 9. The adolescent brain continues to grow while restructuring the internal networks. It ends about age 32 (!), when the adult brain takes over and compartmentalizes more. At 66 the aging brain sees reduced connectivity. Around age 83, the late aging brain is marked by a further decline in whole brain connectivity, with more reliance on particular regions.

Clearly many things have been happening inside our skulls, unseen and unannounced, to create changes. As areas of our brain shrink in volume, the neurons retract their dendrites, which receive electrical signals, and the neurons begin to lose their connections to other neurons. New neurons are still being created, but not fast enough to make up for the losses of old neurons. Meanwhile the brain is generating fewer messenger chemicals, such as serotonin and dopamine.

Ah, yes, dopamine. Which, it turns out, does a lot more than trigger smiles. It also plays roles in motivation and movement, in learning and cognitive flexibility, in balance and motor coordination. This sets the stage for falls. Also, the less dopamine we receive, the harder it is to get excited about anything – and the more dopamine we seek to feel much of anything. (And don’t think the designers of social media haven’t considered that. These media are designed to be as addictive as Las Vegas slot machines.)

On a positive note, older brains get more adept at certain things, studies have found. Among them, a greater depth and breadth of knowledge, and a better understanding of what words mean. For what that’s worth.

The Usual Suspects

Can we turn back the clock and reverse aging between our ears? Well, maybe, if we work really hard. Scientists at McGill University found that doing rigorous mental exercises for 30 minutes daily over 10 weeks increased levels of one chemical messenger by 2.3%. This can offset the average 2.5% decrease per decade.

Aside from that, it’s time to follow the advice of a famous French police captain in Casablanca: “Round up the usual suspects.”

• Exercise.

• Eat nutritious meals.

• Get sunlight.

• Get enough quality sleep.

• Meditate.

• Cultivate social connections.

• Be creative.

• Challenge your mind regularly.

• Manage stress.

• Learn new things.

• Keep your blood pressure in check.

Each of these activities can be pleasurable and therefore good candidates to stimulate those deficient dopamine droppers.

And for the sake of all that is holy, don’t let social media drain your batteries! Our brains need all the juice we can generate.

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No. 104/April 1, 2026

NewScan is a biweekly briefing on news relevant to readers of The EndGame. NewScan is a premium feature exclusively for paid subscribers.

Is Aging a Burden?

In many conversations about end-of-life arrangements, the part that is often unspoken is the fear of becoming a burden on loved ones. Jane Barratt, an internationally known strate…

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Photo by Joel Timothy on Unsplash

If you’re one of those few remaining well-bred humans who responds to gifts, dinner invitations, and other delightful acts of kindness and friendship with a thank-you note – written by hand, in ink, of course – then you may be doing more than most to stave off cognitive decline.

That’s one implication from a fascinating study that compared how handwriting and typing affect the brain. Researchers in Norway asked 36 students, who were connected to electrodes to measure their brain activity, to write or type 15 words that were displayed on a screen. When the students wrote by hand, they activated connection patterns in areas of the brain that controlled vision, motor functions, and processing sensory information. Typing the words resulted in minimal activity in those regions.

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“We don’t see that [synchronized activity] in typewriting at all,” said Audrey van der Meer, professor of neuropsychology and co-author of the study at Norwegian University of Science and Technology. She suggests that writing by hand is a richer process neurobiologically and that the richness has cognitive benefits.

Her research follows an earlier study that compared how students retained information. Half the participants were pen-and-paper notetakers and half took notes using keyboards. The groups scored similarly on factual information, but the manual notetakers scored far higher in recalling the conceptual ideas.

What makes the difference, says van der Meer, is that most typists try to record information verbatim. “It kind of goes in through your ears and comes out through your fingertips, but you don’t process the incoming information,” she says. Taking notes by hand is slower, making it impossible to take down every word, so the notetaker must actively process the information – prioritizing key points, consolidating, and relating it to what they already know. This keeps the notetaker engaged and facilitates learning.

Most of the people who find these studies important are focused on what it means for educating children. It’s evidence cited by those who advocate keeping cursive writing in the elementary school curriculum and limiting the use of keyboards in the early grades.

But at the other end of the age spectrum, the studies have important implications for those of us who worry about keeping our minds engaged and sharp.

The studies suggest that the act of handwriting facilitates learning and cognitive development in ways that typing does not. While many factors play a role in a person’s risk of dementia, the scientific consensus holds that mental stimulation (i.e., learning) is among the most protective measures you can take. Activities that challenge the brain stimulate neurotransmitter chemicals that reinforce connections between neurons and tend to offset cognitive decline. The Norway study is particularly encouraging, in that it shows that handwriting activates intricate webs of connections.

[A personal note: I have strong sympathies on both sides of this divide. In my former career as a journalist, I learned to compose my words at a typewriter and later at a computer). That is how I compose these essays. On the other hand, my journalistic career also compelled me to take copious handwritten notes at every meeting, interview, speech, or crime scene, and I still take notes compulsively. In other words, I’m covering my bets.]

There are other ways besides thank-you notes to incorporate handwriting into your routine. Journaling may have the added benefit of giving your emotional states an outlet, and it may even help arrive at resolutions. Drawing and painting also require mental concentration and close coordination between the eyes and the hand.

While there is no solid evidence that handwritten notes are a protection against cognitive decline, the neuroscience to date certainly suggests that it could be true. So my advice is to take note. In fact, take lots of notes. And don’t forget the thank-you notes.

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This week I am pleased to feature a guest post by Richard Sheffield, the author of Spend Your Damn Retirement Money: Beat the Spending Fear to Find Your Dream Retirement. Richard also contributes regular retirement advice on Medium.

Retirement advice has a weird habit of sounding like the last ten minutes of a Mission Impossible movie.

Cut the red wire, not the blue.
Take Social Security at exactly the right age.
Withdraw the correct percentage.
Downsize, but not too much.
Spend, but not recklessly.
Stay invested, but not emotionally.
Don’t run out of money.
Also don’t die with too much.

By the time you finish reading posts from the gurus, you’re convinced that if you make one “Sub-Optimal Allocation,” your entire financial existence will detonate, leveling three city blocks and causing every smart-fridge in the zip code to spontaneously order a case of rainbow kale.

This is, to use a technical financial term, baloney (or bologna depending on your Adjusted Gross Income — Line 11).

Not every retirement decision has to be perfect. In fact, you are socially obligated to get some of them spectacularly wrong. What else do we have to laugh at these days?

You’ll wait too long to spend. Or you’ll spend too soon and realize you’ve bought a $90,000 Italian sports car that you literally cannot get in or out of without starting and ending up on your hands and knees (just Google the Lambo crawl). You’ll stay too conservative, or you’ll discover that your “Dream Retirement Town” is charming for exactly 36 hours, about the time it takes for the local “Historical Society” to tell you that your mailbox is the wrong shade of “Colonial Eggshell.” After which the town reverts to its true form: a desolate museum of closed shops, aggressive brunch, and people who have very strong opinions about leaf-blowing (and those doing the blowing).

Welcome to being alive.

The real problem isn’t making a mistake.

The real problem is what happens after.

A lot of retirees make one imperfect decision and immediately turn it into a personal mythology.
I took Social Security too early.
We bought the wrong house.
I should’ve stayed more invested.
We should’ve traveled sooner.
It’s too late now.

That’s the second most dangerous phrase in financial planning, the first being, “this time it’s different.”

But, “It’s too late now,” is right up there in the top flight of wrong ideas.

Because in most cases, it’s not too late. It’s just no longer ideal.

And “ideal” left the building a long time ago anyway.

You are allowed to adjust in retirement.

This should not be a radical statement. It should be the sort of thing everyone nods at politely, the way we nod when someone says, “Water is wet,” or “You probably shouldn’t store gasoline next to the toaster.”

You are allowed to admit the dream house isn’t dreamy and sell it.
You are allowed to spend more if fear has had both hands around your wallet for ten years.
You are allowed to work part-time if you want income, structure, or a reason to wear big-boy pants twice a week.
You are allowed to stop if your “fun little retirement project” has quietly promoted itself to Director of the Department of Things That Were Supposed to Be Relaxing.

We Adjust

None of that is failure.

Pilots adjust. Good investors adjust. People driving through LA traffic definitely adjust. Why would retirement be the one part of life where changing course is treated like some kind of moral collapse?

Part of the problem is that the retirement world loves precision. It loves charts, withdrawal models, optimized claiming strategies, and neat little projections that imply if you just plan carefully enough, you can avoid uncertainty forever.

But the fundamental problem with the “Experts” is that they believe Retirement is a Math Problem, like calculating the trajectory of a deep-space probe or figuring out how many “Reward Points” you need to fly to Cleveland the morning before a periodontist’s convention.

Your health changes. Your energy changes. Your marriage changes. Your interests change. Your tolerance for airports, stairs, winter, and golf communities change. The plan you made at 61 may look pretty questionable at 71.

That doesn’t mean the plan failed.

It means the plan was a draft.

A lot of retirement “mistakes” are less catastrophic than people make them out to be.

Took Social Security earlier than the mathematically perfect age? Fine. Maybe it gave you freedom sooner. There’s value in that.

Stayed too conservative? Then rebalance.

Waited too long to spend and now regret it? Then stop making today worse by fucking repeating yesterday.

Bought the wrong house? Sell the damn house.

Retired and discovered you hate unstructured time? Also normal. Some people don’t need endless freedom. They need rhythm, purpose, and something on the calendar besides “wander around Costco.”

A lot of what retirees call disaster is really just revision.

You Gotta Hack Retirement — Because It Ain’t What They Sold You

12 Ways to Hack Retirement so It’s Truly Yours

medium.com

That’s an important distinction.

Disaster is running out of money with no options.

Disaster is major illness with no plan.

Disaster is fraud, denial, or total paralysis.

But “we chose the wrong location,” “we’re too cautious,” “this house doesn’t fit,” or “we should have started enjoying this money sooner” … those are not disasters.

Those are course corrections.

In a world run by greed-heads and lizard-brained actuaries, the idea of ‘getting it right’ is a cruel joke played on us. You will fail. You will buy into a fraudulent ‘Luxury Retirement Compound’ in the high desert that turns out to be a sun-bleached concrete slab guarded by a man with a sawed-off shotgun and a profound hatred of outsiders. At that point, ‘Accuracy’ is irrelevant. What matters is Surgical Recovery. It’s about Recovering Intelligently, which is a technical term for “Let’s try not to cry in front of the Realtor.”

Can you notice when the plan and reality are no longer aligned?
Can you admit it without turning it into a courtroom drama?
Can you Claw Your Way Out before pride wastes another five years of your dwindling biological clock?

That’s the skill.

Not perfection.
Not prediction.

The only skill that counts when the engine starts smoking and the sky turns the color of a bruised kidney is Adaptation. You don’t need to review the old map; you need the animal instinct to move before the concrete sets around your feet. Adapt or die, those are the only two options left on the menu. In a world of shifting markets and predatory heirs, ‘Perfection’ is a sucker’s bet, a cheap parlor trick for the rubes.

Some retirees put all their confidence in the size of the pile. This is a dangerous hallucination. In a world governed by the laws of Savage Entropy, the size of your pile is irrelevant when the sky starts raining bricks. You can have a pile the size of the Matterhorn, but if you’re too paralyzed by the The Fear to move when the ground starts shaking, you’re just the richest corpse in the rubble.

True confidence… the kind of cold, jagged nerve you need to survive the Final Stretch doesn’t come from the ledger. It comes from your innate Ability to Respond when the script goes into the shredder. It’s the instinct to kick out the windshield when the car hits the swamp.

Life doesn’t care about your ‘Original Script.’ Life is a drunken editor with a grudge and a fat red crayon, and he’s going to cut your favorite scenes without warning. Your only hope is to be faster than the blade. You have to be able to look at the smoking crater where your ‘Safe Harbor’ used to be, shrug your shoulders, and find a new way to get to the coast before the tide comes in. It’s not the size of the hoard that saves you; it’s the speed, and willingness, of the pivot.

That doesn’t mean your retirement is broken. It means you’re still in it.

And unless you are somehow reading this from the afterlife, which would be a hell of a subscriber perk, the story is still being written.

The ‘Perfect retirement Plan’ is a simpleton’s fantasy, a shimmering mirage for the terminally naive. You will blow the engine. You will smell the failing transmission of your own bad decisions. But a good retirement is simply one where the smoking wreckage doesn’t get the Final Word. After the car flips, you don’t sit in the seat and wait for the explosion… you grab the bag, reload your nerves, and keep moving toward the coast.

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No. 103/March 18, 2026

NewScan is a biweekly briefing on news relevant to readers of The EndGame. NewScan is a premium feature exclusively for paid subscribers.

You Really Might Be Getting Better!

Contrary to conventional wisdom, aging is not a one-way, downhill slide. A Yale University study led by Dr. Becca R. Levy, professor of social and behavioral sci…

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Photo by Milan Popovic on Unsplash

In the spring, says poet Alfred Lord Tennyson, “ a young man’s fancy lightly turns to thoughts of love.”

In the spring, says I, an old man’s fancy heavily turns to thoughts of eternity.

Not to be morose, but it comes with the territory. At a certain age, your mind naturally tends to process and synthesize all you have seen, all you have done, all you have learned. You recognize patterns that repeat and situations you have lived through that are now recurring. And you tend to have a long-range perspective on your life and your legacy.

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My thoughts on this are influenced by the work of Mary Catherine Bateson, an anthropologist and the daughter of anthropologists Margaret Mead and Gregory Bateson. Among her works are two memoirs, Composing a Life and Composing a Further Life, published 20 years apart. In the latter, as well as in a talk available on YouTube, she describes an emerging new stage of life, the one between ending a career and aging’s final decline, which she calls Adulthood II (and I call The AfterWork). She contends that society would benefit by mobilizing older adults to share their wisdom and energy, as well as their life experience.

Denise Taylor, whose essay about “olderhood” introduced me to Bateson, believes our brains in this new stage of life have the potential to think in a different way. In particular, they can resist the cultural narrative urging them to withdraw and segregate themselves from the world, on the one hand, and “the dominant narrative about later life [which] has become a relentless pursuit of productivity….’Never stop working’ has become a moral imperative disguised as encouragement.” The polar opposite of seeing older people as superfluous, it suggests that the only good senior is a working senior.

Life as a Whole

Bateson advocates neither. What her conception of Adulthood II offers, according to Taylor, “is the possibility of perspective: the ability to see one’s life as a whole, to recognize patterns across decades, and to weight present decisions against longer consequences.”

It suggests to me that all the striving of our adult years has brought us to a mountain peak. Behind us, we see generations past that informed the people we have become. Before us, we envision the younger generations that we have influenced and try to imagine how they will use what we taught them. We have to wonder if anything we said or did will help them (or, God forbid, harm them) as their lives go forward.

On the mountain peak we stand at the center of a five-generation wingspan that extends from our grandparents to our grandchildren. Viewing our lives from that perspective puts the immediate issues of the present day into a different light.

As the author of Ecclesiastes, obviously a person well up in years and having the scars to prove it, famously framed it:

What has been will be again,
what has been done will be done again;
there is nothing new under the sun.

But it’s exactly this perspective that can be valuable when you see younger people around you in a lather about the prospect of an oil embargo (been there, done that), a government led by bad actors and idiots (anyone remember the Nixon years?), or rapid climate change (but did you know the Sahara Desert was lush and green just 5,000 years ago?), or a true love gone awry (not the first, nor the last). From our hard-earned perspective, we can assure younger companions that no, the world is not coming to an end just yet, and life does go on. (Whether they choose to heed our hard-earned wisdom is another matter.)

This way of thinking – perhaps it is advanced age’s superpower – can also be conceived as peripheral vision, enabling us to see past the dominant narrative – particularly the one that says our value is only measured by our output – and to consider a larger outlook, one where human value is measured by one’s character and depth.

Make the hike up to the mountain peak. The view can be oddly comforting.

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Photo by Getty Images for Unsplash+

Once upon a time, in a land that now seems very far away, health care was considered a public good. Hospitals and nursing homes were mission-driven, not profit-driven. Their number one priority was the health and well-being of patients. They weren’t expected to make money. That’s why most of these institutions operated as nonprofit organizations.

A rather quaint idea, wouldn’t you say?

Today we are well into the corporatization of health care. Nothing demonstrates this better than the deluge of private equity capital flooding the sector – more than $1 trillion over the past decade.

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Private equity (PE) firms operate differently than banks or other investors. When a PE firm buys a company or nonprofit, it finances the purchase by taking on a sizeable amount of debt, using the asset they have acquired as collateral. (The term of art is leveraged buyout.) Then the PE firm shifts most of the debt onto the books of the newly acquired asset. This generally forces the acquired company to reduce costs, reduce staff, and increase revenues by raising prices and focusing on its most profitable procedures.

PE firms are organized to generate large returns for their investors in the short term, usually three to seven years. In most PE deals, the PE investors are first in line for payouts. Once the PE investors carve out their generous share, they have no further interest in the company they purchased, leaving it to sink or swim under the weight of its massive debt load.

Short-Term Focus

Some health care providers have sunk. A PE firm acquired Philadelphia’s Hahnemann Hospital and sold off its real estate. In 2019 the hospital was forced to close. Companies acquired through leveraged buyouts are ten times as likely to go bankrupt.

The rationale for PE is that it can infuse needed capital, introduce efficiencies, and rescue failing enterprises. The reality within the healthcare system is somewhat different: PE’s short-term focus on generating revenue and investor profit often leads to stripping assets, forcing prices upward, reducing staff to dangerously low levels, avoiding infrastructure investments, and eliminating vital services that are less profitable.

Evidence of improved quality of care or improved patient outcomes “is thus far scant.”

Nursing homes that have been acquired by PE firms, for example, have higher mortality rates, a lower ratio of patients to staff, and a 50% probability that patients will be sedated with antipsychotic drugs.

A more recent development is PE acquisition of medical practices, often consolidating multiple practices in the same specialty. PE firms have purchased 6,000 physician practices in a decade. In one-third of metro areas in the U.S., PE-purchased practices have more than a 30% market share in at least one specialty. In 13% of metro areas, a single firm owns more than half the physician market for one or specialties. That degree of market clout has led to price increases of 10-20%, with impacts on quality ranging from mixed to harmful.

Apparently, that’s not enough. Now PE is gobbling up small care navigation companies. Why? Because these companies help families decide where to get care, which services to use, and how long to maintain those services. “Private equity is industrializing a relationship-based profession,” writes Kathy Heery, a nurse with more than two decades of experience in the industry. “What once relied on local expertise is being transformed into a tech-enabled, repeatable, standardized, and national service model.”

Out of Control?

Is there any way to control this particular form of vulture capitalism, which has been compared, even in business publications, to an octopus, a band of pirates, and “financial termites devouring the woodwork and foundations of the U.S. healthcare system?”

More than a dozen states have passed laws requiring PE to notify state regulators in advance about planned transactions, and several require state approval. At the federal level, while several senators attempted to hold hearings on PE, regulatory agencies are too understaffed and underfunded to review more than a handful of PE acquisitions. Between 2010 and 2020, PE acquisitions in health care rose 167%, while full-time positions at the Federal Trade Commission decreased by 1%. And that was before the Trump Administration took an axe to federal employment.

There are no federal laws that protect patients or health care employees after a PE acquisition. Anti-trust reform is unlikely to get through the current Congress.

Perhaps it is worth noting that the federal tax code gives PE firms special privileges. Unlike publicly traded companies, they have minimal regulatory oversight. The income of general partners is treated as capital gains, which is taxed at a maximum of 20%, rather than as ordinary income. PE firms can also deduct the interest on the debt they rack up, lowering taxable income. They are also exempt from the corporate minimum tax.

These privileges have enabled the sector to accumulate tremendous wealth. Given the sector’s less-than-stellar record in health care of raising costs without improving care, is it reasonable to question whether PE firms deserve such special treatment?

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