PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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Quakers: The Society of Friends
According to an old Quaker joke, the Holy Trinity consists of the fatherhood of God, the brotherhood of man, and the neighborhood of Philadelphia.

The Whole Town as a Retirement Center

THE automobile changed American living habits. A few suburbs had once organized around railroad commuting, and even earlier a few had organized around steamboat commuting. But universal auto ownership was what triggered wholesale flight to the suburbs, completely reorganizing metropolitan living patterns. As suburbs tumbled into neighboring farmland, they seemed to obey a rule that 30-minute commuting was normal. Extremes of regular two-hour commuting do exist, but they conflict with a second hidden rule of suburbs, that some adult must be available when the kids get out of school. A third rule is that most young families move from town to distant suburbs when the first child reaches fourth grade. The unspoken reason this is true is pretty obvious, and I had hoped the election of Barack Obama would focus the Presidential leadership on fixing the inner-city schools, as only a black President would be uniquely qualified to do. Instead, his focus was on reforming the medical system, where he was probably uniquely unqualified. Suburban parents eventually seek a different lifestyle when their last child graduates from high school. For American families attracted by the schools, automobile commuting makes suburbs attractive, while empty nests largely end that interest. And social unrest at school makes parents flee to the exits no matter where they live.

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Remaining in your own home after retirement requires administration. {bottom quote}

Although it takes one extra logical step to get there, this insight suggests suburban retirement patterns surprisingly might be changed by improving the inner-city school system. Upgrade the quality and safety of inner-city schools, the rush to the suburbs will slow down, and suburbs become less expensive places for elderly folks to live. That's because school taxes are now the most expensive component of suburban living. Two-earner families are also more likely to be three-car families when they have high school children, so driving would become easier for retirees without so much overconfident competition for the roads if we could find ways to reduce the concentration of high schools in suburbs. If suburbs become a more natural place for retirees to live, they become more natural places for retirement villages to locate, which is the main point of this article.

The concentration of high schools in suburbs is a somewhat artificial response to urban disorders. My local suburban school system acquired a reputation for outstanding quality in a couple of decades. It did so by pouring money into the system, bragging about the schools somewhat unrealistically, usually stopping considerably short of demanding the academic rigor found in private boarding schools. The process was abetted by the local real estate industry, who shrewdly recognized that a popular product was high school glamor, not necessarily discipline and homework. This maneuver uncomfortably transformed a town which, fifty years earlier, found two thirds of the houses owned by families without children in public school. By contrast, just about every house in town today houses nearly two school children, and the school taxes have been driven uncomfortably high. Meanwhile, four or five neighboring suburbs actually developed shortages of children, two school districts even have closed. It seemed clear that families were moving into the "good school" suburb, willingly paying higher taxes while there were children to educate, but eventually moving back to low-tax neighboring suburbs when school quality no longer mattered to them. This recirculation was economically rational, although not necessarily the most efficient use of community resources.

Retirees now have difficulty living in my town, because school taxes are prohibitively high for residents without children in school. Long-time residents regularly sell half-empty houses to newcomers with lots of kids, and then those old-timers move a mile or so away to a low-tax suburb, often into a house as large as the one they just left. Others respond to the situation by moving to a CCRC. Is this a rational way to make rather basic life decisions? Is a suburb dominated suburb by teen-agers really the best place to locate a retirement village? Is a locality created by universal automobile ownership a good place to put an age group with cataracts and slow muscle reflexes?

So retirement villages are located in or nearby to suburbs because potential clents want to live there. The answer they usually give when asked is they want to retain the local medical system they had grown accustomed to. Since every one of them is covered by Medicare, that seems a strange answer, which more specifically means they want to keep the same cluster of doctors, pharmacies and hospitals they got accustomed to when their kids were in high school. They formed those habits at a stage in life when health care was a less dominant feature of their lives, so the connection is not strong. But they were young enough to experiment, and now they are old enough to quit experimenting. The politicians who continue to monkey with the payment system seem strangely unaware of this affiliation. Or the irritation these people will feel if they are coerced into changing.

Among the various reasons given to move to a retirement community, a chief one advanced by many people is that it is cheaper. Alternatively moving back into the center of a neighboring city might be more suitable, substituting a richer cultural and educational environment for a monastic one. In either case, retirement moves imply making a new set of friends, not particularly easy for old people to do. Commuting is no longer a price retirees are willing to pay; hardly anyone without children is willing to commute. Safety from crime, and nearness to medical care beat cultural richness most of the time; sadly, even golf and bridge games usually beat culture, which is more a European ideal than an American one. Although most retirees have forgotten how to enjoy what a city has to offer, center-city life really seems like a more natural attraction for retirees. Although the soccer moms seem to be having a fairly good time at the PTA, teenage cultural dominance of suburbs warps the livability for almost everyone else. Even for teenagers, commuting seems a rather high price to pay for six or seven years of high school excitement, particularly if note is made of the disconsolate loneliness of most adolescents. Inner city schools should improve, dissuading many from moving to the suburbs in the first place; inner city crime and taxes should be controlled to entice a return of the empty-nesters. At the very least, the suburban merchants and real estate agents should be squelched for their constant bad mouthing of neighboring cities. The present sociology of suburbs is a rather fragile thing.

If it becomes financially and socially possible for retirees to continue living in their lifetime homes, is it wise for them to do so? There is, first, the potential need for making financial provision for nursing, convalescent, or hospice care. Long-term care insurance aims at covering this need, but because these costs are high, the premiums for coverage are also high. It is difficult to know whether these prices are reasonable, because they must contain a margin of error against inflation, risk selection, and moral hazard. The technical insurance terms refer to the fact that the client almost certainly knows more about his impending health risks than the insurance company does, and secondly the mere existence of the insurance presents a temptation to use it. Someone living in the residential area of a retirement village surely has less temptation to move to its nursing facility than some other person still living in a house but potentially able to sell it and cash in his long term care insurance. There is also the danger lurking in the insurance that a client may get tired of paying premiums and drop the insurance shortly before needing it. Some types of insurance, notably term life insurance, actually pay claims to less than ten percent of clients; the rest drop the policies prematurely and receive no benefit. The tentative conclusion has to be reached that entering a CCRC is probably a better concept than buying long term care insurance, at least when both members of a marriage couple are comparatively healthy. Once the first one gets impaired or dies, the plight of the survivor definitely gets more precarious, without a volunteer caregiver or at least an in-house alert system.

One thing is pretty clear. At the present time, almost everyone is strongly advised to get on the waiting list of some CCRC, without hesitating to consider whether that is a final best decision. The deposit is ordinarily rather small, typically around a thousand dollars (returnable if unused). It at least eliminates that dreadful situation of urgently requiring admission, only to find the waiting list is years long. Even paying a deposit on several of these facilities at once can be justified if children move around enough to make a specific choice hard to make. An estate lawyer who was my patient was on the waiting list of five CCRCs for many years before he made a final choice; in his profession, he had many opportunities to see the wisdom of this approach. A less advisable choice made by many people is to enter the community before they need to. Comparatively few of these CCRCs permit you to sell out and move elsewhere without a penalty.

Nevertheless, why should you go, why should you disrupt your life this way? The answer seems to lie in the organization and its administration. When life choices are complex, unforeseeable and largely undesirable, and when your abilities may be slipping away, you may want some help without knowing it, or knowing where it get it. Maybe all you need is a new lawyer or tax accountant, or a different type of doctor, but have a little trouble telling a good one from a bad one. A tightly-knit little town can sometimes supply this service, but somehow it must be supplied. For that purpose, a Quaker organization in Philadelphia called Friends Lifecare at Home will manage an annual reassessment and call in the help necessary to remaining in your own home. It is a noble experiment, steadily growing in success. In a way, it supplies the function of the absent spouse, part caregiver, part watchman, and with a large Rolodex. Its main difficulties have come from Medicare, when seemingly capricious program changes change the assumptions in the yearly premium. Lifecare supplies service when Medicare doesn't; what happens when Medicare stops providing something? Lifecare helps you get a new doctor; what if the old doctor doesn't like that very much? The network of specialists and institutions may be just as important as the doctor, but the network changes when you change doctors. Many nursing care agencies refuse to allow their employees to have a key to the house, on advice of a lawyer who senses liability. Sometimes there is an emergency, no one can get in the door, and the fire department must be summoned to break in. There are problems with any arrangement, and there are problems with any alternative arrangement. This one works best when it is selected, not because it is cheaper, but because living at home is strongly preferred.

There's an architectural problem. Most suburban houses are built for families with children. If you plan to live in that house as a frail old pensioner, you had better fix the stair problem. One-story houses are certainly best, and even one-story houses often have stairs at the front door. Installing a home elevator is often prohibitively expensive, but would not be at the time the house is built. Most of the cost of an elevator lies in the construction of a shaft which has not been anticipated. If an elevator is added to a new house, the shaft is little more than two matching closets on two floors. The cab and motor are surprisingly inexpensive, and need not be added when the house is built. It's the design of closet over closet that makes it inexpensively feasible; what house could not use two extra closets? There are a lot of less defensible requirements in most building codes. While you are at it, be sure the doorways are wide enough to admit a wheelchair, the toilet seats low enough to permit wheelchair use, at least one walk-in shower is available, and handlebars provided near the bathtubs. These are things to think about, before you break your hip. If you don't it may add many thousands of dollars of unwelcome expenses at a rehab center, nursing home, or whatever. And not only expense; your roommate in a semi-private room may enjoy raunchy television channels.

There's also a local government problem, I'm afraid. The local volunteer ambulance service, often but not always run by the police or fire department, has its rules. If you are counting on this service to take you to a hospital or other medical service, you'd do well to check with them to see if they will take you to the place of your choice, if that ever becomes necessary. That's particularly true if you have enrolled in some "medical home" or home care service. If the local ambulance service won't take you there, you better know that in advance. If that's the case, don't argue with them. Either take effective political steps to get them to change their rules, or make other plans to get where you might want to go, at that unknown time in the future when you want to go there. If you live in a little town, drop in and visit with the Mayor or Commissioner, who might be unaware of your problem and easily able to fix it. If you live in a larger town, you may not be able to puzzle out where you could appeal. One easy way to work this particular system is to join the ambulance service as a volunteer, and make inquiries when you are on the inside. As a final last resort, if you live in a big city, go see the local ward leader who can fix things. Some of them will want money, but more likely they will only want your vote at the next election. If you are a member of a very large family, you will get more attention, because there are potentially lots of votes in your family. It's all rather sad, but the fact is that local politics usually control local ambulances, and their allowed destinations. A solution to the problem more directly available, is to talk with some of your neighbors who have cars. All that's needed except for unusual circumstances is transportation. You need not, and in fact usually should not, speed. Whenever I have put someone in an ambulance, my parting words to the driver are, "Don't go through any red lights!" Most of the cumbersome rules hampering ambulance use are imposed by insurance companies because of the high rate of accidents from those sirens and flashing red lights on the roof. If not insurance rules, it's lawyers, watchful for, or against, all the lawsuits which have been induced by Section 1983, a Reconstruction-era statute more recently reinterpreted to encourage citizens to sue local officials for just about anything at all, not just Jim Crow abuse.

And finally, there's a neighbor problem. It was first illustrated to me by my own 90-year old mother, who found everybody in her address book had died, so she threw the book away. One day when she needed a plumber, she just dialed zero and asked for "central", which in this case amazingly called the local police, who took care of it. But don't count on being that lucky. Portable cell phones help a lot with the problem of summoning assistance, providing you know someone to call. In a suburb, a lot of people move away for various reasons, and eventually an elderly pensioner living there is marooned in a neighborhood of strangers, never mind living in the same house for seventy years. The television and the Internet can be a great comfort to a hermit, but when help is needed, some familiar name should be pasted to the refrigerator door. Meals on wheels are nice, but they don't come when your sink is plugged up. A friendly local plumber is nice, but he won't help if the roof leaks. Everybody builds up a local network of friends and vendors, but older people need to watch out that it doesn't get out of date. They badly need what many of them don't think they need, a circle of friends.

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