Our Bodies, Ourselves (122 page)
Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
You can't predict the future, but the more prepared you are, the more likely it is that your wishes will be respected. Following are some useful resources to help with the planning process.
Since 2003, the official retirement age at which we can collect full Social Security has been phased upward gradually from sixty-five to sixty-seven, depending on your date of birth. You can collect reduced benefits as early as age sixty-two or delay collecting until age seventy. Planning ahead is critical to deal with gaps in earning power during employment years. If you have taken time off for raising children or elder-parent care, you may have less in savings put aside or retirement income. If you collect early, the law limits how much you can earn from working in retirement. If you decide to keep working after full retirement age, your earnings will not result in a reduction in Social Security benefits. For more information, visit Women's Institute for a Secure Retirement (WISER) (wiserwomen.org).
Social Security benefits may be based on your own earnings or those of a husband. Wives, widows, or divorced women may be entitled to a higher benefit from a husband's or ex-husband's Social Security than from their own. Unmarried women, even in long relationships, and women in same-sex marriages are not yet entitled to benefits from a partner's Social Security or, in most states, from job-related pensions or insurance.
As you get older, you may consider moving to smaller quarters or share living space with friends or other relatives. Cohousing movements are becoming more popular with retirees. Naturally Occurring Retirement Communities (NORC), where older adults age in place with community services, are cropping up. And Volunteers of America (voa.org) launched an Aging with Options initiative in 2009, helping people to stay in their own homes while receiving care.
MEDICARE BASICS
Medicare is the federal insurance program administered by the Centers for Medicare and Medicaid Services (CMS) for all people age sixty-five and over and for people with disabilities under age sixty-five.
Part A, which applies to everyone, covers acute medical care in hospitals (sixty days at full cost, after which a patient copay is required) and short-term nursing home or home care. Part B, which is optional, covers 80 percent of follow-up and outpatient medical treatments, as well as tests and some equipment. It doesn't cover vision or dental care. Part D, also optional, covers prescription drugs and is made necessary by the high cost of medicines.
You have to pay for Parts B and D yourself. Monthly payments for Part B can be deducted from your Social Security benefits. Medigap, the supplemental insurance sold by private insurers, or Medicare Advantage (which contracts with Medicare), covers the deductibles for parts A and B and 20 percent of costs of procedures and supplies
not
covered by Medicare Part B. Some retirees obtain these supplemental policies from employers as part of a benefits package, but most of us have to buy this insurance ourselves. People under age sixty-five with disabilities who are unable to work are eligible for Supplemental Security Income (SSI).
Part D is purchased through a private insurance stand-alone drug plan or Medicare Advantage, or it may be covered by Medicaid (the government insurance plan for people with low incomes). Prior to implementation of the Patient Protection and Affordable Care Act (the health care reform bill enacted in 2010), after you and your plan together spent a certain amount on co-payments, deductible, and insurance combined, you reached a coverage gap (the so-called donut hole), and you would have to pay 100 percent of total drug costs up to the catastrophic coverage limit. Once that limit was reached, you'd pay a small co-payment for each drug.
The new health care law addresses this by providing Medicare beneficiaries who reached the donut hole in 2010 with a $250 rebate, after which they receive a pharmaceutical manufacturers' 50 percent discount on brand-name drugs. The discount will increase to 75 percent off brand-name and generic drugs to close the donut hole by 2020.
The same law requires everyone in the United States to have health care insurance. Depending on your income level, you may be eligible for Medicaid or a subsidy to help you pay for insurance. The new law also forbids private insurers to deny coverage to people with preexisting conditions and to make women pay higher premiums just because they tend to live longer than men. Age rating (charging higher rates for older adults) is still permitted, and premiums can vary by as much as a three-to-one ratio (they previously varied by as much as six to one). Some providers do not accept Medicare patients because the reimbursement rate is too low. Medicare's major limitations are that it focuses on acute care
and does not cover long-term care, either in nursing homes or at home. It also does not cover routine eye care or dental care.
The State Health Insurance Assistance Program (SHIP) is a national program that provides counseling and assistance to Medicare beneficiaries. Visit shiptalk.org to learn more about a SHIP program in your state.
In addition, more thought is being given to supporting elder-friendly communities that provide opportunities for people to age in place by ensuring the accessibility of community resources, such as shopping, medical care, transportation, and places of worship. Partners for Livable Communities (livable.org), a national nonprofit organization, has long focused on older adult populations in its work on urban development and community planning and has formed partnerships with municipal organizations for an Aging in Place Initiative (aginginplaceinitiative.org). Such communities, which are deemed livable for older citizens, are livable for
all
ages.
Some neighborhood residents are banding together to form intentional communities, in which residents stay in their homes as they age, supported by local programs and services. One such community is Beacon Hill Village (beacon hillvillage.org), a membership organization located in the heart of Boston that was founded in 2001.
You may be eligible for subsidized housing when you reach a certain age or if your income drops below a certain level. Contact Administration on Aging (aoa.gov) and National Council on Aging (ncoa.org) to find local affiliates. Your state department on aging also can provide information about subsidized housing options and combined housing and services options.
Long-term care services are currently fragmented and expensive. Out-of-pocket expenses for long-term care represent the greatest financial risk for older adults, especially those who have cognitive, physical, or mental problems. Medicare covers only short-term home or nursing home care for acute illness after a hospital stay. All other expenses must be paid out of pocket, including long-term care at home, in the community, or in a nursing home.
Medicaid is a primary source of funding for home care and nursing home care, but only those of us with very low incomes or who spend down most of our assets are eligible. Private long-term care insurance usually has strict limits on the kind of care covered and where it must occur for it to be reimbursed. Most people age sixty-five or older lack such coverage.
The Community Living Assistance Services and Supports Act (CLASS Act), instituted under the 2010 health care reform law, establishes a national, voluntary long-term care insurance program to help seniors and those with disabilities pay for nonmedical services and support. It is the first step toward publicly financed long-term care supporting aging in place, with both home and community-based options. After contributing for five years, participants will be eligible for benefits on the average of $50 a day to apply toward the daily cost of care. The program, effective in 2011, is financed through voluntary payroll
deductions. All working adults will be enrolled unless they choose to opt out. Proponents argue that this program will reduce medical costs in the long run. It remains to be seen whether the amounts provided will really be enough to help most of us pay for the care we need. Various organizations can help you find services and people to assist you or other family members. Use the Eldercare Locator (
www.eldercare.gov
) or call 1-800-677-1116 to find resources in your area.
Designating someone you trust to make legal and health care decisions for you if you are unable to communicate your wishes can help ensure that your preferences will be respected. Check with your state attorney general's office for the specifics of state laws and for copies of forms to use for health care proxies, advance directives forms and/or living wills. For more information concerning state laws and hospital policies, visit estate.findlaw.com/estate-planning.
A durable power of attorney
gives someone you trust the authority to act on your behalf in financial and other legal matters if you are unable to take action yourself.
A health care proxy document
gives someone you trust the authority to make medical testing and treatment decisions for you if you are unable to make them for yourself. The proxy is sometimes referred to as a health care agent or durable power of attorney for health care. Choose a health care proxy in advance and talk about your values and wishes with that person.
A medical advance directive or living will
describes the medical treatment you wish to receive (or refuse), and under what conditions. This makes your wishes clear to your proxy person, family members, and medical care providers. It can be written as a letter to the person who has your health care proxy and to your lawyer. Share the information with at least one trustworthy person who does not live in the same home as you. Federal law requires hospitals to give patients information about their right to make health care decisions and to appoint proxies and complete advance directives and do not resuscitate (DNR) documents. Living wills are not legal documents in some states; even so, it's better to put your wishes into writing and communicate those wishes to your loved ones than to stay silent.
We need to do more to normalize discussing end-of-life issues. Sometimes medical science, rather than concern for quality of life, shapes the advice we receive about death and dying. It's up to you to say what you want or don't want, and it's essential to talk with your doctor or health care provider about your wishes. Even then, however, it's a good idea to also talk with someone who can advocate on your behalf, if needed. Researchers have found that black patients tend to receive life-prolonging measures even when they have DNR orders or state a preference for symptom-directed care.
39
You may choose palliative care to relieve, reduce, or soothe the symptoms of disease or disorders while keeping your dignity. You may refuse inappropriate, aggressive treatment. Some people who say they want to die are really saying they can't bear living with severe pain or depression, for which treatment may make life satisfactory. Medical professionals are trained to save lives, but they are also bound by oath to do no harm.
END-OF-LIFE DOCUMENTS AND RESOURCES
Aging with Dignity
(agingwithdignity.org) offers a comprehensive living will called Five Wishes that addresses numerous aspects of medical and comfort care. It is available in twenty-six languages and in braille.
Caring Connections
(caringinfo.org), a program of the National Hospice and Palliative Care Organization, is a national initiative to improve care at the end of life, supported by a grant from the Robert Wood Johnson Foundation.
DoYourProxy.org
(doyourproxy.org) is a free online tool that enables you to quickly and easily create a living will and designate a health care proxy. The site was created by medical students at the University of Rochester School of Medicine and Dentistry as a project for the Community Health Improvement Clerkship.
It may be possible to choose where you dieâat home or in a hospital or a hospice facility. Hospice workers are specially trained to provide support and comfort to the dying, rather than trying to prolong life by whatever means possible. They can help manage pain and improve the quality of life for patients with serious, advancing illness. They can assist with dying comfortably at home if primary caregivers are available, or in hospice facilities, which may be self-contained or attached to a hospital or nursing home. If your priority is to have your wishes and values respected and your symptoms controlled, allowing you to spend meaningful time with the ones you love, this is your right.
Compassionate end-of-life care that addresses your emotional, spiritual, and practical needs is essential, regardless of the type of treatment or care you choose. Though legal, medical, and theological controversies abound, the right to make decisions about our quality of life is part of our basic right to control our bodies and our lives.
Women have been the primary caregivers for generations. With increased longevity, a growing number of us will see our parents live to old age as we head there ourselves. Though caregiving can be immensely fulfilling, the resulting responsibilities, which may involve years of care, have to be balanced with workplace and other family commitments.
Sixty-six percent of all caregivers are women; 41 percent of these women work full-time, and 13 percent work part-time.
40
The average age of the adult care recipient is sixty-nine years old. Sixty-seven percent of working women who are caregivers have had to make workplace adjustments, such as going in late, leaving early, or taking time off, while 22 percent have had to take a leave of absence. Often the caregiving is taken for granted, with little support or appreciation. The economic value of caregivers' unpaid contributions is estimated at $375 billion.
41
Research shows that caregivers have higher rates of depression, chronic disease, infection, and exhaustion than peers of the same age who don't look after others.