Heffner: I am Alexander Heffner, your host on The Open Mind.

I'm delighted to welcome our guest today, M.T.

Connolly.

She's a widely recognized leading national expert on elder justice, for which she was honored with the MacArthur Foundation Genius Award.

She's also author of the new book, The Measure of Our Age.

Before we talk about the public policy implications, did you arrive at this subject, uh, because of seeing the, the, um, negative conditions in which older people have been living in this country?

Was there at all any kind of impetus based on anecdote or personal experience with this issue?

Connolly: Well, I think as with many things, it started with my mother.

Um, my mother was a psychiatrist, and, um, she worked for a big state, um, psychiatric hospital back when there were more of them.

And so, you know, that it was a place where we went as children.

We visited her at work, and when I was in college, I was trying to decide whether to go into medicine specifically into psychiatry like her.

And so I lived there for six months on a general admission psych ward, which it was a position called a resident volunteer.

And as I was there, it, what I got a chance to see were some of the real structural problems in our mental health system.

And so I thought, well, maybe I should go to law school, because in law school, one learns more about sort of tools with which one can change broken systems.

So that sent me to law school, and then I went to the Department of Justice and started bringing these big fraud cases, um, including some against, uh, nursing homes, big nursing home chains.

Um, and then I had an opportunity to, um, to lead the Elder Justice initiative, which was initially called the Nursing Home Initiative.

And the thing that was really apparent was that in aging, as in mental health, um, there were a lot of issues in common.

And one of the primary ones was that we don't really have a community based mental health system, and we don't have really good community resources for aging either to help older people or to help those who are trying to care for them.

And like those big psych hospitals, the nursing homes, um, are problematic institutions as a whole.

There are good ones, but there are way too many bad ones too.

So that was sort of how I got my start.

I initially was interested in mental health law, but then I had this opportunity, so I, I ended up, um, in aging and, uh, I guess I would say of both fields that they're both, um, huge and too often invisible.

And certainly aging is a, um, is a growth industry, Heffner: Right.

And too often today in America in crisis, I mean, there's an unpaid caregiver crisis.

There's a mental health crisis.

I have to ask you, just because of that origin story and that issue, um, again, we'll, we'll cover the aging issue and perhaps it intersects with this somehow, but you point out the declining number of mental health institutions and the rise of incarceration and the decline of mental health facilities, and that now with a gun crisis epidemic that is daily shootings, and we're lucky if there's not a massacre each day of the week.

Um, do you at all look back at that history and, and, and understand the trajectory we're on based on the lack of, of those facilities that that folks, uh, can potentially be admitted to?

Connolly: I guess looking back, I feel like the thing that we didn't do, we, we abolished the state hospitals, but we never created a community-based system to give people the help they need.

There's a very recent book by, um, a physician named Thomas Insole called, um, healing, which really looks at the failure of the mental health system historically starting in the sixties.

And, um, and that we, we got rid of one kind of, um, service, but never created another one.

And that from a social perspective, and this is true in the aging field too, what we've ended up doing, I think with mental health is approaching it way too far down the line after it's become a horrible crisis.

And we expect cops and prosecutors to deal with the a, uh, with mental health problems once really dire things have happened often, um, and prisons and, and sometimes nursing homes.

And so what we have not done is create the services that we need to help people who either have mental health needs or aging needs.

And we, you know, we, we just don't have the social infrastructure and it's, it's not that complicated to build.

Um, but we as a society have gotten increasingly reactive to issues as opposed to trying to say, okay, what is helpful?

What's preventive?

And how do we, how do we shift that lens to, uh, um, to solutions that are further upstream?

Heffner: M.T., you have been involved in the legal accountability to ensure the dignity of older folks, um, and elder care.

We have a lot of contradictory things going on in the sense that, you know, your book points out that we are living longer and yet the pandemic, um, and other factors, perhaps social conditions in which we were living during the pandemic led to decline in life expectancy just within the last few years, especially within particular underserved groups.

Um, we have a social security system, which is the means of livelihood for you can tell us what percent of older people that is going to expire in 2030 something, maybe 32, 33 based on the latest estimates.

Um, we have a Gen Z and millennials and older folks paying into this system that may go broke.

Uh, and not only are we going to deal with the crisis of the 70 and 80 somethings now, the 60 and 50 somethings now.

So you, you, you say what something's got to give, um, and what, what is that?

Uh, how, how, how are we going to be addressing this kind of multiplicity of crises?

Connolly: Uh, well, just going to the crisis and then to the Sure.

To many solutions.

I mean, I think what some people have called it a longevity paradox.

We want to get old, right?

We've moved heaven and earth like this with incredible science and all kinds of different sorts of progress to live longer lives.

But what we have not paid equal attention to is, um, how to live better long lives, both individually and in families as well as a society.

And so we have a caregiving crisis.

We have various financial crises, you know, we have multiple, we have a long-term care, an inadequate long-term care system.

I mean, I guess I think it's a failure of political will.

Um, because we have this heroic notion of science and, you know, and figuring out how to extend, extend, extend life, which is great.

All of us want additional time.

It's a huge privilege and achievement of our age.

But if we're going to do that, then we also have to pay attention to, um, caregiving, to, um, to long-term care insurance and long-term care infrastructure.

Um, we need- Heffner: I want to ask you specifically about that because it is this precise paradox that, uh, we're developing lifesaving medicines to, um, to keep us going, but we are accepting an insurance industry that is not allowing long-term plans in a lot of instances and making family members necessary, um, unpaid caregivers.

And if you aren't aware of this, I am personally aware of this because a plan that a grandmother smartly invested in many, many years ago is still in operation.

And fortunately she has it.

Um, but you couldn't get that plan in, in most every one of our 50 states now.

Connolly: That's correct.

Again, there are multiple crises, long-term care insurance is not accessible.

It's very expensive.

Often it doesn't care what you need when you need it, and it's beyond the financial reach of a lot of people.

Um, Medicare does not cover long-term care.

Medicaid only covers long-term care once you are impoverished.

And so what we see is, I mean, the numbers are staggering.

There are more than 40 million informal or unpaid caregivers, or mostly unpaid caregivers that's bigger than the population of California.

Um, and providing not just a little bit of care, but, you know, 24 hour, 24 hours a week on average.

Um, and we're not supporting them.

I mean, we're expecting 40 million people to take care of often, um, people who need a lot of help and the people providing the help need much more help.

And that is something that has been largely invisible in terms of, um, in terms of our civic discourse.

There's begun to be a little bit of attention.

Um, uh, iGen Poo, who is an organizer who also runs carrying across generations, um, has been doing a great job in raising up these issues.

But we've got a long way to go.

Heffner: Thank you for that.

Um, so you said we have 40 million people, um, unpaid caregiving.

Um, and I asked you before, and I didn't give you a chance to answer, what percent of older folks are relying on their social security now to live for rent or house payments and, and food basic necessities?

Connolly: I don't have the exact number.

I don't have the exact number, Heffner: But I mean, I surmised that it's fairly high.

Connolly: Yes, it's very high, and- Heffner: Like over 50%.

Connolly: Yes.

And, and there are 15 million older people who live in poverty, Heffner: And there was a, um, inflation boost, uh, of social security at some point within the last few years, but it, it wasn't adequate.

I mean, on the other side, I know a, a, a person in the same position.

I mean, it's, it's, they're, these are life lived anecdotes that we, we, most of us who are not in the ivory tower, you know, 1% bubble, um, we're grappling with, but, but someone in many municipalities cannot afford to rent an apartment or house on social security.

Connolly: That's exactly right.

The average age of Medicare recipients or people 65 and older is, I mean, the average income is about $30,000 a year.

That's more, that's less than one needs to hire, um, a full-time caregiver.

It's less than one than the average cost of an assisted living or nursing home.

It's beyond making long-term care beyond the financial reach of a lot of people of the average older American.

Heffner: So the question is, what do we do about it?

Dealing with these multiplicity of crises is not something that has to be politicized.

In fact, there has been bipartisan legislation drafted, if not legislated, um, on this issue.

It's an issue where it's really hard to tag a Republican or a Democrat as something other than compassionate and concerned about their parents or their grandparents.

Right.

So there, there is some fertile ground to build political capital on this issue.

Connolly: Exactly right.

I mean, it turns out both Republicans and Democrats get old and have older family members.

Um, and indeed there have been, um, members of both parties who have moved the ball and taken a lot of interest in aging issues.

Um, I mean, I think we need to look at it from a number of different perspectives.

Um, there's the perspective of what we do as individuals who are getting older than what we do in our families.

And then there are policy makers, what do we push them to do?

And then there's a, there are big cultural questions too, and I think a lot of this comes from, um, our fear of aging and our loathing of aging.

I mean, we are a society that we want to get old, but we don't really want to be old and we don't want to do what we need to do to think about being old.

Um, or prepare for it.

And so that paradox leaves us in a bind, because if we're not willing to think about it, it's harder to plan.

Heffner: And that leads me to this question of an ethical dilemma, um, because we do know how many hours might be expended on care for someone who doesn't have dignity by their very condition.

And so where did that fall in your assessment at the Justice Department thinking about this as a le a legal matter, but also a moral or ethical issue?

When you think of all these young people who at the current rate are going to be denied dignity into their thirties or forties or fifties, much less their eighties or nineties or 100 s, and it is a legitimate question of how long is too long?

Connolly: Right?

And what should be expected?

I mean, I, I've come to the view that no one should be forced to become a caregiver.

Um, because you don't know a family situation.

You don't know anyone's personal situation.

And so I think that is, um, that is unreasonable.

Um, in terms of what the law can do, you know, the laws, um, law enforcement, enforcement of civil and criminal laws is by its nature reactive.

So for example, if big nursing home chain defraud Medicare, Medicaid, then you can sue them under fraud loss.

Um, if an individual, um, commits a crime steals from an older person, say whether it's a family member or, um, uh, somebody else, then there might be criminal laws.

Um, but really that's focusing our sites, um, too late in the game because Understood, Heffner: Understood.

I do wonder if these insurance companies, to the extent they're thinking about this intellectually as you and I are, it, that, that they in their mind are justifying the absence of certain policies, uh, or rolling back certain policies on this basis of how long is too long and, and policies that are going to provide resources to people who can't contribute to society anymore.

I don't mean to be laissez faire about it, I just want to be blunt about it.

Connolly: I think people are, should be entitled to the care that they need.

But then there's a question about how we define that and how the, what we reimburse and is by and large, very expensive things that are connected to big money, right?

The drugs and the devices and the procedures as opposed to primary care.

There's an awful, I, there's an awful lot that we could do that's much less expensive than what we do now.

And provide people basic dignity.

But that's not the way that our healthcare system is organized.

Heffner: Based on your career and your reporting for the book, what percent of folks in that age bracket who are having trouble, they're, they're paralyzed, uh, or disabled to the point of not functioning anymore, how many of them, if they have the agency to say, so want to pull the plug?

Again, a serious question in, in the sense that, that in, in this country, that is not legal in most, uh, municipalities.

Um, you know, even if you voluntarily want to pull the plug.

Um, but I'm just curious what, what percent, if any, people want to move forward with that but are not able to?

Connolly: I don't know the answer to that.

Yeah.

I'm sorry.

Heffner: You're a MacArthur genius.

I shouldn't expect you to be an encyclopedia, but, I guess, my, my question is, is the answer to that relevant, right?

Is that data worth having?

I think it is.

But you're the expert.

Connolly: I mean, I think that, um, when families are having conversations and when people look into their hearts, they want to think about what the options are.

And, um, and people make really different kinds of decisions.

I mean, I know people who had such a hard journey with caregiving that they're very, very reluctant to put their children into that position, right?

Um, and suffer mightily.

And I would say that is probably the more dominant sentiment.

I mean, more people are scared of, um, having a disabling disease like dementia and being a burden on their children, then are afraid of dying.

That those data, we know, um, that that's a scarier prospect for a lot of people.

And you understand it, although I, I was interviewing somebody, a quite old family member or extended family member, and said, well, you know, people don't want to live forever.

And he said, well, guys my age, they say that, but then when they get there, you know, they may change their minds.

And there's a, um, there's a geriatrician, um, who has referred to that, um, who, who talks about a Mexican proverb.

But when you get into the ring with the bull, the bull looks different.

And so it's very hard to anticipate, I think what you're going to feel when you are an older person, um, whatever your capacities.

Um, and, and as a family member, uh, how you're going to feel you do work.

The only thing I would say is that I think it's incredibly important to start having these conversations, um, early on.

I mean, we have conversations around our dinner tables about colleges and about family trips and about all kinds of other things to try to prepare for these big life changes.

And then one, one way I've come to think about this is like, we have moved, um, you know, we've done so much to plan to get to old age, right?

We've bought our plane tickets, we've thought about, you know, where we, you know, how we want to get there.

But we've thought very little about what we want to do when we get there.

And sort of like any other destination, we both don't know what the problems are, who the hucksters are, but we also miss the really good parts.

And, and that is, I think, and I want to make sure we get to that because there's a lot that our ageism, I think our collective and individual ageism tamps down in terms of the potential of old age too.

Um, and our society is really, um, limiting in, in terms of some of the really profound purposeful and meaningful activities that only, and look, Heffner: Look, again, the, the life expectancy.

And this question, this moral question does have implications for how we all the rest of us can live.

I mean, the real estate.

In the same way, if you have, you know, a handful of pieds-à-terre and, and name that city, you know, and they're not being used, it, it's a, it's a real question.

It's not an unfair or unsympathetic question.

It's a question from a public policy lens that must be asked as we must reevaluate the legacy of the New deal.

And understand that Roosevelt, perhaps because of his own medical ailment, was cognizant of that and thought that the foundation for safety net ought to primarily be at that level.

Um, later on, programs were developed for younger people who were homeless, underserved need in need of medical care.

But it's clear that the legacy of the New Deal- it's not dead, but it is not adequate to fulfill the present needs- Besides incentivizing unpaid caregiving with tax rebates or even making unpaid caregiving, paid caregiving, which I think is legitimate even for family members.

Where legislatively or philosophically, um, where do we need to go to solve the, the problem?

We know some of the framework that is antiquated from that New Deal era.

Where do we go next?

Connolly: There are several different parts to the question, but one thing I just winna pick up on before I miss it, which is that I, I think you're pointing to something that's really, really important, which is that we need to look at lives over a whole life cycle and not say it's old people versus young people.

Because how we treat young people is essential, has a profound impact on how we, how we age, what our families look like.

Heffner: We live in an anti children, an, you know, there may be a Gen Z, but the, the whole climate of what is possible is not, what is possible is not what was possible for our parents or grandparents.

I mean, it's just a fact.

Connolly: I mean, we manifestly need to take care, I mean, at our education system, right?

We need to take better care of kids on all kinds of different levels and young families and vulnerable families.

I mean, the, yes, the, there, there's a lot to say on this, but I don't want to- Heffner: No, no, I'm sorry.

Connolly: No, I mean, in terms of the evolution of our laws too.

But in terms of the evolution, the reactive evolution, I mean, we should have had child welfare laws and those, you know, Richard Nixon vetoed that.

And instead we got a very, you know, we did not get laws that support children and vulnerable families.

And I mean, we've made legislative choices over the years that are devastating ones.

Um, and that will keep haunting us for decades to come.

Heffner: But on the question of what's after the new, the New Deal, what is next as the guardrails we need?

Connolly: In writing about this stuff, one of the things I had to grapple with is that we can aspire and work as hard as we can to change the world and try and improve it, but we can only live an age in the world that we have right now.

And so there are sort do two different perspectives.

Um, but from a, from a policy perspective, I think we need to, we need to help caregivers.

We need to have a long-term care system that people feel okay about relying on.

And right now we have a, um, the nursing home system is 70% for profit, increasingly in the hands of private equity.

And the data are pretty clear that, that for-profits are not as good as non-profits.

And that private, facilities owned by private equity are worse than the ones that are just owned by other for-profits.

And we don't, you know, they get about a hundred billion dollars a year.

We don't know how the money spent, how much of it reaches the bedside, and we don't know sometimes even who owns these, um, these chains.

And so that is a pretty simple kind of fix.

We need to say, okay, in order to get those hundred billion, you have to tell us how much of that money actually is going to care and who owns these places, right?

I mean, that's not rocket science.

And then on the other side of the, um, the equation, we know that staffing is the most important factor in long-term care in facilities.

So, um, we need to pay staff decently.

We have to have enough staff in facilities.

Heffner: What I hear you saying is, if we expose the malfeasance and corruption of inflation, not even of illicit activities, but just inflated costs of things, uh, that the, the Roosevelt approach may be something we can salvage, you know, the basic framework of the New Deal could be salvaged if you're not paying, you know, a million dollars for one bed for one night.

I mean I hear you saying that that's possible.

Connolly: Yeah.

I mean, I think transparency is very possible.

Transparency and uncertain- um, yes.

I think it's, I think transparency and accountability for how we spend the money is, it is very possible.

Um, and it just, we need the political will to do that, and that, that's just one part of it.

But for example, banks and financial institutions, there are guardrails there too that can help not, you know, reduce financial exploitation, um, more effectively.

Um, there are decent caregiver support models that we need to replicate, you know, there.

So there are, there is low-hanging fruit.

Um, and we just need to belly up to the aging bar and start doing it.

Heffner: Well, if folks bring the vigor we brought to this conversation, to the policy blueprint, I am hopeful M.T.

Connolly, author of the new book, The Measure of Our Age, a welcome discussion today.

Thank you so much.

Connolly: Thank you, Alexander.

Appreciate your interest.

Heffner: Please visit the Open Mind website at thirteen.org/open Mind to view this program online or to access over 1500 other interviews.

And do check us out on Twitter and Facebook at Open Mind TV for updates on future programming.

Continuing production of The Open Mind has been made possible by grants from Anne Ulnick, Joan Ganz Cooney, Lawrence B Benenson, the Angelson Family Foundation, Alfred P. Sloan Foundation, the John S. and James L. Knight Foundation, William and Flora Hewlett Foundation.

JoAnne and Kenneth Wellner Foundation.

And from the corporate community, Mutual of America.