Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

I am not now, nor have I ever been a Marxist. But I studied Marxism in a philosophy class in college. I have visited communist countries (China and the old Soviet Union) and lived in semi-socialist counties (much of Europe) and have taken advantage of their socialized, government health plans when I got sick.

Obviously, I survived. But it has occurred to me that these experiences qualify me to recognize Marxism or socialism when I see it in the health insurance reforms that are about to become law.

Socialism means every provider in the health care system works for the government agency that runs the system. So let’s examine the reforms and see which ones, if any, are Marxist, socialist or in danger of destroying America.

ITEM: Within six months this year, young adults – like your kids in school – may stay on their parents’ health insurance until they are 26. The provision applies to all health plans and includes children under 26 who are married. Socialist? No, but it’s obviously paternalistic; critics could argue that children that age should be able to work and buy their own insurance.

ITEM: Also within six months this year, insurers will be barred from excluding coverage for children with pre-existing conditions. I don’t see anything socialist in this provision, but the administration did extend government power to insist that the insurance companies sell such policies at fair prices.

Later this prohibition will include adults but at least one Republican, Missouri Representative Roy Blount, opposes this on the grounds that adults should take better care of themselves. That may be government interference with the free market. But it’s not socialism.

ITEM: Another regulation that goes into effect in six months would prohibit group health plans and insurers of individual policies from rescinding or canceling a policy except in cases of fraud. It means once you sign up in good faith and pay the premiums, the insurer cannot cancel your policy even if you get very sick. Not socialistic, but another case of government telling a company it must assume the risk that some policy holders will get real sick, which may cost the insurer and stock holders a bundle.

ITEM: Under present law, the government just ordered Aetna, one of the largest insurers, to stop selling Part D drug and Medicare Advantage policies because it suddenly changed the drugs offered current beneficiaries. That’s a no-no. Aetna’s stock prices declined after the order.

ITEM: Similarly, the government is telling companies this year that it cannot set lifetime limits on benefits and in 2014, they will be prohibited from setting yearly limits on benefits. You might argue that that’s getting close to the government dictating and hurting business. Why should a company go on paying and paying even if the patient has some kind of incurable disease. What good would the medical help do? That’s not good for businesses, but it stops short of socialism.

ITEM: In what critics might call another government effort to bribe small businesses, many will be eligible this year for new tax credits to help them pay for their employees’ health insurance which they’ll be required to offer. The full credit will cover 35 percent of the cost of premiums this year and 50 percent in 2014.

This isn’t socialistic or a government takeover of the business but it is interference with an employer’s right not to offer health insurance. A tax break on 50 percent of the cost means the employer must pay the other 50 percent, which he may not be able to afford and besides, what if business is bad?

ITEM: Some critics believe workers should be able to take some responsibility and buy their own insurance or take their kids to an emergency room when they run a high fever. Again, not socialistic, and it’s far from Marxist for here the capitalists and workers help each other with the help of government.

ITEM: Another provision that supporters say is especially good for seniors would gradually close the so-called “doughnut hole.” There was a reason for the coverage gap which was deliberately created by the Republicans in their great Part D drug law in 2003 to help drug companies’ profits. When in that gap, beneficiaries must pay the full cost of the drugs, which will be going up if the companies are practicing the American way of business.

Did you know that the reason the gap was created is called “moral hazard?” Republicans wanted to be sure seniors didn’t overuse their benefit and buy drugs they didn’t need. So because some critics argue that closing the doughnut hole may encourage drug use, it’s probably good for the drug business that the hole won’t close until 2020.

ITEM: I see no ideological objection to another benefit this year touted by Obama - the elimination of cost-sharing (deductibles and co-insurance) for preventive medical screening exams such as colonoscopies, mammograms and prostate examinations and annual checkups. Maybe some people will take advantage of this too often and it can end up frightening people. But I do not think this benefit will bring America down.

ITEM: The primary health reforms come in 2014 with the establishment of state health insurance “exchanges” monitored by the federal government. Contrary to the belief that the government is taking over our health care system, these exchanges are supposed to offer a variety of competing private health plans with various benefits at various prices.

But there are to be standard benefits. And low income people will receive subsidies much the way Medicare helps people pay their premiums. All the companies will be private and so will most of the providers, hospitals, labs and doctors, so no socialism here.

In fact, the VA health care system will not participate in the exchanges because it is thoroughly socialist in that all providers work for the VA and it seems to work well, especially for lawmakers like Senator John McCain.

Sarcasm aside, why do people who do not know anything about Marxism or socialism toss those epithets at reforms that can only help them and millions of others? Perhaps the reforms may help the U.S. catch up to the 30 countries in the Organization for Economic Cooperation and Development, which includes most of capitalist Europe where they have been able to live comfortably with government-run health care. They are social democracies, with social (public) ownership of health care and other vital public services.

Bill Quigley, a Loyola University law professor and a director of the Center for Constitutional Rights has compiled some of the differences between the U.S. and counties that have adopted a modicum of socialism.

Their citizens pay higher taxes, but they get their money’s worth in health care and other benefits including education, transportation and paid leave for new mothers. Infant mortality in the U.S. is fourth worse among the OECD counties, better only than Mexico, Turkey and the Slovak Republic. Child poverty in the U.S. affects one out of five kids; that’s double the average in the 30 OECD countries. See for yourself at oecd.org.

“The facts say the U.S. is not on the path towards socialism,” says Quigley. And surely we are not close to Marxism which holds, among other things, that the rich get richer and the great corporations prevent the rest of the population from enjoying the fruits of their labor. (See, for example, the recent Massey mine disaster).

Write to [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

If you have a friend or a loved one in a nursing home, you should be aware of one of the more insidious practices facing many residents. They can save the nursing home money but they rob patients of what remains of their spirit, dignity and independence.

It’s not easy for residents, especially newcomers, to come to terms with being in a nursing home, especially if they are relatively healthy, ambulatory and generally of sound mind. But if they’re restless, troubled and a bit depressed (and who wouldn’t be), too many nursing homes will take measures that can be debilitating.

Instead of helping unsteady residents go to the restroom when they need to, attendants often will fit them with diapers as a matter of routine because there’s not enough staff to tend to every resident’s needs when they need to go to the toilet quickly. And staff members don’t want to be blamed for a fall.

Worse, if an elderly patient who is rebelling against being in the home and its restrictions or rules, or is unruly, the staff may get a doctor to prescribe a sedative. Only the worst of homes will use physical restraints which are forbidden by law, but more often – too often – nursing homes are resorting to anti-psychotic drugs for residents who are not psychotic but suffering from dementia, anxiety or a show of anger and impatience with being confined.

In January 2007, according to the Center for Medicare Advocacy, a nursing home ombudsman reported to the California Health Department that a resident at a skilled nursing facility had been held down and forcibly injected with an anti-psychotic drug. The patient was not psychotic, but suffering from dementia and Alzheimer’s disease. An investigation, said the Center,

“determined that 22 patients, including some who were suffering from Alzheimer’s...were being given high doses of psychotropic medication not for therapeutic reasons but to simply control them for the convenience of the staff.”

This investigation, which may include criminal prosecutions, is still underway, but the problem persists elsewhere.

The Boston Globe reported on March 8 that 2,500 nursing home residents in Massachusetts were given “powerful anti-psychotic drugs last year that were not intended or recommended for their medical condition.” The drugs were intended and licensed by the Food and Drug Administration for people with severe and diagnosed mental illnesses such as schizophrenia or bipolar disorder.

But the FDA has sought to discourage the use of these drugs for dementia, a gradual loss of memory or anxiety, by issuing what is known as “black box” warnings on the inappropriate uses for the drugs. But warnings are often ignored by doctors who serve nursing homes and are not usually available, or by short-handed nurses and poorly paid or trained attendants who tend to too many demanding patients.

Toby Edelman, a senior attorney for the Center told me, “Anti-psychotic drugs are used because there’s not enough staff and facilities. They know they shouldn’t use physical restraints. Using drugs inappropriately as chemical restraints is less visible, but has the same effect.”

“The misuse of anti-psychotic medications in the treatment or control of nursing home residents is pervasive,” said the Center. “In the fourth quarter of 2009, the federal government reports that 26 percent of the nation’s 1.4 million nursing home residents –354,900 people – received anti-psychotic drugs...frequently for reasons not approved by the FDA.“

In February, 2007, Dr. David Graham, an FDA official, told a congressional committee that as many as “15,000 elderly people in nursing homes (are) dying each year from the off-label (not FDA approved) use of anti-psychotic medications for an indication that FDA knows the drug doesn’t work.”

The drugs include Seroquel, Risperdal and Zyprexa, which replaced an older drug, Haldol. The use of these chemical restraints is not all the fault of besieged nurses and aides. Last November, Omnicare, the nation;’s largest nursing home pharmacy agreed to pay $98 million and its supplier-drug manufacture paid $14 million because of a kickback scheme involving Johnson & Johnson’s drug Risperdal. The scheme allowed Johnson & Johnson to push the sale and use of the drug.

On March 10, Bloomberg News reported that despite the FDA warnings on the possible misuse of Risperdal, the largest selling drug of its kind, Johnson & Johnson made plans to reach $302 million in geriatric sales of the drug for this year claiming it was safe and effective. According to Bloomberg, unsealed documents in a lawsuit by Louisiana against the company disclosed “a J&J business plan...called for increasing the drug’s market share for elderly dementia sales, an unapproved use.”

In January 2009, Eli Lilly agreed to pay fines of $1.4 billion for illegally pushing the sales and off-brand use of its anti-psychotic drug, Zyprexa. According to the U.S. Justice Department, the company promoted the use of Zyprexa by claiming it would help facilities sedate resident who would otherwise require more care.

Nursing homes are handsomely paid by Medicaid, long term care insurance or by the resident. Numerous studies have found that residents get better care in not-for profit homes.

With these drugs at hand, physicians are often unaware of the possible side effects on people who are not psychotic. But then, the Center notes, physicians who are supposed to supervise patients often prescribe without seeing them.

Psychiatrists are rarely available except for the most troubled residents. Edelman said that nursing home and the long term care pharmacies rely on “chart orders” left by doctors when they are unavailable.

“Physicians are present in nursing homes only intermittently,” Edelman said, They do not have offices, they work out of their cars.”

The Center and other patient advocates seek federal legislation to enforce existing law requiring that a physician be on call and available when a patient requires prescription drugs.

Nursing homes and pharmacies argue that if federal law is not amended to allow “chart orders,” residents will not get pain medications they need. But anti-psychotic drugs are not mere pain killers. They can turn an anxious or slightly depressed or forgetful patient into a zombie.

And the easy access to painkillers can tempt staff members into overusing or even stealing them for their own use. That’s why the Drug Enforcement Agency has been involved in the effort to reduce the availability and use of these drugs on unsuspecting patients.

Said Edelman, the Center’s concern “speaks to the dangers of indiscriminate use of pain medications and the lack of physicians to detect and respond to life-threatening problems involving their use.”

Got a friend or loved one in a nursing home? If he or she is asleep most of the time or non-responsive, demand to know the drug that’s been used and question why. If there is no satisfactory answer, complain to the home’s ombudsman or contact the Center for Medicare Advocacy.

Or write to [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Judging from the negative reaction to my attempt last week to provide a fair and balanced assessment of the health insurance reforms, which I support with reservations, I’ve been persuaded to amend my views. The primary reason is the new President Barack Obama, who at last has given us the presidency we hoped for.

Edward Luce of my favorite journal, The Financial Times, said it best. The shock of the election of Republican usurper Scott Brown to Ted Kennedy’s senate seat,

“turned him (Obama) from America’s lecturer-in-chief, who had even his most ardent supporters nodding off in mid-paragraph, into the robust campaigner who could electrify his troops...Mr. Obama finally took day-to-day control...By showing spine, Mr. Obama made it easier for Democrats in marginal seats to show spine as well.”

By finally abandoning his futile and damaging search for bipartisanship, to be liked by everyone, Obama was able to provide strong, more convincing leadership for tepid Democrats without losing committed liberals. In a sense, the blind and dumb Republicans, by hollering “hell, no,” helped remind Obama and the Democrats that they were Democrats – and in the majority, and in 2006 and 2008, were chosen to govern.

Thus, I was impressed by a speech he made in Iowa after his health insurance reforms became law, in which Obama clearly explained why, as he had intended and planned, “this is a middle-of the road bill.”

Perhaps because the burden of the battle had been lifted, Obama seemed to find a different voice, laying out as never before the thinking that went into his version of the health reforms. As he put it, without sounding defensive,

“This isn’t single payer, which some people wanted. It’s also not what the Republicans were looking for, which was basically to deregulate the insurance industry...This is a commonsense bill...It moves us in the direction of universal coverage.”

He dared Republicans to try to repeal its most popular provisions, knowing they would have difficulty seeking the repeal of the measure which would provide insurance, for children under parents' policies, until they reach 26, or covering children in with pre-existing conditions, or giving seniors $250 if they fall into the Part D drug doughnut hole.

But Obama also explained frankly that the bill, more than anything was not about health care, but about regulating and restricting the conduct of insurers so that care becomes accessible when you need it.

“What this reform does is build on the system of private health insurance that we already have,” he said. “But it finally tells the insurance companies that in exchange for all the new customers they’re about to get, they’ve got to start playing by a new set of rules that treats everybody honestly and treats everybody fairly. The days of the insurance industry running roughshod over the American people are over.”

Never before have the nation’s health insurers, which have been subjected to state regulations, faced rather stringent national regulation. Obama acknowledged that “it’s going to taker four years to implement this entire plan–because we’ve got to do it responsibly and we need to do it right.”

The president was challenged by an audience member who asked why a public option was not in the bill as part of the insurance choices. “Because we couldn’t get it through Congress,” Obama replied. That was true, in part, but Obama didn’t really push the issue and use his clout to organize support.

Nevertheless, he told his questioner,

“Thirty two million people are going to have health insurance because of this legislation...what this is is a historic step to enshrine the principle that everybody gets health coverage in this country. Every single person.”

Despite the complicated nature of the reconciliation process, the bill was passed in pieces by the newly disciplined Democrats who ignored the rather childish Republican tantrums. And like a magic potion, its passage has given new life to the Obama presidency, said The Financial Times. First, said the article, he “seems to be getting better at governing.”

That bodes well for him in the next fight for Obama intends to take on, with or without Republican help, the re-regulation of Wall Street and the nation’s rogue banks. That will be more difficult for Republicans to oppose; a few may even say “yes.”

It’s possible, as I have speculated, that with the health care issue behind him, Obama feels free to tend to other issues. Thus within a week of the passage of the bill, Obama fired a warning shot at Israel that said Obama will not be trifled with; sent a similar message to Republicans by making 15 recession appointment that they’ve been obstructing; he announced he had concluded a new arms reduction treaty with Russia, before he flew off to his war in Afghanistan to lecture its leader, Hamid Karzai, on the need to shape up and to tell the American troops why they are there.

Success at home helps build credibility and power and a president’s confidence for success abroad.

Still, the scars and wounds of the health insurance bill remain. And Obama will struggle to prove that he has no illusions about the for-profit insurance industry, which is beholden to stockholders and the bottom line. Already, the administration came down hard to thwart an effort by some insurance companies to avoid providing insurance to children with pre-existing conditions.

The companies promised to behave, but you know they won’t. Even as we speak, they’re plotting ways around the law. With his legislative success, Obama has gained power to be used to compel, as well as persuade the insurance companies to abide by the new rules.

But there will be plenty of opportunity, as the government writes the rules and regulations, for the insurance and drug companies to make mischief. New Yorker medical writer Atul Gawande notes in the April 5 issue that in the year after the passage of Medicare, Lyndon Johnson was forced to fight a series of nearly crippling rear guard attacks on the program, which was damned as “socialized medicine” by the American Medical Association and thousands of physicians who threatened to boycott Medicare. Today the AMA is an ally, but will the insurers and drug manufacturers behave?

While the Obama health reforms “could prove as momentous as Medicare,” Gawande wrote, “because most of the provisions phase in more slowly than Medicare did, they are even more vulnerable to attack. “ This time, he said, the threat comes from party politics, specifically the obstructionist Republicans.

If Obama and the Democrats follow up their legislative victory with an improvement in their prospects for 2010, the Republicans won’t continue a fruitless cause without their natural allies and source of funds, meaning the insurance and drug companies. They could use loopholes to deny or delay coverage and thus weaken the complicated the law and keep costs too high.

States could help implement and strengthen the law, yet 14 state attorneys general seek to overturn as unconstitutional its provision that everyone must buy health insurance eventually or face penalties. That is similar to state laws mandating the purchase of auto insurance or Medicare’s Part B penalties for persons who don’t sign up.

Nevertheless it’s a sign that resistance among conservative states and communities could endanger even this middle of the road health reform without the continued tough leadership of the new Obama.

Write to [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Amid all the well-deserved celebrations and self-congratulations on the passage of the health insurance reform bill, I thought I heard a dog bark. I was wrong. From the very beginnings of the late great debate, this dog didn’t bark.

I speak of the one most popular alternatives to provide guaranteed comprehensive and universal health care coverage – not just private insurance - for all of us; Medicare for All was not even considered.

As a state legislator, senator and candidate, that was Barack Obama’s choice. But despite what he now says, he does not tell the truth when he says every idea was truly considered. In fact, he refused to allow others to consider any proposal for single-payer health coverage.

As a result, Obama, Nancy Pelosi, Harry Reid and most health research groups, and the mainstream press boycotted and wouldn’t permit discussions of the simplest, most straight forward possibility for health care reform, Medicare for All. It was shut out of White House meetings. Not even Kaiser or the Commonwealth Fund or AARP responded to my repeated appeals to at least give an airing to the single-payer alternative. Eventually, the process passed it by.

So it was ironic that John Dingell, a Michigan Democrat and the longest-serving member of the House was given the honor of calling for the decisive vote on the reform bill. But the universal health care legislation he and his late New Dealer father championed for years was ignored. Nevertheless, Dingell gallantly praised the passage of the Obama bill and was at the signing.

But the second longest-serving member of Congress, John Conyers, Jr., also from Michigan, was nowhere to be seen in the celebrations. His bill, HR 676, the U.S. National Health Care Act, Expanded and Improved Medicare for All, just 30 pages long, had nearly 100 congressional sponsors, including several blue-dog Democrats who voted against the Obama bill, plus more unions, doctors, nurses, advocacy groups and consumers than the White House was able to enlist for its proposal.

But Conyers was gracious, praising passage of “the first comprehensive set of reforms to our ailing health care system.” He noted that he “would have preferred a different approach,” but he didn’t repeat an earlier observation, that after a year of debate and compromises and deals with insurance companies and drug makers, the Obama bill passed the House by only three votes more than needed.

Conyers reiterated his support for a public health option which Obama gave away, “because I fundamentally believe in the value of public health insurance and remain an ardent supporter of universal single-payer health care,” like Medicare. And he called for a new campaign to achieve it.

Obama has said he would have favored Medicare For All “if we were starting from scratch.” So let’s review what might have been and may yet be.

The Conyers legislation would have established a “publicly financed, privately delivered health care system that uses the already existing Medicare program...”

It would cover, at no charge, all medically necessary services, dentistry, long term care with patients having the right to choose their providers. And because the free care would be paid for by taxes and premiums, private health insurers would be unnecessary and would be prohibited from selling coverage that duplicates the benefits.

And unlike the plan that has passed, HR 676 would eliminate the need for dozens of fragmented, wasteful programs by including the Children’s Health Insurance Program, Medicaid, and other government funded programs with the exception of the VA health program, which may eventually become part of the system. And it sets a goal of converting to a non-profit system in 15 years. Read for yourself here.

One problem with the bill that has passed is that it leaves in place all the federal, state and private insurance bureaucracies for the dozens of competing and duplicative agencies with their complex rules that differ from state to state. Premiums for Medicare Advantage and the Part D drug benefit, for example, may differ from one county to another. While subsidies for Medicare Advantage insurers are to be eliminated over time, the current system is to remain in place, although these plans will be required to spend at least 85 percent of their revenues on the care of patients.

Indeed, to give the Obama bill its due, while it is not a health care plan, it is a health insurance reform which can be strong measure to regulate and restrict the behavior of health insurance providers.

Insurance companies will be barred from dropping people from coverage when they get sick. They will be barred from excluding children for pre-existing conditions; later that will apply to adults as well. They must provide immediate access to insurance for Americans who are uninsured because of a pre-existing condition. Children will be able to remain on their parents’ health plan until age 26.

In addition, insurers cannot impose lifetime or yearly caps on benefits, and new plans are required to cover preventive services such as mammograms, colonoscopies and immunizations without cost-sharing. That’s to become a standard Medicare benefit for all beneficiaries, who have been required to pay for co-insurance.

As expected, the 40,000-member Physicians for a National Health Program, which supports HR 676, worried that the bill that has passed will take too long to implement, that it will further enrich the for-profit insurance industry by $447 billion, that costs will go higher and that the new regulations are riddled with loopholes.

All we can do is see how it works. Here is the best and clearest graphic to explain the bill. (pdf)

If things don’t really change for the better and Democrats remain in the majority in Congress, maybe we can come closer to the Conyers bill, and hear the dog bark.

Questions? Write [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

[NOTE: This cancer they say I have is isolated in my stomach, has not spread and is slow growing. I begin taking pills (xoloda) for chemotherapy in a week or so. Otherwise I feel OK.]

The dozens of books on aging that come to me from publishers and authors are mostly useless. One reason: There is no such thing as an instruction book on aging, although Aging for Dummies, would be appropriate since most of us take it and learn one day at a time.

My complaint is that most of the advice is rather obvious, as in The Complete Idiot’s Guide to Secrets of Longevity. “How do you live, sleep, eat and play to live a long, healthy life? Adopting a longevity lifestyle. Quitting smoking is the single most important lifestyle measure you can do to increase your overall longevity.” Really?

I don’t mean to poke fun, but for those of us who have achieved a certain age, we don’t need to be told what we already know. Aging is not necessarily “golden,” as one book has it. (My late sister-in-law had a throw-pillow which said, “Screw the Golden Years.”)

This column was designed as a survival guide, for as most of us have learned, our older years, rather than becoming simpler, have become more complicated – from learning to negotiate the thickets of Medicare to conserving and protecting your home and savings, your estate.

Thus I am partial to books like Estate Planning Smarts ($19.95) by Deborah Jacobs, a lawyer and financial journalist, because it takes on a subject that we need to know about, and that provides solid, useful information. As I told her, this book is a keeper for those of us who need help riding the unpredictable currents of the economy and surviving with our estates intact.

The notion of an “estate” may seem overblown for many of us. But if you have some savings, a house, a pension, some bonds, insurance policies, a car and maybe an IRA, you have an estate to protect and care for. Estates are not just for the rich. As Jacobs writes,

“Estate planning is, above all, a way to take care of yourself and the people you love. It can minimize the hardships of your old age and ensure that less of what you leave behind goes to taxes...”

And keeping up with contemporary issues can help you make intelligent and money-saving decisions.

For example, financial advisers these days, leaping on the latest commission-making fad, are trying to sell clients on converting their traditional IRAs to the more recently created Roth IRAs. For the first time this year, there are no restrictions on one’s income in order to be eligible for a Roth.

The big advantage over a traditional IRA: There are no requirements that the owner must take required minimum distributions after age 70-1/2, which means the assets can grow tax free as long as the markets are kind. And after five years you may withdraw some of the converted funds, tax free. Non-converted funds are taxable.

It sounds great, but Jacobs, who has devoted a chapter to the Roth says, “they are a wonderful tool for some people but not right for everyone.”

The biggest problem, which your financial adviser may minimize, is the cost of conversion, for if you’re rolling over $100,000 from a traditional IRA to a Roth, that $100,000 is deemed income on which you must pay income tax.

If you convert, this year only, says Jacobs, you can delay the tax payment until next year and take two years to pay. But raising your income by, say, $100,000 may have complicating consequences for means-tested Medicare premiums and other benefits pegged to income.

In a neatly summed up table on page 106, Jacobs’ bottom line: If you can’t afford to pay taxes on the amount converted and you won’t recoup that money anytime soon, don’t do a Roth. If you don’t or won’t need the money in the IRA for household expenses (or emergencies) and you want to leave as much as possible to heirs, a Roth can build your estate, tax free, which is as close you can legally get to money growing on trees.

On a more mundane level, many readers have puzzled over whether a simple will is enough to leave behind. That depends on the will, the size and value of the estate and the probate laws and issues in your state.

Wills are subject to probate, a court-ordered process, which seeks to determine whether the estate has left debts to be settled and whether there are contesting heirs. Probate can take time and it could be expensive, so except for the most modest estates, probate should be avoided.

Enter the living trust.

Simply stated in an AARP paper, “...just like a will, a revocable living trust is a written document that lets you direct how your property will pass after your death.” But “unlike a will, it also directs how you want your property managed during disability.” When creating a living trust, the creator may name himself or herself as trustee, with a loved one as co-trustee. That means you maintain control over the property during your lifetime.

The trust does not take effect until the creator transfers ownership of the property, such as the home, to the trust. That’s called “funding the trust.” For example, you transfer ownership of the home to the trust and you become the owner-trustee. IRAs need not be transferred because the beneficiaries are designated.

A living trust may not be necessary if the estate is small and probate is not problem, but it’s a handy device for avoiding probate in many states and allowing the co-trustee to manage the estate and divide the assets among heirs.

As Jacobs points out, while a will is a public document, a trust is private. One caveat: A living trust won’t help you escape estate taxes. But it can help save on those taxes on properties that appreciate in value after they’ve been put into the trust. And because you, the living person, has control of the trust, a spendthrift nephew can be prevented from stealing from it.

Trusts may also be used to transfer funds from older persons as part of what has become known as “Medicaid planning,” divesting one’s self of assets to qualify for Medicaid, which will pay for long term nursing care for persons with few assets. But be careful, Congress during the last eight years has imposed restrictions on such transfers and Medicaid funds are being slashed in every state.

Here, in sum, is Jacobs list of documents you ought to have:

• Will


• Living revocable trust


• Durable power of attorney given to a trusted family member, friend or adviser


• Health care proxy (some states won’t recognize the right of a spouse or child to make decisions)


• Explicitly written living will or advance directive

For more information, visit Deborah Jacobs' Estate Planning Smarts website.

Questions? Write [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

[NOTE FROM RONNI] While reporting on Medicare and home health care in this column last month, Saul wrote about one of the most common accidents that afflict elders, falling, and his own recent fall. Now he has been diagnosed with stomach cancer. But I will let him explain, as he did in an email he sent earlier this week:

“I'm anxious to get back to writing, but better to hold off until we see what's in store.

“This week I will be getting my new denture, then later in the week a conference with the oncologist to see what my options are. Near as I can tell, the cancer in the stomach is slow-growing and in its earliest stage.

“Only two options, radiation and/or chemo, here in Annapolis or Johns Hopkins in Baltimore, which would be a shlep. Radiation is usually a daily thing; chemo is weekly. But they are both weakening. I am truly optimistic, but the question is how much strength will I have. I'll be better able to tell in a few days.

“I have signed up again for home health care, which will keep track of my general health (blood levels) during the next few weeks. And I'll be doing physical/occupational therapy to regain my muscle strength.”

As Nance wrote in a comment on last Saturday's post: We wish you wellness and well-being, Saul.

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

[NOTE FROM RONNI] Saul is under the weather – hence, no Gray Matters column today. He is taking some time to recuperate and refresh, and will return to these pages as soon as possible.

Meanwhile, you can read his always excellent and thoughtful past Gray Matters columns here or his other Time Goes By column, Reflections. Also, you may want to know that Saul celebrated his birthday on Thursday 4 March. We wish him a speedy recovery and many more birthdays. We need his important voice.

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

This time President Obama, in his obsessive reaching across the political aisle, may have gone a stretch too far. For the Republican he picked to co-chair the so-called deficit reduction commission, former Senator Alan Simpson, has been a harsh critic of Social Security and Medicare. And he sought to destroy their most powerful defenders, especially AARP.

That was 15 years ago, but as recently as 2005, Simpson, a conservative from Wyoming who left the Senate in 1997, supported attempts by President George Bush to privatize Social Security by turning part of the pension and insurance program into millions of individual investment accounts, which by now would have lost 20 percent of their value.

Bush’s plan failed, largely because of the opposition of AARP and other advocates that Simpson sought to discredit.

Even now, Simpson, who should know better, conflates or deliberately confuses Social Security’s long term fiscal problems, which are minor, with its supposed contribution to the federal deficit, which is almost nil.

In an interview with the NewsHour after his appointment, Simpson said of Social Security,

“You have two choices...you either raise the payroll tax or decrease the benefits or start affluence testing. The rest of it is B.S. And if the people are really ingesting B.S. all day long, their grandchildren will be picking grit with the chickens. This country is gonna go to the bow-wows unless we deal with entitlements, Social Security and Medicare.”

His colorful language aside, what does one problem have to do with another? The Social Security trustees and the Congressional Budget Office have said the nearly $3 trillion trust fund will last for at least another 30 years. Former Federal Reserve Chairman Alan Greenspan said the projected shortfall after that is easily fixed for decades with a small raise (two percent split between employer and employee) in payroll taxes.

Obama also minimizes Social Security’s fiscal problem and suggests simply raising or removing the current $106,000 ceiling on salaries subject to the tax. Will his pledge to maintain Social Security as a pension program clash with Simpson?

But here’s my point: Social Security's long term fiscal problem has nothing, absolutely nothing, to do with Social Security’s role in the deficit. For, as I have emphasized in my column for years, Social Security costs the budget not one cent – aside from the one percent it spends on its thousands of employees and field offices.

Indeed, Social Security helps finance the deficit by loaning the treasury money, for which it earns interest (about $700 million a year.) If what’s owed to Social Security must be cut as part of deficit reduction, will that help Social Security?

Nevertheless, Simpson’s statements help perpetuate the myth among right-wingers that Social Security contributes to the deficit. Here is former Texas Representative Dick Armey, chief organizer of the Tea Baggers and a longtime enemy of Medicare and Social Security:

“If you’re not courageous enough to look at mandatory spending the two biggest components being Medicare and Social Security, then don’t tell me you’re serious about fighting the deficit.”

Simpson’s record in the Senate raises questions about his appointment: Did the president have any notion of his background of hostility towards the twin pillars of American social insurance? Has Simpson left his right-wing politics far enough behind? Can he be an honest broker when, say, advocates for Social Security and Medicare come before his panel? Here’s why I ask.

In December 1994, when the Republicans were on the verge of taking over the House, the right-wing Capital Research Center, one of several relatively new think-tanks funded by prominent and wealthy conservatives, launched assaults on the Clinton administration and two major organizations that supported Clinton’s failed efforts to pass health care reform and resisted Republican efforts to cut Medicare funds.

The organizations were AARP and the labor-backed National Council of Senior Citizens (NCSC), which had played a major role in the 1965 passage of Medicare – over Republican objections. They were vulnerable because they held small federal contracts to train workers and also lobbied, which they were permitted to do.

According to consumer and medical affairs writer Trudy Lieberman, in her book, Slanting the Story, the conservative campaign took off when it was joined by Simpson, a rich rancher who was chairman of the Senate Finance subcommittee on Social Security and Family Policy.

A rather goofy dilettante, he was about to announce his retirement and had nothing to lose so he took on his antagonists, especially AARP, which had criticized him and lobbied against Republican efforts to slash Medicare funds and privatize Social Security. According to Lieberman,

“Simpson liked to tell stories about how he had to pay out of his pocket for his own parents’ care and believed everyone should do the same.”

Simpson’s father, Milward Simpson, had been Wyoming’s governor and a U.S. Senator.

Using what Capital Research had found, Simpson wrote an op-ed column in the conservative Washington Times in February 1995, attacking AARP’s director, Horace Deets for criticizing the Republicans and charged that AARP was illegally using member funds and the federal grants for lobbying.

Simpson also resented AARP’s opposition to the pending Balanced Budget Agreement. AARP had run afoul of the IRS for mixing its royalty revenues with its nonprofit business and was forced to pay a fine and separate its profit and nonprofit ventures.

But with the help of the press and the network of conservative groups, Simpson’s assaults –and his hearings – put AARP and the NCSC on the defensive. The latter folded and reorganized as today’s Alliance of Retired Americans. AARP’s Deets retired and was replaced by a Republican, public relations executive, William Novelli, who had become friendly with House Speaker Newt Gingrich.

Novelli, in 2003, stunned congressional Democrats when he threw AARP’s support behind George Bush’s private Part D drug program, which also provided huge subsidies for private Medicare Advantage plans.

Those plans, then called Medicare Plus Choice, became the first wedge in the privatization of Medicare in 1997. Under pressure from Republicans to slash Medicare funds, AARP was toothless, and Clinton agreed to allow private companies to sell insurance under Medicare.

That was part of the 1997 Balanced Budget Agreement, which slashed more deeply than ever into Medicare and Medicaid funds and severely restricted the use of Medicaid for long term care.

The Balanced Budget Agreement, which did produce a one-year balanced budget, was shepherded through the Congress by Clinton’s chief of staff, Erskine Bowles, now president of the University of North Carolina and the other co-chair of Obama's new Deficit Reduction Commission.

Write [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Thanks to the Republicans’ lurch to the far-out right, they can at last be honest in their intentions if they get another chance at governing in 2010 or 2012. They no longer need hide in sheep’s clothing; they can now be more comfortable as what they are: wolves in wolves’ clothing. And that means they will do what they say if they get the chance.

That is to say, the present Republican leadership and its young new ideologues, have put pretense aside and now openly intend to destroy, during their next watch, the twin pillars of the nation’s public social insurance system – 75-year-old Social Security and 50-year-old Medicare.

If you think I exaggerate, check out their legislation, for H.R. 4529, introduced by the top Republican on the Budget Committee, Representative Paul Ryan of Wisconsin and S. 1240, introduced by the most right wing member of the Senate, Jim DeMint of South Carolina.

Some excerpts in a moment, but underlying the proposals, “Roadmap for America’s Future,” is the belief of the now-dominant right-wing of the Republican Party that Americans should be weaned from Medicare and Social Security to reduce the national debt, permit deep reductions in taxes for the wealthy, encourage self-reliance, personal responsibility and less dependence on government and while putting the billions in Social Security taxes to work in American enterprises, the stock markets, to build individual investment accounts instead of a pension.

Republicans, of course, have long advocated self-reliance and individual responsibility - when they opposed child labor laws and opposed Social Security during the Great Depression and Medicare and Medicaid in 1965. But they’ve been disguising their opposition partly because these programs have been so successful and popular with the hundreds of millions of Americans who have been made whole with medical care and pensions. And the Republican Party was closer to the main stream.

Thus, when Ronald Reagan won the presidency in 1980, he calmed the fears of older Americans when he promised to cut only “waste, fraud and abuse” in government. As a commentator, he had spoken in vigorous, ideological opposition to Social Security and Medicare – as the harbingers of socialism. But as president, Reagan left Medicare alone and in 1983, he appointed a commission that strengthened Social Security to build today’s $3 trillion trust fund for the boomers’ retirement. The Trustees say the trust fund will last until 2037, unless the recession drains it more rapidly.

More background: In 1994-5, when Southern Republicans under House Speaker Newt Gingrich of Georgia, his sidekicks Richard Armey and Tom Delay of Texas took over the Congress, their “Contract with America” noted that Reagan had been unable to end many federal programs and the contract proposed a “Personal Responsibility Act,” to end welfare for poor women. But the Contract refrained from frightening the nation for it mentioned not a word about Social Security - which Gingrich called “the third rail” in American politics - nor Medicare.

But Armey let it be known at a press breakfast that the Republicans intended “wean our old people away from dependence on Medicare.” An aide quickly denied Armey meant to kill Medicare. Gingrich told health insurers that the Medicare agency would “wither on the vine.” Eventually it became clear what they meant.

Under the Republican threats to slash Medicare, Bill Clinton agreed to allow private companies to sell Medicare policies, now called Medicare Advantage, which are heavily subsidized and serve a fifth of Medicare beneficiaries.

In 2003, George Bush took Medicare privatization further with the Medicare Part D drug benefit which is wholly private. That bill also put limits on Medicare’s budget growth and instituted a means test for the first time.

Some of that has been reversed in the Democratic Congress, but Medicare is more private than it has ever been, although the proposed health reforms would end most of the $250 billion subsidy for Medicare Advantage.

In 2005, Bush sought to build on his Medicare privatization with an attempt to turn Social Security and its trillions into millions of individual investment accounts. While no one, except Bush, was burned by the third rail, his effort failed partly because even Republicans were afraid of ending Social Security’s $650 billion a year in insurance and pension benefits.

But the opposition, which continues to denigrate and undermine Social Security, has grown bolder and more radical and has not given up.

Sensing new opportunities because of the deficits they helped create and the strain the recession has put on Social Security and Medicare, the Republicans and Democratic deficit hawks have set their sights on both programs as if all “entitlements” contribute to the deficit. Social Security, for example, is self-sustaining and only its administrative costs (one percent) contributes to the deficit.

Nevertheless, the “Roadmap for America’s Future” (a more appealing name than the legalistic “Contract With America,“) would end future Social Security protection for all persons under 55 and substitute a “Personal Social Security Savings Program” - that is, investment accounts like that provided by the government (federal employees now also get Social Security).

Incidentally, the trust fund would no longer be available to loan money to the treasury and thus earn money. Instead the trillions in the trust fund, which belong to you and me, would be “liquidated” and available for Wall Street.

Instead of the guarantees of Medicare, persons who will become eligible in, say ten years, would get an average of $11,000, in vouchers to purchase health insurance on the open market. That would be available through a newly merged Federal Hospital Insurance Trust fund and Federal Supplementary Medical Insurance Fund. You tell me if that would be enough insurance to last the rest of your life even if, G-D forbid you have a catastrophic illness. Funds would be slashed for the Part D drug program, which would be means tested and voluntary.

There is no mention of restraining the costs of premiums or regulating insurance companies’ practices; that would be a restraint on free enterprise. The clever part of the proposal would pit the old against the young who will be on their own and would no longer have to pay for their elders.

But imagine grandma or grandpa, when Medicare is no longer available, having to shop for coverage if they are already ill or disabled or suffering from dementia. Ask your parents what it was like before Medicare. Consider what would be lost if there was no longer any intergenerational responsibility.

But the juiciest part of the Roadmap, the one that will bring joy to the rich and appeal to fiscally conscious Republicans are the numerous tax breaks it proposes. It would end taxes on capital gains, dividends and interest, estate and gift taxes and the corporate income tax. (Unfortunately, President Obama has caved in to the deficit fears with his creation of a deficit commission and he even praised Ryan as a person with “ideas.”)

Finally, a page from Dickens and the 19th century workhouses: The bill would end, next January 1, the Children’s Health Insurance Program (CHIP), which the Congress passed over George Bush’s veto. You don’t believe Americans would do this to children? Look for the bills at GovTrack or OpenCongress.

Write to [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

For those of us along the East Coast, flooded by weeks of rain and buried by five feet of snow since December, this surely is our winter of discontent, or worse. Add to that the state of the economy and the stock market, and as I warned during the approaching winter after 9/11 2001, older people need to be very aware of the danger of depression.

That desire to crawl under the covers and hibernate can be more than the winter blues. I know; I had a brush with depression only because of a fall and a bump on the noggin, which laid me low for a few days and nagged at my thoughts: “Why wasn’t I bouncing back faster? Will I regain my strength?

When last I wrote about depression, an unprecedented surgeon general’s report on mental health in 2000 pointed out that depression, in one form or another “is strikingly prevalent among older people,” too often accompanied by alcohol or drug dependence. But many older people tried to ignore their symptoms as simply a sign of age.

Coincidentally, just after my fall, Ilaina Edison, a vice-president and researcher for the superb Visiting Nurse Service of New York, the nation’s leading home health care provider, told me that ten to 20 percent of older people seen by primary care physicians “have critically significant depression.”

Moreover, many of these physicians, not specializing in geriatrics, don’t diagnose or they under-treat depression. Edison wants home health care nurses, who know their patients best, to be able to diagnose a case of depression before it takes root.

In one of her papers, Edison says that depression “places a significant burden on the health system” and impedes a patient’s ability to comply with medical treatment. The classic symptoms – sad, empty, hopeless feelings, trouble concentrating, a lack of energy, trouble sleeping, a loss of interest in what you like to do, and even vague or passing thoughts of suicide – can complicate getting better from even a routine illness.

The surgeon general’s report noted that there is no need for older people to put up with depression and risk their health further because there are modern and relatively safe drugs, among other treatments. And since the report, Medicare has led the way in recognizing and paying closer to parity for the treatment of mental as well as physical illness.

However, Medicare has been slower in understanding how its regulations can become a barrier to home health care for depression which, in a sense, is the front lines for the discovery and treatment of depression. Says Edison, ”Mental health status is not being addressed by hospitals when discharging a patient, even if he or she is taking an antidepressant.”

When I was discharged from a fine hospital after my fall, a doctor prescribed home health care for my physical problems, including physical therapy. But no one asked after my emotional well-being.

“Another barrier,” said Edison, “is the way Medicare reimburses for depression and mental health services in home health care.” Medicare has been demanding a positive diagnosis before it will pay. But if a home health care nurse discovers a patient’s depression, mild or severe, during a visit for other purposes, reimbursement may be complicated.

Thus she believes Medicare should allow and train the visiting nurse practitioners to diagnose depression and help guide a patient’s treatment with guidance from a psychiatrist.

Medicare Part A helps pay for inpatient mental health care; Part B covers outpatient visits to mental professionals, subject to the yearly deductible ($155). For a visit with a doctor to diagnose your problem, Medicare pays 80 percent of the cost. But to get treatments, such as psychotherapy, the patient now pays 45 percent and that will decline to the parity of 20 percent in 2014.

But to return to the surgeon general’s report, it recommended getting help from modern drugs that can treat and even prevent anxiety and depression. And if you feel you need something, a pre-emptive strike to get you through the winter, consult with your physician but be very careful about what you choose.

The surgeon general reported that certain widely used anti-anxiety drugs, called benzodiazepines – Ativan, Lorazepam, Librium, Valium, Xanax – are immediately effective but have been misused by many older people because they are chemically addictive over time, which means the more you take, the more you need. Some Medicare Part D drug plans are not required to provide these drugs.

These drugs are often over-prescribed and withdrawal from these drugs is likely to be difficult and could be dangerous. Similarly, sedatives and sleeping pills such as barbiturates, including Butisol, Nembutal and Seconal are highly addictive.

Less dangerous or addictive, although they take longer to work, are the anti-depressants including the granddaddy, Prozac, along with Zoloft and Paxil and other newer compounds such as Celexa, which are purged more quickly from the body and present fewer problems for older adults. These are a class of anti-depressants known as selective serotonin reuptake inhibitors (SSRIs), which can prevent mild depression from getting worse.

Other new anti-depressants (SNRIs), including Cymbalta, are being advertised for more serious problems.

However, all these drugs may produce unpleasant side effects and dependency. Your physician can fit the drug to your needs – if you need drugs at all. A pet that you can care for where you live, or perhaps a trip this winter to somewhere sunny could give you the lift you need.

What we’ve been calling the winter blahs has been given an appropriate name, SAD, for Seasonally Affective Disorder. And if you use a computer (which can be a great help in keeping you mentally fit (I play freecell or spider solitaire to check on my mind.), you can find sources for special lamps and lighting which, according to many legitimate-sounding claims, helps brighten those dark days.

You may want to visit the Medicare website and search for “mental health care and Medicare.” To learn more about the services of the Visiting Nurse Service of New York, visit their website.

Write to [email protected].

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

I learned the hard way: The greatest and the most predictable danger for older people is falling. Too often, a broken hip can lead to a deep and irreversible decline in one’s health or well-being if you don’t get the best of help quickly. For me, I was laid temporarily low by a mild concussion.

Fortunately, for those of us who are eligible, Medicare and Medicaid have made some advances in fashioning benefits that will keep patients at home to mend instead of keeping them in a hospital which can be dirty, dangerous and expensive, or sending them to a nursing home, where the pampering, diapering and surroundings can be even more debilitating.

I hope this is not too basic, but in case you’re a caregiver or a potential patient and you don’t know, or haven’t read the 2010 “Medicare and You” manual, under the Medicare law, after a hospitalization of at least three days – say, for an accident, a stroke or for a broken or surgically mended hip – a patient is entitled to up to 20 days of rehabilitation and therapy in a skilled nursing facility at no cost. (After 20 days the cost is more than $133 a day). The skilled nursing facility, I should add, is not a nursing home. But nurses and therapists are available to help you bathe and dress until you’re able to do so for yourself.

A very important (and inexpensive) alternative, when leaving the hospital or the nursing facility or if you simply need medical help getting over a wound or illness is home health care, which Medicare covers and will cost you nothing. This is one of the best Medicare benefits, although too few beneficiaries or caregivers know about it.

I learned something about Medicare Home Health Care just a few days ago after I took a serious fall from the steep brick steps leading into my home, which left me with bruises, a minor concussion and further impairment of my right arm and leg, which had been weakened by a stroke six years ago. For those of you who are wondering, even six years into a stroke, therapy can help.

That meant I needed trained professionals to look after my recovery from the concussion and to provide physical therapy to get me back on my feet. All it took to get part-time home health care was a prescription from a savvy emergency room physician who wrote in his Rx that the care was “medically necessary.”

As the manual says, “a doctor must order it and a Medicare-certified home health agency must provide it.” That’s especially important for in past years, Medicare cracked down on fly-by-night agencies who charged but didn’t deliver adequate care.

The hospital may recommend an agency, but you should use one that is recognized. In my area, the best is the Johns Hopkins Home Health group.

The home health services may include medical social services, making sure you have help in the home, and part-time or intermittent home health aide services such as checking on a bandage or an IV, administering drugs or simply keeping track of your vital signs and the healing of a wound or a surgical site. The manual says that “you must be homebound” to receive such services, but that means you can leave home to visit a doctor, go to religious services or even go to adult day care.

In my case, the nurse, Anne Bilderback, came to the house twice a week to check my progress in getting over that concussion which left me weakened and occasionally dizzy. Another fall in the house could have been disastrous. She checked to make sure there were no side effects and lectured me on the need to drink fluids and keep my feet up to minimize swelling. And twice a week a physical therapist came to the house and spent an hour with me helping me to walk, exercise my leg and even get up and down the steps from which I fell.

Medicare will not provide 24-hour nursing care nor will it provide meals or help with bathing and dressing unless these services are necessary for your plan of care. In short, if bathing, dressing and meal taking are the only problems you have, they won’t be covered by Medicare. And if oxygen or a wheelchair or other durable medical equipment is required, Medicare will pay 80 percent of the cost.

One more important thing about home health care. Medicare generally pays for up to nine weeks of visits and as much as 35 hours of care per week, although that may vary depending on the reasons for the care. My problem required much less than nine weeks. But Anne told me that a private, for profit company, for which she worked would urge her to discharge patients too soon in order to save money.

If you have a Medicare Advantage HMO or PPO, it is supposed to offer you the same benefits that original Medicare offers. But some private insurance companies use only those health care agencies with which they have special business relationships - such as getting kickbacks. This, plus the fact that some agencies billed Medicare for patients they did not see, were among of the reasons Medicare cut its support for home health care a few years back.

So be careful about which company you choose; check with a doctor or someone you know. And if you think you’ve been discharged too soon, you have the right to make a quick appeal.

See the Medicare website where you or a care giver may find and compare Medicare certified private (proprietary) and public non-profit home health care agencies. Or if you enter home health care in the search box, you may download or read all 35 pages of the manual on the subject, which may be more than you want or need to know.

After discharge from home health care, you may continue physical or occupational, or speech therapy with a doctor’s prescription. If you go to a private therapist, you may run into a cap on the number of visits which was imposed by Congress a few years ago, although there are exceptions for some conditions.

But there are no caps if the therapy takes place in a hospital. In any case, Medicare pays 80 percent of the cost of therapy; you or your supplemental policy pays the rest.

Finally, most of the benefits I’ve described are provided by Part B of Medicare which, as most of you know, pays most of the cost of outpatient services – doctor visits, labs, x-rays. If you don’t have Part B, it’s open for general enrollment until March 31.

This is one of two pieces on Home Health Care. Next time: Medicare and the blight of Depression.

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Another piece of Ted Kennedy’s dream of universal health care may be lost in the compromise meat grinder that has produced a deformed, complicated, top heavy and unpopular pro-insurance company bill – his proposal to begin building, for the first time, a civilized policy for the long term care of millions of elderly and disabled Americans.

First, the apparent loss of a strong public Medicare-like choice among the insurance options, included in Kennedy’s bill, will likely mean that private insurers won’t offer younger workers and aging boomers long term care insurance at an affordable price. Only a few employers, including the federal government, offer such policies.

But more specifically, there is doubt that Kennedy’s measure, called the CLASS Act (for Community Living Assistance Services and Support) will survive in the health reform legislation strong enough to be any good.

The CLASS Act, though far from adequate, would provide for workers to voluntarily contribute to individual accounts that eventually would pay part (perhaps $100 a day) of the cost of their long term care. Some suggest this should be mandatory.

It would be the first, small step towards a public program to eventually provide long term care for every American who needs it. Naturally, it is opposed by long term care insurers and their allies among Republicans, and conservative Democrats who worry more about the bottom line than people’s well-being.

So far, the proposal does not have a high priority among advocates of health care reform, including the White House, for they’re concentrating their efforts on the 47 million middle and working class people, mostly young, who are without basic health coverage.

Yet AARP said years ago that the lack of a long term care policy was the nation’s “greatest unmet health care need.” And little has changed. Just as the young don’t plan for the infirmities of age, it’s easy for policy makers to ignore the needs of elderly American couples facing the terrible time when one or the other needs long term nursing care – at home or in an institutional setting.

It didn’t have to be that way. President Obama, mistakenly, I think, abandoned his own earlier views and refused, from the beginning, to consider the long-standing congressional proposals by the two most senior House members – Michigan Democrats John Dingell (1955) and John Conyers (1965) – to provide Medicare for All. It would have gradually eliminated the costs of health insurance, which, along with payroll taxes would have financed universal health care including long term care. See the text of the bill here

But Obama, who has since retreated on the public option, said the country was not ready for Medicare for All despite advice to the contrary from his own Chicago-area doctors. But I doubt he even read the Dingell or Conyers bills, nor did most interested Americans, for as I’ve written, most of the main stream press blacked out these single-payer proposals for months while the debate was taking shape.

The Washington Post ignored these bills. Even the Kaiser Family Foundation, the Commonwealth Fund and AARP declined to include the proposals in their discussions on the grounds that they did not have a chance to pass, thus guaranteeing that their self-fulfilling prophecy would be fulfilled.

But I have digressed, for I meant to emphasize that among the biggest gaps in Medicare coverage – which many older Americans don’t realize - is that it does not cover long term nursing care. After a three-day hospital stay, Medicare will cover – with high co-payments to be paid by the beneficiary or his/her supplemental insurance – up to 100 days in a skilled nursing facility for rehabilitation, say for a hip replacement or to recover from an accident. And that’s all.

If your partner, spouse or loved one needs long term care, meaning help with what are called the “activities of daily living,” or ADLs, such as bathing and dressing, Medicare will only help pay for medical needs. I repeat, for nursing care, at home or in an institutional settling, there is no rational, national public program for the long term care of the elderly.

In this, America is alone among most of the countries of Europe; we say we venerate the aged, but our policy doesn’t reflect that.

There is long term care insurance, but the cost for a 65-year-old is hardly affordable at about $3,000 a year – if he or he has no illnesses and can qualify. The long term care insurance industry exhorts workers to buy when they are young and the cost is relatively inexpensive.

But chances are a person will pay the premiums for 25 years and never use the policy; less than one in three need long term care and nursing home stays are relatively short. A long term insurance policy usually has limits, in dollar amounts or the length of stay. And as an investment it sucks for unless you spend considerably more, there is no surrender value. If you don’t use it, you lose the thousands you’ve spent.

In addition, many insurers raise the premiums when the beneficiary is old and can least afford it. Not surprisingly, some drop their policies. Several insurers have changed hands, or they have sought to save money by challenging claims, when the beneficiary is at a disadvantage seeking to appeal. Most of the very old in nursing homes tend to be widows. And despite inflation riders in some policies (which cost more), many do not keep up with the cost of a nursing home, now averaging between $79,000 and $125,000 a year depending on where you live.

The Bush administration and Republican congresses, which rejected any public long term care program, have sought to encourage the purchase of long term care insurance by allowing people to deduct portions of the premiums as part of their medical costs. They’ve even encouraged people to take out reverse mortgages on their homes or sell their life insurance policies to finance long term care policies.

But more important, the last Republican-led congresses have sought to make it more difficult for the middle and working class elderly to use the only public program that has become a vehicle for long term care – Medicaid. It may be demeaning for families and couples to turn to welfare to get long term nursing care for a loved one, but it has been the only alternative for millions of the elderly.

Medicaid, passed around the same time as Medicare, is a federal program, administered by the states, that provides comprehensive medical care, including medicines, for the poor – people whose incomes are beneath or just above the official poverty line. But over the years, with the help of elder lawyers, families have found that with planning, they can “spend down” the savings of a loved one, impoverishing him or her, to get long term nursing care. That’s called “Medicaid planning” and it has become an elder law specialty.

A few years ago, at the behest of the long term care insurance industry, the Republican congress made Medicaid planning a crime, but the “granny goes to jail” attempt was unenforceable and dropped.

Nevertheless, Congress has since made it tougher to take advantage of Medicaid requiring, for example, that a beneficiary wait five years and exhaust his/her savings before becoming eligible for Medicaid in a nursing home.

Thus you are poor, but have worked most of your life, Medicaid long term care is a blessing, but it means spending your last days on welfare. And even those funds are being cut by many states hard-hit by the recession. Nursing homes by law may not discriminate between the paying and Medicaid patients, but they do. And fewer doctors will take Medicaid patients because compensation rates are low.

Among couples or families with modest nest eggs, their problem is how to avoid impoverishing the spouses (most are women) who remain at home when a loved one must be sent to a nursing home.

Under the arcane law, the spouse may keep half the couple’s assets up to around $109,000 (not counting the home, a car and the spouse’s personal IRAs, if any). In addition, the spouse is limited to a monthly allowance of up to $2,739 a month – not a lot to pay for food and other bills, taxes and upkeep on the home while looking after a husband in nursing care.

Some states allow the spouse to refuse to pay any bills for his/her loved one in nursing care and keep all their next egg, if any. That means that a wife must sign an affidavit abandoning financial responsibility for the father of her children. But even then, hard-up states can and do sue to get the Medicaid money back from women whose savings are diminishing.

I’ve gone at length into this thicket to demonstrate that middle-class families, as well as working couples who have been the backbone of American society, are obliged to scheme and, yes, cheat and give up their savings and dignity to get loved ones on welfare to obtain long term nursing care. That is how America treats millions of its older citizens.

A few year ago a woman, a former gym teacher in the New York public schools, told me that she had just put her husband in a nursing home because he was suffering from rapidly advancing Parkinson’s. A lawyer helped her impoverish him to get him on Medicaid. After years of hard work in the garment industry, he was on welfare and she hoped, with her teacher’s pension and their savings, she would have enough to live on for the rest of her days.

“Who knew we would live this long?” she lamented. Little has changed in the years since. And now, with all the talk of health reform, there will be no long term care and few seem to care.

Write [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Pete Peterson is still at it, and he’s still wrong. He’s the billionaire financier who, along with his Wall Street buddies watched the economy burn, let dozens of old companies go bankrupt, a couple of hundred banks close and millions of people get thrown out of work.

Yet here he is again, as I remember him more than a decade ago, crusading with his billions to cut the Social Security benefits, disability and survivor insurance payments for millions of Americans because he believes that the $120 or so a month that they get will break the United States.

But this time, alas, his hopes to slash and burn the social insurance contracts with America, are getting some sympathy in the Congress and even the White House, more on which in a moment.

I do not exaggerate; I am merely carrying to their logical conclusion his efforts, now before the Congress, to sharply change, replace and certainly cut the nation’s twin social Insurance entitlement programs for older and disabled Americans. Peterson, a former cabinet officer in the Nixon administration, supported George W. Bush’s 2005 failed effort to turn Social Security into millions of Wall Street accounts.

He profited from Bush’s tax cuts for high-end earners and he remained silent in the face of billions in off-the-budget war spending. Yet, as Ronald Reagan once did, Peterson and his right-wing allies are deliberately using the growth of federal deficits they helped create to argue for reining in spending on Medicare and Social Security, neither of which he will ever need.

Peterson gets a good and respectful press as a fiscal conservative. So it would be instructive to look back on his crusade, for according to historian and Guggenheim Fellow Theodore Roszak, in his 1998 book, America the Wise, Peterson is one of the first to call attention to “The Gray Peril.”

Instead of celebrating the great strides in achieving longevity, says Roszak, Peterson invoked fear that the fast growing population of layabout older Americans and aging boomers will overwhelm America’s economy and its social, medical and cultural structures.

Roszak recalls that in 1996, Peterson, who made billions as CEO of now-defunct Lehman Brothers then as co-founder of the private investment firm, the Blackstone Group, wrote in The Atlantic that senior entitlements are unsustainable, undeserved, unprincipled, and unfair. Said Peterson,

“We now face public budgets strained to the breaking point by demographic aging which will crowd out all forms of capital accumulation, private and public, material and human.” He saw (the horror of it all) “a nation of Floridas” as part of “a gray wave of senior citizens that fills the state’s streets, beaches, parks, hotels, shopping malls, hospitals, Social Security offices and senior centers.”

Peterson’s money created the Peter G. Peterson Foundation, run by former comptroller David Walker, the Concord Coalition, headed by Peterson and most recently, The Fiscal Times for which he hired out-of-work journalists - all of which has been aimed to reduce the budget deficit by slashing entitlements, especially the largest and most lucrative for Wall Street - Social Security, which provides benefits of more than $620 billion a year and has nearly $3 trillion in reserves, much of which is in special, interest-bearing Treasury bonds.

It’s more than strange that the press should take his age-mongering seriously for despite the economy’s meltdown, Social Security was able to give its beneficiaries raises of nearly six percent last year and, according to its (mostly Republican) trustees, is safe and solvent for at least another 30 years, which is more than many banks, blue chip companies and the late Lehman Brothers could say.

Social Security, celebrating 70 years of helping millions avoid poverty, may become the last defined benefit program standing, as private companies end their traditional pension systems for those iffy, market-oriented defined contribution 401(k)s that Peterson and friends favor.

Defined contribution plans are not good for retirement, say the experts, but they’re a good way for business to shift responsibilities to employees.

But even the fiscal uber-conservative Alan Greenspan, has said Social Security’s projected shortfall in 2037 is “not a big problem” and could be solved without slashing benefits. His 1983-4 commission, appointed by Reagan, which so many seem to have forgotten, fixed Social Security for 75 years with various actions, including raising payroll taxes in order to provide benefits for the 76 million aging boomers who, Peterson says, will overwhelm the system. The boomers are aging, but Social Security and the nation have not been shaken.

It is true that Social Security has run into temporary trouble because high unemployment has diminished its current receipts in payroll taxes, but it ruled out a cost-of-living raise for the next year or two to save billions and the system has ridden out other recessions without missing a benefit payment and is expected to do so again.

In 2009, Social Security took in $180 billion more than it paid out and the Congressional Budget Office said full benefits can be paid through 2043.

Another point seemingly ignored by these deficit crazies is that Social Security, while paying out retirement, disability and survivor insurance benefits, does not cost the federal budget a single penny aside from its administrative costs. I repeat, Social Security is not a drag on the budget; indeed it earns $700 million a year in interest.

Specifically, because of the extra work and thousands of new personnel required by new programs and the recession, Social Security has asked for $11.6 billion in 2010 for its more than 71,000 employees and 1,400 offices throughout the country. That’s less than one percent of the total benefits it pays and it is the only budget expenditure for Social Security.

So why this “entitlement hysteria,” as the New Republic’s Jonathan Chait called it a year ago? Social Security is no longer the problem it has been, said Chait,

“but among Washington’s establishment types who remember those days, the issue retains its totemic significance. Entitlement hysteria becomes less a response to a crisis than an expression of statesmanship.”

Thus Peterson, with the help of the hack media, has persuaded members of Congress, like Senators. Kent Conrad (D. N.D.) and Judd Gregg (R. N.H.), to propose a deficit reduction commission to focus on controlling entitlements – Social Security and Medicare – and to come up with cost savings solutions that Congress must either approve or disapprove without amendment.

And while that is not expected to pass, President Obama, who has pledged not to weaken Social Security or Medicare, is about to cave in to Peterson’s allies and sign off on a similar type commission to cut the deficit in general but entitlements in particular.

AARP, which strongly opposes such a commission, along with virtually every aging organization, labor unions, advocacy groups and most Democrats, has noted in a paper on “Entitlement Growth and the Economy” that entitlement spending has actually been stable as a percentage of the Gross Domestic Product for the past two decades and by 2016 “it will still consume about the same share of the economy as it did when Reagan was elected.”

The great exception is the alarming growth of health care spending, including Medicare and Medicaid. And that’s one reason Peterson and company should be supporting rather than opposing Democratic efforts to pass proposed health reforms, including the $500 billion in Medicare savings over ten years, much of it in subsidy payments for private insurance companies, which Peterson’s fellow Republicans and Wall Streeters are trying to torpedo.

If Peterson and others were truly worried about the deficits, they would be in the front ranks of those fighting for universal health care and an end to the trillions that are being spent on war.

Why does Peterson concentrate his efforts on Social Security? He gave his motive away in 1996 when he complained that the growth of Social Security among other entitlements “will crowd out all forms of capital accumulation.”

Give Peterson his due; he’s smart enough to know that Social Security is not in serious difficulty, that it’s not a big drag on the federal budget and that it’s not a “Ponzi scheme,” as some ignorant right-wingers charge.

But Social Security’s nearly $800 billion a year in income and its growing trust fund are tempting for a shrewd financier and the Wall Street crowd; they demonstrated that in 2005. What a prize it would be for the wonderful world of finance if, as Peterson now proposes, at least part of Social Security’s revenues and its trust fund could be available for investment or government programs to his liking.

Fellow Wall Streeter and present Federal Reserve Chairman Ben Bernanke, a co-conspirator in the financial disaster, testified last month before the Senate Finance Committee and called for cutbacks in Social Security and Medicare to lower the deficit. He aimed not at higher taxes, but the entitlements to balance the budget which would make more capital available for investment.

He explained, “Willie Sutton robbed banks because that’s where the money is. The money in this case is in entitlements.”

Pete Peterson must have applauded. Will Obama become an accomplice?

Questions? Write to [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

This is how bad things got when the economy and Wall Street tanked: Sales of antacids topped $10 billion for the year. And the people who figure such things say that 100 million Americans suffered from heartburn once a month and 15 million battle it at least once a day.

That could strike you as amusing, but it’s not. For as a longtime chewer of Tums or Rolaids, I can tell you that what we call “heartburn,” or “acid indigestion” is not only a literal pain. It is also potentially dangerous, especially when the discomfort is relieved repeatedly with one of the many over-the-counter antacids that are heavily advertised — without including a warning.

Anyone remember that Alka-Seltzer commercial? “You ate the whole thing? I ate the whole thing!” The Alka-Seltzer provided relief from the indigestion, but the guy we laughed at may have been killing himself with each heavy meal and a burp.

One large reason for my concern right now is the approaching fifth anniversary next month of the thunderous, life-changing discovery – through a routine endoscopy – that I had cancer of the esophagus. The fifth anniversary means I have survived. Not cured, mind you, survived, as in so far, so good. For whether you know it or not, cancer can be arrested but there is no cure yet.

The other reason is a new website which caught my attention with this: “I want you to know that heartburn can cause cancer.” Based in Maryland, the website belongs to the new Esophageal Cancer Action Network founded by Mindy Mintz Mordecai who lost her husband, Monte, to the disease two years ago. And she has enlisted her two daughters to appeal to those of you who may be in danger without knowing it.

I understood their appeal, for I have two daughters and narrowly escaped this damned disease because of sheer luck. As Mindy Mordecai wrote, she discovered during her husband’s struggle, as I did during my ordeal, that

“...the cancer that was consuming my husband was caused by acid reflux, something we often call persistent heartburn. And I was angry that I had never been told that heartburn could cause cancer. Angry that, because we didn’t know, we never took any steps to try to catch my husband’s disease.”

When I began my research on the disease following that diagnosis – on St. Valentine’s Day, 2005 – what I learned was not encouraging. The incidence of esophageal cancer was rising faster than any other cancer, and the survival rate was (and is) only 15 percent.

It’s three or for times more common in men, especially if they smoke cigarettes, are overweight and eat too much or irregularly, all of which describe the lifestyles of busy men with stressful jobs. And that was me. Eating too much, chewing an antacid, getting relief and forgetting about until the next time – a potentially deadly cycle.

The incidence of esophageal cancer increases with age; eight of ten people diagnosed with this cancer are between 55 and 85. About 17,000 new cases are diagnosed each year. And most victims die because the cancer is usually caught at the too-late stage. Why? In large part because antacids mask what’s going on when your body is trying to warn you with heartburn or acid reflux.

The medical name for this condition is “gastroesophageal reflux disease,” or GERD. Heartburn, or acid reflux, occurs when digestive acids - that may accompany certain foods, over-eating, along with smoking – splash up from the stomach into the esophagus, the muscular tube that sends food to the stomach.

The cells in the walls of the stomach are tough and acid resistant. But the acid battering of the esophagus changes its cells into the type found in the stomach. That condition is called Barrett’s Esophagus which affects about ten percent of people with GERD and which increases the chance of developing a cancer by 30 to 125 times.

It’s good news when the cancer is spotted very early, when it’s confined to the esophagus. Even so, as it was with me and two friends, treatment involved weeks of chemotherapy, radiation and radical surgery in which most of the esophagus is removed and what remains is attached to the stomach.

Depending on the stage at which the cancer is discovered, there are other, less invasive treatments which can be found at the American Cancer Society site. Unfortunately there are few warning symptoms beyond persistent heartburn. By the time you have difficulty swallowing, as Mindy Mordecai’s husband’s learned, the cancer had spread beyond the esophagus. Even now, I’m subject to periodic checkups.

Despite the rapid growth in the incidence of esophageal cancer, it gets about only $23 million in research funds from the National Cancer Institute. That’s about ten percent or, $1,500 per death, compared to $14,000 per breast cancer death. Indeed, lung and esophageal cancers are shortchanged on research funds, I believe, because there are not too many survivors to lobby for more money and they are considered diseases in which the lifestyle of the victims – smoking and obesity – are blamed.

And it’s true that the increase in cancers of the esophagus seems to have coincided with the increase in obesity.

That suggests some obvious ways to prevent this cancer, according to the American Cancer Society, including cutting down on over-eating, especially spicy or fatty fast foods before bed time or before plunking yourself down on the couch, which increases the chance of acid reflux. If you tend to have acid reflux after meals, don’t lie down. Prop yourself up in bed. I shouldn’t need to tell you that smoking is also strongly linked to esophageal cancer as well as other nasty illnesses.

Beyond this, instead of chewing or swallowing those too-well advertised, over-the-counter remedies to relive the discomfort from GERD, which may mask the development of Barrett’s esophagus, take the antacid before the onset of reflux. Or better, ask your physician for the several prescription drugs available to prevent or control reflux.

And whether or not they work, if you have a history of heartburn, you should ask for an upper endoscopy – a probe of the esophagus and the upper stomach to determine if you’re one of an estimated 3 million Americans with Barrett’s Esophagus – which should be watched closely. Medicare and most insurance companies will cover an endoscopy if it’s prescribed by your primary care physician.

The Esophageal Cancer Action Network has on its board several distinguished physicians including the surgeon who operated on me. And Mindy Mordecai is selling for $2.50 blue wristbands, one of which says, “Heartburn can cause cancer.”

Need more information? Write [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

It’s foolish at a certain age to make New Year’s resolutions. We’ve been there and done that, which is how we got to be our age.

Besides, you don’t need a resolution to be good to yourself in this new year, this new decade. It’s bound to be better than the last one. But I suspect this recession hangover will be with us for some time and there are some steps to consider to get through another down year. I’ll get to that in a moment.

Too many older Americans, according to the latest studies of the economy, are just getting by. Or worse. I don’t need to tell you the dismal facts. The stock market is staging a halting comeback, but retirement savings plans are still down. Those 401(k)s have not grown enough to be counted on for retirement. Even traditional pension funds are hurting.

Poverty rates remain the same for older Americans at 9.7 percent, but that doesn’t tell the real story. By other legitimate measures, perhaps 20 percent of people over 65 are hovering near the brink. Older women, especially widows, are among the hardest hit.

But because they are above the official poverty lines ($10,830 for an individual; $14,570 per couple), many low income people and families don’t qualify for many state and federal programs. The Associated Press reported around Thanksgiving that the number of older people living alone and seeking help from food pantries had nearly doubled to over 400,000 in 2008, before the recession. And bankruptcies have increased among older people , many because of medical bills they couldn’t pay before they were eligible for Medicare.

Finally, as I’ve reported, there is no cost-of-living increase in your Social Security benefit this year because there’s been no inflation. But the Consumer Price Index, on which this decision was based, doesn’t tell the real story for most older people.

Typical among the cries of foul was an e-mail from Mike Griske, 62, of Hicksville, New York, who was in the life insurance business for most of his working life until he became disabled with spinal problems eight years ago.

With an insurance man’s eye, Griske took apart the items that go into the official CPI-W (which stands for workers), down to a box of tissues, to demonstrate the reality: prices are going up faster than the index, especially for older people. And he’s written to everyone he can think of to appeal for change.

Unfortunately, nothing will change soon, if at all. The proposed $250 payoff for Social Security recipients, which was left out of recent legislation, won’t help much anyway. And like other retirees, Griske has been informed that his pension, which is tied to the CPI-W, will be going down by 1.8 percent.

His story is not unusual but if he owned a home with substantial equity, there is a way he could get some relief. And I’ve been pushing it each year about this time - the Home Equity Conversion Mortgage (HECM), the best and most popular Reverse Mortgage, because it’s guaranteed by the still-solid Federal Housing Administration (FHA).

The guaranty means the borrower is protected from losing his/her property and the lender is protected from losing his/her money if the value of the property declines below the worth of the loan.

While that’s been a large problem in the conventional (forward) mortgage market, it has not happened to HECMs despite the unfounded warnings of lawmakers with family ties to the private mortgage market. Indeed, FHA remains so financially solid that this Congress decided no taxpayer funds were needed to offset possible losses.

To make sure it stays that way, the FHA implemented a 10 percent reduction in the proceeds that homeowner-borrowers can get from an HECM. Someone who qualified for a $100,000 loan before the change, will now get $90,000. That means the program is expected to operate in the black, as usual, with few, if any defaults.

I am an HECM borrower and like most participants, the cash I got from the reverse mortgage served as a cushion which was carefully invested. The proceeds may also be taken as a line of credit or as period payments. This is one federal government program that has worked as intended for millions of borrowers yet relatively few Americans have taken advantage of it partly because they don’t like to mortgage a home that’s free and clear, or they’re concerned about their heirs. So they let all that equity remain idle.

Private (non-guaranteed) reverse mortgages have been around for years. But only after years of study by housing and aging experts did the FHA get into the business when President Reagan signed it into law on February 5, 1988. (Note to his present day admirers: He helped save Social Security while expanding the federal government into the reverse mortgage business.)

Now, although many younger homeowners can’t refinance because greedy banks are refusing to part with their money, reverse mortgages are available because of the FHA guarantees. And as Kiplinger has reported, older homeowners facing foreclosure have been rescued by HECMs which can supply the cash needed to catch up on payments.

I assume you know the basics: To qualify for a HECM, you must be 62 or older, own the property outright or have accumulated sufficient equity and occupy the property as your principal residence. There are no income or credit qualifications. Unlike a second mortgage or home equity loan, there are no monthly payments for a HECM. And no repayment is necessary as long as you live in the home.

All closing costs, insurance and interest may be financed in the mortgage. None of the proceeds is taxable. But all closing costs and interest, which mount up, are tax deductible when the loan is paid. The loan comes due when the property is vacated, at which time the borrower or, more likely, his/her heirs may pay off the loan and take possession of the house. In general the value of the home will exceed the payoff amount.

While many conventional mortgages are in trouble because they are said to be “under water” because the amount owed exceeds the value of the property, under the law, the homeowner with a HECM is NOT liable if that happens because the lender is guaranteed against loss. One requirement, however, is that the property must be maintained and the property taxes are paid.

Another requirement, which has helped the program stay mostly honest, is the provision that all applicants must undergo personal and usually face-to-face counseling by an expert designated and licensed by the Department of Housing and Urban Development (HUD). The permitted fee is $125 and it’s worth it because the counselor can and should tell you the downsides of reverse mortgages: the interest that must be paid at the end of the loan will be great; if the beneficiary is in a nursing home for a year, the loan comes due.

Susan R. Lagville, of Housing Help Inc. in Greenlawn, New York, is a HUD counselor and helped bring me up to date on the latest HECM news. First, HUD has raised the maximum loan value of the homes to $625,000 throughout the country as a result of rising home prices. For the same reason, the required insurance (2 percent) will cost more. The one-time fee to the lender has been reduced from two percent of the home value to a flat $6,000.

More important, as I mentioned, HUD usually loaned about 60 percent of a home’s value (although there are other factors such as the neighborhood, the condition of the home and age of the borrower). Now, said Lagville, HUD is reducing the average loan by ten percent.

While single-family homes, condominiums and certain manufactured homes qualify for HECMs, sources tell me that HUD may soon include co-ops, which would be important for many city-dwellers. Beginning last year HUD permitted borrowers to use the proceeds to buy another home, perhaps for retirement, after selling the first home.

Finally, while the HECMs themselves have been mostly free of problems, there are some greedy types who want a piece of the HECM’s cash proceeds. Some lenders or their agents have talked borrowers into putting the proceeds into questionable annuities and other investments.

Langville recommends against taking all of the funds in cash, on which you pay interest. Better alternatives include taking the HECM in lines of credit or periodic payments. I repeat, these proceeds are tax free.

Some good websites to learn more: FHA Reverse Mortgages; the U.S. Department of Housing and Urban Development; and the industry's website, National Reverse Mortgage Lenders Association, where you may calculate the possible proceeds you can get from a HECM.

Questions? Write to [email protected].

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

In this the season of miracles, the one we have celebrated at our house is the birth in 1770 of Ludwig Van Beethoven which prompts me to suggest some things you might consider doing one of these cold winter weeks. It’s called adding a few synapses, better known as learning.

I do not wish to disparage Christmas; the obscene orgy of shopping does that. We usually send a check in the name of our family to one of our favorite charities, like the hospital that saved my life, in an amount approximating the money we’d spent on gifts. And we notify the kids and grandkids what we’ve done. I somehow think they appreciate it more than tchotchkes that have a short half-life.

Also, someone in the family will have a tree that will have no religious meaning. And we will get together to observe Hanukkah, the festival of lights, so that I can make, as I do every year, those potato latkes (pancakes) served with sour cream and/or applesauce. I will smell of the cooking oil for days. Hanukkah and Christmas, like Passover and Easter, become interfaith holidays that meet over food.

But starting some years ago, it occurred to me that Mr. Beethoven’s birthday, generally thought to be on December 16, was the more spiritually meaningful day coming in the midst of just about all of the religious observances. Jews, Christians and Muslims (this has been the time of the Haj) have been disappointing in their conduct over the years. Not Beethoven. He meant and he lived his words in the Choral movement of the Ninth Symphony: “All men become brothers.”

We don’t think of Beethoven as a political figure but he was a political hero; part of the revolutions of the early 19th century, tearing up the dedication to Napoleon on the first page of the Eroica Symphony because he, Napoleon, had declared himself emperor. Napoleon is long gone and so are all the kings, ministers and despots who have come after him. But Beethoven prevails; the Eroica was a revolution; the Ninth was a revelation.

So each year close to his birthday we have put on a dinner, serving the German foods Beethoven was known to eat (including prunes for his stomach upsets). And we play his music, ending with an Ode To Joy sing-a-long at midnight (badly done), toasting his birthday – his 239th this year.

All this has been a teaser, to urge those of you who live near the east coast to take advantage of a superb and inexpensive series of five-day Exploritas (formerly Elderhostel) programs at a favorite venue, the Peabody Institute in Baltimore, one of the nation’s oldest and most distinguished conservatories.

The upcoming program, beginning on January 24, includes “Symphonies of the Romantic Era,” Beethoven among them; “Piano Music of Chopin and Lizst” and “Great Piano Concertos.” The price, which includes all meals and lodging is $619.

Elderhostel changed its name to Exploritas to relieve itself of the misleading word “elder.” For those unfamiliar with Peabody, it offers year-round Exploritas programs on its campus, with rooms in its comfortable Peabody Inn where many of the classes are taught by Peabody faculty members. The inn has rooms that are accessible for the disabled.

The cafeteria is a short walk from the inn. The beautiful Baltimore waterfront, with great seafood, is a short drive away. Peabody invites participants to its student recitals and concerts, which are free. The Baltimore Symphony performs nearby. And so is the Walters Gallery.

If the classics are not to your taste, Peabody is famous for appealing to all tastes – for good music. One favorite is on Klezmer music. Beginning on March 21, the scheduled five-day program will include a retrospective on Al Jolson, Bing Crosby and Frank Sinatra as well as the films and melodies of Hoagy Carmichael, Gene Kelly and others.

Having attended a couple of Peabody programs, it’s a lovely way to spend a week. Recently, my wife and I splurged on a New York weekend. Whatever you do, be good to yourself.

Readers of Gray Matters, who have sent me their poems and stories, and contributors to Time Goes By’s Elder Story Telling Place, will appreciate another wintertime possibility - learning, thinking and writing for pleasure. We of a certain age know a great deal that we should not keep to ourselves. And the limitlessness of the internet and the freedom of blogging has afforded us an opportunity to stretch our minds with something to think and write about.

Only recently have we learned that, barring illness, there is no such thing as senility that comes with age. Our brains continue to add synapses as long as we live and as long as we exercise our minds. Truly, we may lose it if we don’t use it.

Thus, I’m putting in a plug for New Pathways for Aging, a paperback published as a product of a pioneer program of the Harvard Institute for Learning in Retirement. It’s a venerable program in which older men and women, some of them professionals, have found, as the title suggests, new pathways for their own lives beyond their working years.

The book was sent to me by one of the editors, Dr. Rhoada Wald, who has been a member of and a study group leader at the Institute for 11 of its 32 years. It includes a series of essays, poems and personal reflections on the very serious but rewarding business of growing older.

The Harvard Institute, I learned from Wald, is one of nearly 400 such “learning in retirement” centers around the country - most of them, like Exploritas, are associated with colleges. There are one or more in each state including Alaska and several in each major city. Harvard’s Institute, part of the university’s Division of Continuing Education, has enrolled 550 members for 62 study groups. And the tuition is a modest $400.

You may find out more at the Harvard Institute for Learning in Retirement website or in the book, New Pathways for Aging, and to see what’s available in your area you can consult the University of Maine website for the network of Osher Lifelong Learning Institutes.

There is no room here, of course, for the 27 contributions to this book, but unlike other such volumes that gild the lily of aging, this one does not ignore the illnesses and death that come as student colleagues and friends age. But of great wonder is the human impulse to keep going and learning in the face of mortality. One man, a cancer patient, called his poem, Set Dylan T. Aside.

Lillian Broderick, facing blindness from macular degeneration wrote:

“I’m not suffering the ravages of chemotherapy or drifting into the no man’s land of Alzheimer’s. I remind myself of all that remains–Mozart, Bach, the promise of spring in the air, the faces of my children and grandchildren safely lodged in memory, enduring friendships, the companionship of a 56-year-old marriage.”

Antonia Woods celebrated “the joy of slowing down” in Personal Best:

Once I scrambled up the mountain
Getting to the top my only goal
Now I stop often,
Resting in protected, sunny spots in the cold months
Finding shady rocks with breezes in the summer,
Sacred places where I can sit and watch and wait and listen.

(The book time for this hike is three hours, but my personal best is eight.)

What’s your story? Write to me at [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

This is a good time, before the year is out, to catch up on some things financial that older Americans need to know. Much can be left to your adviser or accountant, but these days it’s better if you understand and have a hand in your finances and what’s going on with your Social Security and Medicare benefits.

Social Security
As you’ve probably heard, there will be no cost of living adjustment (COLA) or increase beginning in January for Social Security beneficiaries. This is a first, but it’s difficult to complain; the COLA in 2009 was a healthy 5.8 percent, the highest since 1982, and many Americans who worked (if they did) did not see that sort of increase in their wages, if any.

I know that the actual cost of living – housing, food, medical care and drugs - grew faster for older people than the official Consumer Price Index, which has been flat during this recession. The same inequity is involved in calculating poverty levels, which cheats some people out of benefits. Several members of Congress have promised legislation to change the CPI for the benefit of older consumers, but it won’t happen anytime soon.

Medicare
President Obama has said he’s considering a flat payment of $250 for every beneficiary in lieu of the COLA and Congress may stir to act on this. For most beneficiaries, the lack of a COLA increase means that the present Medicare Part B monthly premium of $96.40 cannot be raised because of what are called the “hold harmless” provisions in the law which say your Social Security benefits cannot be reduced.

However, for newcomers to Medicare, the standard Part B premium next year will be $110.50. And because of the Medicare Part D law of 2003, the program now provides means testing for the first time whereby more affluent beneficiaries will pay still higher premiums.

Thus, the premium for individuals with yearly incomes between $85,000 and $107,00 will be $154.70; between $107,000 and $160,000: $221; between $260,000 and $214,000: $287.30; greater than $214,000: $353.60. For couples filing joint returns, double all these income numbers to find your premium.

There are other Medicare numbers for next year: The Part B yearly deductible (now at $110) is going up to $155. While Medicare pays 100 percent of the first 20 days of skilled nursing care (usually after a hospital stay of at least three days), the co-insurance for days 21 to 100 will be a hefty $137.50 a day, which is why Medicare cannot be considered long term nursing care.

The Part A hospital deductible is going up to $1,100 per spell of illness. Hospital stays for the first 60 days are fully covered, but co-insurance is $275 a day for days 61 to 90 and $550 for days 91 to 150.

The 2010 resource limits, recently announced, for the full Low Income Subsidy to pay for Part D premiums and other costs are $8,100 for an individual and $12,910 per couple. And for the partial subsidy, $12,510 for an individual and $25,010 if married.

While Medicare does not cover long term nursing care, it does cover most of the costs of medical care for nursing home residents or during home care. Medicaid, the federal program administered by states, will cover nursing care and in a future column, we’ll explore planning for Medicaid when a loved one needs nursing care and while the spouse remains at home.

There’s been some talk on Capitol Hill that the health care reforms now before the Congress may eliminate some higher Part B premiums which, I believe, were approved by the Republican Congress in 2003 to encourage more affluent people to desert Medicare for private insurance.

One more Medicare note: Under the law, Part B premiums must pay for one-quarter the cost of Medicare services for doctors and other outpatient services. Because the Congress is expected to cancel scheduled cuts and raise fees for doctors, the Associated Press and critics of health reform have reported that this would result in higher Part B premiums during the next ten years.

The one-quarter rule and rising doctor fees have been responsible for past premium increases, but David Certner of AARP told me that the increase in the fees for doctors will be offset by other savings in the Medicare program and premium raises will be held down. We’ll see.

Mandated IRA Withdrawals
On another money issue, my sources in Congress tell me that the IRS will NOT suspend for another year, the requirement that persons over 70-1/2 must, during the year, withdraw from their IRAs and other tax-deferred savings plans a certain amount of money, based on one’s age. It’s called the Required Minimum Distribution (RMD). Your financial adviser or plan administrator, who usually arranges for the distribution, has the IRS uniform table which tells you how to figure what you need to withdraw. But if you want to know how much of a distribution to make, I have the table and I can e-mail to you if you ask.

For the uninitiated, the first RMD must be taken by April 1 in the year after you reach 70-1/2, and subsequent distributions are taken each year by December 31. If 2009 is the year in which you turned 70-1/2, you may delay the withdrawal until 2010 because of the suspension. But if there is no suspension for 2010, it would be best to make the withdrawal during the year rather than waiting until April 1, 2011.

The withdrawal amount next year will be a percentage based on the total value of all your IRAs (or 401(k)s), as of this coming December 31, when the market is expected to be relatively high. That means the withdrawal will be high and while you may save or reinvest it, you must add it to your income and pay taxes on the amount.

Roth IRAs are exempt from required withdrawals. You should ask your accountant, administrator or financial adviser early next year to begin planning to set aside the funds for the distribution. And let’s hope that the congress or the IRS does us a favor and suspends RMDs for another year.

Income Tax Deductions
If you itemize on your tax returns, I assume you know that all the Medicare (and Medigap) premiums, deductibles and co-pays are tax deductible provided that they, along with other unreimbursed medical expenses exceed 7.5 percent of your adjusted gross income.

But many taxpayers don’t realize that part of those hefty long term insurance premiums are deductible. Here are the allowed deductions for this year and 2010:

• Age 40 to 50: $600, $620


• 50 to 60: $1,190, $1,230


• 60 to 70: $3,180, $3,290


• Over 70: $3,980 and $4,110

The self employed may deduct the entire premium regardless of the 7.5 percent threshold.

Entitlement Commission
A warning: As Time Goes By has told us, be very afraid of proposals by Senate conservatives (Democrats and Republicans) to create a bi-partisan commission to deal with the deficit in general and Social Security and Medicare in particular. One reason: that would take the future of these programs out of the hands of Congress.

More important, when will these idiot lawmakers learn that Social Security is not in crisis and the benefits do not contribute one penny to the deficit.

Don’t agree? Need help? Write to [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Despite the sounds and seeming fury of the health care reform debate in the U.S. Senate, it seems to me that it has been missing real passion and commitment from the nebbish Senate Majority Leader Harry Reid, and the too cool and aloof President of the United States, Barack Obama. But what the Senate and the debate has been missing, most of all, is Senator Edward M. Kennedy.

I covered Ted Kennedy for a number of years, including his early days in the Senate as he fought for a place in the leadership, his re-election campaign after the blight of Chappaquiddick and his 1980 run for the presidency. And I’ve talked with other reporters who knew him well. And Teddy’s passion, his personality, his personal and political appeal would have made a difference.

As Senator Tom Harkin, (D, Iowa) has said, “He would lend gravitas to the issue that we’re kind of missing right now.”

Ted Kennedy, who was a young and vibrant 77 until brain cancer killed him on August 25, electrified the Democratic National Convention exactly a year earlier with one of his greatest speeches supporting the election of Obama: ”The work begins anew, the hope rises again, and the dream lives on,” he said, and he looked forward to the health care reform struggle now before the Congress which he said, is “the cause of my life.”

He came to the Senate infrequently during his long illness, once in 2008 to override George Bush’s veto of child health care legislation. And last year he helped break a Republican filibuster which threatened Obama’s first stimulus which Obama should remember.

Last July, Kennedy’s Senate Health, Education, Labor and Pensions Committee (HELP) passed and sent to the Senate floor its proposal for health care reform, The Affordable Health Choices Act.

It was relatively clean – 615 pages – and it included a strong public plan called the Community Health Insurance Option with reimbursement rates patterned after Medicare. It would have given workers and their families another choice besides private insurance.

And the Congressional Budget Office blessed it as money-saving. Some liberals complained it did not go far enough, but it was a strong bill with premiums no greater than 12.5 percent of a worker’s income, and with government subsidies for low-income men and women (compared with 17 to 22 percent in the current bill).

Unfortunately, it was overtaken by the more right-wing, insurance industry friendly bill of the Senate Finance Committee chaired by Senator Max Baucus (D, Montana), who has no record fighting for health care. The ranking Republican member, Senator Charles Grassley of Iowa, said during Kennedy’s absence: ”If Kennedy were here, it would make melding the Finance Committee bill and the HELP Committee bill much easier.”

Of course, Grassley tried to kill any bill and had no intention of supporting real reform. But he had a point. A Washington veteran who used to be a bureau chief told me that Kennedy would not have dismissed the Baucus bill, as Reid did, but would have found a way to work with Baucus and others on his committee including Democrats and Republican Senator Olympia Snowe, a fellow New Englander.

Kennedy’s powers of persuasion were formidable, especially when he thundered his commitment on the Senate floor.

The former bureau chief added that Republican Senators Orin Hatch of Utah and John McCain of Arizona, both of whom were close to Kennedy “would never have opened their mouths if he were still here.” Without Kennedy on the offensive, he added, “the Republicans have absolutely framed the debate in a way that could kill the whole thing.”

The Kennedy I knew and watched rarely played defense on the Senate floor. Thus I doubt that he would have permitted the Democrats to remain on the defensive with Reid wondering how far he has to retreat and seeming to care little for what’s in the bill as long as he has the votes to break a filibuster.

Watching Senator Joe Lieberman and other Democrats gum up any chance that at least some parts of the HELP Committee bill would make it to a vote, a Boston editor who became a Kennedy watcher said, “It does make me think that Kennedy could have made a difference. By all accounts his ability to cajole colleagues into line, in some cases by securing their commitments in advance was peerless. It might have worked with Lieberman. You have to believe he would have made a difference.”

A Boston friend who covered Kennedy and is still an active reporter said, “If Teddy had still been in the Senate, I think he would have been able to put down any mini-rebellions and figured how to keep Lieberman in the tent.” It would have been difficult for Lieberman or any Senate Democrat to withstand the kind of buttonholing, cajoling and impassioned appeals Kennedy could make.

Some Republicans who won’t vote for any compromise suggest, hypocritically, that Kennedy would have moved to the right to get a bill. Perhaps, but it’s also likely that Kennedy, because of who he is, could successfully resist deal-breakers like cracking down on abortion rights.

Finally, and most important, Barack Obama owes Ted Kennedy a great deal–including the presidency. And my Boston friend says, “I also think Kennedy would have goosed Obama to expend more political capital on this issue early on, when it would have mattered.”

As it has turned out, virtually everything that smacked of real reform has disappeared in favor of the health insurance companies. They can even get away with raising premiums on account of age or preexisting conditions. Or capping benefits.

Obama said all the right things after Kennedy died. But then he always says all the right things. But neither he nor Reid nor any of Kennedy’s colleagues on the HELP Committee have moved to pass the cause of his life.

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

None of the proposed health reforms will fix one of the most troublesome problems for patients and their families – reaching a doctor after hours or on a weekend. That’s a major reason emergency rooms are packed at night and on weekends with sick and feverish people in great distress and getting sicker.

And that’s not going to get better anytime soon. According to the American Academy of Family Physicians, there is a shortage of primary care physicians and it’s likely to get worse in large part, ironically, because the health insurance reforms will increase access to care when there will be fewer family doctors to provide basic and timely care.

Even now if you really need your doctor, after, say 4PM, it’s likely you will get this message: “If it’s an emergency, hang up and dial 911...or call 555-4444 and ask for the doctor on call.” In that case, while you’re waiting anxiously, if or when he or she calls back, you will be told to go to the emergency room anyway.

It used to be that you could get your doctor on the phone to ask his or her advice. Or there was a time when your physician, who you assumed was primarily responsible for your care, would meet you in the emergency room to see to your needs, or at least call ahead (as one of my doctors did a few years ago) to clear the way through triage.

No more. Now you’re passed, like a buck, to the emergency room physician on duty or to a “hospitalist,” your doctor’s designated hospital representative, neither of whom ever laid eyes on you.

It’s difficult to get through to your doctor even during office hours (“Your call is important to us”). And it used to be that you did not take a crying child running a high fever out in the cold. Now you have no choice. It’s either a walk-in clinic, where you may have to pay cash, or the emergency room.

I’m not blaming doctors or the medical profession. We all have our doctor stories but today, beleaguered physicians as well as patients have become the prisoners, or victims, of corporate for-profit medicine and the demands of insurance companies (including Medicare and its regulations).

Doctors work under great pressure, accepting too many patients, often in large practices owned by a corporate entity, trying to keep up with the latest drugs and developments, and dealing too quickly with each patient no matter their needs. Many abandon individual practices that they can’t afford for multi-physician specialties that operate like factories. And although they have lives in their care, most don’t get rich. Last time I looked, doctors earned on average about $200,000 a year, nowhere near what a Wall Street trader makes for producing nothing.

No wonder thousands of doctors, including most of my own, favor single-payer national health insurance. Not surprisingly, a survey last year by the University of Indiana School of Medicine found that support for such a system was particularly strong among emergency physicians (69 percent), pediatricians (65), and family doctors (60).

“Across the board,” said Dr. Ronald Ackerman, who helped direct the survey, “more physicians feel that our fragmented and for-profit insurance system is obstructing good patient care.”

I’d go further; under these circumstances, present patient care can be downright dangerous or frightening especially or if you are really in trouble or you’re older, like me. I don’t ordinarily become personally involved in these columns, but permit me to cite a couple of my recent experiences, because they are not untypical and relevant.

On a Friday evening, a usually routine urological procedure which many older men undergo, went awry with bleeding. Stuff happens. But the doctor’s office was closed and the emergency room –where the wait was less than an hour – was the only recourse. Further complications, included blood clots in the catheter and great pain, which mean a night in the hospital attended by strange doctors. And there were two more night time trips to the emergency room that week.

The surprised urologist was dismayed by my problems and shocked that I had to wait hours in the emergency room for help, but he did not come to the hospital to see to my care. One of his nurse-practitioners told me later, “We can’t be on call 24 hours for every patient.”

Actually, I’m told by a doctor friend, they are responsible for my care – for 24 hours or however long it takes. The total bills, for Medicare and my secondary insurer will come to more than $8,000.

One more story about the same time: As some of you may know, I am a survivor (nearly five years) of esophageal cancer. But during my last checkup, my oncologist suggested a new endoscopy to find the cause of some internal problems. That was done in early November by the gastroenterologist who had discovered my cancer in 2005, and he reported finding “causes for concern.”

He ordered biopsies, the results of which, he said, would not be available for nearly two weeks. Why so long? There were others ahead of me, he said. The doctor’s report would be available via phone recording, but not for two weeks.

You can imagine my anxiety, especially because the oncologist reading the initial report sent me an email suggesting one possibility was a recurrence of the cancer. But he too was puzzled by the long wait for the biopsy results. And in response to my pleas, late on a Friday afternoon, he reached the gastroenterologist. The biopses were available – and negative; apparently I had had a mild stomach inflammation.

Why hadn’t he let me know sooner? When I complained, he told me he had been busy with other patients. “The ideal is not always achievable,” he wrote. “I got no call of alarm from the pathologist about you.” So it was not necessary to call. He had 100 patients and could not notify all of them, he said.

National health insurance, if it ever comes, will not solve all such problems in modern medicine. But perhaps it may relieve the pressure of having to make enough money to support large factory-like practices so a urologist and gastroenterologist could pay closer attention to their patients. When you are too busy to do that, you are too busy.

A similar experience to ask about? Write [email protected]

Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. His Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, appears here at Time Goes By twice each month.

Approaching the time for an assessment of Barack Obama’s first year in the presidency, those of us with memory have discovered that he’s not a Franklin Roosevelt of tough bank regulation and Social Security, or a Lyndon Johnson of civil rights and Medicare.

So it’s all the more ridiculous that Republicans and assorted right-wing loonies demonize him as a socialist, fascist, communist and Nazi and have nothing else to offer except to obstruct. But that makes it all the more puzzling that Obama, with the kind of Democratic majorities in Congress that Roosevelt and Johnson had, has not been able to accomplish more than he has.

Let me suggest one reason. After grappling with the financial and automobile industry crises with limited success, Obama’s 10-month preoccupation with health care reform, while well-intentioned and necessary, has chewed up his time and political energy and has gotten in the way of the changes he had promised and Americans had hoped for. And how much he has to show for it is uncertain.

Obama has depended on stirring rhetoric rather than hands-on leadership. He has shown no inclination to fight or twist arms. But both battles have sapped his political strength. As polls show, the $700 billion federal bailouts of banks and Wall Street have become deeply unpopular and the proposed health reforms have been whittled away with so many compromises it has become top-heavy with qualifiers that it is no longer seen by even its supporters as a real and immediate breakthrough.

Rep. John Conyers, (D., Michigan,), the second longest-serving House member, who voted for the health care reform, uncharacteristically let loose on Obama in a November 18 interview with Bill Press. “I’m getting tired of saving Obama’s can,” said Conyers. “I mean he won by only five votes in the House and this bill wasn’t anything to write home about.” Asked if the president had demonstrated leadership, Conyers said,

“Of course not. Holding hands out and beer on Friday nights in the White House and bowing down to every nutty right-wing proposal about health care and saying on occasion that public options aren’t all that important is doing a disservice to the Barack Obama that I first met who was an ardent single-payer enthusiast himself.”

Conyers’ long standing proposal, Medicare for All, was given no consideration or even a hearing by the White House despite appeals from loyal supporters and his doctors. And Conyers noted that the reforms now before the Senate and endorsed by Obama would not begin until 2014. “Many of the people we are trying to help will be dead by then,” said Conyers.

His frustration was shared not only among liberals and progressives, but among independents and younger voters who seem to have lost enthusiasm for Obama as his drive for health care reform has become mangled in the sausage-making machine called Congress.

Politico reported last month that “mounting evidence that independent voters have soured on the Democrats is prompting debate among party officials about what rhetorical and substantive changes are needed to halt the damage.”

The story quoted Michael Dimock, a pollster with Pew Research, who found that Democrats are suffering for “their inability to move the ball on key agenda items such as health care...the public wants to see action. I’m not sure words are going to help Democrats. They’ve got to achieve some success.”

To be sure, Obama’s early actions and the $787 billion stimulus have, for the time being, averted deeper financial disaster. Original Medicare and Social Security are safe for the next three years. He has reversed the stiff-necked, anti-government conservatism of the Bush years. Washington, where I’ve lived, is more relaxed and open.

The president is a hit everywhere he goes overseas. The U.S. is about to hold talks with North Korea, has engaged in dialogue with Iran and re-engaged with European and Asian allies and Africa. An opening to Cuba is in sight.

The U.S. has sent a delegate to the United Nations war crimes court in The Hague, which Washington has boycotted for years. Torture has ended. And the administration is returning to the rule of law in detaining and prosecuting accused terrorists, although they can still be held without recourse and some will be tried by military tribunals.

But there is a political truism in the song: “What have you done for me lately.” And because most, if not all politics is local, civil libertarians want to know, why can’t Obama keep his pledge, made on his first day in office, to close the prison at Guantanamo? Can he not tell, order, his subordinates: Get it done? And what’s holding up his promise to end the military’s “don’t-ask-don’t-tell” policy towards gays and lesbians? Isn’t Obama the commander-in-chief?

More immediately, while the Troubled Assets Relief Program (TARP) has helped make Wall Street whole, no one has moved to restore the restrictions of the New Deal law, Glass-Steagall, that for 75 years kept the banking and investment wolves at bay. And Democrats have still been unable to restore the regulation of derivatives and other exotic instruments. Why not? Because both these regulatory pillars were brought down ten years ago by men who are now Obama’s economic advisers. And neither the president or the leading liberal Democrats dealing with these issues have moved forcefully to restore the regulations.

Rep. Peter DeFazio (D., Oregon) told The Huffington Post, “It is pretty embarrassing for a Democratic administration and a Democratic congress to be identified with total attention to Wall Street and nothing for main street and jobs.”

The stimulus – which was gutted by conservative Democrats in the Senate – has not created the promised 640,000 jobs; that turned out to be a mirage that has embarrassed Democrats. And on November 19, an angry group of Congressional Black Caucus members, ten of whom are on the House Financial Services Committee, blocked the Committee’s scheduled vote on (weak) financial regulation to protest what they believe is the lack of attention being paid by the White House to the immediate economic crises – official unemployment at 10.2 percent; real unemployment at 17 percent with no relief in sight; one in ten households behind on mortgage payments.

One can blame much of the lethargy on the insane partisanship in Congress and the ideological splits within the Democrats. But the president has not yet begun to fight, to assert the leadership he promised he’d provide. Perhaps we’ll see that when the health care issue is behind him.

Worried that they’ve been unresponsive because of their preoccupation with health care, House and Senate leaders will belatedly work on a jobs bill for Christmas, although no one knows what will be in it or where the money will come from. And when you don’t know what else to do, you call for a forum on jobs, which was held this week.

After all the talk, I would hope for a new WPA to rebuild rutted roads, rotted bridges and decaying cities. But that’s because I’m old enough to have memory of the Roosevelt years.

Need help on an issue? Write saulfriedmanATcomcastDOTnet.