Aging, Sexuality, End-of-Life Decisions & the U.S. Health-Care System – Comprehensive Class Notes

Household Economics & Everyday Financial Stress

Opening class anecdote: routine grocery shopping (e.g., eggs, milk) easily reaches \$100 for a week’s supplies.
Acknowledgment of financial pressures amplified for parents or those caring for large families.

Societal discomfort with older‐adult sexuality:
- Misconception that elders “shouldn’t have the energy” or desire.
- Stigma toward intimacy, companionship, or remarriage after spousal death.
Case example:
- Father (widower) remarried a woman ≈ 3 years older than his daughter after 49 years with late spouse.
- Class debate: whether he should have remained single, potential issues of having children at advanced age.
Age‐gap double standard:
- In high school, a 3–4 yr gap (senior ↔ freshman) = socially taboo.
- In midlife (e.g., 47 yr man + 44 yr woman) = socially acceptable.
- Sexist framing: older men dating younger women viewed differently than older women dating younger men.
Biological vs social “prime”:
- Women: fertility concerns and obstetric risk rise after ≈ 40 yrs; label “geriatric pregnancy”.
- Men often perceived “in prime” until nearly 70 yrs.
Key point: Time is linear (birth → death), but social rules around relationships vary by cohort and culture.

U.S. ethos: “save life” → reluctance to discuss death.
Ethical questions raised:
1. Should the terminally ill have the right to refuse treatment ("right to die")?
2. Personal reactions shaped by age, condition, family dynamics.
Cultural references:
- Dr. Jack Kevorkian (1990s) & assisted suicide debates.
- Novel/film “Me Before You” – quadriplegic choosing death despite care.
DNR (Do Not Resuscitate):
- Legal pre‐statement refusing CPR/advanced life support.
- Distinction: live refusal vs. advance directive signed while cognitively intact.
- Complexity when families disagree but document is valid.
Advance directives: clarify wishes (ventilators, feeding tubes, etc.) while competent.

Hospitals consult families if patient is potential donor; cannot harvest organs without consent.
Eligibility limits: cancer, leukemia, age > 70 yrs may exclude organ donation.
Hollywood exaggerates frequency of unethical procurement; real‐world practice highly regulated.

Gerontology = scientific study of aging.
Government agencies: every state + many cities host “Office of Aging”.
Older Americans Act (1965): goals—income, health, dignity, meaningful activity, community services.
Powerful elder lobbies: e.g., AARP.

Nursing homes created as cheaper alternative to hospitals; funded via Medicare/Medicaid.
Average U.S. cost: 7,900 per month ⇒ yearly 7,900\times12 = 94,800.
Assisted-living anecdote: 8,000 per month (lowest local quote).
Few families can self-fund; underscores need for public support.

Broker services, case management, advocacy, counseling (brief, grief, crisis), adult day care, respite care, transportation.
Mandatory reporters for elder abuse/neglect.
Growing job market in nursing, rehab, and long-term care facilities.

Philosophical tension: service orientation (health as a right) vs. profit orientation.
Technological leadership but widespread lack of “proper” care.
Prevention underfunded vs. treatment; high deductible plans deter annual physicals.
Typical annual physical copay example: \approx97.

Physicians in private practice.
Group outpatient clinics.
Hospitals (public, private, teaching).
Public health services:
- Local → Regional → State → National → International (e.g., measles outbreak progression).

Employer-based model dominates; no job = often no insurance.
Vision & dental frequently separate, harder to access (few eye doctors accept major medical plans).
Health Savings Accounts (HSA):
- Pre-tax contributions; employer match possible; debit card access.
Contractors & temp agency workers frequently uninsured.

Emergence of neighborhood urgent-care centers ≤ 10 yrs ago reduces ER burden.
Offer assessment regardless of insurance, cheaper than ER; can triage true emergencies.

HIV/AIDS shifted medical protocols; now nearing potential cure breakthroughs.
Women’s reproductive services: still lower quality/access, especially for Medicaid recipients.

Medicaid: income-based (poor/near-poor, children). Low reimbursement ⇒ many private providers refuse.
Medicare: age ≥ 65 or certain disabilities.
Dual eligibility possible (Medicare + Medicaid).

Covers kids whose family income too high for Medicaid but too low for private insurance.

St. Jude Children’s Research Hospital: 100 % donor-funded, no cost to patients, covers travel/lodging.
Hospitals rely on mixed payer mix; uninsured ER use forces hospitals to absorb costs → higher overall pricing.

Autonomy vs beneficence: honoring DNRs, respecting right-to-die while balancing family wishes.
Ageism influences policy, romantic norms, and health-care practice.
Social workers must navigate legal mandates (elder abuse reporting), resource brokering, and advocacy for equitable care.
Economic structures (insurance, long-term care costs) critically shape health outcomes and family stress.

Note

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