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A Cultural and Economic History of Old Age in America
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Symposium on Geriatrics
A Cultural and Economic History of Old Age in America KEVIN C. FLEMING, MD; JONATHAN M. EVANS, MD; AND DARRYL S. CHUTKA, MD resulted in the relative moving to the dreaded poorhouse. Passage of Medicare and Medicaid legislation resulted in the rapid development of commercial nursing homes, accelerating the trend away from nonprofit and government facilities. However, serious deficiencies in care have continued to occur, prompting additional federal legislation. Knowledge of the history of aging in America can provide a useful touchstone: it can expose past problems that could happen again, identify what is worth preserving from the past, and help us avoid relearning painful lessons. Mayo Clin Proc. 2003;78:914-921
The lives of today’s elderly population have deep historical precedents by which we can better understand current social policies, health care, and retirement. The history of old age in America is more complex and varied than most people realize. This history has been shaped largely by the search for economic security. In the agricultural economy of preindustrial America, few individuals saved sufficient resources for their declining years, and most elderly people either continued to work or lived in dependent poverty. More than any other factor, the lack of family members willing or able to provide for an elderly relative
children younger than 2 years.2 As late as 1870, only 3% of the US population was aged 65 years or older, and only 0.37% was older than 80 years. The corresponding figures for England were 4.7% and 0.65% (in 1851), reflecting the large number of young immigrants in America.3 Because survival to old age was rare, older citizens were imbued with the mystique of wisdom. Most elderly individuals in early America lived in nuclear households or with an unmarried child and were generally treated with deference and respect, according to cultural norms and religious tradition. In more affluent families, control of valuable farmland by elder patriarchs contributed to economic, familial, and political authority through the potential for inheritance. But there were relatively few aged poor people; longevity was primarily achieved among the privileged classes. Seen as a burden on the local taxes, the destitute elderly population was not venerated but despised and often treated as outcasts.4-6 About the time of the American Revolution, a similar revolution in age relations occurred. Old age began to decline in status, and a new youth culture arose. From 1770 to 1820, this cultural shift was reflected in language, dress, customs, and art. In meeting halls, front-row seats were no longer reserved for elderly citizens. Fashion came to favor a more youthful look; white wigs were dropped in favor of toupees, and clothing ceased to flatter the older frame. Although people had once commonly pretended to be older than they actually were, claimed ages in the census drifted downward from this time on. Fewer children were named after grandparents, and contempt for elderly people began to be expressed in terms such as old fogey, codger, and geezer. Around 1790, for the first time, retirement from public office at 60 or 70 years of age became mandatory in many states. The ideal of age equality overthrew the “tyr-
T
he huge post–World War II baby-boom population, described as the demographic imperative or the graying of America, is expected to survive well into their 80s and 90s. By the year 2020, 1 in 5 Americans will be older than 65 years. The last epoch of Western civilization in which a large percentage of the population was elderly was during the Black Death period in the Middle Ages; 15% of the population was older than 60 years because older adults typically were not infected with bubonic plague.1 What does the looming increase in the population of older adults mean to individuals, families, and society? The lives of today’s elderly population have deep historical precedents from which we can gain a better understanding of current social policies, health care, and retirement. We analyze America’s past for its traditions and approaches to aging. The histories of elderly poor populations, long-term care, health care financing, and the regulatory environment have great relevance to current old-age concerns and can stimulate informed discussions on the future of the elderly population. GROWING OLD IN EARLY AMERICA From 1650 to 1850, the number of elderly Americans was small, consisting of less than 2% of the population. In those times of high birth rate and high mortality, old age was commonly defined as life after the age of 60 years. Many children did not survive the dangers of infancy and young adulthood. In some regions, 40% of all deaths were among From the Division of General Internal Medicine (K.C.F.) and Division of Preventive and Occupational Medicine and Internal Medicine (D.S.C.), Mayo Clinic, Rochester, Minn; and Division of Internal Medicine, University of Virginia, Charlottesville (J.M.E.). Individual reprints of this article are not available. The entire Symposium on Geriatrics will be available for purchase as a bound booklet from the Proceedings Editorial Office at a later date. Mayo Clin Proc. 2003;78:914-921
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anny of age,” and the exaltation of the old began to be replaced by the cult of youth.5 Yet, in many ways, social customs and cultural expressions of early America tended to ignore such age distinctions. Adults in preindustrial society generally were not segregated by age from farm work, social affairs, or community activities. Contemporary novels, diaries, autobiographies, and books on etiquette attest to the absence of agebased norms, recognizing only childhood as a separate class (although “manhood” occurred as early as 10 years of age). For example, birthdays were accorded no special observance until the latter half of the 19th century.2 United States census data confirm the lack of older-age distinctions until at least 1830. At that time, older adults were blurred among those “45 years and over.” Before 1850, blacks had even fewer age classifications than did whites (Table 1).7 However, by the end of the 19th century, stratification by age became institutionalized in American life. Cultural transitions such as school attendance, marriage, and retirement began to be based on age. This arose in part because of the needs of a modern industrial society for a different kind of economic order and social control. In the new era, based on science, the need for time clocks and calendars contrasted with the “timelessness” of early America. Thus, age would become an organizing principle for education, work, welfare, leisure, and senescence.2 By the start of the 20th century, the status of seniors had reached its nadir. Reductions in mortality contributed to increasing numbers of older adults. Focus shifted to medical and scientific advances and to big business, leading to a devaluation of the elderly population, whose remaining years were now bounded by dependency, decay, and dementia. Old age itself was believed to be a disease. Not surprisingly, equating old age with obsolescence resulted in cultural ramifications, such as job loss, early retirement, and segregation into rest homes.6,8 In summary, few survived to old age, but age was not a defining factor for work or social life in early America. The rise of industry was accompanied by a cultural shift favoring the young, and age divisions grew in importance. The elderly population was not valued as its numbers increased. FROM PAUPERS TO PENSIONERS: DEALING WITH THE ELDERLY POOR Old age long has been a serious problem for all but the wealthy. In America’s first 150 years, old age frequently meant financial ruin, the poorhouse, and dependency. Most people saved little during a lifetime of work. Consequently, most could not afford to retire and either moved in with children or worked until they could no longer do their jobs or were fired.5 In his 1795 pamphlet, Agrarian Justice, Thomas
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Table 1. Age Classifications in Early America Year of US census
Age-based categories (y)
1790 1800 1820
White males >16 Free whites <10, 10-15, 16-25, 26-44, ≥45 Free whites <10, 10-15, 16-25, 26-44, ≥45 “Free colored” and slaves <14, 14-25, 26-44, ≥45
1830
Free whites <5, 5-9, 10-14, 15-19, 20-29, 30-39, …, 90-99, ≥100 “Free colored” and slaves <10, 10-23, 24-35, 36-54, 55-99, ≥100 Free whites, “free colored,” and slaves 1-4, 5-9, 10-14, 15-19, 20-29, …, 90-99, ≥100 Males and females 5-17, males 18-44; males ≥21
1850 1880
Paine9 advocated national pensions so that older citizens could “live without wretchedness in Old Age, and go decently out of the World.” But unlike his influential Common Sense, fellow citizens largely ignored these concerns. By the mid-1800s, approximately $230 was needed to finance expenditures for an older adult for 1 year. At that time, 70% of men older than 65 years had less than $800 in assets; 30% had less than $100. Less than 20% of older men could finance 10 years of retirement without additional income. Poverty was even greater in the South, especially among widows and blacks.5 Widows frequently inherited almost nothing. Without savings, pension, or family to care for them, older people continued to labor or found themselves destitute.10 Even aging presidents faced indigence, including Thomas Jefferson, James Monroe, and Ulysses S. Grant.8,11,12 Immigrants and blacks had the fewest resources for old age. By 1850, 3.8% of blacks were older than 60 years (Table 2), and 1.4% were older than 70 years. The vast majority were slaves, unable to hold property or generate savings.7 Elderly slaves were sometimes freed before they became a burden to the plantation, but they were denied food and shelter and were left to starve. Recalled one former slave, When my mother became old, she was sent to live in a little lonely log-hut in the woods. Aged and worn out slaves, whether men or women, are commonly so treated. No care is taken of them, except, perhaps, that a little ground is cleared about the hut, on which the old slave, if able, may raise a little corn. As far as the owner is concerned, they live or die as it happens; it is just the same thing as turning out an old horse.…She was not treated worse than others: it is the general practice.13,14
Although abandonment was discouraged in some regions, senescence did not reduce the owner’s demand for labor, and few slaves were allowed to retire; some were given menial tasks, and others were sold. Auction and plantation
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Table 2. Comparison of Black Populations Between 1800 and 1850* Year US census category
1800
1850
Slaves “Free colored” “Free colored” or slaves >60 y Total US population
887,612 107,410 NA 5,084,912
3,200,600 424,183 138,176 23,054,152
*NA = not applicable.
records document that elderly slaves were sold as mere fractions of a “full hand.”6 No national or state programs for poor people existed in early America. In the tradition of English poor laws of the 1600s, townships assisted poor, elderly residents as a local duty, either in almshouses or with direct subsidies for food and housing. Tradition and legal prescription demanded kin responsibility. Thus, relief was denied to elderly people who had family who could care for them, even when this introduced economic hardship. Communities placed elderly citizens without kin among neighbors or in boarding houses.6 In response to rising relief taxes, a number of towns rid themselves of poor, elderly residents by auctioning them off to farms for labor. This practice continued until the 1820s, frequently accompanied by neglect, cruelty, and even torture. Some communities denied refuge to nonresidents, forcing the old and sick to wander from town to town in search of assistance, even in the middle of winter.10,15 Almshouses, poorhouses, and rural poor farms had existed since colonial times as both a refuge for the helpless and a deterrent to the able-bodied. Assistance to poor people was based on the assumption that the recipient must be truly incapacitated for work. A common belief was that poor people were poor because of immorality, laziness, or alcohol abuse. Thus, able-bodied but nonworking poor individuals were deemed unworthy of assistance and were disciplined in an attempt to force them back into the labor market. The “worthy poor,” however, were those unable to support themselves because of sickness, disability, or old age (ie, through no fault of their own). However, some believed that those who had not accumulated sufficient savings for their own later years were also unworthy.16 Designed to dissuade the “undeserving poor” from seeking relief, poorhouses provided a meager existence. Residents were known as “inmates,” and labor was expected of all but the most frail. Fear of the poorhouse was believed key to maintaining the work ethic among laborers and the poor. Although few questioned that elderly paupers deserved public assistance, shame and fear stigmatized all those on relief, worthy or not. “Dread of life in an institution seems to be almost universal, although the most dreaded is, of course, the poorhouse.”17 More than any
other factor then, the lack of family members willing or able to care for an elderly relative resulted in the relative moving to the poorhouse.10 Although there was a great deal of variability among poorhouses, public demands to keep expenses down frequently resulted in “wretched quarters” and “meager provisions.” Widows and unmarried mothers shared filthy poorhouse rooms with criminals, “drunks,” prostitutes, and the mentally infirm. Dreary, vermin-infested, and laden with human waste, poorhouses were dreaded as a last resort for the elderly poor population, “one of humanity’s great degradations.” Residents were physically abused and experienced severe social stigma.8,18-20 An 1897 investigation found that only 12 cents per day was expended toward each pauper.21 However, despite the alleged frugality of poorhouses—their principal selling point in Britain and America—the cost was invariably more to keep paupers in poorhouses than the cost to support them in their homes by direct income assistance.10 In 1861, shortly after the start of the Civil War, Congress passed a military pension system. These pensions were to compensate soldiers for combat injuries, to recruit soldiers, and to bolster nationalist pride. In the decades after the war, the military pension was transformed into a rudimentary old-age system of social insurance for the working class. In 1904, President Theodore Roosevelt expanded eligibility beyond those with war-related wounds by establishing old age itself as a disability.22 By 1910, 93% of Northern white veterans or their widows received pensions, representing 25% of the elderly US population. At this point, military pensions consumed 43% of all federal expenditures. In today’s dollars, the stipend would be comparable to the average Social Security retirement benefit. However, this program did not lead to a national old-age pension because of corruption, high costs, the financial panic of 1907, and a lack of political organization among the elderly population. Although this first national experiment in disability and pension assistance died with the last Union veterans and their families, it marked a shift away from local relief for the elderly.8,23 After the Emancipation Proclamation and the Civil War, elderly blacks continued to work as sharecroppers or became dependents of extended households. Economically and socially, the term sharecropper signified one of the lowest rungs on the Southern agricultural ladder. Lacking education and property rights and rarely showing a profit from cotton, black, white, and Hispanic tenant farmers labored well into old age. However, the advent of the mechanical cotton picker eventually pushed sharecroppers off the land. As a result, older blacks migrated to cities for employment. For those who remained, there were few government services and persistent poverty.6,24,25
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According to some authors, urbanization, immigration, and the Industrial Revolution left many elderly people alone, without income, and bereft of social status.5,8 However, recent research suggests that, compared with spartan farm life, industrialization improved the fortunes for most elderly people. For poorer families, factory wages and living spaces were shared in households spanning 3 generations. But the growing middle-class elderly population could afford separate housing, avoiding the disharmony common to crowded city life.6 The industrial age had raised per capita incomes for young and old alike. Poverty began to diminish for many older people, although primarily among white men and their spouses. Single women, widows, minorities, and immigrants remained economically vulnerable with senescence. For these groups, continued labor and severe poverty marked old age. Increasingly, however, many senior citizens were able to fulfill the growing desire to maintain independent households in their later years. This preference for independent living remains today. In the 1920s, Americans increasingly viewed the elderly population as obsolete. Industrial managers and proponents of the scientific management theory regarded older workers as less productive and lacking the stamina, speed, and dexterity needed for factory work. In addition, older workers were more likely to be injured on the job, increasing a firm’s liability. At the same time, organized labor wanted superannuated employees to make room for younger laborers. Increasing numbers of firms began to introduce mandatory retirement ages, and pensions were few. As a result, opportunities for employment after 45 years of age became limited. Without work, health benefits, or unemployment insurance, many people reached old age without sufficient savings.5,26,27 After World War I, efforts by welfare authorities and reformers to address the indignities of the almshouse gave rise to various programs to assist needy elderly individuals. Charity and fraternal organizations, meager union pensions, and state and local government programs served in a piecemeal and incomplete fashion.8 But inflation and stock market losses in the 1920s and the Great Depression of the 1930s caused this fragile safety net to fail. About 1910, nearly one quarter of older Americans were in dependent poverty. By 1930, before the Depression began, fully 30% of the elderly population was in poverty. This number rose to 50% in 1935 and to two thirds by 1940.5,6 The economic collapse of the Great Depression resulted in mass unemployment and social dislocation. Charitable donations dwindled, and few families could support their aging kin. Increasing numbers of poor, elderly people soon overwhelmed state and county resources. Of the few states that could afford old-age assistance, most offered paltry sums for living. Most middle-class elderly people faced the poorhouse and “the stark terror of penniless, helpless old age.”28
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The Great Depression revived the old-age pension movement, a populist response that became a decisive election-year issue in 1934.23 When President Franklin D. Roosevelt signed the Social Security Act of 1935, he said, We can never insure one-hundred percent of the population against one-hundred percent of the hazards and vicissitudes of life. But we have tried to frame a law which will give some measure of protection to the average citizen and to his family against the loss of a job and against poverty-ridden old age.29
Amendments to include health care benefits with Social Security were first proposed in 1934.30 However, strong opposition from insurers, businessmen, and the American Medical Association defeated these measures. Unable to afford rising medical costs on Social Security incomes, a growing number of the elderly population relied on state assistance to pay their medical bills or on “free” care from hospitals and physicians. The high costs of medical care became the greatest single cause of economic dependency in old age because only 1 in 4 elderly people had adequate insurance. Hospitals increasingly bore the brunt of unpaid health expenses for older people, which came to be viewed as a threat to their existence. By 1960, a bill for health insurance limited to Social Security obtained a floor vote in the US Senate for the first time in its half century as a national issue, losing by a small margin.30 Pressure for relief persisted, and Senator John F. Kennedy made the newly termed Medicare a major issue in his run for president. With increasing numbers and entitlement financing, the elderly population was fast becoming an influential political force. As a result, Congress finally was persuaded that older Americans needed help defraying medical costs.8,23 As part of his vision of the “Great Society,” President Lyndon B. Johnson signed Medicare and Medicaid into law in 1965. With these programs, the government had stepped in to fill a void left by the marketplace, the uninsurable elderly population. The combination of income assistance in the form of Social Security and health insurance through Medicare made retirement increasingly attractive and, for the first time, financially feasible for most elderly people. In 1880, three quarters of men aged 65 years or older were gainfully employed, but few had the means to retire. Most left work because of poor health or the inability to find work and became dependent on their children or on charity. Labor force participation slowly declined in the following decades (augmented by the passage of Old Age Assistance and Social Security), and by 1950, less than half of older men were still working. Today, less than one fifth of men older than 65 years work full-time or part-time. Among men aged 55 to 64 years, labor force participation has also
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declined, from a peak of 95% in 1880 to 67% in 1990. In agriculture and early factory work, laborers reached peak earnings in their 30s. In contrast, contemporary workers have experienced steady gains in earnings until retirement. The trend toward early retirement has resulted from relatively high levels of wealth and affordable leisure activities such as travel.6,23 In summary, America has experienced the demise of elder pauperism and the poorhouse and the rise of pensions and retirement. FROM POORHOUSE TO NURSING HOME: THE HISTORY OF LONG-TERM CARE By 1900, county-run poorhouses had transformed into oldage homes, and 37% of residents were elderly.10 To transfer rising costs from local treasuries, many senile elderly residents were moved from county-run almshouses to statefunded mental hospitals, eventually housing 70,000 elderly inmates.31 Charitable “Homes for the Aged” arose, frequently funded by churches, fraternal orders, benevolent societies, and ethnic organizations. These nonprofit facilities provided room and board for poor, elderly people with no families. Proprietary nursing facilities also developed in the early 1900s, primarily serving the chronically ill or disabled. State licensure programs developed in the 1920s, but standards and oversight were minimal, focused primarily on building and safety codes. Still, county poor farms accounted for the bulk of assistance provided to the elderly, poor population. The poor farms were selected frequently on the basis of least cost to the county, a practice decried as “farming out the poor to the lowest bidder.” Increasingly large numbers of disabled and chronically ill elderly people were being admitted. Inhumane conditions, fears of institutionalization, and the destitution of 7 million elderly persons from the Depression resulted in a provision of the Social Security Act (SSA), which denied funding to poorhouse residents. Without funding, these facilities soon died out. By the 1940s, poor farm residents had relocated to private “rest homes,” which were allowed to receive Social Security funds. As a result, numerous small private nursing homes opened. Frequently, these were converted farmhouses, mansions, or motels with poor safety, fire, and access features, and the quality of care varied widely. Many were not equipped to care for frail or ill elderly residents and provided only a room and meals. During the Depression, unemployed nurses often ran these facilities, but most of the care remained custodial in nature.26,32 A consequence of legislation directed against publicly funded poorhouses was the nurturing of an emerging forprofit nursing home industry. Social Security cash in citizens’ hands helped transform long-term care into a largely
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proprietary endeavor. Subsequent legislation, taxes, and building codes continued to favor corporate dominance.33 In the 1950s, states began to receive federal matching funds for direct payments to nursing home “vendors” providing resident care. This marked a shift toward a federal relationship with providers, rather than with elderly residents. Government-backed construction loans and the regular income of vendor payments ensured a secure return on investment. This attracted developers and real-estate speculators; some of their names soon became synonymous with nursing home scandals. Yet, despite a 181% increase in spending on nursing home care, there was still a shortage of a half million beds by the early 1960s.33 Passage of Medicare and Medicaid resulted in the rapid development of commercial nursing homes, accelerating the trend away from nonprofit and government facilities. Congress had intended the nursing home benefit as a mechanism to shorten hospital stays, thereby hoping to reduce costs. These programs provided considerable funds to the states, which agreed to minimum federal standards where none had existed previously. However, these regulations were lenient; providing a written plan of correction satisfied most violations.34 Providers were reimbursed for mortgage interest, depreciation, self-reported costs of care, and an added profit margin. Together, Medicaid and Medicare seemed to eliminate much of the risk in this real-estate venture. However, the need for capital was enormous because many new nursing homes were needed to meet existing shortages and replace obsolete facilities. Consequently, in the late 1960s, Wall Street developed a kind of frenzy over corporate investment in nursing homes. Firms with backgrounds in construction, real estate, and the motel industry dominated this speculative market. As a result, bed supply increased from 460,000 to 1.1 million in less than a decade.33 Recurrent scandals of theft, maltreatment, food poisonings, and deadly fires prompted hearings in the Senate Aging and Finance Committees. In 1971, President Richard M. Nixon made speeches deploring nursing home conditions and presented a plan for tougher regulations.34 Although they were once the hottest stocks in the market, by 1972, nursing home stocks went bust. Corporate financial fraud, securities violations, and reports of inferior care and patient abuse fueled investor concerns. Far worse for stockholders, nursing home owners had badly misjudged Medicare. These generous posthospital payments covered less than 2% of expenses, whereas Medicaid accounted for nearly half of long-term care reimbursement and was far less lucrative. At times, conditions worsened because some nursing homes cut back on food or staff to maintain profitability.32 The expense of complying with new stricter building and safety standards forced many smaller nursing homes
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out of business. State restrictions on new bed construction encouraged corporate acquisition of existing facilities. Medicaid reimbursement of the costs of care further favored larger chains. Corporations were able to profit by selling goods and services such as food, laundry, management, and housekeeping to their own subsidiaries. In this manner, large nursing home chains came to control an increasing number of beds. Of the 16,700 nursing homes in the United States today, two thirds are for-profit, one quarter are nonprofit, and 8% are government-owned. More than half belong to management or ownership chains.35 PERSISTENT QUALITY CONCERNS: LONG-TERM CARE IN THE MODERN ERA In 1982, the Ronald W. Reagan administration proposed deregulation of nursing homes in response to industry complaints. However, these plans were withdrawn under heavy public criticism.36 Instead, the Institute of Medicine was commissioned to study long-term care policies and issued the 1986 report Improving the Quality of Care in Nursing Homes.34 It charged that many substandard nursing homes were allowed to operate and that residents frequently received inadequate, sometimes “shockingly deficient” care. Although abuse and neglect had declined in nursing homes, poor quality of life and inadequate medical care were far too common. Rather than relaxing regulations, the Institute of Medicine recommended far more stringent ones. These changes were enacted in the Nursing Home Reform Act of the Omnibus Budget Reconciliation Act of 1987, with farreaching revisions to standards, inspection, and enforcement.36 This legislation mandated more nurse’s aide training and a broader array of care, including the provision of rehabilitative, physician, and social services. A uniform resident assessment instrument was implemented to ensure comprehensive evaluation, and states were now required to provide ombudsmen as resident advocates. Polypharmacy, restraint use, and resident rights issues were addressed. There is good evidence that these regulations have improved the quality of care and created standards where few existed before. However, the expanded services (and paperwork) exacerbated budgetary pressures, conflicting with simultaneous cost-containment efforts.34,35 In 1997, under pressure from states to reduce Medicaid spending, the federal government repealed the 1980 Boren Amendment, which had required that Medicaid nursing home rates be “reasonable and adequate.” The nursing home industry warned that Medicaid reimbursement levels were already too low and that further reductions would adversely affect quality of care.37,38 These changing financial incentives soon led to the development of lower-cost alternatives to the nursing home.
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In 1997, scandal again erupted when a Time magazine article charged that California nursing home residents were being denied food and water and were not being treated for infections. Blaming “greedy owners and slipshod facilities,” the report claimed that thousands of frail, elderly residents were dying of neglect.39 In response, the General Accounting Office later identified glaring quality-of-care deficiencies in fully one third of California nursing homes.40 In 1999, the US Senate Committee on Aging held critical hearings on nursing homes and their regulators, and President William J. Clinton unveiled tougher enforcement standards.41-43 The resulting surprise inspections and higher fines were decried by the industry as excessive and counterproductive because they occurred during a financial crisis that had led to numerous nursing home bankruptcies. In 2001, the Institute of Medicine updated their seminal report,44 now entitled Improving the Quality of Long-Term Care, to encompass alternative services and settings. Quality of care in nursing homes was believed to have improved as a direct result of regulatory scrutiny. However, pressure sores, malnutrition, and pain continued to pose serious quality concerns. The report again called for more data, more penalties, and greater enforcement of standards. Low Medicaid reimbursement was also recognized as a potential source of quality problems. SUMMARY The history of America’s elderly population is more complex and varied than most people realize. The Revolutionary War not only brought forth a new nation but also heralded an overthrow of a cultural hierarchy in which privilege was based on age, sex, race, and class. Subsequent changes have been slow and sorely incomplete but continue unrelentingly. Over the past 200 years, declining birth and mortality rates have made reaching even extreme old age commonplace. Although being elderly is no longer associated with wisdom and value, today’s aged population is more robust and productive and promises to define its worth in ways beyond mere scarcity or wealth. The history of old age in the United States has been shaped largely by the search for economic security. In the agricultural economy of preindustrial America, the standard of living was low for young and old alike. Because the price of labor closely mirrored the cost of living, few were able to save sufficient resources for their declining years, and most elderly people either continued to work or lived in dependent poverty. More than any other factor, the lack of family willing or able to provide for an elderly relative resulted in the relative moving to the dreaded poorhouse. However, welfare and charity to older people were frequently condemned, much like poor people in general were
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condemned, as representing immoral, lazy, and spendthrift behaviors that should not be rewarded. The industrial era expanded opportunities for economic and social independence among older Americans. The desire to live independently as long as possible has gained increasing importance since the 18th century. Rather than representing a weakening of family bonds or kin responsibility, the gradual decline of the extended-family dwelling was welcomed across generations. The rise of the middle class made this long-desired goal a reality for more and more of the elderly population. Although the Great Depression wiped out many of these economic gains, cultural demands for a more secure and independent old age remained. A larger national role evolved with the failure of state and charitable resources. The era of governmental assurance of security in old age began with income assistance (Social Security) and later included health care (Medicare) and institutional long-term care (Medicaid). This restated the social contract to say that each generation supports its elderly population in return for similar support from subsequent generations. Although “old” no longer means “obsolete,” most workers prefer to retire as soon as financially possible. The advent of Social Security made this feasible for many thousands of elderly people. However, a key concept to maintaining popular support for these assistance programs has been avoiding associations with welfare and charity. Therefore, recipients prefer entitlement based on age and vigorously resist means testing or other methods of determining worthiness. Modern concerns about long-term care are rooted in the moral implications of poverty and welfare. The unresolved conflict over individual and societal responsibilities has shaped policies regarding retirement and old-age dependency. The almshouse and poor farm carried the stigma of unworthy dependency and led to underfunding and appalling care of the elderly. Nursing homes then arose by redefining dependent old age as a medical problem and asserting funds as entitlements rather than charity. A hospital-like atmosphere supplanted the traditional board-and-care approach, creating an institutional quality of life. Regulations imposed architectural standards, care directives, and extensive documentation of nearly every activity, which increased the costs of care, all in the name of limiting error, neglect, and the risk of sanctions. Despite this, nursing home history is replete with the same scandals of abuse and neglect that made the poorhouse so fearsome, becoming a place where few care to go. However, the scandalous history of long-term care has itself resulted in the current regulatory approach, which rests on a core of mistrust. To ensure competent care, we require paid caregivers to follow numerous regulations and copiously document nearly every activity. Not surprisingly,
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the result is an impersonal bureaucracy but not a “home.” This is because the keys to high quality of life in long-term care, such as the nature of staff and resident interactions, cannot be achieved through regulation.36,45 Seniors and their advocates demand expert health care services and a low-risk environment but at the same time expect individual freedom, a residential atmosphere, and limited expense. These desires may be mutually exclusive, perhaps even unattainable, but a balance of goals may be achievable. These quandaries continue because critical questions remain not only unanswered but also undiscussed. What kind of old age do we want for our parents and ourselves? What risks will we allow for the sake of individual autonomy? Given finite resources, what limits will we accept? What are we willing to pay for? Who should pay? To what degree must we prepare for our own futures? What level of financial burden can we demand of later generations? These questions represent some of the unresolved tensions between generations and economic classes. Conflicting values regarding autonomy, personal responsibility, and the proper role of government also contribute to the lack of consensus. There has never been a national aging or longterm care policy in America. The present system seems to have arisen primarily while attempting to reduce expenses, “an afterthought, a side effect of decisions directed at other problems.”33 Unless the debate expands beyond budgetary concerns, the historical pattern of scandal-reform-scandal in long-term care will likely continue unabated. Knowledge of the history of aging in America can provide a useful touchstone: it can expose past problems that could happen again, identify what is worth preserving from the past, and help us avoid relearning painful lessons.46 However, it would be a mistake to presume that this history merely repeats itself. The chronology of elder care is indeed often bleak and sad, but the kind of care received today, although far from ideal, is a vast improvement over previous decades. An understanding of the issues in elder care as they occurred over time can suggest limitations on future possibilities. But equally important, we must discern how the present diverges from the past. A more thorough analysis of the history of the elderly population in the United States, one that revisits our presumptions and “common wisdom” regarding long-term care, can permit a more prudent view of the future, perhaps one more feasible than fanciful. REFERENCES 1. 2. 3. 4.
Minois G. History of Old Age: From Antiquity to the Renaissance. Chicago, Ill: University of Chicago Press; 1989:210-217. Chudacoff HP. How Old Are You? Age Consciousness in American Culture. Princeton, NJ: Princeton University Press; 1989:13. Posner RA. Aging and Old Age. Chicago, Ill: University of Chicago Press; 1995:32-33. de Beauvoir S. The Coming of Age. New York, NY: GP Putnam’s Sons; 1972:134, 272.
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5. 6. 7.
8. 9. 10. 11. 12. 13.
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16. 17. 18.
19. 20.
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22. 23. 24. 25. 26.
Fischer DH. Growing Old in America. Oxford, England: Oxford University Press; 1978:64, 77-102, 174, 208, 228. Haber C, Gratton B. Old Age and the Search for Security: An American Social History. Bloomington, Ind: Indiana University Press; 1994:21-47, 69-79, 91-95, 110-114, 122-123, 174-179. United States Historical Census Data Browser. Inter-university Consortium for Political and Social Research. Historical, Demographic, Economic, and Social Data: The United States, 17901970. Available at: http://fisher.lib.virginia.edu/census/. Accessibility verified May 16, 2003. Achenbaum WA. Old Age in the New Land: The American Experience Since 1790. Baltimore, Md: Johns Hopkins University Press; 1978:29, 46-48, 60, 91, 113-125, 146. Paine T. Agrarian Justice. Philadelphia, Pa: R Folwell; 1797. Available at: www.ssa.gov/history/tpaine3.html. Accessibility verified May 16, 2003. Katz MB. In the Shadow of the Poorhouse: A Social History of Welfare in America. New York, NY: Basic Books; 1986:9. Saltow L. Men and Wealth in the United States, 1850-1870. New Haven, Conn: Yale University Press; 1975:72-73. Katz MB. The Price of Citizenship: Redefining America’s Welfare State. New York, NY: Metropolitan Books; 2001:232-233. Narrative of the Life of Moses Grandy; Late a Slave in the United States of America 1843. University of North Carolina at Chapel Hill Libraries Web site; 1996:51-52. Available at: http://docsouth .unc.edu/grandy/grandy.html. Accessibility verified May 16, 2003. Gergen KJ, Gergen MM. The new aging: self construction and social values [draft copy]. In: Schaie KW, ed. Social Structures and Aging. New York, NY: Springer. Available at: www .swarthmore.edu/SocSci/kgergen1/web/page.phtml?id=manu16&st =manuscripts&hf=1. Accessibility verified May 21, 2003. Newton JH, ed. History of the Pan-Handle; Being Historical Collections of the Counties of Ohio, Brooke, Marshall and Hancock, West Virginia. Evansville, Ind: Unigraphic Inc; 1973:382. Available at: www.rootsweb.com/~wvmarsha/poorhouse.htm. Accessibility verified May 22, 2003. Gans HJ. The War Against the Poor: The Underclass and Antipoverty Policy. New York, NY: Basic Books; 1995. Solenberger AW. One Thousand Homeless Men: A Study of Original Records. New York, NY: Charities Publication Committee; 1911:314. A disgrace to humanity: shocking condition of affairs that exists at the Sheldon Poor House. St Albans Weekly Messenger. February 4, 1897. Available at: www.poorhousestory.com/VT_st_albans _weekly_messenger_ _ _1897.htm. Accessibility verified May 22, 2003. Evans HC. The American Poorfarm and Its Inmates. Mooseheart, Ill: Loyal Order of Moose; 1926:5. The Almshouse: testimony of last night’s meeting of the investigating committee. The Philadelphia North American and United States Gazette. January 11, 1882. Available at: www.poorhousestory.com /PA_PHIL_Scandal.htm. Accessibility verified May 22, 2003. Brammer R. A home for the homeless: remembering the Pleasants County poor farm. GOLDENSEAL. Fall 1994. Available at: www.rootsweb.com/~wvpleasa/poor.htm. Accessibility verified May 22, 2003. Blanck P. Civil War pensions and disability. Ohio State Law J. 2001;62:109-238. Costa DL. The Evolution of Retirement: An American Economic History, 1880-1990. Chicago, Ill: University of Chicago Press; 1998:1-8, 162-169, 176-177, 195-196. Grim V, Effland ABW. Sustaining a rural black farming community in the South: a portrait of Brooks Farm, Mississippi. Rural Dev Perspect. 12(3):47-52. Kester H. Revolt Among the Sharecroppers. Knoxville, Tenn: University of Tennessee Press; 1997. McClure E. More Than a Roof: The Development of Minnesota Poor Farms and Homes for the Aged. St Paul, Minn: Minnesota Historical Society; 1968:102, 128-129.
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29. 30.
31. 32.
33. 34. 35. 36. 37.
38.
39. 40.
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44. 45. 46.
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Hirshbein Davidow L. William Osler and the fixed period: conflicting medical and popular ideas about old age. Arch Intern Med. 2001;161:2074-2078. Eliot TH. The legal background of the Social Security Act. Presented at: Social Security Administration Headquarters; Baltimore, Md; February 3, 1961. Available at: www.ssa.gov/history /eliot2.html. Accessibility verified May 22, 2003. Social Security Administration. A Brief History of Social Security. Baltimore, Md: Social Security Administration; 2000. SSA publication 21-059. Corning PA. The Evolution of Medicare…From Idea to Law. Social Security Administration Office of Research and Statistics; 1969. Available at: www.ssa.gov/history/corning.html. Accessibility verified May 22, 2003. Vogel RJ, Palmer HC, eds. Long-Term Care: Perspectives From Research and Demonstrations. Rockville, Md: Aspen Systems Corp; 1985. Committee on Implications of For-Profit Enterprise in Health Care, Institute of Medicine; Gray BH, ed. For-Profit Enterprise in Health Care. Washington, DC: National Academy Press; 1986: 494. Vladeck BC. Unloving Care: The Nursing Home Tragedy. New York, NY: Basic Books; 1980:115-121. Committee on Nursing Home Regulation, Institute of Medicine. Improving the Quality of Care in Nursing Homes. Washington, DC: National Academy Press; 1986:Appendix A, 1-44, 241-243. Giacalone JA. The U.S. Nursing Home Industry. Armonk, NY: ME Sharpe; 2001:80-81, 121-132. Hawes C. Regulation and the politics of long-term care. Generations. 1997-1998;21(4):5-9. Wiener JM, Stevenson DG. Repeal of the Boren Amendment: Implications for Quality of Care in Nursing Homes. Washington, DC: Urban Institute; 1998. New Federalism: Issues and Options for States, No. A-30. Available at: http://newfederalism.urban.org /html/anf30.html. Accessibility verified May 23, 2003. Clarke LW. The demise of the Boren Amendment: what comes next in the struggle over hospital payment standards under the Medicaid Act? Available at: www.duanemorris.com/publications /pub14.html. Accessibility verified May 28, 2003. Thompson M. Fatal neglect: in possibly thousands of cases, nursing-home residents are dying from a lack of food and water and the most basic level of hygiene. Time. 1997;150:34-38. US General Accounting Office. California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. Washington, DC: US General Accounting Office; 1998. Publication GAO/ HEHS-98-202. Grassley CE, Chairman. Hearing before the United States Senate Special Committee on Aging. Betrayal: The Quality of Care in California Nursing Homes; July 27-28, 1998. SHrg 105-735, Serial No. 105-30. Washington, DC: US Government Printing Office. GPO Stock No. 552-070-23271-1. Grassley CE, Chairman. Hearing before the United States Senate Special Committee on Aging. Residents at Risk? Weaknesses Persist in Nursing Home Complaint Investigation and Enforcement; March 22, 1999. SHrg 106-108, Serial No. 106-3. Washington, DC: US Government Printing Office. GPO Stock No. 552-070-24230-9. Grassley CE, Chairman. Hearing before the United States Senate Special Committee on Aging. The Nursing Home Initiative: Results at Year One; June 30, 1999. SHrg 106-353, Serial No. 10611. Washington, DC: US Government Printing Office. GPO Stock No. 552-070-25045-0. Wunderlich, GS, Kohler PO, eds; Committee on Improving Quality in Long-term Care. Improving the Quality of Long-Term Care. Washington, DC: National Academy Press; 2001:1-20. Howard PK. The Lost Art of Drawing the Line: How Fairness Went Too Far. New York, NY: Random House; 2001:78-171. Neustadt RE, May ER. Thinking in Time: The Uses of History for Decision Makers. New York, NY: Free Press; 1988.
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Symposium on Geriatrics
A Cultural and Economic History of Old Age in America KEVIN C. FLEMING, MD; JONATHAN M. EVANS, MD; AND DARRYL S. CHUTKA, MD resulted in the relative moving to the dreaded poorhouse. Passage of Medicare and Medicaid legislation resulted in the rapid development of commercial nursing homes, accelerating the trend away from nonprofit and government facilities. However, serious deficiencies in care have continued to occur, prompting additional federal legislation. Knowledge of the history of aging in America can provide a useful touchstone: it can expose past problems that could happen again, identify what is worth preserving from the past, and help us avoid relearning painful lessons. Mayo Clin Proc. 2003;78:914-921
The lives of today’s elderly population have deep historical precedents by which we can better understand current social policies, health care, and retirement. The history of old age in America is more complex and varied than most people realize. This history has been shaped largely by the search for economic security. In the agricultural economy of preindustrial America, few individuals saved sufficient resources for their declining years, and most elderly people either continued to work or lived in dependent poverty. More than any other factor, the lack of family members willing or able to provide for an elderly relative
children younger than 2 years.2 As late as 1870, only 3% of the US population was aged 65 years or older, and only 0.37% was older than 80 years. The corresponding figures for England were 4.7% and 0.65% (in 1851), reflecting the large number of young immigrants in America.3 Because survival to old age was rare, older citizens were imbued with the mystique of wisdom. Most elderly individuals in early America lived in nuclear households or with an unmarried child and were generally treated with deference and respect, according to cultural norms and religious tradition. In more affluent families, control of valuable farmland by elder patriarchs contributed to economic, familial, and political authority through the potential for inheritance. But there were relatively few aged poor people; longevity was primarily achieved among the privileged classes. Seen as a burden on the local taxes, the destitute elderly population was not venerated but despised and often treated as outcasts.4-6 About the time of the American Revolution, a similar revolution in age relations occurred. Old age began to decline in status, and a new youth culture arose. From 1770 to 1820, this cultural shift was reflected in language, dress, customs, and art. In meeting halls, front-row seats were no longer reserved for elderly citizens. Fashion came to favor a more youthful look; white wigs were dropped in favor of toupees, and clothing ceased to flatter the older frame. Although people had once commonly pretended to be older than they actually were, claimed ages in the census drifted downward from this time on. Fewer children were named after grandparents, and contempt for elderly people began to be expressed in terms such as old fogey, codger, and geezer. Around 1790, for the first time, retirement from public office at 60 or 70 years of age became mandatory in many states. The ideal of age equality overthrew the “tyr-
T
he huge post–World War II baby-boom population, described as the demographic imperative or the graying of America, is expected to survive well into their 80s and 90s. By the year 2020, 1 in 5 Americans will be older than 65 years. The last epoch of Western civilization in which a large percentage of the population was elderly was during the Black Death period in the Middle Ages; 15% of the population was older than 60 years because older adults typically were not infected with bubonic plague.1 What does the looming increase in the population of older adults mean to individuals, families, and society? The lives of today’s elderly population have deep historical precedents from which we can gain a better understanding of current social policies, health care, and retirement. We analyze America’s past for its traditions and approaches to aging. The histories of elderly poor populations, long-term care, health care financing, and the regulatory environment have great relevance to current old-age concerns and can stimulate informed discussions on the future of the elderly population. GROWING OLD IN EARLY AMERICA From 1650 to 1850, the number of elderly Americans was small, consisting of less than 2% of the population. In those times of high birth rate and high mortality, old age was commonly defined as life after the age of 60 years. Many children did not survive the dangers of infancy and young adulthood. In some regions, 40% of all deaths were among From the Division of General Internal Medicine (K.C.F.) and Division of Preventive and Occupational Medicine and Internal Medicine (D.S.C.), Mayo Clinic, Rochester, Minn; and Division of Internal Medicine, University of Virginia, Charlottesville (J.M.E.). Individual reprints of this article are not available. The entire Symposium on Geriatrics will be available for purchase as a bound booklet from the Proceedings Editorial Office at a later date. Mayo Clin Proc. 2003;78:914-921
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anny of age,” and the exaltation of the old began to be replaced by the cult of youth.5 Yet, in many ways, social customs and cultural expressions of early America tended to ignore such age distinctions. Adults in preindustrial society generally were not segregated by age from farm work, social affairs, or community activities. Contemporary novels, diaries, autobiographies, and books on etiquette attest to the absence of agebased norms, recognizing only childhood as a separate class (although “manhood” occurred as early as 10 years of age). For example, birthdays were accorded no special observance until the latter half of the 19th century.2 United States census data confirm the lack of older-age distinctions until at least 1830. At that time, older adults were blurred among those “45 years and over.” Before 1850, blacks had even fewer age classifications than did whites (Table 1).7 However, by the end of the 19th century, stratification by age became institutionalized in American life. Cultural transitions such as school attendance, marriage, and retirement began to be based on age. This arose in part because of the needs of a modern industrial society for a different kind of economic order and social control. In the new era, based on science, the need for time clocks and calendars contrasted with the “timelessness” of early America. Thus, age would become an organizing principle for education, work, welfare, leisure, and senescence.2 By the start of the 20th century, the status of seniors had reached its nadir. Reductions in mortality contributed to increasing numbers of older adults. Focus shifted to medical and scientific advances and to big business, leading to a devaluation of the elderly population, whose remaining years were now bounded by dependency, decay, and dementia. Old age itself was believed to be a disease. Not surprisingly, equating old age with obsolescence resulted in cultural ramifications, such as job loss, early retirement, and segregation into rest homes.6,8 In summary, few survived to old age, but age was not a defining factor for work or social life in early America. The rise of industry was accompanied by a cultural shift favoring the young, and age divisions grew in importance. The elderly population was not valued as its numbers increased. FROM PAUPERS TO PENSIONERS: DEALING WITH THE ELDERLY POOR Old age long has been a serious problem for all but the wealthy. In America’s first 150 years, old age frequently meant financial ruin, the poorhouse, and dependency. Most people saved little during a lifetime of work. Consequently, most could not afford to retire and either moved in with children or worked until they could no longer do their jobs or were fired.5 In his 1795 pamphlet, Agrarian Justice, Thomas
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Table 1. Age Classifications in Early America Year of US census
Age-based categories (y)
1790 1800 1820
White males >16 Free whites <10, 10-15, 16-25, 26-44, ≥45 Free whites <10, 10-15, 16-25, 26-44, ≥45 “Free colored” and slaves <14, 14-25, 26-44, ≥45
1830
Free whites <5, 5-9, 10-14, 15-19, 20-29, 30-39, …, 90-99, ≥100 “Free colored” and slaves <10, 10-23, 24-35, 36-54, 55-99, ≥100 Free whites, “free colored,” and slaves 1-4, 5-9, 10-14, 15-19, 20-29, …, 90-99, ≥100 Males and females 5-17, males 18-44; males ≥21
1850 1880
Paine9 advocated national pensions so that older citizens could “live without wretchedness in Old Age, and go decently out of the World.” But unlike his influential Common Sense, fellow citizens largely ignored these concerns. By the mid-1800s, approximately $230 was needed to finance expenditures for an older adult for 1 year. At that time, 70% of men older than 65 years had less than $800 in assets; 30% had less than $100. Less than 20% of older men could finance 10 years of retirement without additional income. Poverty was even greater in the South, especially among widows and blacks.5 Widows frequently inherited almost nothing. Without savings, pension, or family to care for them, older people continued to labor or found themselves destitute.10 Even aging presidents faced indigence, including Thomas Jefferson, James Monroe, and Ulysses S. Grant.8,11,12 Immigrants and blacks had the fewest resources for old age. By 1850, 3.8% of blacks were older than 60 years (Table 2), and 1.4% were older than 70 years. The vast majority were slaves, unable to hold property or generate savings.7 Elderly slaves were sometimes freed before they became a burden to the plantation, but they were denied food and shelter and were left to starve. Recalled one former slave, When my mother became old, she was sent to live in a little lonely log-hut in the woods. Aged and worn out slaves, whether men or women, are commonly so treated. No care is taken of them, except, perhaps, that a little ground is cleared about the hut, on which the old slave, if able, may raise a little corn. As far as the owner is concerned, they live or die as it happens; it is just the same thing as turning out an old horse.…She was not treated worse than others: it is the general practice.13,14
Although abandonment was discouraged in some regions, senescence did not reduce the owner’s demand for labor, and few slaves were allowed to retire; some were given menial tasks, and others were sold. Auction and plantation
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Table 2. Comparison of Black Populations Between 1800 and 1850* Year US census category
1800
1850
Slaves “Free colored” “Free colored” or slaves >60 y Total US population
887,612 107,410 NA 5,084,912
3,200,600 424,183 138,176 23,054,152
*NA = not applicable.
records document that elderly slaves were sold as mere fractions of a “full hand.”6 No national or state programs for poor people existed in early America. In the tradition of English poor laws of the 1600s, townships assisted poor, elderly residents as a local duty, either in almshouses or with direct subsidies for food and housing. Tradition and legal prescription demanded kin responsibility. Thus, relief was denied to elderly people who had family who could care for them, even when this introduced economic hardship. Communities placed elderly citizens without kin among neighbors or in boarding houses.6 In response to rising relief taxes, a number of towns rid themselves of poor, elderly residents by auctioning them off to farms for labor. This practice continued until the 1820s, frequently accompanied by neglect, cruelty, and even torture. Some communities denied refuge to nonresidents, forcing the old and sick to wander from town to town in search of assistance, even in the middle of winter.10,15 Almshouses, poorhouses, and rural poor farms had existed since colonial times as both a refuge for the helpless and a deterrent to the able-bodied. Assistance to poor people was based on the assumption that the recipient must be truly incapacitated for work. A common belief was that poor people were poor because of immorality, laziness, or alcohol abuse. Thus, able-bodied but nonworking poor individuals were deemed unworthy of assistance and were disciplined in an attempt to force them back into the labor market. The “worthy poor,” however, were those unable to support themselves because of sickness, disability, or old age (ie, through no fault of their own). However, some believed that those who had not accumulated sufficient savings for their own later years were also unworthy.16 Designed to dissuade the “undeserving poor” from seeking relief, poorhouses provided a meager existence. Residents were known as “inmates,” and labor was expected of all but the most frail. Fear of the poorhouse was believed key to maintaining the work ethic among laborers and the poor. Although few questioned that elderly paupers deserved public assistance, shame and fear stigmatized all those on relief, worthy or not. “Dread of life in an institution seems to be almost universal, although the most dreaded is, of course, the poorhouse.”17 More than any
other factor then, the lack of family members willing or able to care for an elderly relative resulted in the relative moving to the poorhouse.10 Although there was a great deal of variability among poorhouses, public demands to keep expenses down frequently resulted in “wretched quarters” and “meager provisions.” Widows and unmarried mothers shared filthy poorhouse rooms with criminals, “drunks,” prostitutes, and the mentally infirm. Dreary, vermin-infested, and laden with human waste, poorhouses were dreaded as a last resort for the elderly poor population, “one of humanity’s great degradations.” Residents were physically abused and experienced severe social stigma.8,18-20 An 1897 investigation found that only 12 cents per day was expended toward each pauper.21 However, despite the alleged frugality of poorhouses—their principal selling point in Britain and America—the cost was invariably more to keep paupers in poorhouses than the cost to support them in their homes by direct income assistance.10 In 1861, shortly after the start of the Civil War, Congress passed a military pension system. These pensions were to compensate soldiers for combat injuries, to recruit soldiers, and to bolster nationalist pride. In the decades after the war, the military pension was transformed into a rudimentary old-age system of social insurance for the working class. In 1904, President Theodore Roosevelt expanded eligibility beyond those with war-related wounds by establishing old age itself as a disability.22 By 1910, 93% of Northern white veterans or their widows received pensions, representing 25% of the elderly US population. At this point, military pensions consumed 43% of all federal expenditures. In today’s dollars, the stipend would be comparable to the average Social Security retirement benefit. However, this program did not lead to a national old-age pension because of corruption, high costs, the financial panic of 1907, and a lack of political organization among the elderly population. Although this first national experiment in disability and pension assistance died with the last Union veterans and their families, it marked a shift away from local relief for the elderly.8,23 After the Emancipation Proclamation and the Civil War, elderly blacks continued to work as sharecroppers or became dependents of extended households. Economically and socially, the term sharecropper signified one of the lowest rungs on the Southern agricultural ladder. Lacking education and property rights and rarely showing a profit from cotton, black, white, and Hispanic tenant farmers labored well into old age. However, the advent of the mechanical cotton picker eventually pushed sharecroppers off the land. As a result, older blacks migrated to cities for employment. For those who remained, there were few government services and persistent poverty.6,24,25
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According to some authors, urbanization, immigration, and the Industrial Revolution left many elderly people alone, without income, and bereft of social status.5,8 However, recent research suggests that, compared with spartan farm life, industrialization improved the fortunes for most elderly people. For poorer families, factory wages and living spaces were shared in households spanning 3 generations. But the growing middle-class elderly population could afford separate housing, avoiding the disharmony common to crowded city life.6 The industrial age had raised per capita incomes for young and old alike. Poverty began to diminish for many older people, although primarily among white men and their spouses. Single women, widows, minorities, and immigrants remained economically vulnerable with senescence. For these groups, continued labor and severe poverty marked old age. Increasingly, however, many senior citizens were able to fulfill the growing desire to maintain independent households in their later years. This preference for independent living remains today. In the 1920s, Americans increasingly viewed the elderly population as obsolete. Industrial managers and proponents of the scientific management theory regarded older workers as less productive and lacking the stamina, speed, and dexterity needed for factory work. In addition, older workers were more likely to be injured on the job, increasing a firm’s liability. At the same time, organized labor wanted superannuated employees to make room for younger laborers. Increasing numbers of firms began to introduce mandatory retirement ages, and pensions were few. As a result, opportunities for employment after 45 years of age became limited. Without work, health benefits, or unemployment insurance, many people reached old age without sufficient savings.5,26,27 After World War I, efforts by welfare authorities and reformers to address the indignities of the almshouse gave rise to various programs to assist needy elderly individuals. Charity and fraternal organizations, meager union pensions, and state and local government programs served in a piecemeal and incomplete fashion.8 But inflation and stock market losses in the 1920s and the Great Depression of the 1930s caused this fragile safety net to fail. About 1910, nearly one quarter of older Americans were in dependent poverty. By 1930, before the Depression began, fully 30% of the elderly population was in poverty. This number rose to 50% in 1935 and to two thirds by 1940.5,6 The economic collapse of the Great Depression resulted in mass unemployment and social dislocation. Charitable donations dwindled, and few families could support their aging kin. Increasing numbers of poor, elderly people soon overwhelmed state and county resources. Of the few states that could afford old-age assistance, most offered paltry sums for living. Most middle-class elderly people faced the poorhouse and “the stark terror of penniless, helpless old age.”28
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The Great Depression revived the old-age pension movement, a populist response that became a decisive election-year issue in 1934.23 When President Franklin D. Roosevelt signed the Social Security Act of 1935, he said, We can never insure one-hundred percent of the population against one-hundred percent of the hazards and vicissitudes of life. But we have tried to frame a law which will give some measure of protection to the average citizen and to his family against the loss of a job and against poverty-ridden old age.29
Amendments to include health care benefits with Social Security were first proposed in 1934.30 However, strong opposition from insurers, businessmen, and the American Medical Association defeated these measures. Unable to afford rising medical costs on Social Security incomes, a growing number of the elderly population relied on state assistance to pay their medical bills or on “free” care from hospitals and physicians. The high costs of medical care became the greatest single cause of economic dependency in old age because only 1 in 4 elderly people had adequate insurance. Hospitals increasingly bore the brunt of unpaid health expenses for older people, which came to be viewed as a threat to their existence. By 1960, a bill for health insurance limited to Social Security obtained a floor vote in the US Senate for the first time in its half century as a national issue, losing by a small margin.30 Pressure for relief persisted, and Senator John F. Kennedy made the newly termed Medicare a major issue in his run for president. With increasing numbers and entitlement financing, the elderly population was fast becoming an influential political force. As a result, Congress finally was persuaded that older Americans needed help defraying medical costs.8,23 As part of his vision of the “Great Society,” President Lyndon B. Johnson signed Medicare and Medicaid into law in 1965. With these programs, the government had stepped in to fill a void left by the marketplace, the uninsurable elderly population. The combination of income assistance in the form of Social Security and health insurance through Medicare made retirement increasingly attractive and, for the first time, financially feasible for most elderly people. In 1880, three quarters of men aged 65 years or older were gainfully employed, but few had the means to retire. Most left work because of poor health or the inability to find work and became dependent on their children or on charity. Labor force participation slowly declined in the following decades (augmented by the passage of Old Age Assistance and Social Security), and by 1950, less than half of older men were still working. Today, less than one fifth of men older than 65 years work full-time or part-time. Among men aged 55 to 64 years, labor force participation has also
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declined, from a peak of 95% in 1880 to 67% in 1990. In agriculture and early factory work, laborers reached peak earnings in their 30s. In contrast, contemporary workers have experienced steady gains in earnings until retirement. The trend toward early retirement has resulted from relatively high levels of wealth and affordable leisure activities such as travel.6,23 In summary, America has experienced the demise of elder pauperism and the poorhouse and the rise of pensions and retirement. FROM POORHOUSE TO NURSING HOME: THE HISTORY OF LONG-TERM CARE By 1900, county-run poorhouses had transformed into oldage homes, and 37% of residents were elderly.10 To transfer rising costs from local treasuries, many senile elderly residents were moved from county-run almshouses to statefunded mental hospitals, eventually housing 70,000 elderly inmates.31 Charitable “Homes for the Aged” arose, frequently funded by churches, fraternal orders, benevolent societies, and ethnic organizations. These nonprofit facilities provided room and board for poor, elderly people with no families. Proprietary nursing facilities also developed in the early 1900s, primarily serving the chronically ill or disabled. State licensure programs developed in the 1920s, but standards and oversight were minimal, focused primarily on building and safety codes. Still, county poor farms accounted for the bulk of assistance provided to the elderly, poor population. The poor farms were selected frequently on the basis of least cost to the county, a practice decried as “farming out the poor to the lowest bidder.” Increasingly large numbers of disabled and chronically ill elderly people were being admitted. Inhumane conditions, fears of institutionalization, and the destitution of 7 million elderly persons from the Depression resulted in a provision of the Social Security Act (SSA), which denied funding to poorhouse residents. Without funding, these facilities soon died out. By the 1940s, poor farm residents had relocated to private “rest homes,” which were allowed to receive Social Security funds. As a result, numerous small private nursing homes opened. Frequently, these were converted farmhouses, mansions, or motels with poor safety, fire, and access features, and the quality of care varied widely. Many were not equipped to care for frail or ill elderly residents and provided only a room and meals. During the Depression, unemployed nurses often ran these facilities, but most of the care remained custodial in nature.26,32 A consequence of legislation directed against publicly funded poorhouses was the nurturing of an emerging forprofit nursing home industry. Social Security cash in citizens’ hands helped transform long-term care into a largely
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proprietary endeavor. Subsequent legislation, taxes, and building codes continued to favor corporate dominance.33 In the 1950s, states began to receive federal matching funds for direct payments to nursing home “vendors” providing resident care. This marked a shift toward a federal relationship with providers, rather than with elderly residents. Government-backed construction loans and the regular income of vendor payments ensured a secure return on investment. This attracted developers and real-estate speculators; some of their names soon became synonymous with nursing home scandals. Yet, despite a 181% increase in spending on nursing home care, there was still a shortage of a half million beds by the early 1960s.33 Passage of Medicare and Medicaid resulted in the rapid development of commercial nursing homes, accelerating the trend away from nonprofit and government facilities. Congress had intended the nursing home benefit as a mechanism to shorten hospital stays, thereby hoping to reduce costs. These programs provided considerable funds to the states, which agreed to minimum federal standards where none had existed previously. However, these regulations were lenient; providing a written plan of correction satisfied most violations.34 Providers were reimbursed for mortgage interest, depreciation, self-reported costs of care, and an added profit margin. Together, Medicaid and Medicare seemed to eliminate much of the risk in this real-estate venture. However, the need for capital was enormous because many new nursing homes were needed to meet existing shortages and replace obsolete facilities. Consequently, in the late 1960s, Wall Street developed a kind of frenzy over corporate investment in nursing homes. Firms with backgrounds in construction, real estate, and the motel industry dominated this speculative market. As a result, bed supply increased from 460,000 to 1.1 million in less than a decade.33 Recurrent scandals of theft, maltreatment, food poisonings, and deadly fires prompted hearings in the Senate Aging and Finance Committees. In 1971, President Richard M. Nixon made speeches deploring nursing home conditions and presented a plan for tougher regulations.34 Although they were once the hottest stocks in the market, by 1972, nursing home stocks went bust. Corporate financial fraud, securities violations, and reports of inferior care and patient abuse fueled investor concerns. Far worse for stockholders, nursing home owners had badly misjudged Medicare. These generous posthospital payments covered less than 2% of expenses, whereas Medicaid accounted for nearly half of long-term care reimbursement and was far less lucrative. At times, conditions worsened because some nursing homes cut back on food or staff to maintain profitability.32 The expense of complying with new stricter building and safety standards forced many smaller nursing homes
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out of business. State restrictions on new bed construction encouraged corporate acquisition of existing facilities. Medicaid reimbursement of the costs of care further favored larger chains. Corporations were able to profit by selling goods and services such as food, laundry, management, and housekeeping to their own subsidiaries. In this manner, large nursing home chains came to control an increasing number of beds. Of the 16,700 nursing homes in the United States today, two thirds are for-profit, one quarter are nonprofit, and 8% are government-owned. More than half belong to management or ownership chains.35 PERSISTENT QUALITY CONCERNS: LONG-TERM CARE IN THE MODERN ERA In 1982, the Ronald W. Reagan administration proposed deregulation of nursing homes in response to industry complaints. However, these plans were withdrawn under heavy public criticism.36 Instead, the Institute of Medicine was commissioned to study long-term care policies and issued the 1986 report Improving the Quality of Care in Nursing Homes.34 It charged that many substandard nursing homes were allowed to operate and that residents frequently received inadequate, sometimes “shockingly deficient” care. Although abuse and neglect had declined in nursing homes, poor quality of life and inadequate medical care were far too common. Rather than relaxing regulations, the Institute of Medicine recommended far more stringent ones. These changes were enacted in the Nursing Home Reform Act of the Omnibus Budget Reconciliation Act of 1987, with farreaching revisions to standards, inspection, and enforcement.36 This legislation mandated more nurse’s aide training and a broader array of care, including the provision of rehabilitative, physician, and social services. A uniform resident assessment instrument was implemented to ensure comprehensive evaluation, and states were now required to provide ombudsmen as resident advocates. Polypharmacy, restraint use, and resident rights issues were addressed. There is good evidence that these regulations have improved the quality of care and created standards where few existed before. However, the expanded services (and paperwork) exacerbated budgetary pressures, conflicting with simultaneous cost-containment efforts.34,35 In 1997, under pressure from states to reduce Medicaid spending, the federal government repealed the 1980 Boren Amendment, which had required that Medicaid nursing home rates be “reasonable and adequate.” The nursing home industry warned that Medicaid reimbursement levels were already too low and that further reductions would adversely affect quality of care.37,38 These changing financial incentives soon led to the development of lower-cost alternatives to the nursing home.
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In 1997, scandal again erupted when a Time magazine article charged that California nursing home residents were being denied food and water and were not being treated for infections. Blaming “greedy owners and slipshod facilities,” the report claimed that thousands of frail, elderly residents were dying of neglect.39 In response, the General Accounting Office later identified glaring quality-of-care deficiencies in fully one third of California nursing homes.40 In 1999, the US Senate Committee on Aging held critical hearings on nursing homes and their regulators, and President William J. Clinton unveiled tougher enforcement standards.41-43 The resulting surprise inspections and higher fines were decried by the industry as excessive and counterproductive because they occurred during a financial crisis that had led to numerous nursing home bankruptcies. In 2001, the Institute of Medicine updated their seminal report,44 now entitled Improving the Quality of Long-Term Care, to encompass alternative services and settings. Quality of care in nursing homes was believed to have improved as a direct result of regulatory scrutiny. However, pressure sores, malnutrition, and pain continued to pose serious quality concerns. The report again called for more data, more penalties, and greater enforcement of standards. Low Medicaid reimbursement was also recognized as a potential source of quality problems. SUMMARY The history of America’s elderly population is more complex and varied than most people realize. The Revolutionary War not only brought forth a new nation but also heralded an overthrow of a cultural hierarchy in which privilege was based on age, sex, race, and class. Subsequent changes have been slow and sorely incomplete but continue unrelentingly. Over the past 200 years, declining birth and mortality rates have made reaching even extreme old age commonplace. Although being elderly is no longer associated with wisdom and value, today’s aged population is more robust and productive and promises to define its worth in ways beyond mere scarcity or wealth. The history of old age in the United States has been shaped largely by the search for economic security. In the agricultural economy of preindustrial America, the standard of living was low for young and old alike. Because the price of labor closely mirrored the cost of living, few were able to save sufficient resources for their declining years, and most elderly people either continued to work or lived in dependent poverty. More than any other factor, the lack of family willing or able to provide for an elderly relative resulted in the relative moving to the dreaded poorhouse. However, welfare and charity to older people were frequently condemned, much like poor people in general were
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condemned, as representing immoral, lazy, and spendthrift behaviors that should not be rewarded. The industrial era expanded opportunities for economic and social independence among older Americans. The desire to live independently as long as possible has gained increasing importance since the 18th century. Rather than representing a weakening of family bonds or kin responsibility, the gradual decline of the extended-family dwelling was welcomed across generations. The rise of the middle class made this long-desired goal a reality for more and more of the elderly population. Although the Great Depression wiped out many of these economic gains, cultural demands for a more secure and independent old age remained. A larger national role evolved with the failure of state and charitable resources. The era of governmental assurance of security in old age began with income assistance (Social Security) and later included health care (Medicare) and institutional long-term care (Medicaid). This restated the social contract to say that each generation supports its elderly population in return for similar support from subsequent generations. Although “old” no longer means “obsolete,” most workers prefer to retire as soon as financially possible. The advent of Social Security made this feasible for many thousands of elderly people. However, a key concept to maintaining popular support for these assistance programs has been avoiding associations with welfare and charity. Therefore, recipients prefer entitlement based on age and vigorously resist means testing or other methods of determining worthiness. Modern concerns about long-term care are rooted in the moral implications of poverty and welfare. The unresolved conflict over individual and societal responsibilities has shaped policies regarding retirement and old-age dependency. The almshouse and poor farm carried the stigma of unworthy dependency and led to underfunding and appalling care of the elderly. Nursing homes then arose by redefining dependent old age as a medical problem and asserting funds as entitlements rather than charity. A hospital-like atmosphere supplanted the traditional board-and-care approach, creating an institutional quality of life. Regulations imposed architectural standards, care directives, and extensive documentation of nearly every activity, which increased the costs of care, all in the name of limiting error, neglect, and the risk of sanctions. Despite this, nursing home history is replete with the same scandals of abuse and neglect that made the poorhouse so fearsome, becoming a place where few care to go. However, the scandalous history of long-term care has itself resulted in the current regulatory approach, which rests on a core of mistrust. To ensure competent care, we require paid caregivers to follow numerous regulations and copiously document nearly every activity. Not surprisingly,
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the result is an impersonal bureaucracy but not a “home.” This is because the keys to high quality of life in long-term care, such as the nature of staff and resident interactions, cannot be achieved through regulation.36,45 Seniors and their advocates demand expert health care services and a low-risk environment but at the same time expect individual freedom, a residential atmosphere, and limited expense. These desires may be mutually exclusive, perhaps even unattainable, but a balance of goals may be achievable. These quandaries continue because critical questions remain not only unanswered but also undiscussed. What kind of old age do we want for our parents and ourselves? What risks will we allow for the sake of individual autonomy? Given finite resources, what limits will we accept? What are we willing to pay for? Who should pay? To what degree must we prepare for our own futures? What level of financial burden can we demand of later generations? These questions represent some of the unresolved tensions between generations and economic classes. Conflicting values regarding autonomy, personal responsibility, and the proper role of government also contribute to the lack of consensus. There has never been a national aging or longterm care policy in America. The present system seems to have arisen primarily while attempting to reduce expenses, “an afterthought, a side effect of decisions directed at other problems.”33 Unless the debate expands beyond budgetary concerns, the historical pattern of scandal-reform-scandal in long-term care will likely continue unabated. Knowledge of the history of aging in America can provide a useful touchstone: it can expose past problems that could happen again, identify what is worth preserving from the past, and help us avoid relearning painful lessons.46 However, it would be a mistake to presume that this history merely repeats itself. The chronology of elder care is indeed often bleak and sad, but the kind of care received today, although far from ideal, is a vast improvement over previous decades. An understanding of the issues in elder care as they occurred over time can suggest limitations on future possibilities. But equally important, we must discern how the present diverges from the past. A more thorough analysis of the history of the elderly population in the United States, one that revisits our presumptions and “common wisdom” regarding long-term care, can permit a more prudent view of the future, perhaps one more feasible than fanciful. REFERENCES 1. 2. 3. 4.
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Hirshbein Davidow L. William Osler and the fixed period: conflicting medical and popular ideas about old age. Arch Intern Med. 2001;161:2074-2078. Eliot TH. The legal background of the Social Security Act. Presented at: Social Security Administration Headquarters; Baltimore, Md; February 3, 1961. Available at: www.ssa.gov/history /eliot2.html. Accessibility verified May 22, 2003. Social Security Administration. A Brief History of Social Security. Baltimore, Md: Social Security Administration; 2000. SSA publication 21-059. Corning PA. The Evolution of Medicare…From Idea to Law. Social Security Administration Office of Research and Statistics; 1969. Available at: www.ssa.gov/history/corning.html. Accessibility verified May 22, 2003. Vogel RJ, Palmer HC, eds. Long-Term Care: Perspectives From Research and Demonstrations. Rockville, Md: Aspen Systems Corp; 1985. Committee on Implications of For-Profit Enterprise in Health Care, Institute of Medicine; Gray BH, ed. For-Profit Enterprise in Health Care. Washington, DC: National Academy Press; 1986: 494. Vladeck BC. Unloving Care: The Nursing Home Tragedy. New York, NY: Basic Books; 1980:115-121. Committee on Nursing Home Regulation, Institute of Medicine. Improving the Quality of Care in Nursing Homes. Washington, DC: National Academy Press; 1986:Appendix A, 1-44, 241-243. Giacalone JA. The U.S. Nursing Home Industry. Armonk, NY: ME Sharpe; 2001:80-81, 121-132. Hawes C. Regulation and the politics of long-term care. Generations. 1997-1998;21(4):5-9. Wiener JM, Stevenson DG. Repeal of the Boren Amendment: Implications for Quality of Care in Nursing Homes. Washington, DC: Urban Institute; 1998. New Federalism: Issues and Options for States, No. A-30. Available at: http://newfederalism.urban.org /html/anf30.html. Accessibility verified May 23, 2003. Clarke LW. The demise of the Boren Amendment: what comes next in the struggle over hospital payment standards under the Medicaid Act? Available at: www.duanemorris.com/publications /pub14.html. Accessibility verified May 28, 2003. Thompson M. Fatal neglect: in possibly thousands of cases, nursing-home residents are dying from a lack of food and water and the most basic level of hygiene. Time. 1997;150:34-38. US General Accounting Office. California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. Washington, DC: US General Accounting Office; 1998. Publication GAO/ HEHS-98-202. Grassley CE, Chairman. Hearing before the United States Senate Special Committee on Aging. Betrayal: The Quality of Care in California Nursing Homes; July 27-28, 1998. SHrg 105-735, Serial No. 105-30. Washington, DC: US Government Printing Office. GPO Stock No. 552-070-23271-1. Grassley CE, Chairman. Hearing before the United States Senate Special Committee on Aging. Residents at Risk? Weaknesses Persist in Nursing Home Complaint Investigation and Enforcement; March 22, 1999. SHrg 106-108, Serial No. 106-3. Washington, DC: US Government Printing Office. GPO Stock No. 552-070-24230-9. Grassley CE, Chairman. Hearing before the United States Senate Special Committee on Aging. The Nursing Home Initiative: Results at Year One; June 30, 1999. SHrg 106-353, Serial No. 10611. Washington, DC: US Government Printing Office. GPO Stock No. 552-070-25045-0. Wunderlich, GS, Kohler PO, eds; Committee on Improving Quality in Long-term Care. Improving the Quality of Long-Term Care. Washington, DC: National Academy Press; 2001:1-20. Howard PK. The Lost Art of Drawing the Line: How Fairness Went Too Far. New York, NY: Random House; 2001:78-171. Neustadt RE, May ER. Thinking in Time: The Uses of History for Decision Makers. New York, NY: Free Press; 1988.
The Symposium on Geriatrics will continue in the August issue. For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.