Part I of this series was about the controversy around euthanasia. Part II is about the convergence of outliving your quality-of-life and money, and the role of exercise in avoiding such a fate.
Patients have revealed 5 things to me that they fear most about their health:
1) Having to go to a nursing home
2) Being a burden on their children (some folks feel their children owe them)
3) Running out of money (often accompanies #1 and #2)
4) Not being able to think for themselves
5) Not being able to do for themselves / control their body
Intractable pain is also big, probably #6.
That great obsession of medicine – longevity – doesn’t make the list. Yes, most people want to live a long time, but they care a lot more about quality-of-life than quantity-of-life. No patient ever told me they wanted to live as long as possible, despite having a lousy quality-of-life.
As a resident working in the ICU, I saw that modern medicine is really good at not letting acutely ill patients die, and at taking away quality-of-life in the process. Often, the price of surviving a life-threatening crisis is not being able to think and/or fully do for one’s self. Many patients end up in long-term care or going to a nursing home. Others receive care from their children. Sadly, huge numbers of Americans fulfill their worst fears, using up all their savings along the way.
Most Americans Die Penniless Because Long-Term Care Depletes Their Assets
About 45% of Americans will run out of money during retirement. Risks are higher for single women (≈ 55%) than single men (≈ 40%) or couples (≈ 41%).[1] Nearly two‑thirds of Americans (64%) say they’re more worried about running out of money in retirement than dying.[2]
Home equity is the biggest source of wealth for most middle-class Americans, and thus the main method for passing wealth to the next generation.[3] But many seniors—even those with higher incomes—spend down their savings in order to qualify for Medicaid to pay for long-term care. For higher-income seniors who reach their late 90s, about 20% of them only have about $5,500 in home equity, qualifying for Medicaid. Nursing home fees usually drain the remaining equity to $0, leaving little to nothing for heirs.[4]
Only 24% of Americans have a will; 50% to 70% of people die without any legal estate plan, causing their assets to be distributed by state intestacy laws. In a 2024 Caring.com “Wills and Estate Planning Survey”, 40% of those without a will indicated it’s because they “don’t have enough assets to leave anyone” (more common among lower-income Americans).[5] Only 30-40% of American households receive any inheritance, 60%–70% receive nothing.[6]
Outstanding medical bills are generally paid from the deceased’s estate during probate. Family members are typically not personally liable, unless conditions like cosigned agreements or certain state laws apply.[1,7]
Government Pursues the Estate for What is Left
Medicaid Estate Recovery is a federally mandated program requiring states to recoup long‑term care costs—such as nursing facility services, home- and community-based care, and related hospital and prescription costs—from the estates of Medicaid beneficiaries aged 55 or older, or those permanently institutionalized.[8] States have the option to recover other benefits beyond these core services, depending on state-level laws, but estate recovery is not permitted if the deceased has a surviving spouse, child under age 21 or a blind/disabled child. Many states also offer hardship waivers under certain conditions.[9]
It isn’t known how many heirs receive no inheritance due to estate recovery, though most states report recovery amounts. Some states file liens, some pursue only probate assets, some states are aggressive while others aren’t and policies vary widely—complicating any attempt at a cohesive national estimate.[10]
If you die poor and on Medicaid, states are required to come after the remainder of your estate. But If you’re in the top third or so of Americans who have something to bequeath to your heirs, you and your spouse can leave up to $30M, tax free. I think quite unintentionally, America’s system is thus economically regressive, generation after generation, holding back the middle class (especially lower socioeconomic groups) while the upper class is able to perpetuate and increase wealth.[3]
Regular Exercise / Physical Activity is the Investment People Need
The main pathway to fates #1-3 is through #4 and #5 - not being able to adequately think or do for one’s own self. If American medicine were truly “patient-centered”, physicians would be a lot more attentive to helping patients avoid cognitive and physical infirmity.
Poor physical functioning – the inability to perform physical tasks, to exert one’s self – is rarely attended to by doctors other than geriatricians and physiatrists. My colleagues Deborah King, Jacob Veigel and I did a pilot study demonstrating that many middle-aged overweight and obese patients have difficulty with sit-to-stand, sit-and-reach, step and gait speed tests because of soft-tissue pain.[11] Subjects sought out our study, eager to participate despite no compensation, because sarcopenic obesity – having insufficient muscle mass relative to the person’s body weight – is often unaddressed because even most sports medicine physicians don’t address physical activity.[12]
Someone who can walk a quarter- or half-mile but can’t do it hauling a bag or two of groceries, or who can’t carry groceries up a flight of steps to their house, will have to hire help. Since COVID, most grocers now will do your shopping and companies like DoorDash will deliver. But, of course, they charge.
Those who have long-term care insurance can get these costs covered for a while, though there are bureaucratic obstacles. My stepfather paid into a long-term care policy for 30 years, but didn’t live past the 100 day required minimum period before the benefits kicked-in. He might have qualified earlier but didn’t apply because he didn’t see himself as disabled, in part because of my support for his staying active.
If America’s health care system really were patient-centered, we would spend a lot of effort helping patients avoid their worst fears. Helping them not lose their ability to think and do for themselves would be top priorities. The best bet for avoiding these “fates worse than death” is to be physically active (exercise regularly), eat a healthy plant-predominant diet, keep your weight down, stay connected to friends and family, practice good stress coping skills and sleep hygiene, and avoid tobacco, alcohol and street drugs. I put exercise first, because it is the one domain that positively influences all of those risk factors.
Oh, and be careful. Accidents have a way of abruptly altering the best laid plans. And, keeping your options open, consider living somewhere that permits euthanasia.
Geoffrey E. Moore, MD FACSM
REFERENCES
1) https://moneywise.com/retirement/americans-scared-of-running-out-of-money
3) https://inequality.org/article/promise-and-pitfalls-in-transferring-wealth-across-generations/
4) https://time.com/2875791/i-dont-have-enough-to-retire/
5) https://www.caring.com/resources/wills-survey
6) https://endly.co/inheritance-statistics-us/
7) https://www.investopedia.com/medical-debt-when-you-die-11781289
8) https://www.medicaid.gov/medicaid/eligibility/estate-recovery
9) https://apnews.com/article/medicaid-estate-recovery-nursing-homes-65d5e637e19dc27bd1bd3b097d239b53
10) https://govfacts.org/federal/hhs/understanding-medicaid-estate-recovery-what-you-need-to-know/
11) G.E.Moore, D.L.King, J. Veigel. Obesity, lower extremity soft tissue pain & physical functioning. Med Sci Sports Exerc 50(5S):485, 2018.
12) G.E.Moore, C.Carlson, J.P.Bonnet, E.M.Phillips, E.Joy, C.Collings, W.Kraus, W.O.Roberts. Implementation of exercise management services among sports medicine physicians in the United States. Clin J Sports Med, February 8, 2024. doi: 10.1097/JSM.0000000000001209.
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