This is what politicians, pundits, and media machines are doing to us voters every time we hear a word or phrase. We are like Pavlov’s dog. We have been conditioned to respond (pairing) when a specific stimulus (“Social Democrats”, “MAGA”, “It’s a big tent”) is flashed in any of our many screens or mailboxes.

Weakening of Response

Mind you, we all salivate. But after a while (and this is the genius discovery of classical conditioning), our response weakens when the same stimulus is presented over and over. Some of us completely tune out the political messaging. Some of us become engaged and are determined to get rid of that damn bell.

Take Donald Trump’s rallies (think “lock her up”). Every time DJT throws out the red meat to his conditioned followers, they respond with the antiphonal response, “Lock her up!” But over time, even that offering of red meat weakened. Now, “lock her up” is a meme to all but the most habituated followers.

Hello Intermittent Reinforcement

To counteract this weakening and eventual disappearance of the original response, researchers in classical conditioning discovered something called intermittent reinforcement. This is the systematic introduction of new stimuli spaced at random intervals that actually strengthens the conditioned response. Instead of predictable salivation when a bell is rung every time, the bell (or some new stimulus) is introduced and paired with a reward.

All of Us Crave Reward

This applies to all of us, Democrat or Republican, MAGA fanatic or Progressive pundit. When we are exposed to a stimulus, our conditioned response is the same. Pavlov’s dogs responded involuntarily to a paired stimulus; but the voluntary choice to keep engaging — showing up, sharing a message, voting — is shaped by a related but distinct process: operant conditioning, and specifically, intermittent reinforcement.

Intermittent reinforcement is what keeps us playing the game.

Nowhere is this more visible than in how Democrats are currently talking about their own messaging problem.

Pundits point out that the Dems don’t have a “message”. This is a Pavlovian bell. Some campaign managers are suggesting we recycle “Are you better off than you were four years ago?”, and still others are suggesting we hit home with all the things that make life more difficult (higher prices, incompetence, greed). All good messages, but needing intermittent reinforcement to bring the message home.

So What, Now What

With this foundational understanding of classical conditioning, voters can better discern what is merely a stimulus-response message, and which is an opportunity to impact outcomes. The reward for voting is a change in who occupies seats in Congress and the White House. But that reward is a long way off.

Too many folks don’t feel they have any chance of changing things. That is a belief REINFORCED by telling everybody how bad things are.
Change happens when opportunity is matched with energy (stimulus and response). We need to selectively reinforce the preferred behaviors of getting involved not just during election season, but staying active in our communities year-round.

When Will Things Change?

So how do we bridge that gap between now and November? We are now a culture of immediate gratification. We have lost our capacity to wait. We have become conditioned to getting our reward right away. To meet that need, change makers have to provide reward and reinforcement that will incrementally get us to the final goal, not just the next meme.
The long-term goal (the Mid-Terms) is too far away for most folks. Herein lies the dilemma. Voting (the activity that brings the reward) is in the future. What is needed is intermittent reinforcement of behaviors that will guide folks inevitably to voting –

• A website link that lets you check your voter registration status.

• A quiz that reinforces values and offers new-to-me information.

• A social gathering that is fun and builds friendship bonds.

How Can We Influence Change?

B. F. Skinner is quoted as saying, “The consequences of an act affect the probability of it occurring again.” If you are eligible and have never voted, the probability of your voting is low. But if you know someone who has voted, and that someone offers you the reward of friendship, a shared story, or a conversation about shared values, the probability of your turning into a vote-counted-voter increases exponentially.

If you are trying to convince someone of your point of view, first find out what their conditioned response is. If they can quote their favorite pundit line for line, you are up against a strongly conditioned behavior. You can influence that behavior by offering a different stimulus and response.

First, Look in the Mirror

But I caution you – we all respond to stimulus and response. We are all conditioned. Before you go looking for someone else’s conditioned response to interrupt, changing your behavior first will give you a roadmap for guiding others to take a different route.

Positive reinforcement wins the day. It is a bit more rigorous, but in the long run, it is more powerful. Do at least one of the following starting today. And then keep doing them until the next election!

• Thank folks who vote, no matter who they vote for.

• Thank people for sharing their POV, and praise them for not shouting.

• Offer alternatives not as a “must do”, but as a “think about this, and tell me what you learn”.

And, if you haven’t taken an Intro to Psych class, consider dropping in on one!

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Attempts at naming what happens to us after 65 began with the groundbreaking research of Robert Butler, who built on Erik Erikson’s late-life stage of development—gerotranscendence—and expanded it into “young-old,” “old,” and “oldest old.” It was a start. But it remains rooted in the chronological expectation of decline.

As mentioned in the previous post, this description is insufficient to characterize the wide variety of functioning found in aging adults, particularly as our lifespan continues to expand.

Functioning needs to be understood in terms of measures of capacity, compared against new metrics that reflect how aging adults adapt and accommodate to changes within society.

For example, there are people currently alive who grew up without electricity, who made a living working on assembly lines, and who are now using mobile phones to order goods from Amazon. All of this required huge adjustment across functional areas including life skills, cognition, and social change. And there are those who were unable to make those changes—those who linger in care homes because of physical decline or cognitive decline.

Both of these examples are found not just in the U.S., but around the world. This is a condition of humanity, not just of aging Americans. Understanding the territory between high functioning and unable to function is what we now must explore.

Re-Framing the Stages

Before the pandemic, I was in chronic pain from arthritis in both hips. I could barely walk. I still saw patients, but kept a small caseload, as managing all the demands of running a practice had become too taxing. I was functionally disabled. And I was 67—two years past the government-sanctioned age of retirement.

When I got my new hips, I was restored to full functioning. Energy levels were back at capacity. I thought about resuming my practice, but decided I wanted to take a break. After all, I was only 67.

What stage of aging was I in? What category describes that?

That experience clarified something for me: our categories for aging are not neutral. They shape clinical thinking, policy design, and how individuals understand their own worth.

I was being evaluated purely on physical capacity and chronology. Both were easily cited, but poor indicators of just what my functional capacities were.

We can do better.

Proposed Language

Language matters—it shapes how we treat people. The challenge is that chronology is easy to apply, while multidimensional functioning requires more nuance. But nuance is where the truth lies.

A bolder approach would focus on functional stages rather than chronological ones. Just as we chart physical, intellectual, linguistic, and social development in young children, we should be able to agree on comparable benchmarks for aging adults—not in terms of decline, but in terms of capacity.

These might include levels of physical functioning (from fully independent to dependent), cognitive functioning (from fully intact to severely impaired), social functioning (from richly connected to isolated), and financial functioning (from secure to crisis).

Financial deserves its own category because our culture continues to underestimate how profoundly the absence of basic financial security shapes every other dimension of aging. As the current economic climate reminds us, that can change in a flash.

Categories are useful. They guide policy, anticipate future needs, and set expectations.

Applied to the succession problem, this reframes the question entirely. A board, a family, or an electorate would no longer be asking how old someone is, but what their functional capacity actually is—physically, cognitively, socially, financially, and, as I’ll argue next, in terms of wisdom. That is a harder question to answer honestly, but it is a far more useful one than the one we have been asking about presidents, CEOs, and patriarchs all along.

One Additional Category: Wisdom

There is one more category worth naming: wisdom. Not the mere accumulation of facts, but the capacity to hold complexity, sit with uncertainty, and draw meaning from experience that younger people simply have not yet had. A culture that treats this as irrelevant is impoverishing itself.

The question is not whether elder wisdom exists. It does. The question is whether we value it—and whether we can build the language, the institutions, and the cultural norms to make room for it.

All of which brings me to a more personal question—one I suspect many people in this stage of life are quietly sitting with.

What Is Worth Preserving?

I am at a stage in my life where I wonder what people will remember about me after I am gone. Will they recall my wisdom, or the way I told a joke? Depending on the depth of our connection, will I be associated with a time when they needed a friend and I showed up—or a time when I treated them badly, or ignored them altogether?

We are at a tipping point. The new digital age has fully dawned, and the analog world no longer seems relevant. Yet the memories, stories, and hard-won knowledge passed down through previous generations—contributed to and amended by mine—carry real value.

Values, in particular, seem to be the core of every lasting legacy. I have long forgotten the Christmas and birthday presents from my parents and grandparents, but I easily recall what they taught me about compassion and hard work. Their modeling of how to manage conflict, embrace disappointment, and celebrate accomplishment continues to guide me. Not all of it was positive—I also learned from their mistakes. Any legacy I leave will likely be a mixture of both.

What I Bring to the Table

Here is what I have come to believe after more than three decades of sitting with people in every stage of aging: usefulness is not a function of productivity. It is not solely measured in output, income, or market value. A culture that treats those as the only metrics will always struggle to know what to do with its elders—because by those measures, the story only goes one way.

I intend to stay useful. Not the way I was useful at 40—not by grinding, not by proving, not by accumulating. I intend to be useful the way good soil is useful: by being the thing that makes growth possible for whatever comes next.

That means mentoring. It means writing. It means sitting with someone who has lost everything and not promising all will be well, but offering to be the shoulder they can rely on to get them through their moment of darkness.

Setting a New Table

What I bring to the table now is not what I brought when I was younger. It is something harder to quantify but no less real: pattern recognition born of long practice, a tolerance for ambiguity earned through repeated failure and recovery, and the particular kind of calm that comes from having already survived most of the things younger people are currently afraid of.

The gerontocracy problem—the one frustrating everyone from Congress to corporate boards to family dinner tables—is not really about old people having too much power and refusing to get out of the way. It is about the absence of a shared understanding of what this stage of life is for, and what it asks of us. We have not yet built the language, the institutions, or the cultural norms to embrace the shift.

That is what I am here to work on. And yes, I am aware of the irony: an aging psychologist, arguing for the value of aging people, on a platform that did not exist when I was in graduate school.

But here I am. Still at the table.

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The question of what to do with people who are still very much alive and well—and not going anywhere soon—is now squarely on the table. For most of human history, the calculation was actuarial: how long will they live? The tables sorted it out from there. What we have never built is a satisfying answer to the harder question: what do we do with them while they are alive, capable, and occupying the space?

The Old Way of Deciding

For centuries, younger generations simply waited for the old ones to die off. Artifacts of this system still exist in monarchies across the globe. Queen Elizabeth ascended the throne in the 1950s and remained on it until her death in 2022. Charles had to wait until he was 73 to get a real job. This is true gerontocracy—but it offers something we tend to overlook: a reliable, predictable line of succession built into the institution itself.

Contrast this with the slow-moving power struggle between the founder of Fox News, Rupert Murdoch, and his children, who now span the ages from 68 down to the early 20s. Succession there is fraught with stockholder buy-outs, power plays, and made-for-HBO intrigue, all hinging on how well-written Murdoch’s estate plan turns out to be.

One model has clear institutional protocols, but an endless wait for death. The other has lawyers, and an endless wait for resolution. Neither addresses the question of functional capacity.

The Problem Is Not Age

What structures—in business, government, and family—actually help manage the transfer of power, and which ones fail? The problem is not really about age. It is about capacity, relevance, and the willingness to let go. We do not yet have well-established, culturally accepted criteria for determining when the handoff should happen—and that vacuum gets filled by ego, family loyalty, money, and fear.

How do we build a culture that honors what someone has built without requiring that they keep holding the bricks? What are the alternatives to primogeniture—in family businesses, in political institutions, in corporate boardrooms? I believe we have a once-in-a-lifetime opportunity to redefine this transition: not merely as a medical condition to be managed, but as a life stage with its own purpose, protocols, and dignity.

The Language Problem

Part of why we can’t solve the succession problem is that we can’t adequately describe it. Unlike the early stages of human development—which have been mapped into discrete phases of physical, social, moral, and cognitive growth, each with its own benchmarks—“old” collapses three or four radically different life phases into a single, vaguely pejorative word. We would never describe a 22-year-old and a 45-year-old as being in the same stage of life. But we routinely do exactly that for everyone over 65.

Childhood development icons such as Jean Piaget and Erik Erikson gave us measurable stages of development in childhood. These fit neatly into motor development (turning over, crawling, standing, running) and psycho-social development (trust vs. mistrust, autonomy vs. shame, identity vs. confusion).

But Erikson ran out of descriptives when he hit adulthood. His model offered two stages at the upper end of the lifespan—generativity vs. stagnation, and integrity vs. despair—both of which highlighted this shift in valuing old age, and both of which realistically characterized outcomes for too many aging adults who lived in societies where elders had no place or standing.

Language Matters

Things haven’t improved with time. Robert Butler, the father of American gerontology, coined the following terms to describe the lifespan: “young-old,” “old,” and “oldest old.” All remain in the academic and scientific literature as artifacts of our limited ability to describe these new decades.

This extends to every area of our language. Advertising and everyday nomenclature use the term “Seniors” to identify people chronologically ranging from 50 to 100+. Names of government agencies and local organizations offering social support are equally limited: Aging and Disability Resource Centers, Senior Centers. The largest membership organization of older adults in the U.S. is AARP—“Retired Persons.”

Other terms exist—“elder” and “elderhood”—but there is a very real paucity of descriptors that capture the variety of functioning for people who continue to lead useful lives, remain healthy, but no longer fit into familiar categories of work or social status.

What Is Unnamed Becomes Invisible

The consequence of this lack of descriptors is that aging adults become invisible. We become afterthoughts. Or we are lumped together into convenient categories that reflect how our culture embraces or avoids these new stages.

It also allows us to keep at arm’s length the inevitable confrontation with death. When death was an everyday part of life back in “ancient times,” there was no need for specific language. It was the inevitable conclusion of having lived.

Now that we are living in an era where most threats to sickness have been eradicated and we have means of prolonging health, there is increasing space between Erikson’s awareness of self and his integrity vs. despair. We still know we are going to die, but it remains far enough off that we don’t need to deal with it right now.

The Functioning Problem

Every family that has watched a parent cling to the car keys, every corporate board that has delayed an overdue transition, every legislative body that has failed to address the age question directly—all are operating in the same vacuum. We haven’t named what we need because we haven’t been here before. And we can’t describe what we are in the early stages of learning about until we change the language we use.

Once we come up with definitions of functional stages of aging, we will be freed both from the fear of aging (the decline and inevitable ending), as well as being able to lay claim to the benefits of living longer.

When functional development is not tied to chronology, we will be better able to determine when it is time for some folks to give up their jobs or positions of influence, and create better pathways to governing and sustaining the essentials needed to ensure our survival across generations.

The final installment of this four-part series will be published next week: A framework for what we’re missing—including one category that changes everything—and what it means to stay useful in a stage of life we’re still learning to describe.

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You look in the mirror one day and wonder, “Who is that old person staring back at me? When did that happen?” I imagine I am not alone in this. Research suggests the perception gap between our chronological age and our inner felt age can be as much as 20 years. My chronological age may be in my 70s, but my inner birthday girl is firmly in her 50s.

I strongly suspect this is a recent phenomenon—not one our ancient ancestors shared. Living in modern times, we experience the passing of time differently. And to understand why, it helps to trace how we got here.

The Arc of Aging in the 20th Century

From 1900 to 1999, the world saw remarkable achievements in containing diseases that had once cut lives short long before people reached their 60s, 70s, and beyond. Changes in how food was cultivated, preserved, and distributed made the basic building blocks of nutrition more reliable. With a steady food supply, effective medical interventions, and a shift from hard labor to machine-assisted production, what had once been the primary threat to longevity became manageable—assuming you had access to food, income, and healthcare, and stayed away from armed conflict.

The average lifespan went from 40 to the mid-60s—the equivalent of an entire generation. This forced sweeping social changes in education, housing, and healthcare. These changes signaled shifts in expectations around “adulthood.”

Graduating high school became a marker of reaching adulthood, with its expectations of work and family life. This replaced leaving the classroom at the end of eighth grade to become a laborer, or being married off (if you were a girl) at 12 or 13 to produce babies to work the fields. There was no expectation or value in any further education.

Families grew because more children survived childhood. This, in turn, created new demand for housing—higher and denser in cities, expanding into suburbs, and changing the nature of communities where families once stayed for generations, but now dispersed for reasons of economics, environmental disasters, and opportunity.

And in medicine, it gave rise to a new specialty: geriatrics.

How Geriatrics Formed Our Perceptions of Aging

Geriatrics was a nod to the growing awareness that the human species continues to grow and change over the full course of a life. But the outward evidence of aging was most easily catalogued by loss: diminished sight, hearing, sexual potency, bone and muscle strength, and cognitive function.

This became the primary lens through which we understood aging. Without realizing it, the field created an expectation of decline—and only peripherally addressed the inherent value of the individual. It placed a higher premium on chronology than on functional capacity, accumulated experience, and wisdom.

What Was Missed

Because of the focus on loss and disability, we glossed over how “aging” was actually being lived. There have always been people who “lived to a ripe old age”—some celebrated for breaking norms of productivity (“he painted well into his 90s”), physical achievement (“winning gold at the Senior Olympics”), or artistic contribution (“still dancing at 100”). But truthfully, most were celebrated solely for having pulse and breathing beyond what actuarial tables had predicted.

How the Boomers Changed Aging

No generation embodies this perception gap more fully than the Boomers. We didn’t just inherit it—we widened it. And in doing so, we broke every prior model for what aging was supposed to look like.

We are the first generation to live this long while enjoying this level of functional health and economic sufficiency. The former linear lifespan pathway of school to job, to 30-year career with one company, to family, to retirement, to death no longer holds.

But here’s the rub: instead of falling off the treadmill into oblivion, 76 million Boomers are refusing to quietly age out of the workforce. According to the old model, we’re overstaying our welcome. And we haven’t yet built a new framework to replace it.

Tension Is in the Air

The conversation around “out with the old and in with the new” stopped being polite long ago. Employers now question the high cost of health coverage for older employees. Younger job seekers find entry-level positions blocked by tenured older adults who both enjoy the work and need the income.

And those with years of seniority feel mounting pressure to move on—yet too many have insufficient savings to sustain them for another 10 to 15 years.

The model created in the late 1930s and amended in the 1960s no longer fits this generation of actively aging adults. But there has been little will to change it—and, in some quarters, active campaigns to demolish it altogether.

This tension is not only economic. It is the same demographic reality behind every argument about who holds power, and for how long. A generation large enough, healthy enough, and unwilling enough to quietly step aside was always going to reshape more than the workplace—it was going to reshape Congress, corporate boardrooms, and family businesses as well.

Part 3 of this four-part series will be published next week: What happens when the old models of succession break down—in governments, corporations, and families—and we don’t have anything ready to replace them?

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I find myself increasingly defending a position I have held for more than 30 years as a psychologist working with aging adults and as someone who has benefitted from being surrounded by folks who aged well: aging adults have value and should not be shunted aside at 65 and relegated to golf courses, cruise ships, 55+ communities, or posh assisted living “Golden Ghettos.”

My premise is that the cumulative wisdom of having lived seven or eight decades gives a genuine leg up on solving problems that befuddle those with only two or three decades under their belt.

The argument I hear from the other side is blunt: old folks need to move out of the way and make room for the young. Your ideas are outdated, your skills no longer applicable, and your thinking is old-fashioned.

While this makes for funny jokes and fills talk shows and podcasts with hours of conversation, it is neither a new argument nor a persuasive one. It is, however, evidence of classic ageism.

Politics Aside . . .

If limited to the current crop of elders now inhabiting positions of power and influence in government and business, arguments for setting an age limit for office do seem to make sense. The men holding the office of President in recent years have not been stellar examples of functional aging. Biden needed an off-ramp, and Trump still does. Neither was—or is—willing to give it up. Reagan still looked pretty, but demonstrated that looks alone are not sufficient for governing^[1].

The list goes on. Mitch McConnell, Dianne Feinstein, Kay Granger—all older elected officials whose capacity to function in their job had diminished to unacceptable levels. All are used to provide evidence of decline and incapacity.

Lord knows, the political talking heads have opined endlessly on this.

Exceptions to the Rule

These people are not aberrations. They are symptoms of something older and more pervasive: a culture that has never figured out what to do with its elders—one that simultaneously fears aging and clings to the power that comes with it. That fear runs deeper than politics.

Examples of highly functioning elders whose capacity for making decisions and ability to energetically engage in debate and governing really aren’t that hard to find. For every Mitch McConnell, there is a Bernie Sanders. They are just overlooked or ignored.

Proposed solutions to this problem rest on setting chronologic limits for office holders. This is simplistic at best, and does a disservice to countless aging adults whose contributions rest not on when their birthday falls, but on their lived experience and their capacity to turn that into problem solving.

A Different Perspective

I want to offer a different take—a gero-psychologist’s point of view. It may be useful to explain what a gero-psychologist is before moving forward. We are a specialty among psychologists. Not only do we study personality and mental disorders, but we are also intensely aware of just how a person changes over the lifespan. This understanding of functional change over the lifespan is one of the strongest factors counteracting the blindness inherent in ageism.

Functioning, however, is not easy to quantify. People of all ages function at different levels. Those with physical limitations may never be able to accomplish a set number of exercises or run a distance within a set time, but that doesn’t mean they are incapable of voting for or against a specific measure. Those with cognitive limitations may come to a solution using a very different pathway than those without limitations, but that doesn’t mean that conclusion isn’t useful.

Perhaps most persuasively, things didn’t markedly change the day before I turned 21, 55, or 70. What has changed in those intervening years is just how I look at problems and what I see as possibilities for making the world safer, more sustainable, and better for all.

We Fear Getting Old

The notion that we can somehow avoid getting old is not new. What has changed is the actual number of decades it takes to “get old.” As a society, we prefer “new” to “old.” Youth-associated language clusters around vitality, potential, and desirability; elder-associated language clusters around decline, loss, and limitation.

See if any of these sound familiar:

• “Anti-aging” / “age-defying” / “over the hill”

• “Energizing the youth vote” / “elected Gerontocracy”

• “Past his/her prime”

• “Dirty old man” / “cougar”

• “Frail, elderly”

When framed in these terms, the only conclusion that can be reached is that getting “old” is something to be avoided at all costs—which is thrown into sharp relief by our simultaneous, paradoxical obsession with living forever, cataloging health metrics, and chasing the century mark.

My Path to Enlightenment

I have not always had this insight into aging. I am a member of the generation that mockingly said, “Don’t trust anyone over 30.” Youth is filled with hubris like that. Now in my seventh decade, I more fully appreciate the brazenness of that remark.

In the intervening years, I have become a true student of aging—not just through working with aging patients, but by paying attention to my own aging process.

What brought me to this new awareness is a combination of having been raised as an only child, cared for and guided by aging adults who embraced the shifts that aging brought. They defied stereotypes, sometimes out of necessity, and most of the time out of a commitment to being authentic.

And now I find myself squarely in the territory I spent decades studying. It looks different from the inside—and that, it turns out, is the whole point.

Part 2 of this four-part series will be published next week: How a century of medicine and cultural change shaped the way we see—and misread—the aging process, and why one generation broke every model we had.

^[1]Obviously, there are exceptions, perhaps the best example being Jimmy Carter. But we didn’t get to see him in office. Instead, he offered an incredible template of how to live a long and useful life after leaving office.

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Part 2 of this four-part series will publish next week! Stay tuned!

Re-Framing the Stages

Before the pandemic, I was in chronic pain from arthritis in both hips. I could barely walk. I still saw patients, but kept a small caseload, as managing all the demands of running a practice had become too taxing. I was functionally disabled. And I was 67 — two years past the government-sanctioned age of retirement.

When I got my new hips, I was restored to full functioning. Energy levels were back at capacity. I thought about resuming my practice, but decided I wanted to take a break. After all, I was only 67. What stage of aging was I in? What category describes that?

That experience clarified something for me: our categories for aging are not neutral. They shape clinical thinking, policy design, and how individuals understand their own worth. We can do better than what we have.

Proposed Language

Language matters — it shapes how we treat people. The challenge is that chronology is easy to apply, while multidimensional functioning requires more nuance. But nuance is where the truth lies.

A bolder approach would focus on functional stages rather than chronological ones. Just as we chart physical, intellectual, linguistic, and social development in young children, we should be able to agree on comparable benchmarks for aging adults — not in terms of decline, but in terms of capacity.

These might include levels of physical functioning (from fully independent to dependent), cognitive functioning (from fully intact to severely impaired), social functioning (from richly connected to isolated), and financial functioning (from secure to crisis).

Financial deserves its own category because our culture continues to underestimate how profoundly the absence of basic financial security shapes every other dimension of aging. As the current economic climate reminds us, that can change in a flash.

Categories are useful. They guide policy, anticipate future needs, and set expectations.

One Additional Category: Wisdom

There is one more category worth naming: wisdom. Not the mere accumulation of facts, but the capacity to hold complexity, sit with uncertainty, and draw meaning from experience that younger people simply have not yet had. A culture that treats this as irrelevant is impoverishing itself.

The question is not whether elder wisdom exists. It does. The question is whether we value it — and whether we can build the language, the institutions, and the cultural norms to make room for it.

All of which brings me to a more personal question — one I suspect many people in this stage of life are quietly sitting with.

What Is Worth Preserving?

I am at a stage in my life where I wonder what people will remember about me after I am gone. Will they recall my wisdom, or the way I told a joke? Depending on the depth of our connection, will I be associated with a time when they needed a friend and I showed up — or a time when I treated them badly, or ignored them altogether?

We are at a fulcrum. The new digital age has fully dawned, and the analog world no longer seems relevant. Yet the memories, stories, and hard-won knowledge passed down through previous generations — contributed to and amended by mine — carry real value.

Values, in particular, seem to be the core of every lasting legacy. I have long forgotten the Christmas and birthday presents from my parents and grandparents, but I easily recall what they taught me about compassion and hard work. Their modeling of how to manage conflict, embrace disappointment, and celebrate accomplishment continues to guide me. Not all of it was positive — I also learned from their mistakes. Any legacy I leave will likely be a mixture of both.

What I Bring to the Table

Here is what I have come to believe after more than three decades of sitting with people in every stage of aging: usefulness is not a function of productivity. It is not measured in output, income, or market value. A culture that treats those as the only metrics will always struggle to know what to do with its elders — because by those measures, the story only goes one way.

I intend to stay useful. Not the way I was useful at 40 — not by grinding, not by proving, not by accumulating. I intend to be useful the way good soil is useful: by being the thing that makes growth possible for whatever comes next.

That means mentoring. It means writing. It means sitting with someone who has lost everything and not promising all will be well, but offering to be the shoulder they can rely on to get them through their moment of darkness.

Setting a New Table

What I bring to the table now is not what I brought when I was younger. It is something harder to quantify but no less real: pattern recognition born of long practice, a tolerance for ambiguity earned through repeated failure and recovery, and the particular kind of calm that comes from having already survived most of the things younger people are currently afraid of.

The gerontocracy problem — the one frustrating everyone from Congress to corporate boards to family dinner tables — is not really about old people having too much power and refusing to get out of the way. It is about the absence of a shared understanding of what this stage of life is for, and what it asks of us. We have not yet built the language, the institutions, or the cultural norms to embrace the shift.

That is what I am here to work on. And yes, I am aware of the irony: an aging psychologist, arguing for the value of aging people, on a platform that did not exist when I was in graduate school.

But here I am. Still at the table.

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The Old Way of Deciding

For centuries, younger generations simply waited for the old ones to die off. Artifacts of this system still exist in monarchies across the globe. Queen Elizabeth ascended the throne in the 1950s and transitioned to her perpetual rest in 2022. Charles had to wait until he was 73 to get a real job. This is true gerontocracy — but it offers something we tend to overlook: a reliable, predictable line of succession built into the institution itself.

Contrast this with the slow-moving power struggle between the scion of Fox News, Rupert Murdoch, and his children, who now span the ages from 68 down to the early 20s. Succession here is fraught with stockholder buy-outs, power plays, and made-for-HBO intrigue, all hinging on how well-written Murdoch’s estate plan turns out to be. One model has clear institutional protocols. The other has lawyers.

The Problem Is Not Age

What structures — in business, government, and family — actually help manage the transfer of power, and which ones fail? The problem is not really about age. It is about capacity, relevance, and the willingness to let go. We do not yet have well-established, culturally accepted criteria for determining when the handoff should happen — and that vacuum gets filled by ego, family loyalty, money, and fear.

Age is a blunt instrument. We need something sharper.

How do we build a culture that honors what someone has built without requiring that they keep holding the bricks? What are the alternatives to primogeniture — in family businesses, in political institutions, in corporate boardrooms? I believe we have a once-in-a-lifetime opportunity to redefine this transition: not merely as a medical condition to be managed, but as a life stage with its own purpose, protocols, and dignity.

The Language Problem

Part of why we can’t solve the succession problem is that we can’t adequately describe it. Unlike the early stages of human development — which have been mapped into discrete phases of physical, social, moral, and cognitive growth, each with its own benchmarks — “old” collapses three or four radically different life phases into a single, vaguely pejorative word. We would never describe a 22-year-old and a 45-year-old as being in the same stage of life. But we routinely do exactly that for everyone over 65.

Every family that has watched a parent cling to the car keys, every corporate board that has delayed an overdue transition, every legislative body that has failed to address the age question directly — all are operating in the same vacuum. We haven’t named what we need because we haven’t been here before. And we can’t describe what we are in the early stages of learning about until we change the language we use.

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Part 4 published next week: A framework for what we’re missing — including one category that changes everything — and what it means to stay useful in a stage of life we’re still learning to describe.

I strongly suspect this is a recent phenomenon — not one our ancient ancestors shared. Living in modern times, we experience the passing of time differently. And to understand why, it helps to trace how we got here.

The Arc of Aging in the 20th Century

From 1900 to 1999, the world saw remarkable achievements in containing diseases that had once cut lives short long before people reached their 60s, 70s, and beyond. Changes in how food was cultivated, preserved, and distributed made the basic building blocks of nutrition more reliable. With a steady food supply, effective medical interventions, and a shift from hard labor to machine-assisted production, what had once threatened longevity became manageable — assuming you had access to food, income, and healthcare, and stayed away from armed conflict.

The average lifespan went from 40 to the mid-60s — the equivalent of an entire extra generation. This forced sweeping changes to education, housing, and healthcare. Graduating high school replaced leaving the classroom at the end of eighth grade to become a laborer. Population growth demanded new housing — higher and denser in cities, expanding suburbs into rural areas. And in medicine, it gave rise to a new specialty: geriatrics.

How Geriatrics Formed Our Perceptions of Aging

Geriatrics was a nod to the growing awareness that the human species continues to grow and change over the full course of a life. But the outward evidence of aging was most easily catalogued by loss: diminished sight, hearing, sexual potency, bone and muscle strength, and cognitive function.

This became the primary lens through which we understood aging. Without realizing it, the field created an expectation of decline — and only peripherally addressed the inherent value of the individual. It placed a higher premium on chronology than on functional capacity, accumulated experience, and wisdom.

What Was Missed

Because of the focus on loss and disability, we glossed over how “aging” was actually being lived. There have always been people who “lived to a ripe old age” — some celebrated for breaking norms of productivity (“he painted well into his 90s”), physical achievement (“winning gold at the Senior Olympics”), or artistic contribution (“still dancing at 100”). But truthfully, most were celebrated solely for having pulse and breathing beyond what actuarial tables had predicted.

How the Boomers Changed Aging

No generation embodies the perception gap more fully than the Boomers. We didn’t just inherit it — we widened it. And in doing so, we broke every prior model for what aging was supposed to look like.

We are the first generation to live this long while enjoying this level of functional health and wealth. The linear pathway of school to job, to 30-year career with one company, to family, to retirement has been replaced.

But here’s the rub: instead of falling off the treadmill into oblivion, 76 million Boomers are refusing to quietly age out of the workforce. We’re overstaying our welcome, according to the old model — but we haven’t yet built a new framework to replace it.

Tension is in the Air

The conversation around “out with the old and in with the new” stopped being polite long ago. Employers now question the high cost of health coverage for older employees. Younger job seekers find entry-level positions blocked by tenured older adults who both enjoy the work and need the income. And those with years of seniority feel mounting pressure to move on — but most have insufficient savings to sustain them for another 10 to 15 years.

The model created in the late 1930s and amended in the 1960s no longer fits this generation of active aging adults. But there has been little will to change it — and, in some quarters, active campaigns to demolish it altogether.

Part 3 published next week: What happens when the old models of succession break down — in governments, corporations, and families — and we don’t have anything ready to replace them?

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I hold that the cumulative wisdom of having lived seven or eight decades gives a genuine leg up on solving problems that befuddle those with only two or three decades under their belt.

The argument I hear from the other side is blunt: old folks need to move out of the way and make room for the young. Their ideas are outdated, their skills no longer applicable, their thinking old-fashioned.

All evidence of classic ageism.

Evidence Suggests, However…

I am humbled to admit that, given the current crop of elders now inhabiting positions of power and influence in our government and business, these whippersnappers just might be right. The men holding the office of President in recent years have not been stellar examples of functional aging. Biden needed an off-ramp, and Trump still does. Neither was — or is — willing to give it up. Lord knows, the political talking heads have opined endlessly on this.

I want to offer a gero-psychologist’s point of view.

These two men are not aberrations. They are symptoms of something older and more pervasive: a culture that has never figured out what to do with its elders — one that simultaneously fears aging and clings to the power that comes with it. That fear runs deeper than politics.

We Fear Getting Old

The notion that we can somehow beat death is not new. What has changed is the actual number of decades our lives now span. As a society, we prefer “new” to “old.” Youth-associated language clusters around vitality, potential, and desirability; elder-associated language clusters around decline, loss, and limitation.

See if any of these sound familiar:

• “Anti-aging” / “age-defying” / “over the hill”

• “Energizing the youth vote” / “elected Gerontocracy”

• “Past his/her prime”

• “Dirty old man” / “cougar”

• “Frail, elderly”

The only conclusion that can be reached is that getting old is something to be avoided at all costs — which is thrown into sharp relief by our simultaneous, paradoxical obsession with living forever, cataloging health metrics, and chasing the century mark.

My Path to Enlightenment

I have not always had this insight into aging. I am a member of the generation that mockingly said, “Kill anyone over 30.” Youth is filled with hubris like that. Now in my seventh decade, I more fully appreciate the brazenness of that remark.

In the intervening years, I have become a true student of aging — not just through working with patients, but by paying attention to my own aging process. What brought me to this new awareness is a combination of having been raised as an only child, cared for and guided by aging adults who embraced the shifts that aging brought. They defied stereotypes, sometimes out of necessity, and most of the time out of a commitment to being authentic.

And now I find myself squarely in the territory I spent decades studying. It looks different from the inside — and that, it turns out, is the whole point.

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Part 2 published next week: How a century of medicine and cultural change shaped the way we see — and misread — the aging process, and why one generation broke every model we had.

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My reading habits have changed over the years, mostly because how the material is made available has changed, but also because my body has changed.

Visceral Objects

Books, magazines, comics, and newspapers all used to be visceral objects. Some were unwieldy, others were toss-aways. Newspapers had many purposes, especially for ‘after-use’.

Books were objects of reverence in my family. Appreciation of the binding, the quality of the paper, and different print faces all contributed to the enjoyment of “reading”.

I used to read paperbacks anywhere. I’d assume postures that a yoga master would envy when I was young. These ranged from stomach-down, back arched and supported by my forearms, to curled tightly on one side or the other, nose sticking out from under the covers with a flashlight propped up so I could read in the night.

Benches and molded seats in bus stations or airports, deep-cushioned wingback chairs to hammocks, all were appropriate spots for losing myself in a book.

The Blessings and Curse of E-Readers

Remember the Palm Pilot? I know – last century technology – well that started me transitioning from paper to digital publishing. Books are beautiful, bulky companions easily accessible wherever there is light to be had. Perhaps I should feel more guilty, but I dumped them like an old boyfriend for the new, shiny make and model that lets me read in the comfort of my bed without expending excess energy except that needed to turn my Kindle on and tap the screen to turn the page.

My Kindle takes up little space, only needs occasional maintenance, and is available to me during daytime or at night (as long as I remember to keep her charged!) The books I want to read are delivered in seconds and I can be relieved of the pressures of reality and slip into alternative worlds literally by only lifting a finger.

I am so spoiled!

I used to comfort myself that switching to digital was a small act of environmental citizenship—fewer trees, less ink, no shipping. And I still believe there is something to that. But I have come to think that every format carries a cost; we just distribute it differently. Print asks something visible of the land. Digital asks something invisible of the grid, the supply chain, and the distant places where devices are built and eventually discarded. Neither is innocent. What shifts is not the burden but where it lands—and whether we are paying attention.

A House Full of Old Friends

With that said, my home is filled with the vestiges of my past. Bookcases line my living room and bedroom. The books on the shelves are not there as background for Zoom meeting, but actually are an archive of my education, my hobbies, and attempts at feeding my insatiable desire to know and understand things better.

I know I need to cull my collections, but this would be like deciding which child to keep and which to send away. It is painful to let go and I am choosing to not experience that pain just right now.

Some Books Are Easier to Pass Along

My dilemma in downsizing is that books that I deem “valuable” are now either outdated or no longer considered useful by current-day standards. Books collected during my graduate years were specific to my goal: clinical psychology. What was being taught back then and how these same issues are treated 30 years after no longer apply.

You would think it would be easy to pass them along to budding therapists. But no — and not just because the information has changed, but because no one wants an actual volume. It turns out that the next generation of clinicians is no more interested in a shelf of physical textbooks than they are in a filing cabinet. So, the books remain on my shelf, reminders of an exciting time when I was discovering the world of psychology.

Picture Books Are the Hardest to Release

I have lots of oversize books containing photographs, cartoons, artwork of the Old Masters, and pictures of beauty from all over. These books all weigh a ton and require sturdy platforms to open and view. And they are ones I return to over and over.

E-versions of these kinds of books just don’t cut it for me. I need the physicality of the binding and the sheen of the paper. I openly admire the decision-making that went into the layout and production of not just the individual pages, but the entire collection from cover to cover.

These are a feast for all my senses and a stimulant to my imagination. Which brings me back to my coming to terms with my decision to not buy “Remembering Earth”. The actual acquisition of the book now rests on the awareness that it will now become another thing I will need to be getting rid of.

Truth is, this is a bittersweet yet strangely enjoyable experience. I can imagine sitting and drinking in the photos and the descriptions, experiencing each as if it were a library wine, now opened and enjoyed after years of aging.

After the Moment Passes

But then it will be done. And the book will need to find a place to rest, only to collect dust or be moved when things need rearranging.

I haven’t decided quite yet what I will do. There is a part of me that says, “just order it!” and another that says, “don’t be foolish – get it from the library”.

Truth is, I cannot live without books, whether they are on my shelves or in my Kindle. They are an old friend who I depend on to keep me company and offer me sanctuary from the demands of the unpredictable world I am currently living in.

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These are useful survival traits. Sometimes, however, we lose the keen sense of discernment that guarantees survival. Like the teaching story of crabs in a pot of hot water, where the water temp is raised gradually until, too late, the crabs realize they are cooked. This is what has been happening to us in recent years.

Clear and Present Danger

More and more of us are just now waking up to the multiple clear and present dangers that are surrounding us. For example, I was re-filling a prescription today that I have been on for decades now. It is a generic, so I rarely pay attention to the cost, as it has been reasonable, manageable, and well within my budget for longer that I can remember.

I use Cost Plus Drugs to fill all my generics because I get the best price. I use my insurance, which is supposed to cover the cost of this essential (to me) medication. But when I filled out all the fields this morning, I was shocked to find the price of my medicine had almost doubled in cost and shipping and handling had skyrocketed. I had never paid this much previously.

This Is Our Hot Water Moment

I am old enough to remember compounding pharmacies, where the pharmacist in his white tunic would be mixing potions from colorful bottles and powders. These would be put in glass bottles with droppers or carefully formed into individual pills, counted out by hand and sent home in a small box or envelope. My expectations of what a prescription looked like — and what it cost — were formed in that world.

Today, sitting in front of my computer and ordering my medication is simple and effortless. All I do is click a box, confirm my shipping and payment information, and magically my medicine ends up at my door in a day or two. I am remarkably lacking in curiosity about how all that happens. Instead, I get frustrated when it doesn’t.

Stepping Down from My Righteous Platform

Mind you, I have been rather prideful over the years because I understood the ins and outs of the labyrinthine world of corporate health insurance and pharmacy benefit management. I thought I had found a reasonable work-around that provided me with medication that is treating a chronic condition successfully for a manageable cost. The water in my pot was lukewarm, at best.

I read, on an increasingly frequent basis, stories about older adults having to make the hard choice between paying for medications or choosing food. I railed against the unfairness of it all! But it wasn’t impacting me directly – or so I thought. The temperature of the water was rising.

We Don’t Know What We Don’t Want to Know

Fact of the matter, I didn’t want to know what was happening to others. I was only concerned about my own little bubble. I found myself taking strong stands against the health insurance industry. I wrote essay after essay explaining their greed and attempting to influence my elected officials to do something about it. But I didn’t mind the water temp. As a matter of fact, it was actually comfortable.

This is another quirk of being human. We have been given empathy, but it is only a substitute for actually experiencing our own suffering. I think I know what others are going through, but until it actually happens to me, it is all just imagination.

Of course, once it does happen to me, it becomes fact – and fact worthy of 36-point headlines in the NY Times! I also become infuriated that others aren’t as upset as I am. This is not hypocrisy. It is a fundamental design flaw of our human wiring.

If we are lucky, we will lay down sufficient memory neural pathways to at least spark awareness that our suffering is also the suffering of others, just to a different degree. From that awareness might just arise the impetus to find ways to ease that suffering not just for me, or those close to me, but for others. This is how change happens.

Unmet Expectations

To the healthcare insurance industry and to faceless shareholders in multi-billion-dollar investment banks, I am nothing more than a line item in the profit or loss column. In spite of lofty mission statements and soaring corporate visions, the literal bottom line is that my existence functions as a tool for profit — nothing more.

My expectation, however, has always been simpler: that I can access effective, affordable medication for as long as I need it, and that my insurer will be there when I need them most. Those expectations, it turns out, were set in a different era.

How Times Have Changed

To be clear, I am not suggesting that things were better in the ‘good old days’. My point is that my expectations were set differently. What I take for granted now is far more complicated than it once was. Pharmaceuticals are sourced and manufactured around the world. Distribution requires understanding international economics, trade agreements, and shipping forecasts. Delivery to my doorstep requires complex algorithms, data systems interoperability, and electronic banking.

The system grew more complex, but my awareness of that complexity did not keep pace. That gap — between what I expect and what is actually required to deliver it — is precisely where my shock lived.

The Water is Getting Hotter

I am now aware of just how hot the water is getting. Because I have lived seven decades plus, I can predict with fair accuracy that we are in for a rude awakening. I am also aware, having lived this long, that too many will be shocked and surprised to learn that their ‘but-it’s-always-been-this-way world’ has changed.

This is the design flaw I mentioned earlier. Instead of acting when the water was tepid, the default was just to hang out a little bit longer. In those intervening years, we lost the ability to gauge the change in temperature that would have allowed us to get out, re-set the pot, and move on without too many negative consequences.

Paying the Piper

The bill has now come due. The cost of my medications this month has gone up almost as much as the cost of gas at the pump. I am in that untenable position of both needing my medications and needing gas. My income has not bridged that gap sufficiently, so I am now “economizing.”

Too many of us haven’t the luxury of “economizing.” This is no longer a problem for “them”; it is a problem for “me”!

The Fulcrum of Change

This is the point where change happens. The recognition that my life is impacted motivates me to first expect others to fix it, and then to come to the realization that if it is to be, it is up to me.

But here is the good news: we are not without tools. Those of us who have lived through previous upheavals — civil rights, economic recessions, health crises — know that change is possible when enough of us decide the water is too hot to ignore. We know how to organize, how to vote, how to speak up, and how to show up for one another.

The methods may need updating, but the will does not. Get involved. Stay informed. Talk to your neighbors. Keep contacting your representatives. Support organizations that are fighting for affordable healthcare and fair medication pricing.

We are seeing change occurring. It is building momentum daily. My hope is that I can get out of the pot before it’s too late. And I hope you can, too — not just by hoping someone else turns down the heat, but by reaching over and turning that dial yourself.

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Obviously, I am the problem. Unlike the unerring logic of the chatbots, I have a tendency to just hit a key or come up with my own solution — one that has proven to muddy the waters sufficiently so that I am now employing experts (located around the world!) to forensically reassemble what had been, heretofore, a reliable and predictable location in the cybersphere where you could find information about me and I could post my thoughts.

Sigh.

Starting Over

Fortunately, I am a trained psychologist. I have skill sets to help me manage my levels of anger, stress, and frustration. I have countless hours of mindfulness training to support me in returning to my center and focusing on my breathing. (I hope you are rolling your eyes and see that my tongue is firmly planted in cheek.)

I am also of a mind to use this as a moment to reflect on how this fits into the overall collapse of taken-for-granted systems that have regulated my life over the past decades — hence, the liminal space. Here’s what I am finding.

Patience/Impatience

Back in the day, when something went wrong, I knew and understood the systems well enough to find a solution or find someone who could solve the problem for me. If my car had a flat tire, I’d call AAA. If I was running a fever, I would take a couple of aspirin, and if I didn’t feel better in a couple of days, I’d call my doctor.

All these problem-solving endeavors took time and patience. I had to wait for the tow truck. I had to wait for my fever to resolve. I might have bristled at my plans being interrupted, but generally I could wait a day or two and just let things unfold.

No longer.

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I Need It Now!

Now I need a fix immediately. And here’s the seductive promise of the internet– a chatbot will give me information NOW!

The only problem is, I no longer have a way of gauging the accuracy of that information. At least when the tow truck guy came, I could tell if he (it was always a “he”) was stoned or actually knew his way around a car. If my fever kept going up, even after the aspirin, I had a sense of trust with my doctor or friends who were medical professionals that I could call and get answers.

Turns out my need for reassurance outweighs my need for factual information. That’s an important insight for me.

My Current Dilemma

I now have a file folder full of step-by-step instructions from chatbots telling me how to fix my website. My website, however, is not functioning. What I want is a “real person” to hold my hand, tell me it’s going to be all right, and then go off and fix the whole thing.

If you have ever watched “This Old House” on PBS, you will know the kind of folks I am hoping will come to my rescue – experts in their fields, working together to restore a once-proud website that has now fallen into disrepair.

Unfortunately, I have yet to encounter such a team.

A Business Opportunity Awaits: Boomer Hand-Holding

Seriously, my issue is not that I am unfamiliar with technology. It is that the way I am talking about my issues does not accurately translate into either chatbot logic or Gen Z customer service agents.

I learned how to solve problems back in the 1950s. My foundation is to follow step-by-step instructions. I am not a visual learner (watch and do). I am a read it first, try it out, then figure out what I did wrong and try again.

The New Problem-Solvers

The folks on the other end of the chat (live or bots), I will hazard, are from a different generation. I suspect they learned problem-solving differently. Unless we can figure out how to connect with and understand each other, the road to the solution is going to be bumpy.

This wreaks havoc with my impatience. There are some things I am willing to wait for and there are others that raise my blood pressure, cause me to swear loudly enough to scare my cats, and result in nothing more than reinforcing my helplessness.

I know when I am in this zone because I’m clued in by the fact that “they” are not listening to me and are only parroting a script. My belief is that if “they only listened to me and understood what I was saying” they would be able to fix my problem.

If only.

Workarounds

I am at a temporary impasse with my website. So, I am taking my blog to my Substack page for the interim. You don’t have to subscribe or even follow me on Substack, but if you want to, you will find additional essays (spews?) on topics near and dear to me.

Thank you for hanging with me during this transition — and for meeting me here, in the liminal space.

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Americans have recently been witness to how important succession planning is. Leadership transitions in our government have exposed just how much our system relies on unspoken assumptions — that those in power are cognitively intact, that there is someone prepared to step in, that the plan on paper reflects reality.

Businesses, too, have offered instructive examples. It is easy to hold up storied family enterprises like the Murdochs as an example of a family business that continues to struggle because of fractured relationships and no clear answers addressing what comes next.

But here’s what strikes me most about these large-scale dramas. They are the same problem that plays out in households across this nation every day, just with more media coverage and cadres of lawyers to sort it out.

The question of who takes over — and when, and how — is not only a question for nations and media empires. It is a question for all of us who are growing older. And at every scale — personal, familial, institutional, national — we have chosen, for the most part, to put it on hold until something happens.

Avoidance Is the Problem

Modern industrialized culture here in the United States has systematically deferred even thinking about aging. Media abhor aging. The beauty and fitness industries demand agelessness and eternal youth.

We hide older people away in 55 + “Senior Communities” or “care homes” that no one wants to end up in. This makes it easy not to think about what to do with Mom or Dad until we have to. And then, when the time comes, we are shocked to learn how far short the reality is from what our expectations were.

This is both a cultural and a personal failing — and it operates at every level.

Many of us avoid making plans because the conversation is based on a stereotype of a future self who is diminished, dependent, or gone. Families avoid the conversation because it is either anchored in grief, conflict, or shame for not having been able to care for our parents or having to admit that we haven’t a clue who will actually be there for us when we need the assistance.

And even this model rests on the “ideal family”, when in fact more and more of us are solo-agers, choosing to remain without partner or children. The consequence of this is both institutional protections and social networks are often unprepared to manage the needs of these individuals.

The irony is that for those who have resources, you have probably already spent good money and time making sure your assets are preserved and cared for, but much less time is spent on actually identifying who and what you want if you are unable to manage your lives and remain autonomous.

Policymakers avoid the expensive, uncomfortable restructuring because there are no votes in planning ahead for other people’s old age. The reality is that the systems we currently have were built for a different era and have been left largely untouched, while the population they were designed to serve has transformed.

Lao Tzu is credited with saying, “Confront the difficult while it is still easy.” This is as true for social policy as it is for family end-of-life planning. Nobody wants to confront what to do with Mom (or Dad) until a crisis forces it.

Built for a Different Era

Our systems for supporting aging adults were built in the 1960s. It shows.

Medicare, Medicaid, Social Security, and the patchwork of community and residential care services that developed alongside these safety-net programs were designed for a population with a lifespan of roughly 67 to 74 years.

The primary need then was physical and palliative: care for people in the final months of life. Provide affordable housing, access to food, and medical care. Today, the average American can expect to live into their late seventies or eighties even with chronic medical conditions, now successfully managed through modern medicine. Many will live significantly longer.

A closer review reveals the cracks in the picture. We are living long enough to spend years — sometimes decades — in situations that are functionally compromised: able to move through a day physically, but not to manage an increasingly complex and expensive medical system; aware enough to have preferences about where to live and who to live with, but not to enforce them; alive and well enough to experience isolation and loneliness, but not connected enough either via the internet or local networks to stay engaged.

This is the gap the system does not address well. And the gap is growing.

Our government, and charities, along with for-profit industries such as residential care facilities, face huge challenges removing the constraints found within because of institutional rules, routines, and power structures. These have become “self-reinforcing,” and virtually impossible to alter without significant disruption. The safety-net infrastructure created for a population who died in their late sixties is failing now that we are living into our nineties.

What Looking Directly at It Requires

So, what would it take — at every scale — to stop deferring?

For individuals and families:

It requires conversations that go deeper than, “How much is in your 401K?” or “where will you live?” The harder and more vital questions are: “What does it mean to you to age well?” “What role do you want to play in your community as you age?” “What do you need to retain your dignity and autonomy, and who do you trust to see that happens?”

These conversations are uncomfortable. But the resistance does yield. And people consistently report that having these conversations — however uncomfortable or awkward — brings relief rather than dread. Because what we fear, underneath the avoidance, is not the conversation. It is the uncertainty. And a plan, even an imperfect one, replaces uncertainty with something we can work with.

For systems:

Significant restructuring is called for and it requires the same kind of honest evaluation. Care management, housing support, food access, healthcare navigation, and legal protection for older adults all need to be redesigned for a population that is living longer, needs management of and care for chronic physical and cognitive issues, and that is increasingly likely to be aging without robust financial or family support. None of this was projected in the 1930s or the 1960s.

And the cost of deferring changing these systems is already too high — and paid for in the suffering and isolation of aging adults, in overburdened medical and crisis systems, in inadequate and unaffordable housing, and in legal systems that step in only after things have gone wrong.

The Legal Gap, Personal and Systemic

Perhaps nowhere is the gap between individual avoidance and systemic failure more starkly visible than in the legal domain. At the personal level, the tools that allow people to direct their own care — durable powers of attorney, healthcare proxies, advance directives, revocable living trusts — are available and relatively straightforward to put in place. But they require people to think ahead and to name someone they trust. And they require access to legal counsel or at least enough knowledge to not screw up a do-it-yourself will.

For solo agers and others without an obvious proxy such as a child, partner, or spouse, professional fiduciaries and public guardian services exist. But they are expensive, differ from state to state, are inconsistently available, poorly regulated, and largely unknown to the people who most need them.

When someone can no longer manage their own affairs and has not made a plan, the state typically steps in through guardianship or conservatorship proceedings: slow, expensive, often adversarial, and frequently resulting in arrangements that do not reflect what the person would have wanted. It is a last resort that too many people reach because there was no earlier plan. And, again, it varies from state to state.

At the policy level, this is entirely addressable. Strengthening these legal resources, making them better known and accessible, ensuring they are adequately funded — these are not radical proposals. They are the systemic equivalent of the individual’s decision to finally sit down and call an attorney. They require only the willingness to act before a crisis forces the issue.

What Other Societies Have Figured Out

Other countries have developed approaches to aging that are worth studying seriously — not to import wholesale, but to adapt. Denmark’s community-based care systems prioritize helping people remain in their own homes and communities. Japan’s long-term care insurance model distributes the financial burden broadly. The Netherlands’ dementia villages offer a radical reimagining of what residential care can look like. Various Latin American and Indigenous community models center intergenerational connection rather than age-segregated care.

Some of these models emphasize the state’s role; others emphasize community. All of them take the aging person’s dignity as a starting point rather than an afterthought. And all of them reflect a collective decision, made in advance, about what kind of society they want to be when their members grow old.

That decision does not happen on its own. It happens because enough people insisted on having the conversation. It happens because of effort, persistence, and collective action.

This Is the Moment

The Baby Boom generation is moving through old age right now, in enormous numbers. Boomers have a history of demanding that institutions respond to our needs, and we have the numbers to make demands stick. We are also, many of us, confronting for the first time what aging actually requires — the planning, the conversations, the legal documents, the hard questions about who will help and how. And we are not the only generation having to demand a change.

That collision of personal experience and institutional inertia is an opening.

The conversations we have in our families and communities about what it means to age well are not separate from the policy conversation. They are the policy conversation, happening at the scale where society actually changes. People who have done their own planning become advocates for systems that make planning easier and more accessible. People who have navigated a broken care system become the constituency for fixing it.

The bottom-up and the top-down are not competing approaches. They are the same movement, operating at different scales.

Just Start

Start with the conversation in your own family — the one you’ve been putting off. Think about who your people are, and whether they know what you need from them. Risk asking for what you want. Then get the documents in order.

Then take what you’ve learned into the larger conversation — about what your community may be lacking and how those needs might be met, about what the local, state and federal systems are failing to provide, what models from elsewhere deserve serious attention here.

We are all going to age. We are all going to die. When we are intentional in addressing the challenges of this process, the whole society benefits — whether “we” means you and your family, or all of us together.

The plan won’t make itself. The systems won’t change without a push.

We just need to start

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More of us are aging without children or a partner. Our systems weren’t built for this.

Indeed, aging adults around the world increasingly face a succession gap that opens up not at death, but before it — the long stretch when someone is alive but no longer fully capable of managing their own affairs.

I have made starts at this for myself, but I confess: I haven’t completely sorted out my own plan for that eventuality, despite spending thirty years as a geropsychologist.

Part of the reason is practical. I am a solo-ager — someone who is aging without children or a spouse who will naturally step into a caregiving role for me. And for people like me, the ordinary frameworks for succession planning don’t quite fit.

Trends in Aging

Trends in aging show growing numbers of solo-agers — individuals who, by choice or by circumstance, are without someone who will take on the responsibilities of care when they can no longer fully care for themselves.

This is both a legal problem and a social problem. In this post, I’m focusing on the social side. The legal dimensions — guardianship, conservatorship, professional fiduciaries, and what happens when no one has been named — will come in a following post.

Who Do You Trust?

At the center of any succession plan is a deceptively simple question: who do you trust?

For people with children, the question is still real and sometimes painful — but at least there is usually a starting point. For solo-agers, the question has no obvious answer. It requires intentional relationship-building of a kind that our culture doesn’t have a great script for.

Trust, in this context, is not simply affection. It is the specific confidence that someone will act in your interest, know your values, be able to navigate systems on your behalf, and have the skills, willingness, and capacity to do so when the time comes. That is a lot to ask of a friendship. It is even more to ask of someone who hasn’t been approached beforehand.

Don’t Put This Off!

And yet the ask has to happen. One of the most important things a solo-ager can do — now, while it’s still easy — is to identify one or two people in your life who might serve this role, and then have an honest conversation about what it would involve.

The risk, of course, is that we get turned down. That our darkest fear — that no one will be there for us — will come true. For some people, this alone stops them from ever having a conversation, resulting in even greater vulnerability and potential exposure to abuse and neglect.

We all need motivation to address this. Sometimes it is just needing an example of what someone else has done, or finding cultures where this is a given.

How Different Cultures Handle This

We are not the first society to face the challenge of caring for people who have no family to care for them. And looking at how other cultures navigate this is helpful — not because any single model fits perfectly, but because the range of approaches to caring for aging adults reveals how many of our assumptions are choices, not inevitabilities.

In societies that integrate their elders rather than segregate them, the community functions as an extended family. These cultures tend to find value in the person — their experience, their relationships, their presence — not only in what they own or what they do.

Elders remain a vital part of community life until they die. These cultures tend to be organized around relational values and, more often than not, are matriarchal in structure.

Contrast this with cultures — including much of contemporary Western society — where aging is framed primarily as decline, dependency, and disability. In these settings, the response to aging is frequently siloed: older adult communities, care facilities, specialized services that separate the individual from daily engagement with others. These are often segregated within a community.

The structure is efficient, and meets the needs of government and non-profit service agencies, but it often produces dependency and isolation for the people being served. These cultures focus on hierarchy, and hold values of independence and individuality.

For solo-agers, this framing matters enormously.

Framing the Issue

This is not an either/or comparison. Most communities contain elements of both. But addressing the underlying issue is markedly influenced by how the problem is framed.

When aging is understood as a normal developmental stage of life, the social infrastructure around it looks different than when it is treated as a problem to be solved or managed out of sight.

What Solo-Agers Need from Each Other

One of the current trends in solo-aging is mutual care: building intentional networks of peers who support and look out for one another. This is not a new idea — it appears in various forms in “friendship bench” models, aging-in-community cooperatives, and villages programs across the country. But here in the United States, it is underused and under-resourced.

A Different Kind of Plan

What would it look like to build a succession plan for you that names not one person but a small network of friends? Someone who handles medical advocacy. Someone who knows the finances. Someone who checks in regularly. Someone who will know when things have shifted enough to call for more support. Someone who can speak honestly and lovingly and let you know what to expect when things change.

Recruiting people for this requires having conversations that can feel awkward and even distressing in a culture of independence. It may reveal a need for support you might not want to admit.

But the conversations are not as hard as you might think, and the relationships that come out of them are often among the most meaningful and fulfilling that people build in later life.

A Note to Professionals

If you are a professional reading this — a social worker, a care manager, an elder law attorney, a nurse practitioner or a physician — the solo-agers in your orbit may not have raised this issue with you. They may not know how. Or they may be quietly hoping you will bring it up first.

Be that person. Asking “who would you call if something happened to you?” is not intrusive. It is one of the more caring questions anyone can ask. And for a solo-ager who hasn’t been asked by anyone before, it can be the opening they needed.

If You Are a Solo-Ager

If you haven’t already started recruiting your network, here are some key areas to think through as you identify who might fill each role.

Estate Planning – even if you don’t have children, you will still have stuff left over after you die. Consider how that will need to be tidied up. Do you want things to go to historical societies, charities, or just recycled?

Medical Proxy – consider not just who will pull the plug, but also who would make decisions for you if your ability to care for yourself is compromised, either through cognitive decline, or physical limitation.

Succession Planning for Pets—think about who would be good caregivers for your beloved companions. If they outlive you, where will they go and who will care for them?

Housing Needs – Explore different scenarios. What happens if you need to be in a wheelchair, or are unable to pay for maintenance of your home? Are there living situations you could NOT tolerate? For example, shared rooms, congregate dining, noisy environment.

Finances – who will manage your money and preserve your assets?

While all this may seem overwhelming, tackling it one thing at a time is worth your efforts.

Start Where You Are

Aging in the 21^st century requires that we think about things in new ways. Succession planning is just one area where you can take steps to ensure your independence, create a viable safety net, and develop lasting, supportive relationships that will see you through to your end of life.

You can find a wealth of information online. Google “solo-agers” or ask Claude to provide you with a step-by-step plan to organize your life for maximum livability as a solo-ager.

Then start making connections.

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For whatever reason, Americans seem to think that business people are the cat’s meow and have the answers to everything. Evidence would suggest otherwise, given the current economic challenges we face and the daily variations in blood pressure experienced by folks at the Fed.

One example of this is healthcare. Treating healthcare as a profit-making center is just plain wrongheaded. The popular notion — that if we just make hospital fees more transparent, standardize doctor’s reimbursement rates, and use AI to manage tedious paperwork and pre-authorization tasks, all will be … “well” — is seductive, but it is a distraction.

What got me going were two articles. One was about Mark Cuban — of Cost Plus Drugs, Shark Tank, and basketball fame — and his idea of needing to think of hospitals as start-ups. The other was about the application of AI to obtaining pre-authorization, a process that currently causes delays in care and headaches for payers and patients alike.

Here’s the problem. Both articles focused on the architecture of the delivery system — the software, the hardware, the costs associated with employment and billing. Neither addressed why those elements needed to be there in the first place. That omission is the whole ballgame.

The Wrong Diagnosis

Listen, if this were an easy problem to solve, we would have solved it already. Ever since universal healthcare was first conceived, communities, governments, and the people who finance these endeavors have struggled with how to compensate, cover, and keep the doors open for humans whose bodies and minds are not functioning properly.

On a large scale, some 78 nations have decided that it is better to provide care to all their citizens without restriction and have financed that primarily through taxation. Countries such as Canada, Germany, Japan, France, and Australia — each with different populations, needs, and histories — have structured workable systems. The details differ, but the point is that such a goal is achievable.

But what lies at the heart of our struggle in the United States has little to do with financial structuring, supply and demand, or any of the other MBA-curriculum topics. The fundamental problem is that we do not believe healthcare is a right.

I am not going to argue whether it should or shouldn’t be. I am going to make a case for why we keep distracting ourselves from making real progress — why we keep reaching for business tools to fix a problem that is, at its core, a values problem.

Why Markets Fail at Healthcare

Before dismissing the profit-model critique as ideological, it’s worth noting that economics itself explains why markets structurally fail in healthcare. Three conditions make market competition work: informed buyers who can comparison shop, the ability to opt out of a product, and a transaction that happens when both parties are capable of making rational choices.

Healthcare fails all three tests. A patient in cardiac arrest cannot comparison shop between emergency rooms. Nobody can opt out of needing care indefinitely. And the “consumer” is frequently incapacitated at the precise moment of purchase. These are not inefficiencies to be engineered away — they are structural features of illness itself.

The administrative cost data tells the story plainly: the United States spends roughly 25–35% of every healthcare dollar on billing, coding, prior authorizations, and collections. Single-payer systems typically spend 12–15%. The complexity is not incidental to the profit-seeking structure — it is a product of it.

This is the point the Mark Cuban argument misses. Cost Plus Drugs is a genuinely useful innovation for making certain generic medications cheaper. But it operates within a system whose cost structure exists precisely because of the profit motive it’s trying to work around. You cannot start-up your way out of a structural problem.

The Problem with Profit: Perverse Incentives

A for-profit healthcare system is structurally incentivized to maximize billable events, not health outcomes. Prevention is chronically underfunded because a patient who stays healthy generates no revenue. A patient managed just well enough to keep returning does. This is not a conspiracy — it is the predictable behavior of any profit-seeking enterprise responding to the incentives it’s given.

This perverse logic plays out in physician training as well. Because specialist procedures are reimbursed at dramatically higher rates than primary care visits, medical school graduates flood into specialties and avoid primary care — leaving the very foundation of a functional health system chronically understaffed and underpaid. We have built a system that actively discourages the kind of care — longitudinal, preventive, relationship-based — that produces the best long-term outcomes.

The result is a documented burnout epidemic among the providers who remain. Physicians report spending more time on administrative tasks — prior authorizations, billing compliance, documentation for insurers — than on clinical care. The moral injury of being forced to fight a payment system rather than treat patients is driving talented people out of medicine. This is a business-model failure with measurable, human consequences.

The Insurance Industry: Duty to Shareholders, Not the Sick

The health insurance industry arises from a basic awareness that people are poor planners and not skilled at long-term financial thinking. It offers relief from this awareness by promising to take care of things, if they ever need to be taken care of, for a monthly payment.

The problem is that people do make claims, expecting those promises to be kept. So, to manage this inevitable “loss” — and claims are literally classified as losses by insurance companies — the insurer protects its nest egg by having you pay more, banking on the probability that most of you will never collect, and keeping the difference.

That pool of money becomes investment capital for shareholders who share the presumptively low risk of those losses, ultimately securing predictable returns for their retirement portfolios. The legal duty is to the shareholders, not the insured. What looks like greed is, structurally speaking, exactly what a well-run for-profit insurance company is supposed to do. The problem is not bad actors — it is a bad architecture.

A common counterargument here is that people who pay out of pocket consume less care, avoiding wasteful utilization. There is a grain of truth in this. But the evidence consistently shows that when cost-sharing rises, people forgo — not wasteful care — but — preventive screenings, medication adherence, and early intervention. The downstream result is more expensive emergency and acute care. The cost-sharing model does not save money. It shifts it forward in time and backward onto the sickest patients.

The Drug Pricing Case Study

Mark Cuban’s Cost Plus Drugs venture illustrates the larger problem with surgical business-model interventions: it makes one drug cheaper while the architecture producing that drug’s inflated price remains entirely intact.

The United States pays anywhere from 2 to 10 times more for the same branded medications than patients in countries with negotiated national pricing. This is not because American pharmaceutical companies are uniquely innovative — much foundational drug research is publicly funded through the NIH — but because the profit motive is given free rein at the point of sale in a way it is not in peer nations. The patient on a fixed income who cannot afford their insulin is not a market inefficiency. They are the market working exactly as designed.

Healthcare Costs Too Much — But What Does That Even Mean?

“Healthcare” is not a single product. It is an amalgam of services, systems, workers, and people. Expecting it to have a given cost — whether high or low — is inherently unrealistic. What needs to change is how we measure its value: not just the dollar amounts, but the outcomes those dollars produce.

Individually, processes can be deconstructed to identify different cost nodes. This is genuinely where AI and data tools can play a valuable role in reducing duplication, monitoring outcomes, and improving efficiency — but only as instruments in service of a better-defined goal. Here is a visualization of one database currently used in California to track healthcare claims:

Figure 1: California Healthcare Payments Database (HPD) Snapshot, 2023. Over 1.75 billion records across 36.3 million individuals.

What this data represents is staggering: 1.75 billion records for 36.3 million individuals in a single state in a single year — across Medi-Cal, commercial plans, Medicare, and everything in between. The sheer scale of this data underscores a critical point: just because we have tools to measure and manage does not mean the underlying problem is solved, or even accurately identified. We have been trying to optimize this system since Medicare was established in the 1960s, and the core problem — unequal access to care — remains unchanged.

A Brief History: From Fee-for-Service to a Nation-wide Crisis

The problem identified when Medicare was passed was straightforward: too many Americans couldn’t afford to pay for healthcare. Healthcare in those days meant vaccinations, annual check-ups, and hospitalizations measured in days. Costs were reasonably estimable. The doctor — predominantly male then — fixed you up using supplies the practice bought and medications the local pharmacy compounded.

Doctors set their own fees, typically on a sliding scale: more from those who could pay, less from those who couldn’t. This “fee-for-service” model eventually became the basis for how Medicare determined its fee structure. The transition from that individual practitioner model to a nationwide insurance plan was — and remains — an enormous undertaking.

That it has been accomplished at all is remarkable. That it has been accomplished successfully across dozens of other nations proves it can be done. The difference in those countries was not that they universally abolished fee-for-service — many, like France and Germany, still use it. The difference is that they established healthcare as a values-based system with adequate public funding, and then structured the payment architecture to serve that goal. They made health outcomes, not profit margin, the governing measure of success.

This is precisely why we are struggling. As a nation, we are unwilling to abandon the care-for-profit model in favor of the care-for-health model. It is not a matter of mechanism — FICA taxes and income taxes already provide the infrastructure for broad public funding. What is lacking is political will.

The Harder Truth: Who We Are as a Nation

We are not a particularly healthy country. We are largely ignorant of how our bodies work and what to do when they stop working. We are vulnerable to pitches from people in white coats and sports figures promoting supplements. We are bombarded with pharmaceutical advertising for conditions we don’t have. And we have access to unlimited information that either amplifies our fears or provides false reassurance.

Common sense, apparently, is not all that common. Trust in both information and institutions is at a historic low. And yet we persist in diets and behaviors that contribute demonstrably to our chronic disease burden. Although thousands of studies confirm that lifestyle factors shape long-term health, roughly 60% of American adults have at least one chronic condition, and the majority of deaths in this country are attributable to largely preventable diseases. The gap between what we know and what we do is enormous.

At some level, we do need to take responsibility for our own health. I am not laying a guilt trip here — making healthy choices is not equally possible for everyone, and the social, economic, and environmental conditions that shape health are not distributed equally. But when compared with peer nations facing similar conditions, we consistently come out near the bottom. That is not an accident. It is the predictable outcome of a system that has never prioritized the health of its population as a civic good.

What Actually Needs to Change

We can keep attempting to solve the healthcare problem using business models and incremental fixes. AI-powered prior authorization, hospital-as-startup, transparent pricing portals — these may reduce friction at the margins. But they will not improve the health of the American people. Here is a brief accounting of the statements that need to be reckoned with honestly:

• Providers at every level believe they are not paid enough.

• Workers at every level believe leadership is overpaid.

• Very few patients understand how their care is actually financed.

• Health insurance companies, by structural design, prioritize shareholder returns over patient access.

• The majority of American deaths are caused by chronic, largely preventable diseases — yet prevention is systematically underfunded.

• Healthcare costs too much — even though we lack a coherent shared definition of what those costs should be buying us.

Each of these is grounded in evidence. And each, taken together, points to the same conclusion: these are not technical problems awaiting the right app or reimbursement formula. They are structural and moral problems that require structural and moral solutions.

Healthcare needs to be locally governed and federally funded. It needs to adapt to the specific needs of its communities — what is required on Navajo land is not what is required in New York City; what works for a community of aging adults is different from what works for a young population; what a hurricane-prone coastal community needs differs from what an Appalachian town dealing with the legacy of industrial pollution requires.

Funding should come from every person in the country, scaled to means. Those who have more should pay more. Those who have less should pay less. Everyone has a stake in the health of their community and should bear that burden — not be forced to choose whether they can afford to get well.

Closing the Loop

Mark Cuban is a smart, creative entrepreneur. His Cost Plus Drugs venture has genuinely helped some people afford medications they otherwise couldn’t. And AI-assisted prior authorization will reduce some of the administrative waste that plagues providers and patients today. These are not bad ideas. They are just not solutions to the problem.

The problem is not that hospitals haven’t been run enough like start-ups. The problem is that we have structured a system in which the business logic of a start-up — grow fast, maximize return, exit — is fundamentally incompatible with the clinical logic of a hospital, which is: be here tomorrow for whoever needs you, regardless of whether they can pay.

Only through adopting new models of care delivery — ones that guarantee access for all, provide living wages for all care workers, and measure success in health outcomes rather than profit margins — will we address the foundational failures of American healthcare. Business cannot solve this. It is not a business problem.

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As the children aged, they took on additional responsibilities and eventually left their family of origin to start families of their own. Parents continued to play a role until such time as they required help. Then the children cared for their parents until the parents died. This was the continuum. This was the social contract.

Changes to the Social Contract

But things are changing now, and have been for some time. As our lifespan has increased, the stages of aging have expanded. Especially in western, industrialized nations, children remain dependent on their parents for longer, parenthood is starting later, and the number of aging adults reaching their 80s and 90s continues to grow.

According to the World Health Organization, “By 2050, the world’s population of people aged 60 years and older will double (2.1 billion). The number of persons aged 80 years or older is expected to triple between 2020 and 2050 to reach 426 million.”

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More Old Folks/Fewer Youngin’s

Through the Boomer generation (1946–1964) there was a steady increase in worldwide population — to the point that some warned the number of people in the world would overwhelm the available resources to sustain life.

Generations following Boomers, however, have shown an overall decline in births. Fewer couples are having children. Fewer people are forming or maintaining committed relationships. So, there are fewer Millennials, Gen X, Y, Z, and Gen-Alphas.

Trends in Aging: Caregiving

Here in the United States, more people are choosing to live life as “solo-agers” — without partners, but in community with others. Solo-agers include those who have never married or been partnered, those who have lost partners or spouses, and those who, even if they did have children, are not expecting those children to care for them.

Regardless of relationship status or overall wellness, all these folks will need some kind of care over time. Whether it is just having someone come and tidy up, move heavy things, or provide more involved assistance with activities of daily living, some form of help will be required.

Are You Already a Caregiver?

You may already be part of this demand for caregiving. You may be providing care for your partner or spouse — driving them to doctor’s appointments, preparing meals, helping with shopping, or providing tech support for their iPhones.

Or you may be more deeply involved, especially if dealing with chronic health issues such as diabetes, heart conditions, or mobility limitations. If you are an adult child, you may be doing this while still raising children of your own at home.

Harsh Realities

The hard reality is that too few of us have spent the necessary time preparing for just how this will impact our lives. We may have done what was needed in putting aside retirement funds and completing our wills and trusts, but that turns out to have been the easy part.

The hard part starts with understanding the complexities of health insurance and healthcare. That is compounded by our refusal to face our own ageism and the deep levels of denial that surround everything aging means.

Denial Is Not a Strategy

We continue to put off addressing the increasingly urgent challenges of providing adequate housing at affordable costs, recruiting and training caregivers and paying them a livable wage, and creating communities of care that don’t isolate aging adults but include them in every aspect of the communities they live in — and likely have been part of for many years.

Adequate financing to support aging adults living well into their 90s is not an unsolvable problem. It only appears to be one because we refuse to face our own mortality and accept our collective responsibility for caring.

Growing old and not having enough money to pay your mortgage, taxes, or rent is not a moral failing. I know of no one who decided to surrender all autonomy and rely solely on the kindness of strangers. But that is essentially what we are offering the majority of aging adults in this country.

Our nursing homes are largely privately owned, have limited capacity, and have little incentive to expand their services. And nobody wants to end up in a nursing home if they can avoid it.

Assisted living facilities offer amenities — for a fee — that may be out of reach of the “missing middle”: those whose income is too high for public assistance but too limited for the fees charged by the facility. Persons who sell their homes to move into one of these facilities may outlive their ability to pay and face eviction, often with limited legal recourse.

According to A Place for Mom, the national median cost of assisted living is $5,190 per month. This figure can change depending on location, amenities, and how fees are structured. Demand is far outpacing availability as fewer facilities are being built and people are living longer. The waiting lists just continue to grow.

Caring for Cognitively Impaired Aging Adults

And of course there is the specter of cognitive decline. When and if one of the dementias takes over your brain, finding quality care, safe housing, and consistent services at a reasonable price may simply not be available.

The dystopian view is this: thousands of angry, demented, incontinent older adults warehoused in congregate care facilities, staffed by low-wage workers — many of them immigrants facing their own vulnerabilities — who lack the power, resources, or institutional support to advocate for the people in their care, while those residents slowly die a lingering death.

Moral Question

Which is where the moral question comes into play. Who should care for aging adults who are no longer able to care for themselves and who have no one else capable of doing so?

What does that social contract look like? How long should any society be expected to provide for the needs of its elders? What would the criteria be for deciding who receives what will inevitably be limited or rationed care? Care right now is already restricted based on ability to pay — but add in the growing shortage of care providers and the question becomes even more urgent. How do we address that?

We have a difficult enough time as a society addressing abortion. How, then, should we address euthanasia? What constitutes a mercy killing when the individual no longer has a functioning mind, but the body simply keeps going? Who makes that decision if the person has no living family members to withdraw life-sustaining treatment — and neglected to name a healthcare agent?

None of these questions are easily answered — not by AI, not by policy, and not by wishful thinking. But all of them are pressing with increasing urgency on the systems we have built to care for our elders. The same systems that are under direct attack right now.

Already Congress has rolled back minimum nursing staffing requirements for skilled nursing facilities. Cuts to Medicare and Medicaid under H.R. 1 (The Big Beautiful Bill Act) will increase the number of older adults seeking housing and care while stripping away the means for paying for it. This does not bode well for aging adults across the country.

The political will to act exists only when those in power can no longer pretend it won’t happen to them.

This will not be going away any time soon. This is my attempt to start the conversation. I welcome your thoughts.

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Share Deeper Dive with Dr. Mary

Today, however, costs for starting a practice are usually beyond the means of an individual clinician, so many join group practices or are actually employees of healthcare systems. Nowadays, practice income comes primarily in the form of compensation and reimbursement made by insurance companies and government programs. These income sources reflect rates of pay set by the AMA, negotiated with the Centers for Medicare and Medicaid, and lobbying by the insurance and pharmaceutical industry.

So, when you want to start a specialty clinic—say, one focused on weight management—you need a lot of capital to get off the ground. This is where investors come in. And this is where things get complicated.

A Case Study: When Good Medicine Meets Capital

knownwell represents what many consider the ideal model for modern healthcare delivery. This hybrid care company combines in-person medical services with virtual care. Launched in 2023 as a weight-inclusive primary care and metabolic health company, they offer in-person care at nine clinics and provide virtual care across all 50 states. They offer broader services beyond just weight management or GLP-1 prescriptions to include nutrition counseling and behavioral health services both online and in person.

The clinical credentials are impeccable. knownwell was co-founded by Dr. Angela Fitch, who serves as Chief Medical Officer, bringing extensive experience as a primary care clinician and in obesity medicine. She was formerly the Associate Director of the Massachusetts General Hospital Weight Center and past President of the Obesity Medicine Association.

The business backing is equally impressive. The clinic was privately funded with an initial $25 million oversubscribed round led by CVS Health Ventures, with Oak Street Health co-founder Geoff Price participating and joining the company’s board. Geoff Price has an MBA from Harvard, and runs Oak Street Health, an innovative primary care company presently operating centers in the Midwest to provide patients with comprehensive preventive care, including personalized wellness plans, integrated health services, and educational and social activities to support overall health and well-being.

So, there you have it—the perfect marriage of clinical expertise with business savvy. The model makes sense: combine the accessibility of telehealth with the thoroughness of in-person care, wrapped in a sustainable business structure.

But then, as I was reading a piece published January 5, 2026, in Fierce Healthcare, about hybrid care companies poised for growth, I read something that stopped me cold.

The Problem with Being “Unprovocative”

In her article, Heather Landi explores issues facing healthcare with the addition of AI and the trend toward specialty clinics. She looks as several of these clinics and how they are meeting the needs of patients, providers, and a new player: investors.

One of these companies is “knownwell”, currently providing obesity treatment. knownwell CEO Brooke Boyarsky Pratt acknowledges that “click and mortar,” or what’s sometimes referred to as “click and brick,” may not be a provocative sell to investors as compared to AI solutions. But hybrid care that includes a traditional in-person component is the best approach to provide longitudinal and comprehensive care to patients, she asserts.

Read that again. The CEO of a clinically sound, well-designed healthcare company admits that what’s best for patients—comprehensive, longitudinal care with both virtual and in-person components—is less attractive to investors than AI solutions.

Not less effective. Not less needed. Less provocative.

This is the crossroads healthcare is at now. We have a model that clinical experts believe delivers better patient care, but it’s competing for capital against technologies that excite investors more—without a whole lot of evidence demonstrating whether those technologies actually serve patients better.

Am I a Patient or a Customer?

This brings us to a fundamental question that healthcare has been dancing around for decades: Am I a patient or a consumer?

And the related questions: Am I a business owner, healthcare provider, or employee? Is my practice a healing mission or a return-on-investment vehicle? How do these distinctions impact delivery of healthcare?

If healthcare is conceptualized as a right, then the current model of reimbursement and compensation will need to be reworked to ensure there are sufficient numbers of trained professionals and adequate facilities to meet the ongoing needs for preventative, emergency, and long-term care. Investment appeal becomes secondary to access and outcomes.

On the other hand, if healthcare is conceptualized as a business, then supply and demand will drive the kinds of services available, resulting in widely divergent pricing and the policy question of what to do for people who cannot afford to pay—or what to do with patients if a practice fails to deliver its return on investment.

This isn’t a theoretical debate. It has immediate, practical consequences.

What Happens When Healthcare Businesses Fail?

With investments coming from Amazon, CVS, and other highly-resourced companies, the field is wide open to try new models of healthcare delivery. Like any speculation market, there will be those that reap huge benefits, and those that die on the vine.

But what happens to the patients?

When a restaurant closes, you find another place to eat. When your healthcare provider closes—especially if you’re in ongoing treatment for a chronic condition like obesity, diabetes, or mental health issues—the disruption can be devastating. Medical records need transferring. New providers need to get up to speed on your history. Medication regimens may change. Trust needs to be rebuilt.

And if the business model driving healthcare delivery prioritizes what’s “provocative to investors” over what provides “longitudinal and comprehensive care,” we’re setting ourselves up for exactly this kind of disruption.

As individuals potentially become more reliant on AI-driven or investor-favored models, the role of traditional anchor institutions like hospitals and community clinics will change. They may downsize or close completely as more services are delivered via telehealth platforms. This in turn will potentially impact local economies and the adjunct businesses that they support.

The Emerging Landscape

I want to be clear: I see enormous potential in hybrid care models like knownwell. There is no doubt in my mind that there will be great benefit to patients in these kinds of specialty clinics. I can imagine equal opportunities for clinicians to spend more time doing what they have been trained to do instead of having to comply with endless paperwork and data requirements.

The challenge I’m grappling with isn’t whether hybrid care or AI or telehealth are good ideas—they clearly have value. The challenge is what happens when the capital needed to build these models comes from investors whose primary metric of success differs from clinical values.

This is particularly relevant in the current market for weight-loss clinics, which are now sprouting up all over the place—HIMS, HERS, Weight Watchers —along with geographically local clinics. This is a very lucrative market at present and a welcomed one, as obesity is finally recognized and treated as a chronic disease instead of a moral failing. With that said, however, the very nature of the market holds risk. What happens when the GLP-1 boom subsides or becomes less profitable? Do these clinics pivot? Scale back? Close?

Policy Questions We’re Not Asking

There doesn’t seem to be a lot of policy consideration being given to this kind of impact, at least that I could find. We seem to be in the throes of the “brand new shiny thing.” But there will be consequences that could and should be avoided if we take the time to look at these issues now.

Some questions worth exploring:

• Should healthcare businesses that take on ongoing patient care be required to have continuity plans in case the business fails?

• Are there regulatory frameworks that should apply when private equity enters healthcare delivery?

• How do we balance innovation and investment appeal with patient stability and long-term outcomes?

• What happens to healthcare access in communities when investor-driven models favor profitable specialties over comprehensive primary care?

The challenge is that there are so many other things needing attention. This may not seem to be a priority. The irony is that is how many of us approach our own healthcare—we put it off until it becomes a crisis.

Maybe that’s a lesson we shouldn’t apply to healthcare policy as well.

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I was raised by people who didn’t talk about money. It was unseemly and socially frowned upon to discuss how much one earned. Yet, it was clear that those who earned a lot were well regarded and somehow special.

Economically speaking, I was raised in a comfortably middle-class family who lived in a suburb of Chicago where the rich folks lived on the north side of the tracks. My family lived on the south side. I grew up in a duplex, on a corner lot, with a front and back yard. The folks on the north side had big houses and big yards.

What transcended the geographic and economic divides was the agreed-upon social value of giving to charity. Back then, all of us collected for UNICEF, put our nickels and dimes in weekly offering envelopes at whatever religious institution we frequented, and made sure to put change in the Salvation Army bucket at Christmas time.

It’s Not Begging; It’s Charity

I am sharing this because this is the time of year when we are all besieged with requests, demands, and pleas for donations to support the untold numbers of worthy causes that somehow cannot function without my contribution.

Over my lifetime, charity, once considered a moral value and exemplified by tithing, has become a business in and of itself. And I find myself in the uncomfortable position of asking for money.

It’s Not Begging; It’s Business

The shift in how information is collected, digested, and distributed no longer fits the model I was raised with. Books and newspapers were published by companies who hired authors and journalists. Prices were set and people paid for a daily newspaper or magazine or book. Subscriptions ensured a steady income that covered the costs. If you had the money, you paid for any number of subscriptions.

But now, anybody can be a publisher, author, or journalist just by posting on a social media platform. Lord knows, opinions are plentiful and, most of all, free. Perhaps this is truly democratic, but it is a really limiting way of distributing and sharing ideas. There is no longer a shared or agreed-upon fount of information. Now you are subject to algorithms or just searching out your own collection of sources.

Word of mouth (”SHARE!”) becomes the marketing and distribution system that is supposed to even the playing field. And, to a degree it does. But the marketing available to me—my circle of friends and their nodal networks—is vastly different than that of Heather Cox Richardson or Joyce Vance.

This is where platforms like Substack enter the picture, offering writers like me a way of being paid for doing what we love to do without having to be employed by a news agency, represented by an agent, or becoming a marketing maven through self-publishing. It was a platform I resisted joining because it seemed too good to be true. Yet here I am, established and with a modest following that I am hopeful will continue to grow.

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The Weight of Old Messages

I struggle with setting a price for my efforts as a writer. As a consumer of the writing of others, I have no problem paying for what I read. But asking you to pay to read my words seems, well, unseemly.

The burden of having received the message that it is unseemly to talk about money remains heavy with me. That, and the impostor syndrome of not being worthy or good enough, are anchored in my psyche. These ingrained beliefs breed resentment toward folks who seem to have it all figured out or have somehow been gifted with the magic recipe for success. Why them and not me?

I realize this is just in my head. That this imbalance has little to do with worth and much more to do with that whole marketing thing—audience size, timing, networks, and yes, luck.

This is Hard for Me—and That’s Okay

I am acknowledging that it is hard for me to ask you to subscribe to my Substack posts. But that is what I am doing.

Your subscriptions encourage me to continue writing, give me incentive to provide useful, readable, and thoughtful essays on topics of interest, and help me to make ends meet in increasingly challenging economic times.

If my writing adds value to your day—if it makes you think, helps you process the world, or simply provides good company—I hope you’ll consider subscribing or renewing your subscription. For those who are unable to afford a subscription, please consider sharing my work with friends who are able to do so.

With deep gratitude for your readership.

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Let’s face it, any debate about healthcare policy or considering closing a local hospital is both deadening in data and abstractions—budget constraints, utilization rates, system efficiency. Not the stuff easy conversation is made of!

But behind these sterile terms lies a stark human reality: nearly every American will need hospital care during their lifetime. The question is not whether you or I will require these services, but whether those services will be there when we need them.

I live in a small town just north of San Francisco. Our little local hospital is always teetering on the brink financially. My community is now made up of lots of aging adults – prime candidates for needing services that the hospital offers. So I am well aware of the vulnerability faced by someone like me. The burning question is what will it take to keep the doors open given the current threats to healthcare?

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Taking A Deeper Dive

Let me start by saying I am a healthcare policy nerd. You need someone like me to slog through the statistics and minutiae of rules, regulations, and funding streams to put a human face on this. So I did just that. I took a look at the issues that face communities like mine (and yours, if I do this right) that need to be addressed locally. Here’s what I found.

Your Typical User of Services: My Typical “Everywoman”

Here’s the hypothetical. What are the chances of being seen and/or admitted to a hospital during your lifetime? I created my own “Everywoman” drawn from demographic and utilization data published by the Agency for Healthcare Research and Quality (AHRQ): a female, born between 1945 and 1955, high school education, blue collar worker, living in Midwestern state (e.g., Kansas, Nebraska, Minnesota).

My ’Everywoman’ is between 70 and 80 years old. What are the chances she has needed hospital care during her lifetime? For practical purposes, it is a statistical certainty.

Why did she need hospitalization? Because her healthcare risks accumulated over her lifetime.

Accumulated Risks

While any single year might bring only a modest chance of hospitalization, those probabilities compound relentlessly across decades. But many readers may be hard pressed to remember the last time they were admitted to the hospital.

Maybe you had to go to the emergency department, or needed bloodwork, or imaging services. These visits occur at rates of tens per hundred persons annually, with admission rates as a consequence of findings from these visits climbing sharply after age 65.

But never going to a hospital? Centers for Disease Control (CDC) and AHRQ data show that avoiding hospitalization for an entire lifetime is vanishingly rare—less than one chance in a hundred.

Predictors of Need

Demographic and gender factors that define my hypothetical Midwesterner actually increase her already high probability of needing to be seen in the hospital. Women have higher rates of healthcare utilization than men, and this increases with age. It is also higher for certain conditions and emergency department visits.

Age is the dominant predictor, with hospital use rising steeply for Americans in their seventies and eighties as chronic conditions accumulate and acute health crises become more common.

My Everywoman had a high school education and blue-collar work history. These are two characteristics that are consistently associated with higher hospitalization rates, driven by greater chronic disease burden, higher occupational injury rates, and disparities in preventive care access.

And, it turns out where you live does make a difference. Data from Midwestern states, when compared to East/West coast states, show elevated rates of conditions like obesity and heart disease drive hospital utilization.

The Inevitability of Hospitalization

You may be shaking your head thinking, “Yeah – so where’s the news in any of this?” Yet here lies the crucial insight: regardless of these healthcare indicators, the baseline probability is already at the ceiling. You are going to end up in a hospital one of these days.

Whether we’re discussing someone with multiple risk factors or someone more privileged, the lifetime probability of needing hospital care approaches absolute certainty. This universality should carry profound implications for how we think about hospital access.

What Happens When a Hospital Closes?

When a rural hospital closes, it doesn’t just affect a statistical minority who might need care. It affects virtually everyone in that community over the course of their lives. The young mother who will eventually need cardiac care in her seventies. The factory worker whose decades of physical labor will culminate in an orthopedic emergency. The agricultural worker who will face a cancer diagnosis. The grandmother who will suffer a stroke. These are not exceptional cases requiring specialized urban medical centers—these are the predictable, near-universal experiences of human aging.

Seconds Count

In emergencies, proximity isn’t convenience—it’s survival. When someone is having a stroke, if the local hospital is no longer in operation, they face irreversible harm. The closure of a local hospital forces a cruel calculation on a community: how much additional travel time and risk are you willing to accept for something you know will almost certainly happen?

In medical emergencies, where minutes determine outcomes, an extra thirty or forty miles can mean the difference between recovery and permanent disability, between survival and death.

For chronic conditions requiring regular hospital-based care (cancer treatments or dialysis), that same distance becomes a recurring burden that compounds existing health disparities and creates new ones.

Adapt or Die

Older Americans with high school educations and blue-collar work histories—the very people most likely to need hospital care multiple times—are disproportionately represented in rural areas already experiencing hospital closures.

We are removing healthcare infrastructure from the communities that need it most, at the moment when that need is most acute. And we are expecting those who need the infrastructure to adapt to that absence when they have the fewest number of resources to accommodate that change.

Economic Realities: It’s the Money, Stupid

The economic arguments for hospital closures often focus on operational efficiency and financial sustainability as if the profit/loss statement were the driving force. But these analyses frequently fail to account for the near-certainty of how that closure impacts the community’s expectation for having a dependable place to receive care.

To the Board, when the bottom line (typically utilization and reimbursement) appears low in a given quarter or year, it’s easy to conclude the facility is unnecessary. Yet this perspective ignores the cumulative reality: over time, essentially every resident will require these services. A hospital that seems underutilized today becomes indispensable when examined across the decades-long horizon of human lifespans.

What remains unsaid is that keeping a hospital open costs money and the source of payment for that luxury needs to be steady and predictable if the hospital is to be available to all those who need it.

Where’s The Money Coming From?

There is no single answer to this, and that is part of the problem. Generous philanthropists can seed a hospital, but to keep it running in perpetuity requires separate but consistent streams of income. Inevitably, the money to pay to keep your hospital opens has to come from you and other people in your community.

Public/private partnerships would seem the most likely to be sustainable in smaller communities. This would include funding from government sources as well as payments from patients for services received. This would assure “buy-in” from the community without the threat of criticism of socialized medicine. But the likelihood of this actually transpiring is quite low.

Better Minds than Mine

Our current healthcare financing system is terminally ill. There will be no recovery. The patient needs hospice and we all need to prepare for what comes after. It is not able to be sustained.

We need to acknowledge that we are in a moment where opportunity for change exists in ways it hasn’t since Medicare was signed into law in 1965—and proven models already exist to guide us. What is left for us to do is implement those changes at the local community level using local leadership.

Models That Are Already Working

The Critical Access Hospital (CAH) Model is the most common and most fiscally successful rural model in the U.S. As mandated by federal regulation, in this model, a hospital has fewer than 25 inpatient beds, is geographically isolated, and is at least 35 miles from another hospital.

As designed, this works because it removes much of the financial risk experienced by small hospitals due to low patient volume by guaranteeing Medicare payments that often cover the majority of costs. Towns using this combination have the highest long-term survival rate for rural hospitals.

Community goals of matching predictable federal reimbursement with stable local tax revenue provide a foundation for the hospital to maximize resources locally. This often includes access to larger physician and specialty provider networks, in addition to serving as a recruitment tool when a community is trying to attract new healthcare providers.

Not A Good Fit

But the CAH model may not work in all areas. This is where the need for community-based solutions is most felt. For communities near large urban areas and/or university hospital and research campuses, affiliation may be a better route.

Small-to-medium-sized communities may find sound footing in establishing a Hospital District that permits property and sales taxes to be levied. Other communities may find partnerships with local philanthropists or community foundations can cover the day-to-day costs. Still others may find merging with another health system provides what is needed. The take-home message here is that we cannot and should not expect a one-size-fits-all model to work.

We’re Open 24/7

As we face decisions about healthcare infrastructure in our communities, we must recognize this fundamental truth: keeping local hospitals open is not about preparing for unlikely scenarios. It is about maintaining access to services that virtually everyone will need.

Solutions to these problems need to have their roots in the community where the hospital is located. That means folks in the community need to understand the challenges faced by their local hospital and make solving those challenges a priority at every level of community life.

What cannot be denied is that closing a local hospital abandons everyone in that community in their predictable moment of crisis. And we can’t let that happen.

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I don’t like asking for money. But the fact remains that there are costs associated with sharing my thoughts with you. Subscribing to my posts helps to defray these costs. I am most grateful to all who subscribe and support this platform allowing me to share my ideas.

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Here’s what got to me: it seems as if this is the only solution offered when we get into a pickle. Ask the rich folks to bail us out, and that seems hackneyed.

Not All Billionaires Are Bad Guys

I don’t think billionaires are the bad guys. I think the system that perverted wealth accumulation is the problem. But if I’m honest, I also think I’m waiting for someone to fix my financial problems, and I resent (and am really afraid) that no one is coming.

I tell myself I just want “a bit more” money so life isn’t quite so challenging. But that phrase—”a bit more”—is where the trouble starts. My “bit more” looks entirely different to someone who has nothing than someone who has everything. It’s a moving target that keeps me perpetually dissatisfied, perpetually looking elsewhere for relief, and perpetually on pins and needles.

The Two Pillars I Stand Between

My search for relief (both financial and emotional) follows a predictable pattern, rooted in the economic and moral systems I was raised with. I look to two pillars, and both of them are rotting from within.

First, I look outside myself. I was raised in the 1950s, when the social contract was clear: my husband would provide for me. The government would create conditions for prosperity. Employers would reward loyalty with pensions. Someone, somewhere, would ensure that if I played by the rules, I’d be taken care of. When that didn’t happen—when the marriage ended, when the pension evaporated, when “playing by the rules” didn’t get me my millions—I felt betrayed. Why was I on the short end of the bargain?

The other pillar is more of a mirror. I look within myself. What am I deserving of? What am I entitled to? The Puritan work ethic I grew up with, still alive in my bones, whispers that my standard of living is entirely my responsibility. If I had only worked harder, saved more, made better choices, I would inevitably have accumulated sufficient wealth to sustain me through old age.

This voice is just as loud as the first one, and it fills me with shame. Maybe I am not deserving. Maybe no one owes me anything. Maybe I simply failed.

It’s amazing how these pillars remain upstanding even while I know they’re hollow. I lean on both simultaneously—expecting rescue and blaming myself for needing it. So why am I not rich? Why are so many of us poor? Why are so many struggling while others are awarded astronomical sums for seemingly insignificant output? And why do I begrudge them all this, yet somehow expect it to be different for me?

The Contract That Never Existed

Here’s what I understood the deal was: I work hard. I get paid a decent salary. I get to keep a roof over my head, gas in my car, food on the table, and occasionally enjoy a restaurant or a vacation. Is that too much to ask for?

Apparently, yes! Or rather, the contract was never real. It was a story we were told during an unusual moment in history when the American middle class briefly existed as something stable. But it was always conditional, always revocable, always dependent on factors beyond any individual virtues or efforts.

I resent the wealthy not because they have money, but because their version of the contract actually worked. They expected the system to reward them, and it did—exponentially, absurdly, beyond any causal relationship to effort or contribution. They stand between the same two pillars I do: they look outward (the system owes me protection for my wealth) and inward (I earned this through my own merit). The difference is that for them, both pillars are reinforced by laws, tax loopholes, and socio-cultural mythology.

The Billionaire’s Mirror

It’s absurdly naive to imagine that the ultra-wealthy, having more money than they could spend in a dozen lifetimes, would naturally turn their attention to giving it away. After all, what better legacy than to use immense wealth to improve the world?

But the characterological traits that fuel wealth accumulation—relentless optimization, control, competition—don’t easily translate into generosity. Many billionaires see wealth as a scorecard, something to preserve and grow rather than release.

The same cultural story that taught me to feel shame for not having enough taught them to feel pride for having excess. We’re both products of the distinctly Christian tenet that wealth reflects worthiness.

Strategies and Solutions

The problem isn’t that billionaires are uniquely stingy. It’s that we’ve built a system where generosity is optional—where the wealthy get to define what “good” means, where those of us struggling are told to be grateful for crumbs, and where everyone expects someone else to make it right.

When billionaires do give, it’s often strategic rather than transformative. They maintain control, enjoy tax advantages, and promise to give later while keeping power now. They justify restraint by claiming governments “waste” money, positioning themselves as better stewards.

But real solutions—affordable housing, healthcare for all, livable wages—don’t come from another billionaire’s innovation project. They come from community. From shared needs and shared resources. From shared power and governance.

What If No One’s Coming?

I’ve been waiting for someone to save me. A government program. A late-career windfall. An inheritance. Some external force that will finally deliver on the promise that I’d be taken care of if I just worked hard enough, followed the rules, stayed married, and saved my pennies.

But what if no one’s coming? Not for me, not for the millions of others in similar circumstances, and not even—in a different way—for the billionaires who hoard wealth because they can’t imagine a world where their security isn’t tied to control.

The real question isn’t why billionaires don’t give more. It’s why we’ve built a world where any of us—rich or poor—must rely on someone else’s generosity or someone else’s decisions about what we deserve.

True systemic change doesn’t ask the wealthy to be more charitable. It challenges both the conditions that make such extreme inequality possible and those who perpetuate them.

Poverty and wealth have no age limits. Neither does the fantasy that someone, somewhere, will save us from a system that was never designed to catch us when we fall. Maybe admitting that—really admitting it—is where the conversation actually begins.

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