Sunday, 6 October 2013

An Age Old Old Age Question

It is a truth universally acknowledged that the UK population is ageing. To be precise, by 2050 there will be 19million people aged over 65. What is more rarely acknowledged is the scale of the problem this poses. Old age is the price any society pays for improved health care; the trouble is our society simply cannot afford to pay it. In an ideal world of unlimited resources the just solution may be for the state to cover the costs of everyone’s social care. Alas we do not live in such a world. A years stay in an older people’s residential home can cost upwards of £30000. Multiply that by 950 000 (around 5% of older people currently require care) and the bill is staggering.

I intend outline three practically feasible alternative payment mechanisms and consider some of the potential injustices these systems may pose. There will be no 500 word dash to the most plausible/least objectionable/insert-political theory-phraseology here solution. I simply wish to generate some debate around one of the least fashionable, but most pressing, policy issues of our generation. Additionally, I would like to implore political theorists to consider justice through the lens of a real world policy problem. We do not only ourselves but our society a disservice if we are unwilling to be stirred from our ivory towers to get down and dirty in the dilemmas of real world policy making. And in any case, in 50 years time we will all be reaping the life that we sow now.

So, possible solution one: make individuals pay, but provide a safety net for those who cannot. This is pretty much how the system operates in the UK at present. There are two main problems with this. First, the safety net care paid for by the state is inadequate. State funded care is poor in quality and choice and, with the pressure on it increasing, is only likely to get worse. The NHS is based around the intuition that people should not receive inferior care because they cannot afford to pay – why should this be any different in older people’s care? Second, it is highly debateable whether it is fair to ask people to pay for their own care. Not everyone who gets old will need social care. Is it fair to ask an old person who is unlucky enough to need care to pay, often exhausting all their assets in the process, when their neighbour of good health will not part with a penny?

Solution two: up taxes such that all care can be funded. Putting to one side the usual questions that surround high taxes (will it destroy the UK economy, will the super rich move abroad and so on) this seems to be unfair because it places the bulk of the burden on the younger generation. Those who are already retired will avoid having to pay for their care without ever paying any form of punishing tax for it. Given the youth of the UK are already facing greater economic hardships and fewer opportunities than their parent’s generation, is it fair to disadvantage them further by levying a new tax? Or is this one off disadvantage one society must accept for a better care system for future generations? Further, is such a tax sustainable? The latter is an empirical question which depends on economic recovery and projections. In any case, any tax that would be sufficient to cover the scale of the problem would need to be substantial.

Solution three: people are left to insure themselves against the risk of expensive social care. There are already companies that provide services akin to this, but premiums are so high that few people choose to opt for them. This may be more palatable than high taxes because people choose whether or not to insure themselves against the risk of high costs, meaning it is less financially punishing and less paternalistic. Unfortunately, the flip side of an absence of paternalism if that people may fail to insure themselves altogether, meaning people could be forced to pay high costs for their bad decisions in later life. It is my opinion that some form of compulsory insurance system may be the least unpalatable option, not least because old people insuring themselves now would pay significantly more than young people, and pay this equally, thus baring the cost of their generation’s care themselves. However, additional to the problem of paternalism this measure would also be highly inconsistent. There are many things it may be beneficial for people to insure themselves against that are not compulsory. How could this inconsistency be justified? Ultimately, my answer to that is that consistency should be an aid to justice, and not an end in itself. I for one would rather live in an inconsistent society with more just outcomes than one where consistency is pursued above all else.

22 comments:

  1. Imogen, thanks for this post! The UK is not alone with the problem...
    To start the discussion: it seems to me that one can distinguish a number of strands to the debate.
    - the idea of insurance as such: given that we do not know who will need what amount of care, but have reasonable estimates about the distribution of likelihoods for certain age groups, it seems a good idea, and arguably and idea that increases justice, to have everyone participate in an insurance scheme, to avoid the scenario you sketch about one person getting impoverished and another one staying healthy, which seems a matter of sheer luck
    - moral hazard: although it may seem overly harsh to use this term in this context, the basic idea is that if you offer insurance (or support of some other kind), people will behave in riskier ways than they otherwise would. This can be the case when you have private insurance or when you have a public safety net (unless its conditions are really appalling) - if you have a safety net, people might be unwilling to take out private insurance in the first place
    - paternalism: strictly speaking, paternalism is only an issue if people act against their own long-term interest. This might be a problem here, but I assume that making insurance mandatory is attractive because you would not want to have certain groups opt out (this point might be raised against your worries about inconsistency)
    - intra-generational justice: how are benefits and burdens distributed within one age group? If you have mandatory insurance, you can try to distribute fairly within one generation (I'm not sure whether you could cover all costs with this or whether you need subsidies from other generations, depends on the numbers)
    - inter-generational justice: how are benefits and burdens distributed across age groups? This can be really difficult to evaluate because you'd have to measure other things such as technological progress and cultural changes as well. Let me note, though, that if you have an intragenerational mandatory insurance scheme (which seems quite attractive as a solution), this will also be a burden for the next generation because they will not inherit as much wealth from the previous generation. Depending on one's position about inheritance, one may or may not like this!

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  2. Imogen, I'm not sure I understand the problem with the second solution (perhaps because it is my favourite?) If taxation is progressive, then it places the bulk of the burden not on the younger generation as a whole, but on the wealthiest members of the younger generation. These members are likely to enjoy more than their fair share, and hence not overlap with that part of the youth who is 'already facing greater economic hardships and fewer opportunities than their parent’s generation'. (At most, the best off from the younger generation may be less well off that the best off from the older generation. But I don't find this plausible and, even if it is plausible, I don't think it is problematic.)

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    1. A small point to add to Anca’s comment. I wonder if the worry you pose here might be further reduced if one considers that a progressive tax system will also fall, to some extent, more heavily on people as they get older. So, as Anca says, those in lucrative careers will be in a higher tax bracket than those in lower paying careers, but, in addition, those further along in lucrative careers will pay more than those at the beginning of them. If the tax fell most heavily on these individuals, it would not be generally a youth with fewer prospects than a previous generation who face the bulk of it. Indeed, it may be those who are most likely to create the higher number of higher later-life costs – 50-60 year olds in lucrative careers – who will take, at least, the first major hit (after which the progressive tax approach would not seem to harbour the main objection you give to it, at least to the same extent). At any rate, it seems worth thinking about the progressive tax system as a spectrum also in terms of the age-brackets it will affect. Possibly some of your worry is lessened when considered through this lens.

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    2. To add a bit extra on that point: if you are interested, some recent data on earning patterns across age brackets in the UK (and various other patterns relating to pay) can be found here:

      http://www.ons.gov.uk/ons/dcp171766_252474.pdf (p. 21)

      The data suggests my initial estimate of ages on which the tax would fall heaviest is a little out, but close enough for the gist to carry, I think. And it should hopefully be useful for the general thought about the age/tax spectrum.

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  3. In terms of a longer comment, I am wondering a little about unpacking the insurance suggestion. Partly in virtue of the points made above, I think I would guess that the question of ‘who pays’ might not decide between suggestions 2 & 3. I think both could be engineered to weight the costs towards presently older groups in, at least, a moderately fairly intra- & inter-generational way (and to accommodate other aspects of fairness on the issue). For this reason, I think it might be that choosing between them involves mainly other issues. To take two thoughts raised in both your post and Lisa’s comment, perhaps consider the following:

    1) The question of choice & paternalism. In a sense, one thing that might make the insurance idea attractive is the fact that it would allow for somewhat more discriminating choice. A tax and redistribute (cash or kind) might be a rather blanket system that offered a quite generalised system of care. Insurance schemes, on the other hand, could be made rather more particularised. It could be constructed such that there was a compulsory minimum, but various optional add-ons. (This system would be somewhat akin to the Swiss health care system.) That system would ensure that all were provided some basically decent level of care, but allowed people to choose whether to purchase further benefits or use their resources at an earlier stage in life. That, I think, would lessen a worry about paternalism and, I think, be more consistent with a liberal picture on leaving individuals to choose who they live (and end) their lives.

    2) The issue of luck in terms of who needs what kind of later-life care. One worry about the insurance model would be that it would discriminate against people who had, e.g., a family history of later-life medical problems of certain kinds (in particular, those that cost more to treat), because insurance companies would ask for higher premiums from them. Thus, I wonder whether the insurance market in question would need certain types of regulation. Again thinking about the Swiss health care system as an example, perhaps it would be possible to impose differential costs based only on, e.g., the age at which one takes insurance, but not to allow differentiation based on calculated probability of certain kinds of medical problems. (I guess similar ideas might be used to think about the issue Lisa raises on moral hazard; perhaps we could utilise ‘excess’ clauses that would help discourage certain kinds of risk taking.)

    I am not completely sure what I think about either suggestion. My aim here is to explore some of the moral intricacies that might be at work in the insurance idea and how they might contribute to comparisons with the tax system approach. Any thoughts on them, Imogen (or, of course, anyone else)?

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  4. Andrew: I agree that creating a 'basic minimum' of insurance lessens the worry about paternalism but it by no means abolishes it completely. Even a basic minimum of insurance still constitutes a significant restriction on the liberty of individuals, who are deemed incapable of making responsible decisions with their own resources.

    More broadly, I wonder how the issue of social care is effected by ones beliefs about euthanasia. Obviously, I am not suggesting that euthanasia is a solution to the problem. However, if you believe that an individual has the right to choose when they should die it might make some of the solutions you have suggested more problematic. For instance, it might make the compulsory insurance scheme incredibly unfair in particular kinds of circumstance. Should a person who has decided that they would rather die than develop severe Alzheimers then have to pay the costs associated with the risk of them developing that disease?

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    1. NB: Just to clarify I am obviously only talking about voluntary euthanasia.

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    2. I suspect about as much restriction on liberty (and with similar issues at work) as mandatory pension schemes (and various other social insurance programmes). Not sure if I think these are 'significant restrictions' or terribly objectionable. I guess it also depends a lot on what is mandatory and what is optional.

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    3. How much evidence do we need to show that people are (in economics jargon) hyperbolic discounters? People's preferences are not consistent throughout time and they are consistently short term thinkers (one of the reasons why education is compulsory).

      I think of it like a Bank - we're not going to let a bank do whatever it wants because ultimately the cost will fall on society to bail them out, as such we have the right to limit their actions. The same is true of individuals - we are not going to let them starve/live in the cold, but as a result of this we cannot let them take actions which will result in us having to 'bail them out'.

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  5. Definitely agree its an issue which needs a great deal more attention than its currently been given.

    Although I think I'm in favour with your second option, rather than the third. I liked Andrews first response to the potential objection of inter-generational injustice. The idea that realistically it will be those which are most likely to benefit first who will pay the heaviest now.

    I am concerned more generally with the insurance option for a number of reasons. Firstly, as Andrew mentioned, those which need it the most (through no fault of their own) may be burdened with extortionate costs throughout their adult life, which seems unfair. For example I don't think I would consider it fair that a daughter who has a strong history of breast cancer in the female side of her family should necessarily pay crippling insurance costs her whole life because of her horrible luck. Basically the intuition behind insurance option is the same as a hefty tax - make sure we all make a fair contribution towards the costs of keeping us healthy and happy (to a reasonable extent) in our old age. The difference (as far as I can tell) between the two options would simply be those that have higher risks pay more? Considering the above example, as well as that generally the most underprivileged in society are the least healthy, I think a system of paying premiums could end up being very unfair in some cases. Therefore I would rather have a progressive tax.

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  6. Thanks for the post, Imogen. To some extent, I'm tempted to play the devil's advocate here, and so that's the line I'll offer in this comment:

    It might be thought that we simply spend far too much money on care services when we are old. Give me the choice of living for extra year in a residential care home when I'm 97 or having £30,000 now, and I'd opt for the latter. It seems to me therefore that this lends some weight to the idea that we shouldn't force citizens to pay for expensive care service for the elderly. This idea is consistent with the third proposal - namely that it should be up to individuals to decide how much money is spent on their care (and, perhaps this is best done through allowing people to insure themselves).

    An implication of this view is that, if insurance turns out to be prohibitively expensive, then we perhaps shouldn't worry. It seems to me that plenty of things are too expensive to insure against and the appropriate response to them is simply 'tough luck'. The fact that we don't live in a world of abundant resources is, of course, going to force us to have to make tough decisions and sometimes put up with consequences that we don't much like. The fact that care for the elderely is incredibly expensive doesn't challenge the insurance-based approach, it simply produces the conclusion that we shouldn't spend vast amounts of resources on small periods of our lives.

    An important worry is raised in relation to the fact that not all are situated equally with respect to being able to insure for future care. Though this is to some extent as a result of genetic differences, it seems to me that it is primarily as a result of inequalities in income and wealth. That is, whereas some rich people can afford expensive premiums, many poor people cannot. This point is important, though I'm not sure it challenges the insurance-based approach that much. This is because the problem arises only in virtue of considerable income and wealth inequality. Importantly, instead of sanctioning the rejection of the insurance-based approach, our concern for equality in this case instead surely simply gives us further reasons to object to wealth and income inequality more generally.

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    1. Can I just also put out there that this £30,000 figure seems a little crazy? Kind of reminds me of US healthcosts. I'm sure we could find ways of making this much cheaper.

      (I assume these costs exclude medical expenses which fall under discussions of the NHS, which does have cost / benefit analysis of it's treatments.)

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  7. Tom, doesn't your approach presuppose that we can and want to let people whose preferences change over the course of their lives die? Or would people sign a contract, earlier in life, agreeing to euthanasia later? What about those who haven't signed such a contract and are in need of care (that's the situation we have, in practical terms, and which will get worse)? According to research (which I only know from newspaper articles, admittedly), the human psyche is astonishingly adaptable, and people can be quite content in situations that seem appalling from the outside. You saying now that you prefer the £30,000 now isn't necessarily a good indicator of what is the best thing to do with a happy 97 year old.
    It's interesting that no one has brought up families' responsibilities so far; I guess that is because it does not reduce the injustices to shift the burden on families. I'm *not* advocating families' responsibilities here, but it's worth noting that very often, this is what's happening at the moment (with unequal gender distributions as well). One point at which this might be interesting is how you design insurance. Given that individuals might simply be unable to imagine what it is like to be 97 years old, maybe there should be insurance options for families to get support when they decide to take care of their 97 old parents?

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  8. Thanks, Lisa. Let me address the comments in reverse. Yes, I agree that our cognitive capacities are severely limited in all kinds of ways, and I certainly think that more should be done to combat this cognitive biases when making important decisions like the kind we are considering. Two points are relevant here. First, it must not only be that we incorrectly discount the future, it must be that we get it really very badly wrong. In order to justify the very high care costs for the elderly, the elderly's lives must not only be better than expected, they need to be much much better than the lives of the young. Whilst this is true in some cases, I doubt that it is generally true. Second, I tend to think that very often we (have to) make huge decisions that affect our future, and that isn't always a bad thing. To deny someone their shot at their life dream on the grounds that they might come to regret seems to me to be wrong. We allow people to make risky choices that seriously affect their future all the time (consider the risks associated with certain sports, for example). Might it not also be the same with care for old age?

    The first point is more challenge for me, I think. There is clearly something wrong about denying basic care to elderly people who have failed to insure. I'm worried, thought, about analogous case. Let us imagine someone who kept giving all their money away or burning it (because they enjoyed it), and then came to the state to ask for more money. Whilst on the one hand it seems wrong to allow them to starve to death, it also seems wrong to make other citizens have to subsidize this person's expensive lifesytle. Perhaps we are in the same sticky situation in the case of care for the elderly...

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  9. One final thought: In distributing healthcare resources we put a limit on which kinds of medicines and drugs ought to be freely available on the NHS. If a drug is too expensive then it is simply denied to patients and, unfortunately, this often means that patients are left to die. This is clearly an awful situation, but it looks to be a necessary one in situations of resources constraints.

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  10. Well, you might be right that there can be cases in which it seems justified to leave others alone with their fate if they have made irresponsible choices. But I'm not sure this holds for old age care, precisely because the kind of cognitive error is so wide-spread and predictable (even if some old people might be less happy than young people). And with regard to resource constraints, the question is one of proportion, I think: how rich or poor does a society have to be to make it justifiable to let some (irresponsible, short-term orierented, whatever) members die? (There is a huge set of follow-up questions here, about what such a policy would say about the character of a society as a whole, about young but disabled members of society, about the caring professions, etc.)
    (One interesting question in this context (sort of a meta-question): how do our personal experiences influence our philosophical intuitions? I had a grandma with dementia who lived in a residential home, and I am pretty sure that this has influenced my view, although it's hard to spell out in exactly what ways….)

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  11. Thanks, Lisa. I think I'd like to press you on the idea the question 'how rich or poor does a society have to be to make it justifiable to let some (irresponsible, short-term orierented, whatever) members die?' It seems to me as if we are forced to make these kinds of decisions irrespective of how rich or poor we are. In a world with limited resources we are forced in to deciding how to allocate these resources and, unfortunately, this sometimes means that it will be all-things-considered justifiable to allow someone to die who could otherwise be saved. An important question is: How much are we willing to spend to keep someone alive for an extra (quality-adjusted-life-) year? This question is important in healthcare decisions and therefore would seem to be relevant in care for the elderly.

    Interestingly, my understanding is that, roughly speaking, the NHS won't pay for a drug if it costs more than £30,000 per QALY. Why, then, should society pay more than £30,000 for a year's stay in a residential care home? In other words, if we aren't willing to pay £30,000 to extend a young person's life by 1 QALY, then why should we pay £30,000 to extend an older person's life by 1 year (not even quality-adjusted)? Of course, you might think that the NHS should have its budget substantially increased so that it too, like residential care homes, is able to provide many more life-extending services. My worry is that this approach begins to send us into a bottomless pit.

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  12. Well, two things: first, there is what people should get as a pure matter of justice and then there is what societies should decide to give them. Sometimes I think there are good reasons to think that the latter is more than the former (I think there can be analogous cases with regard to migrants, victims of natural disasters, victims of crimes where the criminal cannot compensate them… ).
    Secondly, part of the problem is that as of now, there seems to be a kind of societal consensus that letting people die in old age for lack of funding is not acceptable. People might (conciously or not) build on that. There would have to be very clear messages that it won't be the case any more if it changes.
    I am not sure how far the comparison to the NHS gets us - or maybe it points to some form of irrationality in my thinking. My spontaneous thought was: well, but it's the *illness* that is the cause of the death. It is exceptional, and it gives you a storyline in which you are unable to prevent something happening that would otherwise happen anyway. In the case of old age, you might have some cases that are parallel (keeping someone alive who would otherwise die very soon). But often, these old people can live for years if they get some care - there is no immediate cause (such as an illness) that you can blame when they die. So it is more like a disabled person than like a person with an illness that is very costly to prevent. But is it rational to draw such a line at all? If not, which way would you go - also let disabled people die, or not let old people die?

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    1. Thanks again, Lisa. On the first point, I tend not to draw a distrinctino between 'justice' and 'what societies should decide to give them'. That is, I simply (and stipulatively) use 'justice' to refer to what citizens are entitled to.

      On the second point: hmmm....its a good case and one I certainly need to think more about. My gut reaction is to say that, like with residential care homes, there ought to be limits on the extent to which we are willing to fund care for people with disabilities. In priciple, there seems to be no reason to draw the line in any different place here than in the case of healthcare or residential care homes. My thought, in short, is that, at the end of the day, there are limits on how much we ought to spend any good and, in the case of care, we may be close to or even have crossed that limit.

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  13. Apologies in advance for my reply which hasn't had time to read all of the discussion above!

    Hi Imogen – thanks for the post. A really important issue that is worth a lot of discussion.
    Unfortunately I do not have the time to relay my full thoughts on this issue, but some very brief points (also apologies if there are overlaps with comments – haven’t had time to read them all!):
    - I think you cannot divorce this issue from pensions (How to care for the elderly is really a question of how to keep their consumption above an acceptable level, which then in turn is a function of their savings), so going forwards my points will talk about pensions, but I think transfer just fine for the specific issue you raise.

    - From the economics literature, a directly funded pension system is far more efficient than the current pay as you go one. This is because it is immune to demographic imbalances. Pay as you go systems work when there is a large pool of young workers supporting a small group of retirees, but break down when there are demographic shifts (as there have been in the developed world.) A directly funded system means that the money we pay towards social security/public pensions etc. now are invested on our behalf and then used to pay for our generation’s welfare when we retire.

    - This has to be a state mandated scheme which everyone pays into. I would justify this using a standard veil of ignorance/Dworkinian auction idea. You would definitely pay for insurance against having no savings upon your retirement. Furthermore, as the governments threat to not support the elderly who are in poverty is non-credible (which I think we can all agree is a good thing) – this introduces moral hazard into savings – why save if the government will support you if you’re ‘bad enough’ off? As such this should be a universal system which we all pay into and receive from.

    - The major issue would be how to fund the pension system for the next 30 years as you wait for the last remaining individuals from the pay as you go system to fall out of the system. The answer here is you borrow a huge amount of money and pay it off over many generations. This is exactly the purpose of debt, to smooth consumption over multiple generations (who will all benefit from being on the superior system the debt was required to create!). Currently this is a problem due to our high public debt levels, but it is not unreasonable to think we will be in a much better position in ten years or so to make this shift.

    - I think one of the most interesting components of this debate is how it draws out one of the largest problems of public policy discussions – that it considers problems in isolation. It is highly likely that we will have to raise the retirement age to afford supporting the elderly. However the facts of the situation are that for those at the bottom of the income distribution life expectancy has barely changed in the last 25 years, whereas there have been huge gains for higher earners (http://krugman.blogs.nytimes.com/2012/11/13/life-expectancy-of-the-living-dead/) . As such if we try to address this problem, without facing up to other problems in our society – such as inequality – we will end up with a system where the poor work until they die in order to afford an even higher standard of living for the rich in their retirement.

    - Lots of really good reports have also been written on these issues! Unfortunately they are politically hard to accept and thus gather dust in a draw…

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  14. Imogen, thank you for this post and my apologies for only engaging with it towards the end of the week. I found it very interesting, especially as it relates to a few questions that I have been thinking about. What I would like to suggest is that there is also the potential to look at this problem from the other side. You begin with the estimate that "by 2050 there will be 19million people aged over 65". As you point out, there is an obvious issue here about who should pay for old age care, and how. My natural inclination in such debates is to take the discussion off in a related but distinct direction, one which begins by questioning whether this is, in fact, the major problem that we tend to assume it is, and how we could change our mindsets and cultural attitudes towards old age so that we could begin to see these millions of people as an important national "asset/ resource". My thinking goes as such: (a) older people have a huge reserve of knowledge (both specific and general) and, once retired, they also have lots of time [both important resources]; (b) in my opinion, society currently does not treat older people with due respect, but instead judges them to be a drain on society (even though, in general, they have paid their taxes and served society in numerous ways for let's say half a century) [this seems to me to be a clear by-product of capitalism, whereby people's value is closely aligned with their productive power]; and (c) although there is an issue around the costs of health care for the older generation(s), there are still plenty of healthy, vibrant older people whose health (both mental and physical) would arguably be promoted by having a heightened sense of purpose, belonging, and service in older age [a significant proportion of older people suffer from some of the worse social ills, namely, loneliness, lack of respect, etc.]. It therefore seems to me that perhaps we are beginning the discussion from the wrong starting-point. Why aren't we asking the question, first, of whether/ how to set up both local and national programs that - starting from an understanding of how much the older generations have to give to society - seek to engage them in a number of important roles in a more formalised way [there are already some ways in which older people can get involved in volunteering informally, e.g., in Oxfam shops]. I'm sure that, between us, we could think of many different areas in which extra voluntary "workers" would be greatly beneficial - just take, as an example, classroom/ teaching assistants in primary schools. The idea here is that we would be creating a (potentially) win-win situation for all involved: (i) society is utilising the knowledge, wisdom and time of the older generation in important, and often 'care-based', voluntary societal roles, thereby "off-setting" the health care costs of (some of) these people; (ii) this would begin (hopefully?!) to change cultural attitudes towards older people and give them more of a sense of worth and purpose within society (which they are due); (iii) it would be run on a completely voluntary basis, so those members of the older generation who would prefer not to/ are looking forward to spending their savings/ have a great family network and are keeping busy in other ways/ [enter in what you will] would be able to select whether and/ or when they might like to volunteer: the point is that there would be an established route/ invitation into doing so that would be offered to them along with their pension [we would need to steer away from the idea of incentivisation (through extra pension money or something) as this would likely mean that poorer older people would have to become part of the program, even if they didn't want to be, in order to supplement their pensions, whereas richer older people (with savings) would not need to (though they still might want to)].

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  15. All of this, of course, does not help with the question of health care costs for the growing older generation(s) in any direct way; but I'd be interested in getting your thoughts about the idea of viewing this issue in a different light so as to see the older generation(s) as an asset, not only a drain, to society.

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