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BOOK REVIEW |
27 Lodge Rd. West Newton, MA 02465
Grey Power? Volume 2: Economic and Social Influences, edited by Jean-Phillipe Viriot Durandel. Fédération Internationale des Associations de Personnes Âgées, Paris, 2004, 186 pp., 20.00
(paper).
The New Politics of Old Age Policy, edited by Robert B. Hudson. The John Hopkins University Press, Baltimore, MD, 2005, 309 pp., $58.00 (cloth), $22.95 (paper).
The New Politics of Old Age Policy, edited by Robert B. Hudson, is in some respects a major revision of his previous volume The Future of Age-Based Public Policy (Hudson, 1997), but it is significantly different enough to be considered "an entirely new work" (p. xiii), as Hudson notes in his preface. Because the earlier volume was so widely read, however, some comparison to it is necessary for those previous readers, as well as for new readers who may benefit from observing the changes in issues during the last 8 years.
The number of chapters has been reduced from 16 to 14, while the number of pages has increased from 210 to 309 because of more comprehensive discussions of the various topics. All of the chapters, with one exception, have a wide-ranging list of references. Eight of the 14 are authored or coauthored by contributors to the 1997 volume (Robert Applebaum, Robert Binstock, Judith Gonyea, Martha Holstein, Hudson, Eric Kingson, Marilyn Moon, and John Myles), and 6 new authors are added. Two topics are dropped—the aging network and employee benefits, while two new topics are added—minority workers and senior housing. Adding the issues of minority workers and senior housing is timely and strengthens the usefulness of the book.
Dropping the aging network from a volume on old age policy may strike some readers as odd, but, in fact, it reflects the "new politics" that Hudson is portraying. I saw absolutely no reference to the Administration on Aging (AoA) in any of the chapters and not more than a few cursory mentions of the Older Americans Act as part of lists or as a source of funds. Although AoA was not mentioned, Binstock, in his chapter on contemporary politics, names about 50 organizations and interest groups in aging and devotes five pages of discussion to AARP. Clearly, the politics of old age policy has moved away from being centered on "older Americans" to being centered on policy about programs (Medicare, Medicaid, and Social Security), and about the distribution of public and private responsibilities. This demise is somewhat sad for those of us who remember "the good old days" of elder advocacy.
I don't understand why the topic of employee benefits was excluded. If it was a question of space, I have a suggestion below where it could be substituted. Anna Rappaport's "Employer Policy and the Future of Employee Benefits for an Older Population" in the earlier volume was informative and made some astute predictions about where employee benefits were heading. A new version of this would have been timely in light of declining coverage of retiree health benefits and the apparent decision of corporate America to begin dumping their defined benefit pension obligations onto the Pension Benefit Guaranty Corporation.
Hudson sets the context for the book in an introductory chapter "Contemporary Challenges to Age-Based Policy." He traces the history and development of age-based policy, emerging pressures on age-based programs, and political outlooks. He observes that one of the reasons there is so much focus on old age is that as a nation we neglect the problems of other social groups. But, no matter what policies we choose, he adds, we will still need to face up to the demands of a growing older population. Following Hudson's piece, the book chapters are organized under four headings: Perspectives on Age-Based Policy, Age-Based Policy and Population Dynamics, Age-Based Public Policies, and Old Age Politics and Policy. This review essay, however, will not follow the sequence of the headings. Rather, I am going to begin with those sections that are the easiest for me to assess and then go on to those that are more difficult.
Comprehensive Age-Based Policy Arguments
In the earlier volume Kingson and Jill Quadagno coauthored "Social Security: Marketing Radical Reform." In this volume Kingson and Pamela Herd coauthor "Reforming Social Security: Cures Worse than the Disease." In the earlier piece it seemed to me that Kingson was having a nightmare about the future of Social Security because he observed that it was no longer the "third rail" of American politics. He has awoken now from his dream to find out that reality far exceeds his worst fears. Reminiscent of William Butler Yeats' poem Easter 1916, he and Herd state, "The politics of Social Security is forever changed" (p. 184). This chapter is a fine exposition of the history of social security financing and the strengths and weaknesses of varying proposals for fixing its partial long-term solvency problems. The authors also take apart the ideological arguments of the partisans of privatization. They conclude that rational solutions to a very soluble problem await the arrival of "a more quiescent and less ideologically driven politics ..." (p. 202), hopefully, with the next national election.
Moon, in "Sustaining Medicare as an Age-Related Program," argues that Medicare will continue as an age-based program because there are no viable alternatives. The private health sector can't finance the medical needs of older persons, and it is unlikely that a national health program for all will replace Medicare. Moon says little about the history or current performance of Medicare. Rather, she elucidates the political, economic, and insurance rationales for this age-based program and analyzes some of the options for reform, including raising the age of eligibility. While she doesn't mention it, successful Medicare reform will require, as well, the "quiescent" period called for by Kingson and Herd.
John Pynoos and Christy Nishita, in "The Changing Face of Senior Housing," examine the foundations and history of senior housing, the shift to supportive services and the frail elderly, the development of assisted living, and issues such as reverse mortgages and universal design. Of particular interest is their discussion of the flexibility of the existing housing stock and how it accommodates, through home modifications and service programs, not only frail older people but also disabled persons affected by the Supreme Court's Olmstead decision, which requires states to provide community-based residence to those in its care. Although housing funding and policy debate can be contentious, the arguments seem to lack the affective ideological component of the Social Security and Medicare dispute.
Kingson, Moon, and Pynoos are people I have known personally and professionally for many years, and I am familiar with their writings. The same cannot be said about Colleen Grogan whom I meet for the first time here in her chapter "The Politics of Aging within Medicaid." I am, however, very familiar with the Medicaid program having run the Massachusetts version from 1969 to 1972 and taught about it for 25 years. Grogan's chapter is one of the clearest and most perceptive presentations of Medicaid I have read. It is a wonderful antidote to the pontificators who rail against the costs of Medicaid with the cliché "Medicaid was never intended to allow middle class people to dump their parents in nursing homes." Of course, these critics are right about original intent. Medicaid was intended originally to demolish the universality of Medicare with a means-tested public assistance program. Grogan lays out in detail the history and politics of Medicaid with descriptions of Kerr-Mills, King-Andersen, and other legislative evolutionary phyla. She documents the changing justifications that moved it from a program for the "truly needy" to one that is solving a serious societal problem—care of the aged. She introduces the concept of "universalism within targeting" which means that middle-class eligibility for a targeted program, like Medicaid, will expand if the program benefits are for very expensive goods or services. She traces this development from the initiation of Medicaid to the present by analyzing the ebb and flow of competing frames of elderly deservingness. The chapter is richly documented with both numbers and legislative history. It is a must read for anyone trying to understand Medicaid and the potential effects of changes now being proposed.
Although the chapters reviewed so far make some reference to political factors, in "The Contemporary Politics of Old Age Policies" Binstock makes politics central to his analysis. He describes for us the role of elites, interests groups, and organizations in shaping programs and policy in aging. He assesses the changing perspective of the intergenerational equity position, the shift to conservative thinking about social policy, and the role of elderly voters. He documents the explosion of professional and trade groups playing in the aging domain. Of all the groups involved he focuses particularly on AARP. He credits it with enhancing its position both with its members and Congress by supporting the Medicare Modernization Act (MMA) and its prescription drug provisions, despite strong resistance from Democrats and liberal aging groups. He presents an informative blow-by-blow description of AARP's maneuverings to secure passage of MMA. Support of MMA clearly has helped blunt attacks on AARP as partisan for opposing the President's plan for privatization in the Social Security debate. It remains to be seen, however, whether MMA will be a long-term winner for AARP now that the organization has reopened suspicion of self-interest by advertising its own Medicare drug program. Old-age policies will continue to be high on the political agenda, if for no other reason than the numbers of older people and growing expenditures. The new policies that will emerge, according to Binstock, depend on the broader political milieu—liberal or conservative—of American society.
Gonyea makes a convincing case for age-based policy for the very old—people 85 and beyond. Her chapter, "The Oldest Old and a Long-Lived Society: Challenges for Public Policy," is data driven. It shows the status of the very old in respect to demographics, marital state, living arrangements, economic status, and long-term-care expenditures for older persons. She argues that a national public long-term-care program is the only way to cover the rising costs of an expanding very old population. I agree with her. With the very old, at least, age-based policy makes sense. Gerontologists make a point about the heterogeneity of the elderly and how in the future the group will become even more heterogeneous. That may be true, but it does not negate the fact that the very old are very much alike—they face continued losses and decline, ultimately exiting society through death. The chronicler of myth, Joseph Campbell, referred to them as being located in "the waiting room." For example, a group of 100 people—men, women, and children of many nationalities and religions, rich and poor, educated and uneducated—would be considered heterogeneous, but if they were all suffering with tuberculosis they would be homogeneous in this respect, and policy could be crafted around that fact. Aged-based policy makes sense in certain circumstances.
These six chapters are "go to" chapters for readers interested in a thoughtful and comprehensive review of the subject each encompasses. They would be particularly useful to students. The remaining chapters are more specialized or deal with complex matters that require a different review.
Data Shape the Arguments
Angela O'Rand's chapter, "When Old Age Begins: Implications for Health, Work and Retirement," draws on national data sets to test whether there is an objective means to determine old age, and she demonstrates the difficulty in doing so. She utilizes the concept "life course capital," which she defines as all of the personal capacities and public resources available to an individual over the life course. Drawing on the national data sets, she demonstrates the diversity of individual life experiences prior to reaching the age of eligibility for old age programs and shows how age is an accurate proxy for measuring the career capital of some persons, but not for others. She further demonstrates that these differences in life course capital continue to diverge throughout old age. She concludes that the diversity of individual capital resources makes a policy stance that shifts more risks to individuals very risky in itself.
A similar conclusion is reached by Chenoa Flippen in "Minority Workers and Pathways to Retirement" in which she examines work histories. Using data from the Health and Retirement Study (HRS) gathered in 1992, 1994, 1996, and 1998 she finds that Blacks, especially men, and Hispanics suffer more involuntary job loss in pre-retirement years than other workers. She argues that policies aimed at reducing Social Security costs by extending labor force participation would be particularly discriminatory against minorities. Both of these chapters make it clear that well-being in old age is contingent on well-being throughout the life course and that age-based policy that fails to recognize this will be inadequate and, most likely, unjust.
Madonna Meyer's "Decreasing Welfare, Increasing Old Age Inequality" is a passionate defense of the welfare state, accomplished by cataloguing the sins of our existing social protection programs (Medicare, Medicaid, Supplemental Security Income, and others). The chapter is rich in facts that document the programs' inadequacies and inequities. It is an important perspective that should bring humbling reality to policymakers. The chapter does not, however, lay out a road map to a better system, and her "demand" for a more liberal policy agenda, while welcomed, will not stop the conservative juggernaut.
Applebaum, Sarah Poff Roman, Marc Molea, and Alan Burnett author "Using Local Tax Levies to Fund Programs for Older People: Good Politics and Good Policy?" This chapter updates Logan and Applebaum's case study of Hamilton County, Ohio's tax levy approach to funding home care that appeared in Hudson's earlier volume. The authors report the experience of tax levy programs in five states. They conclude that while it is difficult to make long-range predictions, the approach does have political support and may become more necessary if federal and state governments don't come forth with more home care funding.
Norms and Values Shape the Arguments
Two of the other three chapters approach old age policy from a normative perspective. These are Holstein's "A Normative Defense of Universal Age-Based Public Policy" and Myles' "What Justice Requires: A Normative Foundation for U.S. Pension Reform." The concept of normative presumes the existence of a priori principles or standards that can be used to determine the correct course to take in particular circumstances. Charting the correct course is never easy in the public policy realm, because even if your norms are clear, they may clash with another's, and only political comprise can produce any policy result at all. Both authors draw upon John Rawls' (1972) ideas of justice (as does Grogan in her chapter). Holstein emphasizes his focus on esteem and dignity, while Myles emphasizes his notion that changes to the status quo should be of most advantage to the least advantaged.
Holstein is concerned with dignity and social solidarity linking them to how Social Security and Medicare fare when examined from the point of view of gender and race. While these programs fail her test of justice in some respect, they are more just than most of the changes proposed for them. To achieve justice in American society our individualistic and rights-oriented dispositions must be reined in by the larger community's need for social solidarity and, what the philosopher Jacques Maritain called, civic friendship. Whether this can be accomplished within the context of our particular brand of capitalism is doubtful. Solidarity, the union that toppled communism in Poland, has now been reduced to a shell under our model of capitalism with only about 12% of Poles in unions (as in the United States) and workers being exploited.
Myles' concern is with intergenerational equity both between and among workers and retirees. In addition to Rawls, he draws on theories of public finance to construct his case for reform. Much of his analysis focuses on the distributional effects among workers and retirees of fixed replacement rates and fixed contribution rates in public programs. It is a detailed, interesting presentation that deserves to be read with attention, as is true of the whole chapter. He presents cross-national data on poverty rates and makes a case for more use of general revenue as a just means to reduce the elder poverty gap. Hudson has done his readers a service by arranging for these two chapters, as they force some necessary thinking that can get so easily lost in the daily battles of politics.
The remaining chapter by Steven Teles, "Social Security and the Paradoxes of Welfare State Conservatism," is out of character with the rest of the chapters principally because of its lack of both citations and references. This is due, no doubt, to the fact that it was originally published in The Public Interest in 2000 and not written specifically for this volume. I had a bad reaction to it, so to be fair to you, the reader, I will tell you how Hudson describes this chapter before I do. "... Teles reconstructs the political meaning of Social Security as the cornerstone of a new ‘welfare state conservatism’ so entrenched that meaningful reform has essentially become impossible and allied opportunity costs have grown very large" (p. xii). Hudson may be correct, but in my reading I was distracted by two qualities of Teles' presentation. First, he makes much of the fact that the objective approach of policy analysis conflicts with the real world of politics and argues that policy analysts better understand this. Frankly, I think he has set up a straw man and then knocked it down. The issue of administration, analysis, and politics goes back at least to the late 1800s and Woodrow Wilson's book on administration. It is considered in policy analysis texts, and most good analysts understand the issue. Second, Teles compares Britain's pension systems with those in the United States and argues that the first-best policy is a flat rate pension paid out of general revenue. Using Britain's approach to justify this, he refers extensively to the Beveridge Plan, yet he never tells us about it or its author. In fact, he does not even reference it, relying rather on secondary sources. Who was Beveridge? "Sir William Beveridge is not a Socialist. He has never stood for Parliament and never associated himself with any political movement .... He is a distinguished elderly gentleman, with rosy cheeks, a scythelike nose and a twinkling smile" (Scheu, 1943, p. 18). His 1942 report was titled Social Insurance and Allied Services (Beveridge, 1969). While it was prepared with the advice of British government personnel, it was not an official government document, like a green or white paper, but rather the sole product of Beveridge. Social welfare analysts have drawn on its insights and proposals over the years, but I don't take Beveridge's thinking as normative, and neither did the British government.
The burdens of an aging population will need to be addressed, notes Hudson in his introductory chapter. To do so rationally, however, according to Kingson and Herd, requires, "a more quiescent and less ideologically driven politics ..." (p. 202), which, says Binstock, will be determined by the overall political milieu of the country. It seems to me that the new politics of old age already have been overtaken by the new politics of conservatism, and if this movement is not stopped, life—not only in old age but also throughout the life course—will be demanding for all, except the wealthy. There will be less money in the future to support programs as the financial requirements of the war and security industries grow. Entrenched interests will protect the huge tax cuts that have been put in place. Family responsibility for care of older persons, justified by religious precepts, will become socially and politically normative. We are heading back to the age of rugged individualism and survival of the fittest.
Gerontologists should stop talking about intergenerational equity because it is a diversion from the equity analysis we need. Generations are not static entities but, rather, stages through which we all pass. The intergenerational argument is giving cover to conservative movements both within and outside the United States, as a piece in the volume Grey Power? Volume II: Economic and Social Influences demonstrates. An article from Australia observes that the Australian Federal Treasury's intergenerational report is being "... used extensively by the government to justify its savage health and welfare budget cuts ..." (p. 4).
Programs for older persons also have the effect of being a government subsidy to the corporate and financial sectors of society. Social Security is a great demand side stimulus ensuring that older persons will continue to be consumers, thus helping to shore up the economy. Housing programs support financial institutions and the construction industry. Medicare, Medicaid, and tax expenditures for health care subsidize doctors, nursing home owners, and a huge array of providers, some identified by Binstock. The important question is not why should so much be spent on older people, but why is the ordinary taxpayer subsidizing so much free enterprise while redistributive programs that would improve equity are being cut?
International Perspectives
Grey Power? features authors from a range of countries including France, Germany, Denmark, Britain, the United States, South Africa, Chile, and others. It focuses on economic and social influences, following on Volume 1, which discussed political power and influence. Its three sections cover power and influence over the mass media, senior and social power and influence, and economic and financial power. Apparently, there were no authors' guidelines shaping the presentation of the articles. They range from very brief, such as a two-page case example of senior influence on pensions in Denmark, to a more thorough treatment of an issue, as in a data-driven chapter on work and social security in China. Articles on the idea of social participation of older people mix considerations of participants' mental health benefits with its effectiveness to produce social change. Much of the section on elders' economic power is about marketing to the growing age group 50 years and older. To some of the authors the ideas that older people are very heterogeneous, don't always vote as a bloc, and are not really all poor and decrepit, seem new.
The book is edited by Jean-Phillipe Viriot Durandel and published by the Fédération Internationale des Associations de Personnes Âgées, located in Paris. Durandel's introduction and concluding chapter, "Rethinking ‘Grey Power’ in the Public Arena," are informative and thoughtful and transcend the particular offerings in the book. Many of the chapters are illustrative of his thinking, rather than his thinking being shaped by them. The volume would be useful to a gerontological library, especially in a setting that was concerned with the international dimensions of aging.
Concluding Observations
Age-based policy will continue to be a sensible approach in situations where age surely serves as a proxy for other conditions. Gonyea demonstrates this in her discussion of the very old. In the areas of economic and social programs, however, programs that seek a more fair and just society based on human dignity and solidarity will best serve older people. As I put it in my earlier thinking about the national agenda for aging, which I expressed in a talk at the University of Minnesota in 1992:
The national agenda for aging should be to see clearly the source of the difficulties we face and base our attempts to resolve these very real problems on the basis of the rights of human beings—economic, social, and political. It is only within this framework will we be able to address more intelligently the concerns I delineated at the beginning of this talk.Unemployment and depressed wages now mean lower retirement benefits in the future and less personal income to spend, for example, on one's own long-term care. Greater poverty now means more illness and disability in the future with its attendant demand on the health system. Failure to recognize the human rights of the living now will numb our sensitivity to the dying. Without a concern for human rights now the breakthroughs of medical science will not be equally available to older persons by income, race, or ethnicity. Without a concern for human rights now, there will be no limits on corporations to cut or drop their benefit programs for the future. Without a concern for human rights now, older persons won't be full participating members of the community in the future.
Well-being for older citizens is necessarily linked to the well-being of all citizens.
References
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