Critical Age Theory: Book Review

Published 29 May 2022.

I have been reading widely about aging since 2010.  

A few books take a comprehensive view of the aging process, titles that I often recommend to people who are not gerontologists so that they can get The Big Picture. 

Ten Books: An Essential Library on Aging

I have found another title to add to my list of must reads about aging. 

Mario D. Garrett, PhD has written a jeremiad of sorts about the many institutions that prey on older adults, capitalizing on the vulnerability many face in late life. 

To create a context, I suggest readers first watch the 2020 film, I Care A Lot, directed by J. Blakeson and starring Rosamund Pike. I watched the film the year it was released and found it interesting as an exaggeration, a dramatization of the state of eldercare in the 21st Century. 

Two years after viewing that film, Garrett's book has me rethinking I Care a Lot as being less a niche genre black satirical comedy thriller and more from the genre "based on true events."  I had already planned on mentioning this film in my review before I saw that Garrett references I Care A Lot (2020) himself.   

Watch the film, but if you going to choose one, read Garrett's book.  

Critical Age Theory: Profiteering From the Final Stages of Life (2022) describes the ways for-profit companies and even the government and non-profits fail older adults when they are the most frail of mind, body, and finances. 

I teach college courses on aging (gerontology), and this book would work well to alert my students to the unethical practices that are inherent in the system and challenging for individuals to change at their level. 

The chapters are as follows (with a staccato summary/response for each chapter). 

(Here is my Goodreads review, which I wrote chapter-by-chapter as I read. It's grittier than my blog review.) 

Introduction: This sets the tone with Garrett as the lone voice in the wilderness, asking people to look at the larger systems controlling aging and to spend less time blaming elders and their family caregivers and less time wagging fingers at those paid to offer support directly to older adults.  The problem goes higher up, and it goes deep into the structures of 21st century power structures.  Here is one example that gestures to system rather than the individual as the root problem:

"We make it easy for . . . commercial practices to continue as we tend to see only individuals that commit fraud or harm. As with elder abuse, we personalize the interaction. however, in most cases, the institutional make up--what we euphemistically refer to as their business model, or business culture--determines how individual workers behave within an agency. Since the business model dictates workers' hours, duties, and responsibilities, it is logical to examine the business model being used" (9). 

(I do not remember Garrett using the word "hegemony," but academics use this--and other words--to study the network of power that is pervasive and difficult to combat.)

1. Drugs: Drugs are often improperly prescribed and almost always overpriced.  

*Each chapter ends with a "Playbook" that unearths the game plan that seems to drive decisions based on profitability over patient-centered / customer-centered / client-centered service. One of the items from the "Playbook" on the chapter "Drugs" is this: "Price medications on the basis of what people can afford rather than what they cost to develop and manufacture" (37). 

     

2. Conservatorship: Not just individuals but companies manage conservatorships unethically.
 

3. Housing: Not all elders have equity in homes, but even those who do often lose too much value by using reverse mortgages and other exploitative practices. 

4. Assisted Living: This is expensive and not as comprehensive as touted. A la cart services add up quickly. 

5. Nursing Homes: There are laws in place, but those who are striving to make a profit can find loopholes that diminish care in the name of profits.  Overworked, undereducated CNAs do most of the point-of-contact care. Those at the top (owners, investors) make a lot of profit and shield themselves from law suits about neglect or abuse, pushing the punishments to those who work on site. 

6. Hospitals: The contemporary hospital is complex and patient care often gets lost in the complexity but economics always stays in sharp focus. 

7. Sub-Acute Care / Cryonics: People are fearful about dying. Expensive medical care can keep people alive when their quality of life is extremely low (coma / vegetative state). And those who have the money can find companies promising (but not delivering) eternal life by freezing the body for future reanimation. 

8. Do Not Resuscitate and Hospice: Patients with DNRs do not always get their wishes met because the paperwork is not always reviewed before treatment, and the central tenant of medicine is curative care not palliative care. Hospice can help people with end-of-life care, but its a business, and many business decisions by some hospice companies are made based on which kind of death trajectories (for example, those on hospice with dementia as the primary diagnosis) are profitable to the hospice business. 

9. Funeral Services: Those planning for their own death, burial, services and those who will survive them often fall victim for paying too much for the basics (cremation or coffins) and paying for upgrades or unnecessary additional services and products. 

10. Pensions, Insurance, and Funds: Government programs such as Social Security and Medicare and private programs such as pensions and health insurance are in transition. People used to live very few years post-retirement. Now people live 20 or 30 years past retirement, and it's expensive. Politicians robbed from Social Security, not planning for the dramatic increases of life expectancy, and now the Boomers are drawing SS benefits, and the program cannot pay out. Companies have switched from defined benefits to defined contributions, but not all workers pay into retirement programs. Poverty in late life is a real problem, and our government and businesses are not as well prepared to support our oldest citizens as other industrialized nations.  The individual gets the blame instead of the larger systems. 

Conclusion: The conclusion does a little bit of summary; however, it also includes quite a bit of new information that is relevant across several of the prior chapters.  Some of the conclusion also identifies patterns that cut across various industries. And some of the conclusion makes broad observations about culture in addition to what has been observed throughout by institutions such as healthcare, insurance, and the government. Because of the complexity of the conclusion, it's best if I share the headings that indicate this in-depth, far ranging content: 

The Findings So Far

Government Collusion
The Business Evolution of Dialysis

Policy Limited Fraud and Abuse

The California Master Plan for Aging

Futile Fines

Future of Artificial Intelligence

Failing the Workers

Control of Medicare and Medicaid

Failure of Long-Term Insurance

Combining Insurance Eligibility

The Birth of Medicare Advantage

Gaming the Risk Score

Expropriating Medicare

The Final Playbook

Step Up or Step Down

Shame and Tell

The Future

True, this book does more to describe the problem than to propose specific, practical solutions; nevertheless, the first step to change is acknowledging there is a problem. Yes, the tone of the book is quite heavy, but I applaud Garrett for marshalling a lot of specific detail to support the jeremiad nature of the book.  This is no religious text; it's academic. The facts that he present make a compelling case for brainstorming with others to find a way to intervene, to transform a complex system so that it does less harm and more good. 

(I received a copy of this book in exchange of a fair and honest review.)

Related: 

Books about Aging