I completed three days of home visits this week. It provides such a view of people’s lives and the white coat and stethoscope allow me to look intensely and ask questions. Here is a tour of small town middle America in 2019.

Aging and dementia—the messy realities.

The musty smell of animals as I entered her apartment should have clued me in. She had been funny on the phone when I’d called to remind her of the appointment and wanted to keep engaging me. I discretely placed a paper drape on my chair before I sat down across from her at her kitchen table, my feet near the cat litter box. Fleas jumped around my feet. Across the way the sink was piled with dirty dishes. She had wild gray hair and her clothes were worn and mostly clean. She told me she bought healthy whole wheat bread from a local grocer and ate that every morning with peanut butter, but she couldn’t remember what her other meals included, although she liked the taste of spam. She was proud of the weight she’d lost—to an unhealthy point. She saw her physician once a year, but she couldn’t remember his or her name and couldn’t produce a document or pill bottle amid her piles of newspapers, magazines, coupons, piles of clothing, and bags of cat food and cat litter. She had stories to tell about her life as a high powered chemist, children from whom she was largely estranged. I told her that I was worried about her toenails, 2 inches long and curling. She had an unlikely story of how they got that way, a child dropping a brick on them years ago. But she liked the idea of getting someone to trim them and to help her clean her house a bit. That was how I told her I would be calling the county to help. I wondered if others had made reports. Now, I hope she will let them in and that their strapped budgetary constraints don’t interfere with their ability to help her.

Retirement and fixed income for the middle class—we thought we saved enough!

Three retired business men, well into their seventies and eighties, had buried their wives several years earlier. Now they were on their own with adult children who checked in despite busy lives. All had pensions and had done well in their careers, one even retired early, but they were struggling to afford medications that had gone through the roof. A diarrhea med that had a co-pay of $8 which now cost over $100. The shingles shot which was an out of pocket cost well over $100. And unaffordable vision care and dental care. They owned their homes. I walked back to my car worried about what was happening to middle class America: Promises made to this generation white males who worked hard, and planned well and now what?

Special needs and disabled—the ongoing commitments.

I visited two special needs adults. One woman, I’ll call Sally lived in her own apartment and suffered only physical disabilities, cerebral palsy leaving problems with her left arm and leg. She had made quite a life for herself with friends and a dog, despite no contact with her family. I wondered, but didn’t ask about the story. I sensed it involved rejection of who she was. Despite her upbeat attitude and graciousness, she admitted to thoughts of suicide at times, no plan. She also worried about the low rent apartment closing in the next few years and what that would mean for her. The other woman, I’ll call Patty, had suffered more severe trauma at birth with both physical and mental disabilities. I arrived late in the day to accommodate her work schedule at a day activity program. She was relaxing on the couch, curled in a fetal position and covered with a blanket and watching television. She laughed easily and responded to the group home staff who cared for her and another client who had a similar story. Both were verbal in a manner that took familiarity with them to understand. New management had stabilized Patty’s care and her weight loss stopped thanks to a better pureed food plan.  

Life is fragile and complicated. Health is fragile and our complicated health non-system and social network need shoring up and reconfiguring. Although the ACA is far from perfect, I hope it is not abandoned, unless a better solution is in place. We cannot spend endless dollars on health, lining the pockets of shareholders and paying CEOs outrageously. Continuing this approach will forsake patients and other safety net programs which are important to health and well-being.