Tag Archives: long term care

How to pay for long-term care? Several funding options exist

My Comments: If you don’t think about it, maybe it’ll go away. But for millions of us, living longer than our parents, LTC is an insidious risk that needs to be dealt with. There is probably no best answer, just a better one.

Short of dying early, most of us will need advanced care of some kind. And like shopping for groceries or going out to eat at a restaurant, it ain’t gonna happen without a money source.

The sooner you come to terms with this, the more likely your future years will be less stressful.

Oct 9, 2017 By Greg Iacurci

Roughly half of Americans turning 65 today will require long-term care. As life expectancy continues to rise and the cost of care creeps up, there’s a growing need for financial advisers to be knowledgeable about long-term-care funding mechanisms to help clients choose the best one — or combination.

Long-term-care coverage is delivered primarily through “private” means. Roughly 55% of expenditures from age 65 through death are via these private forms of payment, with 2.7% of that from insurance and the remainder from out-of-pocket expenses, according to the U.S. Department of Health and Human Services.

About 45% of long-term-care funding is from the “public” sector, mainly from Medicaid.

Public and private options have respective benefits and drawbacks concerning expense, level of long-term-care benefits and quality of care.

INSURANCE

Traditional LTC
There are a few insurance options to hedge long-term-care risk: traditional long-term-care insurance, and life insurance policies and annuities with long-term-care features.

In 2017, the national median cost for a private room in a nursing home is roughly $8,100 per month, according to an annual report published by the insurer Genworth. An assisted living facility costs $3,750 a month.

Traditional LTC insurance is a stand-alone policy devoted specifically to providing benefits for long-term care if a need arises. This insurance delivers LTC benefits at the lowest cost and offer inflation protection, observers said.

Sales of these policies have dwindled over the past several years. While insurers sold 700,000 of these policies in 2000, the American Association for Long-Term Care Insurance estimates the industry will close out this year with 75,000 policy sales.

There’s been negative consumer sentiment in the marketplace as insurers have had to raise premiums in recent years on in-force policies due to initial policy mispricing, following a misjudgment in lapse rates and interest rates, said Jesse Slome, executive director of AALTCI. A number of insurers also have abandoned the marketplace.

Advisers typically use traditional LTC insurance if clients have a tolerance for a potential premium increase in the future and if they don’t have a life-insurance need, said Phil Jackson, insurance planner at ValMark Financial Group.

Life insurance – LTC combination
Sales have shifted more to combined life insurance-LTC products. These products drew $3.6 billion in new premiums in 2016, a 500% increase over the $600 million in 2007, according to Limra, an insurance industry group.

Broadly, advisers like the flexibility of these policies. Mr. Jackson explains it in terms of “live, quit or die”: Clients get a long-term-care benefit while living, but can also surrender the policy for a portion of their premium or provide heirs with a death benefit. The latter options aren’t available for traditional policies.

Further, premiums and benefits are guaranteed, he said.

Combo policies come in two flavors: hybrid LTC, and life insurance with LTC riders. Hybrids provide more of a long-term-care benefit and have a “very small, very modest” death benefit, whereas policies with LTC riders are more life-insurance focused, Mr. Jackson said.

One key difference is hybrids typically have an inflation-protection feature allowing a client’s future LTC benefit to grow annually, whereas the benefits are fixed in policies with riders, Mr. Jackson said.

Among LTC-related sales year-to-date at ValMark, 45.9% have been hybrid, 49.5% LTC riders and 4.6% traditional LTC.

Annuities
Annuity products are the least-used among insurance products for providing LTC benefits. Combination annuity-LTC sales were $480 million last year, up from $285 million in 2011 but little-changed since 2014, according to Limra.

The products deliver a lifetime income stream, and increase that income in the event of a long-term-care need.

“Annuities are pretty much a last resort for long-term care,” said Jess Rorar, a planner at ValMark. Life insurance products provide more of a benefit and give more value for the money, she said.

However, in the event insurers decline a client from buying traditional LTC or combined life insurance-LTC, annuities can serve as a backup because the underwriting requirements are easier, said Jamie Hopkins, the Larry R. Pike Chair in Insurance and Investments at the American College of Financial Services.

MEDICAID

“Almost every adviser you talk to has clients that end up on Medicaid. It’s just the reality of aging and living a long time,” Mr. Hopkins said.

The government assesses income and asset levels when determining individual qualifications for Medicaid. Generally, individuals have to essentially run out of money before Medicaid kicks in, Mr. Hopkins said.

Clients often need the help of an elder-care attorney to structure their assets appropriately — for example, there are several exceptions for assets, such as a home, that get protected from a Medicaid spend-down calculation, and an attorney can help protect those to the largest extent possible, Mr. Hopkins said.

Medicaid facilities, though, often aren’t as nice as those provided by private care; so private insurance would likely better protect one’s quality of life, he said.

SELF-INSURANCE

Clients concerned about asset flexibility and freedom, as well as those with an aversion to medical underwriting, are often candidates for self-insuring if they have the appropriate wealth, Mr. Jackson said.

“Generally, even if you have the assets to self-fund, you’ll get a better return on your dollars if you use an insurance solution,” he said.

Clients also “tend to have to hold a lot of assets hostage to that self-insurance,” Mr. Hopkins said. “You’re not really allowed to touch them,” which sometimes leads to a reduction of lifestyle when young people set assets aside in a separate account for LTC purposes.

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How to Get Medicaid for Nursing Home Care Without Going Broke

My Comments: Politicians apparently have no earthly idea what getting old does to your finances. Of the 50 state Medicaid directors, red states and blue states, all 50 came out in opposition to the most recent attempt by Congress to repeal the ACA or ObamaCare.

None of us are willing to allow the elderly to die in the streets for lack of care. That means programs like Medicaid must be properly funded.

We can argue till the cows come home about the need for rules to prohibit unfair advantages and you’ll get my approval for such rules. There will be competing agendas but does that mean we should give up?

And somehow, these rules must be written to allow intelligent financial planning. Rules that include how to be cared for without losing your financial sanity. Gabriel Heiser’s ideas have value for all of us.

Gabriel Heiser 9/21/2017

Well-off people can easily go broke paying for sky-high nursing home care: First they deplete their own funds and then, eventually needing Medicaid, spend down nearly all the rest of their assets to qualify for that government program designed for low-income individuals.

The way to avoid this terrible situation is to put in place a Medicaid asset-protection plan early on. One powerful solution is to buy a single-premium immediate annuity, says attorney K. Gabriel Heiser, an elder care Medicaid expert, in an interview with ThinkAdvisor.

For 25 years, Heiser focused exclusively on elder law, and estate and Medicaid planning. He is author of “How to Protect Your Family’s Assets from Devastating Nursing Home Costs: Medicaid Secrets” (Phylius Press 2017-11th updated edition).

Sixty percent to 70% of nursing home patients are on Medicaid, says Heiser.

In determining eligibility, Medicaid differentiates sharply between “assets” and “income.” The potential Medicaid recipient is permitted to have only $2,000 in assets, though they can still receive certain income under certain circumstances.

In the interview, Heiser discusses a number of techniques — all of them legal — to shelter or reduce assets to qualify for nursing-home Medicaid.

One of the best, he says, is a so-called Medicaid-Friendly annuity, which essentially converts “countable” assets into income, which is exempt.

The average cost of nursing home care is $92,000 a year and much higher in New York and Hawaii, among other states. The average stay is two-and-a-half to three years. Care for a person with Alzheimer’s disease in a locked unit can come to more than $450,000 annually and is typically for a period of at least five years, Heiser says.

Though Medicaid wasn’t created for middle-class people “to pass their money on to their children at taxpayers’ expense,” Heiser writes, he reasons that it makes sense and isn’t unethical to “avail yourself of the laws” in order to minimize expenditures on nursing home care and indeed “pass those savings on to your children.”

Most folks make the mistake of waiting too long to plan for asset protection, says Heiser. They should begin at the first sign that their spouse, parent or sibling likely will need nursing home care.

Heiser was formerly chair of the estate planning committee of the Massachusetts Bar Association and an adjunct professor of the College for Financial Planning at David Lipscomb University. A professional version of his book, “Medicaid Planning: From A to Z,” is directed at attorneys, financial advisors and CPAs.

ThinkAdvisor recently spoke with the semi-retired Heiser, 68, on the phone from home in San Miguel Allende, Mexico. He revealed some of his Medicaid secrets and how they can help clients shelter their assets. Here are highlights:

THINKADVISOR: What’s critical to know about Medicaid?

GABRIEL HEISER: To qualify, you can’t have more than $2,000 in Medicaid-countable assets. So if you have cash in the bank or any other assets that aren’t on the exempt list, they’ll count toward the $2,000. That’s not a very high amount — but the point of Medicaid is that it’s supposed to cover the poor.

You write that hiding money and not reporting an asset on a Medicaid application is fraud.

Yes, fraud against the government. You’ll be disqualified for Medicaid, and there are also criminal penalties.

What about having income?

You can still qualify if you have, say, pension income. But there’s a cap of $2,205 a month for Medicaid recipients. However, some states have a rule that if your income is over that figure, you can direct your Social Security or pension into a trust — a Miller Trust, also known as a Qualified Income Trust.

The trustee pays the money to the nursing home, and Medicaid pays the difference. Typically, the bills are going to be more than $2,000 a month. So even though you have income over the cap, you can still qualify by setting up that trust.

Note: there are three more pages of Gabriel Heiser’s words of wisdom on this topic. To read the rest, click HERE.

The Cost of Long-term Care is Going to Bankrupt Us

My Comments: Demographics and interest rates are things over which few people have any control. It used to be DEATH AND TAXES, but not anymore.

Before DEATH these days is an insidious threat called Long Term Care, or LTC. We can agree it’s not OK to just take old people out into the woods and leave them there. That solution is frowned upon, as it should be.

So… what is the best alternative, not only for them but for you and me who haven’t yet reached that stage of life? We had better start paying more attention, ‘cause hoping for hurricanes and wildfires and tornadoes is not the solution.

by Richard Eisenberg on September 8, 2017


This article is reprinted by permission from NextAvenue.org.

When policy makers, health care analysts and financial journalists talk about the staggering costs of long-term care, it’s often wonky, devoid of humanity.
We throw around statistics like this one from the U.S. Department of Health and Human Services: 52% of individuals turning 65 will require long-term care supports and services at some point in their lives.

But at a Bipartisan Policy Center (BPC) webinar recently pegged to its new report on long-term care financing solutions, family caregiver MaryAnne Sterling poignantly revealed the financial, physical and mental tolls that long-term care can take.

When the long-term care crisis hits home

Three of the four parents of Sterling and her husband died from, or now have, dementia. First, she and her mother provided care for her dad in Sterling’s home as long as they could. Then, her parents depleted their savings so Sterling’s father could qualify for long-term care from Medicaid. “As a surviving spouse, my mother was left destitute after the Medicaid spend-down,” said Sterling, co-founder of Connected Health Resources for family caregivers and patients and owner of Sterling Health IT Consulting, in the Washington, D.C. area.

After that, said Sterling, “my husband and I provided $250,000 for basic living expenses for my mom to keep her out of that system [Medicaid].” Sterling’s caregiving responsibilities for her parents, she says, led her to give up getting an advanced degree and not to have children. In 2013, her mother needed to go into assisted living and her father-in-law was diagnosed with dementia. Sterling and her husband turned to Medicaid for her mother. Otherwise, Sterling said, “It would have cost us $8,000 to $10,000 a month, which was completely untenable.”

To those who say people like Sterling’s family “game the system” so Medicaid will pay for their long-term care, Sterling responded: “You’re not gaming the system. You’re desperate. I kept Mom out of the system for 12 years. By the time we needed the support of Medicaid, we did a pretty good job of not utilizing its resources for as long as we possibly could.”

The long-term care financing morass

Families like the Sterlings might avoid some anguish and financial pain if the government, insurance companies and employers adopt or tweak proposals in the BPC report sponsored by The SCAN Foundation, Financing Long-Term Services and Supports: Seeking Bipartisan Solutions in Politically Challenging Times.

The time to fix America’s long-term care financing morass is long overdue. Over 12 million adults rely on long-term care supports and services (LTSS), the BPC report says, “and the need is expected to rise dramatically in the coming decades.” The average expected lifetime long-term care services and supports cost for a 65-year old American today, BPC says, is $138,000 — and $182,000 for women.

Today, few Americans can afford the steep cost of assisted living facilities, nursing homes or home care (median annual nursing home cost: $91,300; median annual cost for a home health aide: $45,800.) As a recent AARP Long-Term Care Scorecard report noted: “The cost of long-term services and supports over time continues to be much higher than what middle-income families can afford.”

Medicare generally doesn’t cover long-term care expenses. As The SCAN Foundation’s President and CEO Dr. Bruce Chernof said at the BPC webinar: “Medicare is not the primary source of long-term care financing, despite the fact that people think it is or should be.” (A recent Associated Press-University of Chicago NORC Center for Public Affairs Research poll found that 57% of Americans say they expect to rely on Medicare for long-term care services and supports.) And Medicaid essentially requires impoverishment.

Just 11% of Americans age 65 and older own long-term care insurance policies and the market is in decline. Many who don’t buy the coverage find the premiums too steep and the benefits too skimpy, while fearing that premiums will rise dramatically. “We need a vibrant private market and we don’t have that today,” said Chernof, who chaired the federal Commission on Long-Term Care in 2013. (Incidentally, that blue ribbon panel produced a bevy of proposals, but punted on long-term care financing ideas.)

Bipartisan proposals for long-term care costs

The Bipartisan Policy Center’s public-private partnership recommendations, some of which build on ones in the think tank’s 2016 report, include:
• Give employers incentives to offer affordable, simplified “retirement long-term care insurance” as an employee benefit and auto-enroll some employees age 45 and older (BPC estimates annual premiums for someone in the 25 percent bracket might be $600 rather than $2,400 today)
• Let employees withdraw from 401(k)s and similar retirement accounts without owing federal tax penalties if they use the money to buy long-term care insurance policies through their employers
• Let Medicare Advantage plans and other Medicare provider organizations offer up to 14 days a year of respite care coverage to high-need, high-cost Medicare beneficiaries who have three or more chronic conditions and functional or cognitive impairment and are part of a person- and family-centered care plan (today, Medicare only offers respite care to beneficiaries in hospice, who are expected to die within six months)
• Let Medigap and Medicare Advantage plans sell limited, affordable long-term care coverage as an optional, voluntary benefit or a separate insurance policy financed through premiums paid by beneficiaries who choose to enroll (maximum daily benefit: $75; cost of premiums: an estimated $35 to $40 a month or $420 to $480 a year)
• Allow state and federal health insurance marketplaces to sell those lower-cost, limited benefit retirement long-term care insurance policies
Dr. William H. Frist, former Republican Senate Majority Leader and now a BPC Senior Fellow and co-chair of its Health Project, said that if the report’s recommendations turned into reality, Americans age 45 to 69 might own 8.5 million long-term care insurance plans, “twice what we would have otherwise.” Added Frist: “That’s not a total answer, but it’s meant to say there are ways to shape and modify the existing system to take the burden off individuals.”

What the report didn’t recommend

One proposal the Bipartisan Policy Center experts couldn’t quite bring themselves to endorse: adding “catastrophic” long-term care coverage to Medicare and paying for it through an additional Medicare payroll tax. That idea was proposed last year by the Long-Term Care Financing Collaborative.

Today, about 15% of people with long-term care needs require care for five years or longer (what’s known as “catastrophic” care) — far longer than the typical two to three years. The Bipartisan Policy Center report said its experts “stopped short” of endorsing catastrophic long-term care coverage through Medicare. Yet about two-thirds of Americans surveyed favor such a catastrophic insurance program.

“While we are not able to reach agreement on a politically viable means of financing a public catastrophic benefit, we agree that a credible overall LTSS framework would include a public catastrophic LTSS program with a waiting period of two-to-three years,” the report said.

It’s easy to see why this otherwise sensible idea was a nonstarter right now. “Policy makers are focused on squeezing Medicaid today,” said Frist. But, he added, “I’m hopeful that once we get through this phase, we will look at a holistic model.”

The Bipartisan Policy Center analysts also rejected the idea of a family caregiver tax credit “given the high budgetary cost of the policy” and because with the direction of Congress and the administration, “the policy does not seem feasible in the current environment.”

Time for action

Tom Daschle, the former Democratic Senate Majority Leader who is co-founder of the BPC and co-chair of its Health Project, noted that long-term care financing is something that deserves more attention from policy makers. “I don’t think our solution is just spending more money. We’ve got to tear down the silos [between health care providers, long-term care supports and services and insurers] that make it so inefficient today. We need to find ways we can commit resources more effectively and we need leadership in the public and private sector to do that.”

As Chernof noted at the webinar: “Most of us will have long term services and supports needs. This is not something like being struck by lightning.”

Richard Eisenberg is the Senior Web Editor of the Money & Security and Work & Purpose channels of Next Avenue and Managing Editor for the site. He is the author of “How to Avoid a Mid-Life Financial Crisis” and has been a personal finance editor at Money, Yahoo, Good Housekeeping, and CBS Moneywatch. Follow him on Twitter: @richeis315.

This article is reprinted by permission from NextAvenue.org, © 2017 Twin Cities Public Television, Inc. All rights reserved.

Nursing Homes, LTC And College Planning Are Toast, So Is Retirement

My Comments: I graduated from high school some 58 years ago this month. So… Time for a visit and see who is still alive. And also meet up with my college roommate whom I haven’t seen for 54 years. A busy few days. He’s the one in the middle staring at the camera.

So I leave you with these thoughts as you think about your future in retirement…  We’ll be back in a few days.

June 8, 2017 • Evan Simonoff

Retirement isn’t the only stage of life or financial planning discipline that is headed for the history books, Edelman Financial Services founder Ric Edelman believes.

Nursing homes have lost 20 percent of their residents since 2010, and long-term-care insurance will soon be history as well, Edelman told attendees at Singularity University’s Exponential Finance conference in New York on June 8.

Americans’ longevity is increasing, and their financial lives are changing faster than most advisors or their clients can imagine. Clients who live until 2030 can expect far longer lives than most expect today, Edelman said, citing Ray Kurzweil, Google’s chief futurist.

Breakthroughs in health care and medical science are likely to eliminate heart disease and cancer as major causes of death in 15 or 20 years, Edelman said. This may sound like happy talk. But in 1900, cholera, dysentery and scarlet fever were among the five major illnesses that caused people to check out. Where are they now?

This means that retirement, which was only a late 20th century phenomenon, will soon cease to be advisors’ chief challenge. Advisors’ major task will become career counseling, or second-career counseling, Edelman said, because even clients who are well off at 65 and would be able to retire if their life expectancy was 90 will face a different set of variables if they have a good chance of living to 110 or 120.

The upshot is that advisors should start thinking in terms of a cyclical lifeline of education, work, re-education, more work, a sabbatical and a third or fourth career rather than a linear lifeline. It means clients need to diversify skills and occupations and maintain their employment viability as much as they need to diversify their investments.

Edelman also predicted that many forms of education would become free or very inexpensive. States like Oregon, Tennessee, Arkansas and New York already have offered free or very cheap tuition to students, and free online education is appearing all over the planet.

At George Washington University, over 1,000 students are 50, though it’s not cheap. But the cost of college has become so ridiculously high that it is unsustainable, Edelman implied. Free college may sound far-fetched, but it was not that long ago that America’s best state university system, California’s, was essentially free.

Hey, in the 1960s, the Free Speech movement was born at UC, Berkeley, a university that rivals Harvard in America or Cambridge in the United Kingdom. Both speech and tuition once were free at Berkeley, but these days it is hard to believe that was only 50 years ago.

Other industries that can expect to see higher growth rates include leisure and travel. The cruise ship business is booming, and on at least three cruise ships, state rooms have become permanent homes for residents who live there year-round.

Asked how clients in their 40s and 50s respond when they are told retirement at 65 or 66 is so yesterday, Edelman acknowledged that their first reaction is usually denial, followed by fear and anger. But when the idea of living a lot longer in good health sets in, their reaction is more balanced.

The timing of these predictions from Singularity University remains debatable. But as Yogi Berra said, the future isn’t what it used to be.

What’s Killing The Long-Term Care Insurance Industry?

My Comments: This was written almost five years ago. During these years, every reader today is almost five years older and while the world has changed dramatically, the demographics are still with us.

Among the existential risks we all face is what is known as a Long-Term Care, or LTC event. Before we all die, about 70% of us are going to be directly affected. At some point, family and friends can no longer adequately care for someone, and an outside caregiver enters the picture.

It’s not a cheap solution. But I’ve yet to find anyone who says just drop me in the woods somewhere and leave me to the critters. It doesn’t happen that way. My solution of choice is one that requires assets be re-positioned to gain leverage, and provide an escape clause if an LTC event never happens. This article will help you better understand the context in which the solution of choice becomes the answer.

by Howard Gleckman | August 29, 2012

The long-term care insurance industry is in big trouble. Consumers aren’t buying. Carriers are dropping out of the market. And those that are staying are raising premiums, cutting discounts, and eliminating products–all of which are discouraging even more consumers from buying.

What’s gone wrong? The industry has two fundamental problems. A long-standing one–buyers are dropping coverage less often than the industry predicted. And a more serious new one–historically low interest rates are sucking the profit out of the business.

As a result, just about every LTC insurance company has raised premiums in recent years for both old policies and new ones. And now many have begun trimming their product lines and eliminating or reducing discounts.

For instance, Genworth, which dominates the LTC market, announced on Aug. 1 that it plans to raise premiums on pre-2003 policies by 50 percent over the next five years, and on newer policies by 25 percent over the period. It will tighten underwriting for new products, requiring, for the first time, blood tests for applicants. It will also stop selling lifetime benefit policies, reduce spousal discounts from 40 percent to 20 percent, end preferred health discounts, and stop selling products that allow consumers to pay premiums up-front rather than over their lifetimes.

Another big player, Transamerica, has announced similar cut-backs.

Finally, some household names are simply dropping LTC insurance entirely. In February, Unum stopped selling group policies (a product once thought to be the industry savior). In March, Prudential stopped selling individual coverage and on Aug. 1, it abandoned the group market as well.

For years, carriers underestimated how many consumers would let their insurance drop before they went to claim. The companies assumed that as premiums increased and buyers’ disposable income shrank, a certain percentage would drop coverage. The phenomenon, known as the lapse rate, increased returns to insurers and allowed them to keep premiums under control.

But as it turned out, lapse rates have consistently been much lower than the companies figured (typically about 1 percent, compared to 5 percent for other insurance products). That squeezed their profits and forced them to raise rates which, in turn, made insurance less attractive to new potential buyers.

In recent years, the industry has adjusted its estimate for those drop-outs, and newer policies–with higher premiums– are more profitable than older ones. But carriers have had much more trouble adjusting to the newer problem: How to survive in a nearly zero interest rate environment.

To oversimplify a bit, insurance companies earn revenue by collecting premiums and then investing that income. Because long-term care insurance companies typically do not pay claims for many years, they hold premium income for a long time and, thus, investment income is a very important part of their business model.

Those investments are limited by state insurance regulators to ultra-safe bonds. But ten-year Treasury bonds are returning just 1.6 percent. Five-year notes are paying a paltry 0.7 percent. That is far lower than overall inflation and significantly lower than the annual increase in long-term care costs, which is roughly 5 percent.

The math is brutal: No insurance company can pay claims and make a profit when its costs are rising by 5 percent but its investment returns are in the neighborhood of 1 percent.

Keep in mind that long-term care insurers are almost all subsidiaries of much larger life insurance companies. And their parent firms, anxious to manage risk in what was already a very risky business, are not at all troubled by the decline in LTC sales. In fact, slashing sales may be exactly what they have in mind.

Until a few years ago, carriers that stopped selling LTC insurance would sell their existing policies to other firms. But, today, in a reflection of the state of the industry, there are no buyers. In most cases, the large carriers will continue to cover their current customers, though policy-holders should not be surprised to see ongoing rate increases.

Overall, though, the decline of the private LTC market is a huge problem, especially since it is coming just as Washington is seeking ways to reduce Medicaid, the most important payer of long-term care costs. It is yet one more reason why it will be critical to find a workable solution to the problem of long-term care financing.

Another Reason For Donald Trump

My Comments: The white middle class of America is dying faster than other demographics. According to this study, white people with low levels of education have a “cumulative disadvantage”. The result is an increased level of morbidity and mortality.

Relative income is down, health outcomes are worse, unstable marriages more frequent, all leading to a collective despair across a broad cross section of the population.

If I’m in this group, then I’m more likely to want help and recognition for my problems than the Democratic party and its candidates was able or willing to recognize. Time to pay attention people!

From Julia Belluz, on March 23, 2017.

In 2015, a blockbuster study came to a surprising conclusion: Middle-aged white Americans are dying younger for the first time in decades, despite positive life expectancy trends in other wealthy countries and other segments of the US population.

The research, by Princeton University’s Anne Case and Angus Deaton, highlighted the links between economic struggles, suicides, and alcohol and drug overdoses.

Since then, Case and Deaton have been working to more fully explain their findings.

They’ve now come to a compelling conclusion: It’s complicated. There’s no single reason for this disturbing increase in the mortality rate, but a toxic cocktail of factors.

In a new 60-page paper, “Mortality and morbidity in the 21st Century,” out in draft form in the Brookings Papers on Economic Activity Thursday, the researchers weave a narrative of “cumulative disadvantage” over a lifetime for white people ages 45 through 54, particularly those with low levels of education.

Along with worsening job prospects over the past several decades, this group has seen their chances of a stable marriage and family decline, along with their overall health. To manage their despair about the gap between their hopes and what’s come of their lives, they’ve often turned to drugs, alcohol, and suicide.

Meanwhile, gains in fighting heart disease have stalled, and rates of obesity and diabetes have ploddingly climbed.

So the rise in mortality for white mid-life people in America since the late 1990s is actually the final stage of a decades-long process. “It’s about the collapse of white middle class,” said Case. Here are the five big takeaways from the researchers’ new opus.

Reclaim Republicanism for the Conservatives

bumper stickerMy Thoughts: I vowed recently to stop posting anything political. All it does is encourage trolls who eviscerate those who dare to think differently.

But from time to time I’m reminded that a viable two party system is probably critical for the long term survival of our democracy. There is a crisis bubbling up that demands a solution. This article comes from Europe which has it’s own cross to bear.

December 2, 2015 by Peter Wehner – (The writer, a senior fellow at the Ethics and Public Policy Center in Washington, served in the last three Republican administrations.)

The Republican party has traditionally been the predictable party when it comes to nominating a presidential nominee. But for 2016 everything has been tossed on its head. Donald Trump has a double-digit lead over his closest rival, according to a poll published Wednesday, leaving establishment figures trailing. The former reality television star in whom many are investing so much hope is also setting the terms of debate. The understandable frustration of many has transmogrified into a mindless attachment to a political harlequin. Something has gone awry in the party.

To understand how, one needs to understand the peculiar political currents in today’s US. Anti-political anger has descended on many Republican voters. The party’s leading candidates — Mr Trump and the neurosurgeon Ben Carson, neither of whom has governing experience — are benefiting.

This anger is, in some respects, justified. Political institutions have long been unresponsive to the challenges many Americans face, including stagnant wages, rising tuition and health costs, a byzantine tax code, high debt levels and mediocre education. Trust in politicians has fallen to the lowest level in 50 years, according to the Pew Research Center. Hence the appeal of an outsider such as Mr Trump, especially among male blue-collar workers, many of whom have borne the brunt of globalisation.

Mr Trump has also tapped into something that resonates with many of these Republicans: illegal immigration. This has undermined the rule of law and depressed the economic prospects of some low-skilled workers. But he has addressed the issue in a typically Trumpian way. He opts for extreme positions and incendiary language. He has implied that large numbers of those coming from Mexico are rapists and drug dealers, and advocated ending birthright citizenship and forcibly deporting millions of undocumented immigrants. The immigration issue, in turn, may be a proxy for those Americans, many of them older and working class, who feel they have “lost” their country and are fearful of the future.

But Mr Trump is ill informed on crucial issues. Answering a question about the Trans-Pacific Partnership, he railed against China, which is not part of the deal. He confused Iran’s Quds force with the Kurds. In the wake of the Isis attacks in Paris, he says, he “absolutely” wants a database of Muslims in America. He is also perpetuating the libel that “thousands and thousands” of Arab-Americans in New Jersey cheered as the Twin Towers crumbled on 9/11.

He has a tendency to inhabit a fairytale world. Mr Trump claims he will force Mexico to pay for the wall he wants built along its border. He claims that a President Trump would defeat Isis “very quickly”. Meanwhile, he purveys conspiratorial-sounding theories on subjects ranging from President Barack Obama’s birth certificate to the risks of childhood vaccination.

And then there is Mr Trump’s boorish manner. He has implied that a news anchor’s tough questions of him could be attributed to menstruation. He has ridiculed Senator John McCain’s ordeal as a prisoner of war. He has likened Mr Carson to a child molester with pathological tendencies. And last week he mocked a reporter with a disability.

It would be nice to chalk up his success to temporary insanity — an episode of Trumpmania that will end on its own. But a figure like Mr Trump does not appear ex nihilo. He is the product of certain intellectual and political habits that have taken hold over the years: a lazy anti-government ideology, prizing emotivism over empiricism, and conflict in pursuit of lost causes. This is not conservatism; it is splenetic, embittered populism. These habits of thought are discrediting the party of Abraham Lincoln and Ronald Reagan. Now would be a good time to begin to break them.

The Republican field boasts accomplished candidates — senators and governors — with serious reform agendas for the 21st century. The first primary is not until February, so it is not too late for Republicans to rally to one of them. They better had, because if they nominate Mr Trump, America’s avatar of irrationality, it will do grave harm to the party.