A common assumption about the aging population is that the inequities they may have experienced earlier in life — be they economic, health-related or social — dissolve or are diminished with age and with programs such as Social Security and Medicare.
But in a comparative ethnographic study into the lives of American seniors, University of Arizona researcher Corey M. Abramson found that age is not the great equalizer some imagine.
"Some people continue to say that when we hit old age, the playing field finally levels out," said Abramson, an assistant professor in the UA School of Sociology.
"It doesn't. It never levels out. Inequalities shape our life until the very end, in ways that reveal a lot about contemporary American society."
Abramson presented his study and its findings in "The End Game: How Inequality Shapes Our Final Years," published this month by Harvard University Press.
Given the nation's aging population — about 13 percent of the U.S. population is 65 or older, according to U.S. Census data — the investigation of end-of-life issues and how they are shaped is a timely and pragmatic focus.
Abramson says it's true that all seniors develop strategies to navigate challenges associated with declining health and a shrinking social circle. However, persistent inequalities based on a person's race, gender, level of education and earlier income, among other factors, shape options and quality of life at the end of life.
"Inequality is not confined to any particular stage in life, but it is a lifelong process," he said. "Where you start powerfully affects where you end. If you want to address the issue of who gets the chance to grow old and lead a healthy life, you cannot wait until they get a Social Security check to start addressing that. 'Safety net' entitlements are necessary, but not sufficient."
In an endorsement of Abramson's new book, Mario Luis Small, the Grafstein Family Professor of Sociology at Harvard University, wrote: "Abramson brings a qualitative eye to a topic we have mainly known through statistics — mortality rates, actuarial estimates and life expectancies. With a refreshing perspective, 'The End Game' brings us close to what people experience as they age, making clear not only that 'aches and pains' are shared across the board, but also that access to resources matters enormously for how people manage those difficulties."
For example, individuals who had regular and positive interactions with physicians earlier in life were more likely to seek treatment and physician support later on. However, those who experienced negative interactions with health care professionals or were members of communities that historically experienced unethical clinical practices were far less likely to do so. That complicated medical problems.
"The way people behave is not just about values, but how people understand the world, which connects prior inequality with what they are currently experiencing," Abramson said.
Abramson also addresses issues related to one's social life. If a person does not have family and friends nearby, they are more likely to experience social isolation.
He also noted that certain services meant to aid seniors tend to be cut, or are at risk of being cut. He provided the example of home-delivered meals services. In 2013, the federal sequester led to a multimillion-dollar reduction in funding for Meals on Wheels programs and related food services. Abramson noted that such services help provide food security to an already vulnerable population.
"These programs are so easy to strike off as a line in a budget," he said, "but they are essential to allowing people to live any kind of meaningful life."
Abramson also found that, for seniors, the past is prologue.
"A lot of this is not about choice. We make choices within a context, and we are transmitted circumstances," said Abramson, who advocates for major policy changes designed to improve end-of-life issues.
"There is a larger system — the end game — at play," he said. "For many, the safety net is quite thin, and not all people have the additional resources to fill in the gaps. The most vulnerable people don't. Addressing that is a major policy concern."
Social Security benefits and Medicare are not enough, he said. One recommendation is to create communities in which seniors can more readily and actively participate. Abramson also suggests that home-delivered meals services could send social workers during deliveries, providing an expanded lifeline for seniors who may have little or no social support.
Abramson is careful to affirm that seniors are not helpless.
"Some say 70 is the new 40," he said. "We have a flawed view of seniors. Either they can live in a happy retirement community playing golf and holding hands while watching the sunset, or they are all alone, miserable and waiting to die.
"Rather than a dichotomy, we should see a continuum. People face hardships in later life, but that does not mean they are just miserable victims. We need to adjust our understandings to correspond to the on-the-ground realities. People have different values, dispositions and later-in-life goals. One of the things we can do is to understand what people want and respect that. That does not preclude addressing the larger structural issues at play."