53 Is The New 38

belly photo“Middle Age is where your broad mind and your narrow waist begin to change places.” – John Crossman

I never really took a regular medication for a condition before I was in my forties. My mother did not believe in pills. She was one part Christian Scientist and two parts Inuit Darwinist subscribing to the notion that sick children, like old people, should be just set outside the igloo at night and if they were still alive in the morning, they were allowed to rejoin the family. Illness and chronic conditions were things that plagued other people, like old man Norton who lived across the street. At 85, he suffered from heart failure and diabetes and it seemed like every other week they were lopping off one of his appendages as a sort of burnt offering to his disease. It was a preview of a movie I hoped to never see.

As a kid, you averted your eyes from the vagaries of aging, not so much out of denial but out of some misguided sense that old age only happened to other people. Deep down, you knew it would be waiting for you, like that German Shepherd that sometimes chased you on your bike.  On sunny afternoons, I occasionally glimpsed Mr. Norton and he would wave to me from his wheel chair – all two arms, one foot and a half leg. It freaked me out and I made a pact that I would never succumb to old age. I would cheat it and commit to a life either so reckless or physically vigorous that chronic disease would simply shrug and pass me by. I would go out in a flash, perhaps spontaneously combusting on a rock and roll stage or slowly asphyxiating on the side of Mount Everest after rescuing a dozen Sherpas trapped inside a crevasse on the Khombu Icefall.

Despite my best efforts to remain a juvenile, middle age finally collared me. I am now bemused by my own denial – a self deception that seeps in like lugubrious fog obscuring moments of self reflection. I prefer to see myself in a certain light and favor friendships with people who conserve electricity — their “energy-saver” bulbs have a sort of muted Blanche Dubois quality that fails to expose my true age. I prefer pleats, spandex, “comfortable” levis, and larger versions of everything. I wear my shirt outside my pants and tend to avoid stripes which turn me into a large Faberge egg. My wedding day 33” inch waist has eroded like a Florida sinkhole, widening to 38”, a metric that is really only meant to define the circumference of old trees and an athlete’s vertical leap at a football combine. A protective shell has formed near the top of my solar plexus. It feels like a muscle but I am being told it is fat — presumably being stored in the event the Food Emporium ever goes on strike.

Global warming has begun. The canard that only women get hot flashes could not be less accurate. When you are large and in charge, you feel warm all the time. In a single winter day, you are both sweating and freezing as you go from windy, frigid streets to offices hotter than an Indian sweat lodge. In summer, you advocate the notion that thermometers should be calibrated by weight not by temperature as you would prefer to set the air conditioner to a cool 235 pounds each night instead of the balmy 105, favored by your wife who has not gained a pound across three children, two continents and a quarter century.

You start driving a nice sports car because it reminds you of a time when you could sit comfortably in the middle seat of an airplane and not feel like a human smore. People start to whisper when they see your new ride, “Tsk, tsk. He’s having a middle-aged crisis”. Well, folks, I’m here to tell you that in 1986 when I did look good enough to actually drive my own convertible, I did not have two dimes to rub together and drove a puke green Renault Alliance that not unlike the French, would routinely sit down in the middle of a job and go on strike. We sports car drivers are not compensating for anything. We’re just enjoying the fruits of our hard labor and perhaps hoping not to be as invisible as we feel.

At 53, the body starts paying you back. The knees went first. Years of sports and running coupled with a pathetic version of stretching that involved making one effort to briefly touch my toes, gave me a bulging disc and hamstrings as tight as a cat-gut mandolin. The shoulders followed. Years in the weight room with poor technique, a mediocre baseball career as well as annual trips to the emergency room after countless injuries in Turkey Bowl football games, rewarded me with clicking joints reminiscent of a playing card hitting the spokes of a bicycle tire.

The latest manifestation of mortal decline occurred at Halloween while sucking on one of the many Tootsie Pops that I appropriated from my youngest son informing him that he must pay “a toll to the troll’.   He might as well get used to being taxed now. As I succumbed to the inevitable urge to bite the hard candy, my right molar broke off like the Antarctic Ice Shelf. It would turn out to be an $1100 piece of candy and the birth place of my first crown. Thinking back, I’m sure old man Norton had his fair share of crowns but I had always assumed my teeth would be indestructible – at least I thought so in college when we opened beer bottles with them.

Middle Age now means moderation – another profane word. The whole diet thing is a touchy subject in any marriage where there is a weight imbalance. Yet, she tolerates me and often travels great verbal distances to find just the right word for self improvement. I listen in amusement wondering how my spouse might segue from ISIS to my losing ten pounds. It’s diplomatic genius. She ought to work in the UN. She uses code words to hint at lack of restraint – patronizing placeholders like “ healthy”, “balanced” and my favorite “portion control”.

Gratefully, the dog does not seem perturbed by my slow disintegration. He moves at my speed – an adoring shadow that has fallen in love with my insides and considers my outsides, merely a coat of extra fur. The dog and I agree on the true definition of “portion control”: eat until you are going to be sick. Normally, when he overeats, he goes outside, munches on some grass, returns and throws it all up on a nice rug. I just lie down and moan, informing my wife that I think I have the stomach flu. Meanwhile my son comes in the room to incredulously ask, “who ate all the cupcakes?” I try to blame the dog but he is in the other room throwing up grass.

I am suddenly noticing now that everything in the fridge is “low fat”. I search for sweets at midnight and the cupboards are filled with healthy things like nuts, dates and dried apricots. This is no longer my house, it’s a spice market in Baghdad. I search her favorite hiding places including the most clever default– the microwave. I am mildly insulted at our passive aggressive war of weight and wits – but hey, game on. She is Holmes and I am her arch enemy Professor More For Me. The dinners are very healthy with portions smaller than a French restaurant. Like Oliver Twist, I keep waiting for seconds but she has cleverly prepared only enough for one serving. “More? You want…more?!”

It’s not like I don’t try. The problem is the majority of calories I consume occur between 7PM and midnight. Night eating is a problem. It hits every man — the day arrives where you go to bed on a full stomach and wake up coughing with the sensation of napalm in your throat. My first thought was I was turning into a dragon and that perhaps I just needed to light a match to give birth to the fire in my esophagus. The next thing I know I am exchanging proton pump inhibitors like Zantac and Nexium with another middle aged stranger in a late night diner like a couple of crack heads.

Family photos also become an issue. It’s always subtle – one of your kids or your wife will say, “Here’s a good one of you, Dad!” with profound encouragement. This is code for you look like the Hindenburg or a human manatee in most of these shots but this photo (where we can’t see your face), may meet your denial criteria. I now find myself fighting over Christmas photos more than the kids. “Jesus, if you are going to use that one, at least tell everyone my due date.” “Oh great, we don’t need to tell them where this was taken because from this angle, I look like Asia Minor.” In the end, we decide to feature only kids and I finally concede to one couples photo that will be on the inside of the card. She looks great and in this one I look young enough that at least anyone who does not know us will assume she is my second wife and not my daughter.

I can almost hear the Christmas Card comments, “Wow, she looks great!” Pause. “ And he looks…um, prosperous!” The absence of praise should be construed as criticism. Yes, 53 has become the new 38. 38’s are everywhere: 38” waists, a maximum of 38 push-ups, 38 minutes jogging before the knee feels like you have been swatted by Malaysian riot police, 38 ways to hear someone say, “I would not wear that if I were you.”

Life has turned quickly from “do’s” to “don’ts”. The new regulations: Don’t eat fatty foods. Don’t eat after 7pm. Don’t eat meat, Don’t eat fat. Don’t eat refined sugar. Don’t eat gluten. ( I’d actually like an extra helping of gluten please, waitress and can you fry it into a little fritter so I can drizzle honey on it?”

It’s a losing battle in a three front war – with those who conspire to fix me, with my own lack of restraint and with Father Time. Winter is coming and the stakes are increasing.

Did someone say, “steaks”?

Sullen, dreary, dark shadow afternoons. Cold front door mornings that slap like a locker room towel and the endless layers of clothes thick enough to hide a rocket launcher. Comfort foods abound and whisper – hearty soups, breads, pastas, cookies — a universe of simple and complex carbohydrates designed to raise your blood sugar and your mood. It is a never ending battle between good and non fat.

At 53, my superhero outfit is a little tight. I think I popped a button off my lederhosen but its my job to be a “roll” model for other middle aged manatees. You want us on that wall. You need us on that wall. We just all can’t climb up on it at the same time or it might break. We have our purpose. We make the skinny people feel good and aren’t afraid to be the “before” picture in some ad touting self improvement. But inside our 38’s, we’re 33’s busting to get out. We need a little more restraint, a little more sunshine, a vanity based event like a wedding, reunion or family vacation where posing for a photo or removing one’s shirt is a requirement to keep us on the straight and calorie free path. It’s not too late. You may be middle aged but inside your fifty-three is a thirty-eight and underneath that it is a thirty-three. You know, sort of like a burrito. Yeah, that’s it.

Man, I’m hungry.

A Nightmare on Elm Street

images“You think healthcare is expensive now? Wait until it is for free…” PJ O’Rourke

In early 2011, The Boston Globe shared the findings of a 20-page report from the Boston Foundation and Massachusetts Taxpayers Foundation, a report that somberly concluded that cities and towns must substantially increase the amounts their employees are required to pay in out-of-pocket expenses for services and to significantly increase their deductibles. Jeffrey D. Nutting,  Franklin, MA. town manager, complained his town was still facing costs that wildly outpaced declining tax revenues or even the CPI. “Every dollar we spend on health care insurance is a dollar we don’t spend on jobs,’’ he said. “This is all about saving jobs. When insurance costs go up I have cut police, firefighters, or teachers.’’

Nutting said about 10 percent of the town’s $88 million budget now goes to health care costs, and he was facing a double-digit increase for next year. That was 2011.

In 2014, the healthcare conundrum is worsening. Despite the passage of the Affordable Care Act, the gross per capita cost to provide health benefits for public employees is averaging as much as $20,000 per worker. This is almost twice the national figure for most commercial health plans – eclipsing by a decent margin private sector, bargained plans. The mounting evidence is irrefutable – low co-pay plans with maximum amounts of reimbursement do little to improve member health or mitigate chronic illness — and often times lead to overconsumption of services, poor consumerism and limited accountability for personal responsibility around healthcare.

While the private sector has been busy cutting benefits, implementing high deductible plans, health savings accounts, cost sharing, mandatory bio-metric testing and plans designed to promote better consumerism, towns and their employees are still bickering over changing a $10 drug co-pay to a $15.

In the months ahead, we will hear more about a little known provision within the Affordable Care Act (ACA) called “The Cadillac Tax”. After overcoming rare joint opposition from unions and business, the ACA included a provision to impose a 40% excise tax on employers ( public and private) for any benefit plans offered to workers that exceed $10,200 per individual and $27,500 per family. It’s estimated that in 2018, a large percentage of the bargained plans offered to employees of cities and counties will exceed this allowable limit and trigger the tax on excess amounts. Many cities and counties eclipse this threshold today – four years ahead of the tax. The $3.2M question? ( I’m just taking a wild stab at $4,000 excise tax per public employee for a town of 800 workers ) — Are our public officials making provisions to deal with this now or are they tearing a page out of Washington’s self preservation playbook preferring to wait until the crisis is imminent before declaring fiscal martial law.

Its estimated in a recent survey by Consultant Towers Watson that by 2023, 82% of all plans, public and private, will be impacted by the Cadillac Tax – which makes the term “Cadillac Tax” a misnomer. It is really a stealthy first step toward capping or eliminating the last of the two sacred cows of tax exemption – the mortgage interest deduction on your home and the deductibility of employer-provided employee benefits. In the private sector, employers are sobering to this future liability and are planning to either explicitly reduce the cost of their plans, pass on the tax to their employees or simply give employees a stipend of taxable dollars and encourage them to purchase coverage through a public or private insurance exchange.

For communities across the US, the issues stand to become highly polarizing. Many town Board of Education and Town Employee Plans are not integrated, still clinging to generous plan designs that offer first dollar coverage with limited co-insurance and out-of-pocket costs and having not embraced the notion of consumer or personal health accountability.

Workers rightfully argue that the cost of healthcare represents a significant economic threat and these benefits insulate them from financial risk. The question is whether such rich plans result in healthier workers or actually drive costs higher by eliminating incentives to be good consumers or take personal responsibility for one’s health? The belief that having comprehensive, low cost benefits insures good health is belied by the consistently high levels of chronic illness and gaps in care that arise in many populations — conditions that arise out of poor lifestyle choices and from those who do not actively manage their chronic conditions. Aside from being poor consumers on the behalf of plan spsonsors, people covered under rich benefit plans do not have incentives to change.  Change in health lifestyles typically comes from one of two areas: a pain in one’s chest or a pain in one’s pocketbook.  Employers are recognizing the need for a bi-lateral social contract for personal health with employees and are requiring more from participants.  Bargained plans have historically been opposed to any revisions or Big Brother oversight from taxpayers. As for public officials caught in the middle, the debate is a“ third rail” issue – “You touch it and you die!” It is proverbial line of death.

With the 2010 passage of the ACA, Congress heard from public employees that they needed time to renegotiate the terms of their collective bargaining agreements to determine who would absorb any potential tax penalty. Congress delayed implementation of the law until January 1, 2018. In the interim, there is very little evidence that any public officials are actively moving to discuss the potential for a 40% excise tax on as much as 40% of their benefits costs. The quickest road to being voted out of office is to wait until 2018 and attempt to sell taxpayers on the need to finance a 40% tax that could have been averted by planning and negotiation. The Cadillac Tax will pit tax payers and public workers against one another unnecessarily if leaders don’t act now to project the real costs, monetize these differences and renegotiate in good faith adjustments to wages to make up for inevitable reductions in benefits that will get plans more in line with costs – costs that will rise at twice the rate of private plans if left with rich, low co-pay plans and limited out-of-pocket costs.

In defense of many public workers, public officials for years have often negotiated extensions of rich benefits for retirement or medical benefits in lieu of wage increases. Workers were essentially trading modest cost of living wage adjustments for critical security — the promise of generous medical and retirement benefits. Public officials were obligating future generations of taxpayers to the net present value (NPV) of an obligation that they would not be accountable for – and might actually be a benefit from as a retiree. Workers were smart in understanding that annual medical inflation is multiples of the CPI and that guarantees on limited cost sharing and low out-of-pocket costs for healthcare were worth more than modest wage adjustments. The public officials appeared fiscally conservative to their constituents for balancing budgets while presiding over dramatic unfunded NPV increases in medical and pension liabilities. 2018 is the year of reckoning. Once US plans calculate the potential excise tax, most will conclude that the additional taxes are simply unacceptable.

A recent article in the Washington Post cited the Government Accountability Office warning that “health-care spending represents the single greatest threat to state and local government long-term fiscal health. In 2014, the GAO expects local government spending on health care to stand at 4.1 percent of the country’s gross domestic product; by 2060, that number is expected to jump to 7.2 percent.” The article goes on to share that by mid-century, a whopping 50% of local tax dollars would need to go to financing healthcare.

Most Americans don’t understand the elements of the Affordable Care Act and tend to judge the legislation on very philosophical or personal experiences. If you have directly or indirectly benefited from the legislation – possibly due to a dependent or loved one previously unable to secure affordable coverage to a pre-existing condition, it’s a god send. Perhaps you were uninsured and now have coverage provided through an exchange at a cost proportionate to your ability to pay, you may be quick to defend the merits of the law. You may be opposed – confused by the Congressional Budget Office’s math which suggested the law would cut the deficit, costing $800B over ten years but offset by $940B in taxes, fees and penalties. A big part of the $940B is expected revenues raised by the Cadillac Tax. As with any corporate tax, these costs inevitable find their way to consumers. As it relates to the public sector, it remains to be seen how we choose to handle the bill.

One thing for sure, the tab for the party is coming due. The big question, is who is going to pay and do our local and state officials have the right stuff to facilitate a balanced dialogue with our valued public employees over how we are going to work together to absorb this tidal wave of taxation.

Michael Turpin is a part-time columnist, speaker and a thirty-three year veteran of healthcare – having served both as regional CEO of a major insurer and as an executive advising employers on healthcare design and financing.