Old and Sick in America: The Journey through the Health Care System by Muriel R. Gillick (review)

Growing old can, even in the best circumstances, be disorienting. But in America today, the circumstances in which we age are far from best. Old and Sick in America, by Muriel R. Gillick, provides a detailed image of a health care system that is, for elderly patients, fragmentary, confusing, and ultimately punishing. It also presents a path to something better.

Gillick is a seasoned geriatrician and a well-published scholar of health policy, with an appointment in Harvard’s Department of Population Health. This dual perspective makes her extremely well suited to capture the problems that appear in clinical care as well as the policy structures that lead to them.

But Gillick does not just detail the micro and macro elements of our present dilemma. She also constructs a nuanced understanding of how we got to this place. It is the book’s engagement with the history of American medicine that will be of most interest to readers of the Bulletin. And Gillick’s account of this history is compelling in both its content and its practical implications for change. Old and Sick in America is a good example of how historical research can shape solutions to current health care dilemmas.

The book is divided into three sections, each one of which illustrates a location of contemporary elder care: the doctor’s office, the hospital, and the skilled nursing facility (SNF). These sections begin with the story of an elderly patient receiving care in that location. These vignettes are comprehensively told, examining care from the perspective of patients, families, and providers. As stand-alone chapters, they could be easily excerpted for teaching in bioethics and medical humanities.

Integrated into the larger book, they are accessible gateways to a deeper understanding of health policy. Each section’s opening chapter is followed by one chapter that considers, generally, how the particular site of care introduced in the vignette differs from others sites of the same type. For example, chapter 1 describes the experience of a patient in a solo practice affiliated with a community hospital, while chapter 2 details how this solo practice differs from other kinds of offices. The third chapter in each section describes how internal and external forces shape the dynamics of care in each location. For example, chapter 7 shows how physicians, medical device manufacturers, pharmaceutical companies, administrators, and Medicare interact to create the current context for hospital-based geriatric care.

Each section’s fourth chapter is historical. These chapters generally begin in 1965, with the creation of Medicare. The book is the most comprehensive historical account available of how Medicare has shaped our elder care system. But part of what makes it so comprehensive is that Gillick does not consider Medicare in isolation of other factors. It shapes and is shaped by developments in science and technology, economy, family life, and more. The result is a complex model of historical change that is perhaps best illustrated in chapter 12, in which Gillick details the factors leading to the creation and proliferation of skilled nursing facilities.

Gillick’s focus on Medicare makes her book a helpful companion to Sharon Kaufman’s Ordinary Medicine, which explores how Medicare regulations encourage clinicians to provide harmful interventions at the end of life. It also complements historical works such as Emily Abel’s The Inevitable Hour and Shai Lavi’s The Modern Art of Dying. Though these books focus on how American end-of-life care was shaped by developments that significantly predate Medicare, their conclusions can be synthesized with Gillick’s own.

Gillick’s historical analysis informs her political recommendation: to use Medicare as a “lever” to transform America’s system of elder care. Though, as she details, there are multiple forces colluding to create our fragmented elder care system, Medicare is “the only participant in this drama that is single-mindedly concerned with access...