In reporting on ‘aging tsunami,’ it pays to check your assumptions at the door

How do you talk about a problem without a clear solution?

Over the course of more than a year reporting on aging in rural Montana, I kept circling back to that question. I went there to report on the “aging tsunami” the state was bracing for. If estimates proved true, a quarter of Montana residents would be 65 or over by 2030, two decades before the rest of the country registered the same shift.

Montana faces particular challenges. In addition to seeing those changes sooner than the rest of the country, the state was already grappling with a shortage of health care providers and specialists. Montana was about to have a lot of older people who needed their diabetes diagnosed, their hearing checked, their hearts and kidneys monitored. Meanwhile, some 12 counties in this massive, sparsely populated state had no doctor.

I had read the reports. I felt I knew the problem. My question was: What’s the fix?

But when I started making calls to people who worked on aging in Montana, particularly in the frontier areas of eastern Montana, I wondered if I wasn’t getting ahead of myself.

I spoke to government officials, academic experts, and front-line workers, and I kept hearing the same thing: They felt those talking about the “problem” didn’t understand the scope of what communities needed, nor the extent of what they had. They didn’t understand what it meant to lack a pharmacy, to have no support staff or back up nurse, but also the way the providers and community leaders were willing to work together. And those in the dark were not just people in far away Washington, D.C., but also people in the mountainous western side of the state, in places like Bozeman, a growing college town with organic juice bars and ample doctors to repair bones broken on ski slopes.

If other Montanans didn’t know what many counties to the east faced, then readers in New York, or Washington, or my hometown in California, would have an even steeper learning curve.

I decided that before solutions could be discussed, the problem needed to be better understood.

Journalists are tasked with finding the new. But I want to make a case for also doing stories that take a fresh look at what we think we know. Stories that don’t assume we understand the nature of the problem. That question our own premises. That ask the people at the heart of them — not just the experts — what they think they need, or lack, or want. Otherwise, we risk creating solutions without really addressing the issues most pressing to the people whose problems we aim to solve.

Montana had an impending dilemma — how was it going to care for its aging population? But perhaps a more important question to ask was, “What will make, and keep, people’s lives good into old age?”

For many in Montana, aging and dying in place trumped access to a CT scan and a cardiologist, because waking up in the morning to look out the window at the big sky under which they were born made life good.

I saw that in Circle, Montana. The town of 600 made me reexamine the questions I started with. There, I found two things: A place in which the “aging tsunami” was in full force, and also one that had a system that for years worked pretty well. In fact, in this county where nearly one in four people was over 65, aging looked pretty good, despite long distances to health care, snowy roads, and the potential for serious isolation.

True, the community could use more resources. Its nursing home beds were full. Its sole health care provider was getting older. But being 50 miles from anything also meant this town worked together. Health care workers knew their patients. They remembered the last time she came in sick, and what that man was like before Alzheimer's set him low. Moreover, the town controlled costs by providing the kind of coordinated, “patient-centered” care policymakers are trying to incentivize across the nation.

This wasn’t unique to Circle. Billy Oley, a doctor at Beartooth Clinic, nestled below mountains at the gate of Yellowstone Park, has shaped his practice around the community of about 2,000. Few who walk through the doors are strangers. Oley spends time trying to fix small problems and avoid big ones because his patients are friends, but also because he sees tangible results from preventative care. If he doesn’t nip something in the bud, it is he who will get the call at 3 a.m. on the night of a blizzard.

“You take the time to talk to them and figure stuff out instead of just treat ’em and street ’em,” he said. “If I do good outpatient care then there’s less chance they are going to come see me in the ER. It’s better, more cost effective, to do good care.”

The care in Circle and Beartooth Clinic are examples of systems that work. There are many places that have struggled to find providers, putting not just the health of the aging but the health of the town itself at risk. Specialty care often requires a trip of an hour or more, which has proven a problem. But so has the overuse of specialty services. And it doesn’t always make life better, particularly near the end, as this report found.

“There are still parts of this country that are different,” Mike Hanshew, a consultant and former head of Long Term Care in the state told me. “The people who live there are okay with that.” They are willing to take certain risks, balancing access to health care “against the way they want to live their lives, and the way they lived their lives their entire life.”

Montanans may be willing to take more risks, but they are not so different from people aging across America.

Last year, a committee of medical and bioethics experts put together by the Institutes of Medicine called on the U.S. to overhaul end-of-life care. “The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life,” David M. Walker, a Republican and the former U.S. Comptroller General, who was a chairman of the panel, told The New York Times. “The current system is geared towards doing more, more, more, and that system by definition is not necessarily consistent with what patients want, and is also more costly.”

People aging in Montana have often have less — and often cost less — than those with easy access to specialty services. The fact that doctors often cared for people they knew outside the clinic meant that they were often able to have deeper conversations about what their patients wanted. Here one could find glimpses of a system that hewed to what experts said we will need as this country as a whole grows older.

So how do you write about a problem without a clear solution? Maybe you talk about the problem. Maybe you dig in, you question it, you find people who make you rethink it, and then write about them. And maybe, if you do it right, it will make some of your readers rethink it, too. Perhaps that is where the seed of a solution begins — not just for Montana, but nationwide. We are growing older. We are not ready for it. But if we start to talk about the shape of the problem — living longer, or dying well, too little care, or too much — we might get somewhere. More importantly, we might help more people live, and die, in the ways that make life good.

Lisa Riordan Seville is a freelance reporter. Her work has appeared on NBC News and NBCNews.com, The Nation and The Daily Beast, among other outlets.

Photo by David Schott via Flickr.