Time is precious for him. Last year, doctors told the 76-year-old former truck driver that a combination of heart failure, lung disease, and liver damage had left him with only six months to live. “That was about 11 months ago,” Vantrease said in a May interview, smiling at having, for the moment, cheated death.

In June 2025, Vantrease began hospice, which focuses on quality of life for terminally ill patients, receiving regular visits from a nurse in his home in Novato, California. Medicare is covering those services for him. His hospice caregivers reminded him of the attention his unit received from medical staff in Vietnam.

“We used to call them guardian angels,” he said, “because they took such great care of you.”

But the Trump administration’s allegations of unchecked hospice fraud in California have tainted the industry’s reputation, prompting concerns that fewer patients will seek the care they need. Health policy researchers and hospice administrators worry that the negative attention on the industry and potential for overly punitive regulations could put California patients and taxpayers on the losing end.

“The fraud situation has done a lot of damage to the reputation of hospices overall and undone a lot of the progress that had been made in destigmatizing hospice,” said Lauren Hunt, an associate professor at the University of California-San Francisco’s Philip R. Lee Institute for Health Policy Studies who focuses on hospice care. “Policymakers should pursue targeted strategies that root out fraud and abuse without overburdening the many providers who are doing the right thing.”

Hospice care is facing sweeping restrictions. The Centers for Medicare & Medicaid Services in May announced a six-month national moratorium on hospice provider enrollment in Medicare and increased oversight in California and several other states with “elevated fraud risk”: Arizona, Georgia, Nevada, Ohio, and Texas.

In a statement, CMS spokesperson Timothy Foster said state inaction on hospice programs rife with fraud drove the need for federal intervention. Foster said CMS believes the crackdown won’t affect patients’ ability to obtain services, with roughly 7,000 hospices still approved nationwide, and that it will help ensure the hospices that remain provide the care “individuals near end of life deserve.”

“Ensuring patient safety and access to quality hospices and other certified healthcare services is paramount to CMS’ work,” Foster said.

Mehmet Oz, the CMS administrator, has said also protects taxpayer money. that even as for-profit hospices have expanded, the industry has saved Medicare money by offsetting other expensive care. A 2023 University of Chicago report commissioned by industry associations estimated that Medicare patients who used hospice over hospitals in 2019 .

California has already been cracking down on the problems, with Democratic Attorney General Rob Bonta deeming hospice fraud an “” last year and asserting that The state has had its own since 2021, with crimes over the years, and implemented to curb fraud this June.

Hunt said she’s heard from California healthcare providers who are reluctant to refer patients to hospice because they’re unsure the patients will receive high-quality care and from patients who don’t know which hospice providers they can trust. California hospice organizations of any state — as of 2022, according to the California state auditor’s office. That same year, CMS nationwide.

Hospice administrators in good standing have already found themselves in the crosshairs: A found that the federal government’s new anti-fraud task force has already suspended licenses for 43 legitimate hospices.

Still, Hunt and other policy researchers welcome the efforts to target unscrupulous operators.

“While most hospices are committed to providing high-quality care, there are serious concerns about a subset that exploit patients and the system for financial gain,” she said.

The hospice industry is uniquely vulnerable to fraud because of insufficient licensing regulations and inadequate oversight, according to industry researchers. And the percentage of the population aging into Medicare is rapidly rising, with spending expected to accelerate in the next 10 years.

Most of the rapid growth in operators has been among for-profit hospices, a state auditor’s report in 2022 noted. In California, about 94% of hospice providers are now for-profit, a shift from 20 years ago, when nonprofits in California and nationally. On average, for-profit operators per patient in pretax profit and $49 more per patient-day than nonprofit hospice operators, according to one study.

Skelly Wingard, CEO of By the Bay Health, a Northern California nonprofit that provides services to Vantrease, acknowledges that fraud is a big problem in the industry. “These organizations that have exploited patients were extremely savvy,” she said.

But Wingard warns against losing sight of the bigger picture.

“Hospice, when done well, is one of the most compassionate and meaningful benefits in healthcare,” she said. “We should be working to protect that, not inadvertently erode confidence in it.”

By the Bay Health has been in business for 50 years and serves around 750 hospice patients in the Bay Area. About 89% of them are covered by Medicare, 3% by California’s Medicaid program, Medi-Cal, and the rest by commercial health plans, Wingard said.

At home in Novato, Vantrease lifts his shirt to show where a catheter was surgically implanted to drain uncomfortable fluid buildup in his abdomen. The hospital trained his wife, Paula Vantrease, a retired career counselor, to connect a suctioning device to the catheter to siphon the excess fluid. A hospice nurse from By the Bay, Blake Knier, helped her master the technique the first few times she tried it at home.

“Paula is the rock in my foundation,” Mark Vantrease said.

Knier orders all of Vantrease’s medications and rejiggers them when necessary to manage his bouts of intense nausea and pain. Every week, Knier checks the surgical incision around the catheter for infection, listens to Vantrease’s lungs, checks his blood pressure, and cleans and dresses the open wounds that sometimes form from burst blisters on his legs, a complication of the fluid buildup and weakened skin.

Knier helps usher hospice patients and their families through critical turning points. He recalled guiding one patient’s daughter through her mother’s loss of appetite.

“It’s OK if your mother isn’t eating vegetables,” he told the patient’s daughter. “Let her eat ice cream, if that’s what she wants.”

California’s emergency regulations against fraud took effect in late June. In addition to tighter prescreening of license applicants, they call for minimum professional qualifications for management, higher nurse-to-patient ratios, stricter rules around physical office space, and other restrictions.

Hunt said the new regulations are a step in the right direction but urged caution.

“The broader impact on the industry should be closely monitored, particularly to ensure that well-intentioned, high-quality providers are not placed under undue strain or forced to close,” she said.

Late one night last year, when Knier wasn’t available, another hospice nurse from By the Bay Health came promptly to the Vantreases’ home in response to an urgent call from Paula.

“I felt like I was about to die,” Mark Vantrease said, explaining he’d just had a premonition that he wouldn’t wake up in the morning. His sons were called to his bedside. The family needed reassurance. So a nurse arrived, examined him, and checked their father’s vitals.

By midnight, he was sleeping.

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“I want to stay here,” she vowed. “And die here.”

She might pull that off. In relatively good health, Jennett still drives to lunch with friends, does her own housekeeping and grocery shopping, and plows through a book a day, usually a mystery. But her children worry about her living alone at 89, especially after she has had a couple of falls.

Enter her new housemate, Susan Beese. Despite working four days a week in retail, Beese could no longer afford her nearby one-bedroom apartment as the rent topped $1,500 a month. She moved out, first staying with friends and then in what she delicately called “a senior women’s facility.”

Now Beese, who is 79, pays Jennett $800 monthly for a bright two-bedroom space, with a bath and a kitchen, on the lower level of her house. As part of the agreement the housemates worked out, she helps plant and water Jennett’s garden, takes out the trash, and cooks occasional meals.

“It’s been a lifesaver,” Beese said. Jennett even welcomed her dog.

Meet the real-life Golden Girls. In the  1980s sitcom, still in perpetual reruns, the four wisecracking women who share a house in Miami met through an ad on a supermarket bulletin board.

In Denver, the housing matchmaker was Sunshine Home Share Colorado, a local nonprofit that Alison Joucovsky, a senior services administrator, founded in 2016 when the problem became urgent. “My phone was ringing off the hook,” she said, recalling anxious pleas from older residents spending most of their Social Security checks on rising rent or facing years-long waiting lists for subsidized senior housing.

Home sharing “is a really efficient way to create affordable housing and to support older people ,” Joucovsky said. Carefully vetting both “home providers,” who may be rattling around in family houses now too big and too empty, and “home sharers” seeking reasonable rents, Sunshine facilitated 31 shares last year, a record for the nonprofit.

“The cost of developing and building new housing is astronomical, and so is the length of time it takes,” said Laura Fanucchi, president of the National Shared Housing Resource Center and an administrator with HIP Housing, a home-share organization in San Mateo County, California. “Why not make use of existing housing stock?”

About  offer these services — and demand is growing, driven by housing shortages, rising rents, and sales prices that affect both the old and the young. Legislators in several states are working to promote home sharing as an option. (Personal care is not part of these arrangements.)

The need is acute. About a third of households headed by someone 65 or older were “cost-burdened” in 2024, according to  by the Harvard Joint Center for Housing Studies. That means they spent more than 30% of their income on housing.

Although nearly 80% of those people were homeowners, the center found, an increasing proportion are still paying off mortgages or home equity loans, and most contend with higher taxes, utility and maintenance costs, and insurance premiums.

“A lot of the people calling me to complain about property taxes and inflation are senior citizens on fixed incomes whose children have left, and maybe their spouse has died,” said Pennsylvania state Rep. Abby Major, a Republican co-sponsor of a bill that would facilitate home sharing. “They’re a single older adult living in a four-bedroom house.”

Yet most don’t want to relocate. Even if they do, many older adults will find that downsizing has also  as home prices rise and very low interest rates become a memory.

Younger people are similarly cost-burdened, including 37% of those age 25 to 34 and 31% of those 35 to 44, the Joint Center has reported.  both older homeowners who need income and people of any age in search of lower-cost housing.

To help increase their reach, some home-share programs now supplement or replace the traditionally labor-intensive matching process with online platforms. (For-profit companies like Nesterly or roommates.com also facilitate shared housing.)

“It’s like online dating, except that people who have rooms can meet people who need rooms,” said Candice Smith, executive director of HomeShare Oregon. “And it’s a lot more secure.” HomeShare’s online platform has drawn close to 7,000 providers and seekers over five years.

Further support has come from the city of Portland, which this year announced  to pay $1,000 to homeowners who make a spare room available (or $1,500 for two rooms) through qualified home-share programs.

In addition, legislators in several states have introduced or passed bills that prohibit municipalities from unduly restricting homeowners who want to rent spare rooms to nonfamily members. Sponsors in Pennsylvania and Connecticut actually call them Golden Girls bills, and they’ve drawn bipartisan support.

“So many young people have basically given up on buying a home,” said Colorado state Rep. Manny Rutinel. The Democrat helped pass  prohibiting cities and counties from limiting the number of unrelated people who could live together in a single dwelling.

In Pennsylvania, state Rep. Tarik Khan steered  through the House in June; it awaits a Senate vote. “It doesn’t make sense that your cousin can move in but someone unrelated to you can’t,” said Khan, a Democrat.

The Pennsylvania bill caps the number of nonfamily occupants in a home at five; Connecticut’s limit would be three.  passed the Senate in April and then died without a vote in the House. But the bill sponsors plan to reintroduce it next session.

Home sharing can’t solve the housing crisis, its fans acknowledge. But it could make a dent, potentially unlocking thousands of spare bedrooms across the country without requiring new construction that would change the character of neighborhoods.

Admittedly, matching homeowners with those who want to rent a room becomes a delicate process. Home-share staff members typically interview the individual parties, run background checks, verify incomes, coordinate initial phone calls and meetings, and mediate if problems later arise.

They also help applicants sift through the myriad lifestyle preferences that can torpedo a match. “Living together isn’t easy,” Fanucchi said. Will the home provider accept smokers, pets, visitors? Does the sharer work from home? Or need to park a car? Who sets the thermostat?

Sometimes the agreement includes a “service exchange,” in which the newcomer does a few hours of chores like snow shoveling, shopping, or some meal preparation in return for reduced rent.

Jenlyn and Larry Boyer, for instance, have lived in their ranch house in suburban Broomfield, Colorado, for 31 years and never want to leave. But Jenlyn, who is 80, has “gotten unsteady” and uses a walker. Her husband, 70, suffers chronic fibromyalgia pain and needs a wheelchair.

Because they now pay for tasks that they used to undertake themselves, and because inflation has undermined their finances, “I had an epiphany,” Jenlyn said. “We need more help and we need more money.”

Six months ago, through Sunshine Home Share, they met a 46-year-old graduate student whose monthly rent had doubled to an unmanageable $2,000.

The student moved into their furnished downstairs bedroom/family room with a bathroom, a small refrigerator, and a microwave. In exchange for about 10 hours of dishwashing a month, she pays a reduced rent of $600.

The additional income has helped the Boyers cover expenses like van repairs and wheelchair batteries. But they also enjoy chatting with their new housemate.

“She turns out to be just a gem,” Jenlyn said. “We laugh together a lot.”

The New Old Age is produced through a partnership with .

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Overnight, a nurse aide walked into their room and saw blood splattered on the floor, walls, and ceiling, according to a grand jury transcript. Cecchetto’s face “looked twisted and smashed,” the aide testified. A Banning city police officer testified that Timaloa, 77, told him that he had punched Cecchetto twice.

“He just kept saying that Attilio was being too loud: ‘He talks too much,’” the officer said.

Cecchetto died two days later from blunt force facial trauma.

“You get placed in a facility like this to be taken care of, not to be murdered,” one of his sons, Gino Cecchetto, said in an interview. “This was completely preventable at many different points.”

Timaloa pleaded not guilty to assault. The charges were later upgraded to murder, and a judge ordered a mental health evaluation. The judge will rule as early as August on whether Timaloa is competent to stand trial.

PACS Group, the nursing home chain that owns Sunrise, denied negligence. “We strive to provide quality care to everyone we serve, and our hearts continue to go out to the Cecchetto family for their loss,” PACS spokesman Brooks Stevenson said in an email.

In nursing homes primarily occupied by impoverished people as well as posh assisted living facilities that cost upward of $10,000 a month, agitated residents have shoved, punched, bit, and kicked others. They have wielded canes, walkers, pens, a plate, a mop stick, a shoe, a belt buckle, and even the footrests of wheelchairs as weapons, federal inspection reports show.

How often these altercations take place nationwide is unknown, but an of 14 assisted living facilities in New York state led by Cornell University researchers estimated 1 in 7 residents experienced aggression within a month, including verbal, physical, or sexual acts. Their of 10 New York state nursing homes estimated 1 in 5 residents experienced an altercation in a month. Researchers have found that these assailants are to have dementia.

The diseases that cause dementia can impair brain circuits involved in impulse control and threat perception, raising the risk of aggressive behavior. Residents with Alzheimer’s disease and other dementias constitute more than living in these settings, many of which include specialized units.

Often, altercations involving a resident with dementia erupt after danger signals are missed or ineffectively addressed, according to a ³Ô¹Ï²»´òìÈ examination of court records, police reports, and state and federal inspection reports.

Since the start of 2024, the federal Centers for Medicare & Medicaid Services has faulted nursing homes at least 700 times for failing to protect residents from physical, sexual, or verbal abuse by other residents, CMS inspection reports show. The federal records do not include assisted living facilities, which are regulated by states.

In the first three months of this year, CMS cited nursing homes more often for resident-to-resident abuse than for any other type of abuse, neglect, or exploitation, including abuse by employees, the reports show.

The long-term care industry says not every clash can be averted. Presbyterian Homes & Services, a nonprofit Christian chain of senior living facilities, said in a statement: “Caring for individuals living with advanced dementia is complex, and behaviors can change in ways that are difficult to fully predict or prevent, even with clinical interventions in place.”

Eilon Caspi, a and researcher who studies resident-on-resident altercations, said that usually there is a specific unmet need that precedes an altercation. “In the vast majority of incidents,” he said, “there are warning signs in the months, weeks, days, hours, and sometimes minutes and seconds prior.”

Fertile Battlegrounds

One about Alzheimer’s, the most common dementia disease, holds that as the brain’s networks deteriorate, the balance shifts between the prefrontal cortex, which helps govern judgment and self-control, and limbic regions including the amygdala, which helps process fear and threat responses.

As cognition clouds, people lose the ability to understand what is happening around them and to put distress into words, researchers say. Pain, infection, medication side effects, and other physical and emotional distresses through shouting, intimidating gestures, kicking, pushing, or punching. Long-term care facilities can be triggering environments, with intimate care often delivered by a changing stream of aides whom residents can’t recognize. Amid noise, close quarters, and rigid routines, interactions become flash points.

“You don’t feel safe, because you don’t know these strangers who are coming in and taking off your clothes,” said Al Power, a geriatrician and an advocate for alternative models of care for people with cognitive issues. “These things will be distressing to anybody.”

The Cornell researchers found verbal altercations were the most common type of aggressive interaction but estimated 4% of assisted living residents and 5% of nursing home residents in their studies experienced physical assaults in a month.

Another Cornell study found that Connecticut police were called to nursing homes for more often than allegations of staff abuse, theft, and residents wandering away without supervision combined. A national analysis of survey data from the Centers for Disease Control and Prevention calculated in assisted living facilities engaged in physical aggression or abuse toward other residents or staff members.

Many of the physical aggressions ³Ô¹Ï²»´òìÈ identified in CMS inspection reports were perpetrated by residents with diagnoses of dementia, schizophrenia, or other cognitive disorders. In some physical altercations, both residents were aggressors, while other fights were one-sided. Sometimes the residents were roommates.

Laura Mosqueda, a geriatrician at the University of Southern California’s Keck Medicine in Los Angeles and a senior adviser to the National Center on Elder Abuse, said: “What worries me is that we just end up blaming two people who have either cognitive impairment or severe, uncontrolled mental health issues, when they’re supposed to be in an environment where people are safe.”

‘Only a Matter of Time’

Gladys Lynch, a retired department store accountant, transferred into the memory care unit at Harbor Crossing in White Bear Lake, Minnesota, in September 2025. Her monthly cost was more than $10,000, according to an invoice provided by the family.

One of Lynch’s daughters, Rebecca Norton, installed web cameras in her room and often saw another resident inside. “Every day I looked at it, this woman would be walking into my mom’s room, harassing her, digging through her things, using her bathroom, yelling at her,” Norton said in an interview. She informed Harbor Crossing’s administration, and the facility said it would start locking her mother’s door.

Norton emailed a Harbor Crossing administrator a list of issues with her mother’s care. “My biggest concern,” she wrote, was that her mother’s door was not consistently locked and the webcam showed the woman had again entered, rummaged through the bathroom, and taken a couple of adult diapers.

Unknown to Norton, Harbor aides had raised concerns about the other resident, who like Lynch was new to Harbor Crossing’s memory unit, according to a . Diagnosed with Alzheimer’s, severe dementia with agitation, depression, and anxiety, the woman was confused, had difficulty communicating her needs, and hit aides.

Aides repeatedly reported that the woman had “ongoing aggression, entered other residents’ apartments, invaded others’ personal space, and was difficult to redirect,” the health report said. They said medications had been ineffective and pressed for new ones. The report said one nurse told the woman’s doctor it was “only a matter of time before” she “hurts another resident.”

Captured on Camera

On the last day of September, she entered Lynch’s room and resisted leaving, the state report said. The next morning, she reappeared. Video of the incident was described in the police and state reports and reviewed by ³Ô¹Ï²»´òìÈ. It shows Lynch guided the woman out and appeared to attempt to lock the door, but the woman opened it and returned once more.

The woman declared it was her house, went into Lynch’s bathroom, used the toilet, and then returned to the room Lynch was in. Lynch can be seen repeatedly pressing the alert pendant around her neck to signal nurses for help.

The video shows the woman was almost out of her apartment door when she attempted to touch an object near the door. Lynch put her hands up to block her. The woman slapped at her hands and said, “I’m going to kill you if you don’t quit it.” She pushed Lynch, who fell, her head hitting the floor and blood seeping out.

Aides arrived 13 minutes after she had initially pressed her pendant, the state report said. Lynch suffered a brain hemorrhage and fractures to her eye socket and ribs, according to the state report. She died in the hospital five days later at age 96; the medical examiner’s office declared it a homicide.

Norton said her mother was kind and pleasant and never combative. “My mom deserved better than what they gave her,” she said.

Prosecutors declined to bring charges, according to the police report. The Harbor Crossing was responsible for neglect because it was aware the woman “exhibited violent and aggressive behaviors” and yet had failed to put in place effective interventions. Harbor Crossing has requested the state reconsider its findings.

In June, Suzanne Scheller, the attorney for Lynch’s family, filed a wrongful death lawsuit against Presbyterian Homes, which owns Harbor Crossing.

Presbyterian said in a statement: “We are deeply saddened by the loss of Ms. Lynch, and our thoughts remain with her family and all those impacted.” It declined to comment further on the incident or the lawsuit.

Preventive Tactics

Geriatricians, researchers, and resident advocates say long-term care homes should to reduce the risk of altercations, including closer supervision of residents at high risk, relocating them closer to nursing stations, separating residents with repeated conflicts, and adjusting roommate assignments or seating in shared spaces.

Each resident should have a care plan, and homes should train staff to be alert to a resident’s triggers and intervene quickly, dementia specialists say. Organized activities are essential to keep residents occupied and engaged. Antipsychotics and other psychotropic medications are often prescribed, but they can increase the risk of falls, strokes, and .

An aide can be assigned to watch a particularly challenging resident one-on-one, but many places lack enough staff for protracted, dedicated supervision. Some assisted living facilities will tell a resident’s family they must hire a personal aide, who can cost thousands of dollars extra each month. In extreme situations, facilities might send a resident to an emergency room for evaluation or to a psychiatric hospital, or .

Camille Russell, who served as Kansas’ long-term care ombudsman until 2024, said she observed nurses and aides were often “woefully undertrained” in basic elements of dementia care.

“We’ve gotten too far away from making decisions that are caring decisions,” Russell said. “There has to be a balance, and the balance has gotten too far to the profit side.”

A Debilitating Kick

Many physical altercations between residents result in a scratch or a bruise, but nonfatal scraps can leave permanent damage on deeply frail residents.

Linda Twiddy’s first weeks in a Chesapeake, Virginia, memory care unit in August 2024 were happy, her daughter, Barbara Howerin, said in a May interview. Twiddy, a former church secretary with vascular dementia, sang along with a visiting church choir, decorated pumpkins, and visited a cat cafe. The facility, The Vero at Chesapeake, charged Twiddy a one-time $6,825 move-in fee and monthly charges of $7,475, according to the lease.

Seven weeks after Twiddy started living there, a nurse called Howerin. She told her that her mother had been kicked in an altercation with another resident and was being sent to the hospital.

When Howerin arrived at the hospital, she was shocked by the extent of the injury. “It was like 10 inches long by 6 inches wide, the whole front of her shin,” she said. “The calf was just like dangling down.”

According to an internal facility incident report the family obtained, an aide heard Twiddy scream for help and raced over to see a male resident with dementia trying to hit Twiddy as she sat on the floor in “a pool of blood.” The report said, “Linda was screaming get him away from me, he pushed and kicked me.”

The man had prior episodes of aggression, according to documents Twiddy’s family obtained in a lawsuit they brought against The Vero in Chesapeake Circuit Court. At his previous facility, a progress note from 2023 stated, he was “becoming very aggressive in tone and actions to residents and staff.” He “grabbed another resident by the wrists and pushed her,” according to the note. He was sent to an emergency room for evaluation of agitation, according to a hospital report. It did not make clear whether he was discharged back to the facility or elsewhere.

Agitation Tied to Pain

The male resident’s medical records at The Vero said he was diagnosed with late-onset Alzheimer’s disease, agitation, and anxiety, according to his doctor’s deposition. He had chronic pain in his back and trouble sleeping. He could answer simple yes-or-no questions but had trouble providing more extensive answers and couldn’t communicate that he was in pain, she testified. His behavioral changes usually occurred when he had a urinary tract infection, the doctor said.

When he was agitated, aides could sometimes calm him by turning on the television so he could watch his beloved New England Patriots, one aide testified in a deposition. A former aide said she tried to avoid dealing with him altogether. “If you go up to him and he was agitated, he’d reach out to try to grab you,” she testified. “If he had that cane, he would swing that cane or he would punch at you.”

In a court filing, The Vero denied allegations by Twiddy’s family that it should have protected residents from him. The filing said The Vero complied with all standards of care and that any injuries Twiddy sustained “were caused by her own negligence” or acts of others.

In their investigation of the incident, Virginia regulators alleged The Vero had for the health, safety, and well-being of its residents. The inspection report said The Vero pledged to appropriately staff the memory care unit based on the number of residents and to ensure someone completed rounds at least every two hours during sleeping hours.

Twiddy underwent three surgeries at the hospital for her leg, including a skin graft, then spent a month in rehabilitation. “She was never able to walk again,” her son, Doug Twiddy, said in a May interview.

The family moved Linda Twiddy to a different memory care facility where the nursing station had a clear view of all the rooms. She lived there until her death earlier this year.

The lawsuit was settled on confidential terms in early June. Carlton Bennett, the family’s attorney, declined to comment. In an email, Lauren Rogers, a spokesperson for Sinceri Senior Living, which operates The Vero, said the company was pleased the legal case had been resolved but could not comment further, citing confidentiality and patient privacy.

“The Vero at Chesapeake is committed to providing a caring, supportive environment where resident health, safety, and well-being remain our highest priorities,” she said.

A History of Violence

After Attilio Cecchetto was fatally bludgeoned at Sunrise Post Acute, his adult children and their attorney, Jody Moore, discovered disturbing details about Sam Ato Timaloa. He had been imprisoned in 1999 after being convicted of raping an underage girl and sentenced in 2008 to 24 years in prison for attempted murder involving domestic violence, according to Riverside County court records. His public defender declined to comment.

Cecchetto’s sons, Moore, and her colleagues at Moore Hutchins Moore also learned more about the home’s owner, PACS Group, a publicly traded company with more than 300 long-term care facilities. Last year, PACS earned $191 million on revenue of $5.3 billion, according to its .

In the Cecchettos and their father’s widow filed against PACS, they accused the company’s founders, Jason Murray and Mark Hancock, of draining resources from their nursing homes to pay for the chain’s expansion and swell their personal wealth.

The two had earned more than $650 million through stock sales since taking the company public and bought two private luxury jets, according to the lawsuit and securities filings. PACS has also purchased corporate sponsorships for Utah sports teams even though it owns no nursing homes in the state, the lawsuit said.

California regulators fined Sunrise $120,000 for Cecchetto and for not taking Timaloa’s articulated dislike of noise into account when assigning rooms. Medicare issued its own $62,810 fine.

In responding to the Cecchettos’ lawsuit, PACS denied negligence for his death and alleged he “failed to exercise ordinary care on his own behalf for his own safety.” It has sued to overturn the $120,000 state fine, saying it was issued too late and that Sunrise “did what might reasonably be expected of a long-term health care facility licensee acting under similar circumstances” to comply with state rules.

The Cecchettos’ lawsuit asks for a judge to impose robust procedures PACS homes must follow for admissions, staff training, room changes, and the reporting of altercations between residents. The suit asks for a court-appointed monitor to oversee compliance. In its written statement to ³Ô¹Ï²»´òìÈ, PACS said “important context” would come out during the process and declined further comment.

In an interview, Cecchetto’s three sons, Dino, Gino, and Marco Cecchetto, described their father’s life. He spent his childhood on a farm in Italy, growing up under Benito Mussolini. After World War II he moved to Canada, where he learned to tile and lay marble and terrazzo, a decorative flooring material made of chips of stone, glass, or other materials embedded in cement or resin. He relocated to California in the early 1960s, became naturalized, and worked as a tile journeyman and a contractor for decades.

“We don’t want this to happen to somebody again,” Gino Cecchetto said. “With the life he led, he deserved a quiet, dignified death. Instead, he ended his life in pain and fear.”

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Researchers who followed patients for 10 years after they received either the actual procedure, arthroscopic knee surgery to trim degenerative cartilage tears, or merely “sham surgery” — a skin incision — for knee pain, found that the surgery provided little or no benefit and was, in fact, associated with accelerated osteoarthritis and higher rates of reoperation. That generally meant a total knee replacement.

“I don’t know how I would defend this procedure at all,” said one of the study’s authors, Teppo Järvinen, an orthopedist and the head of the Finnish Centre for Evidence-Based Orthopaedics. “What has been shown dramatically is that patients who have this procedure have more pain — they do worse. All the scores pointed in the same direction.”

Järvinen , published in April in the New England Journal of Medicine, was the first to show the surgery left many patients worse off. Though the study was small, the results were compelling, he said, because his team picked the patients “most likely to benefit.”

The study does not apply to cartilage tears incurred from an acute pain-causing injury. It included subjects middle-aged or older who were experiencing knee pain and whose MRIs showed cartilage tears.

Evidence has been accumulating steadily for over a decade that arthroscopic knee surgery to shave torn, degenerative cartilage does not help more than physical therapy. Arthroscopic rates in Finland have dropped 90%, Järvinen said. They have been falling in the U.S., too, but at a far slower rate.

One in the U.S., which counted over 2 million meniscus surgeries from 2010 to 2020, found the number decreased by about 4% each year. Most procedures were performed on women and patients in their 50s.

In the traditional Medicare fee-for-service program, the number of procedures has declined steadily in recent years, from about 169,000 in 2014 to 91,000 in 2024, shows. These figures do not include beneficiaries in Medicare Advantage, private insurance plans that cover more than half of Medicare enrollees.

Prior studies of scans have found that in people over 50, the result of wear and tear and often not painful.

“Nothing supports the idea that a patient’s pain comes from the meniscus,” Järvinen said.

Robert Brophy, director of the Orthopaedic Clinical Research Center at Washington University in St. Louis, said that “evidence is growing for judicious use of this surgery in this population.” But, he noted, “many patients do benefit.”

All the same, he acknowledged that current practice among his peers is “all over the map.” For example, that surgery for meniscus tears in the Medicare population is far more common in the South than in the Northeast.

A massive study committee of orthopedic societies in Europe and the U.S. last June released a noting that “degenerative meniscus lesions can be treated with comparable results with either non-operative (including physical therapy) or surgical approach.” It recommended a trial of physical therapy before surgery but still endorsed the operation.

A concerted campaign by orthopedic specialty societies called the has been ongoing for years. The group advocates for protecting and maintaining long-term knee health through nonsurgical treatments, surgical repair, and other therapies.

One inherent issue in all medical specialties is that appropriate treatment is often in the eye of the physician beholder, meaning that specialists create the guidelines for when a treatment is in order. And financial considerations may influence that decision, Järvinen said.  

In the U.S., physician payments are decided by the , or RUC, a committee of the American Medical Association composed largely of specialists. Department of Health and Human Services Secretary Robert F. Kennedy Jr. and his advisers have reportedly wresting control of that committee from the association, though it’s not clear how that could be done, since the AMA owns the billing codes used to calculate patients’ charges.

Arthroscopic takes 30 to 60 minutes in the operating room, and the patients spend a few hours recovering in a surgery center or in a hospital outpatient department. Medicare allots on average $2,159 to $3,875 for the procedure, depending on where it is performed; patients pay 20% of the fee as coinsurance. There may be additional costs, for example, if more than one doctor is involved in the procedure. Commercial insurers average well more than twice that, said Marcus Dorstel, a senior vice president at the data analytics firm Turquoise Health, adding that the amount providers charge for the procedure varies widely. Those charges do not include the fees of the surgeons and the anesthesiologist.

Treating chronic knee pain has a variegated history.

Fifty years ago, the treatment for cartilage tears, from acute injury or from wear and tear, was to remove the entire piece of cartilage. At that time, doctors did not consider it a shock absorber but a useless, vestigial piece of tissue like the appendix.

Today, the first-line therapy for a painful knee with degenerative tears is physical therapy and, for some people, weight loss. Then there is arthroscopic surgery, depending on the view of the surgeon about its utility.

There is also a menu of injections: Steroids have proved scientifically valuable in the short term. And injections of stem cells and plasma-rich protein are widely offered but are controversial — and not covered by most insurance — because studies have been at best inconclusive about their benefit.

And as orthopedists are backing away from shaving off meniscus tears, they are highlighting a newer procedure — sewing the torn cartilage back into a whole. But that is typically an option for patients under 50 with acute injuries and clean tears, and it is unclear exactly which patients might benefit.

When all else fails, there’s a different surgery that’s also a big moneymaker for hospitals and doctors: knee replacement.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

“On a scale of 1 to 10 of my annoyance with taxes in general, this one is about a 2,” she said. “I see the benefits.”

The small surcharge on wages provides the funding for Washington Cares, the nation’s . It was set to begin distributing benefits July 1.

If Haggett, 67, a systems administrator who lives in Auburn, Washington, needs help with daily activities as she ages — bathing, dressing, grocery shopping, managing medications — she’ll be able to use the benefit she has accrued through WA Cares, as the program is known.

About 3.7 million workers participated last year, paying an additional 0.58% in payroll taxes. Those who contribute for 10 years will qualify for a lifetime benefit of $36,500. The amount will rise with inflation: A 36-year-old now earning about $50,000 a year who contributes $291 a year for a decade will have if she needs assistance at age 75.

Both the WA Cares mandatory premiums and eventual benefits are modest. But for older adults and people with disabilities, they can help pay for a variety of services: home care, transportation, adult day programs, home modifications like ramps and grab bars, compensation for family members who assist them, or assisted living facilities and nursing homes.

Haggett had looked into private long-term care insurance to cover those needs, but she balked. “It’s crazy expensive,” she said. And since premiums can rise, and frequently have, “you’re basically saying, I’ll pay whatever, whenever.”

Haggett knows that WA Cares can’t cover all her long-term care costs. In fact, because she was already in her 60s when payroll deductions began in 2023, and because she is planning to retire in two years, she’ll receive only half the lifetime benefit.

But “if I required care and it would protect my wife from having to spend our savings, $18,250 is not meaningless,” she said.

Washington has been working toward implementing WA Cares for a decade; the program has survived two statewide votes aimed at overturning or weakening it. Now, other states will be paying attention.

‘Most People Have Nothing’

An estimated 70% of Americans will need long-term care at some point in their lives, but “they haven’t planned for it or saved for it,” said Cathleen MacCaul, advocacy director for AARP Washington State, which supported the legislation that created WA Cares.

“People are under the misconception that Medicare will pay for this,” MacCaul said. In fact, while Medicare pays for healthcare, it rarely covers long-term care, either at home or in facilities.

Medicaid does cover long-term care, but it involves such strict limits on income and assets that “most middle-class people are left out, or they have to impoverish themselves” by spending nearly all their assets to qualify, said Richard Frank, director of the Center on Health Policy at the Brookings Institution. Those who are eligible often face lengthy waiting lists for care at home.

“Long-term care is the largest area of unprotected health risk in the United States,” Frank said. “Most people have nothing.”

Previous efforts to establish public long-term care protections have foundered. In 2010, the Affordable Care Act included , a legacy of Sen. Ted Kennedy that would have created a voluntary long-term care insurance program. The Obama administration eventually deemed it unworkable, and “it never saw the light of day,” Frank said.

The private market has also contracted. Most of the largest companies selling long-term care insurance — Genworth, John Hancock, MetLife — have exited the market. The return on their investments plummeted when interest rates fell after the Great Recession, and the number of insured people who abandoned their policies — a profitable development for insurers — was far below projections.

“The psychology of the industry was: Holy smokes, we’re losing money! We’re getting out,” said Claude Thau, who directs the annual Milliman Long-Term Care Insurance Survey. As the losses mounted and premiums spiked, consumers such as Haggett stopped buying policies. Moreover, Thau estimated, 1 in 6 applicants are unable to get coverage for health reasons.

Thus, fewer than 35,000 Americans bought stand-alone policies in 2024, compared with about 235,000 in 2010, according to a , a trade association. The average 60-year-old purchaser would, at age 80, receive a projected maximum benefit of $369 a day, Milliman reported. But the average annual premium on new stand-alone policies in 2024 — $3,265 — can seem daunting to someone close to retirement.

As the purchase of stand-alone policies has dropped, insurance companies have turned to policies bundling some long-term care benefits with life insurance or annuities. Those sales figures are climbing. Still, the association notes, only 3% of Americans age 50 or older have any long-term care insurance.

‘A Five-Alarm Fire’

That has prompted a recent spate of proposals to find public ways to protect Americans from ruinous costs that can continue for years. “This is a five-alarm fire,” said sent in May by U.S. Sen. Ron Wyden of Oregon and 16 fellow Senate Democrats to their colleagues.

The letter, more a statement of purpose than a specific legislative plan, proposed a “home care guarantee” for Medicare beneficiaries, among other efforts. Proponents expect to issue a more detailed report in the fall and to introduce a bill early next year.

A also proposed providing subsidized long-term care at home through Medicare, with beneficiaries making contributions according to their ability to pay. Like most of these programs, it would kick in when people need help with activities related to daily living or require supervision because of cognitive decline. The authors estimate that 8.2 million Americans will be eligible, far more than those who qualify for home-based care under Medicaid.

In the House, Rep. Tom Suozzi, a Democrat from New York, and Rep. John Moolenaar, a Republican from Michigan, have to create a catastrophic-insurance program for older people with disabilities. It would require them to pay for care out-of-pocket or with private insurance for the first several years before they would receive a monthly federal benefit.

Enacting federal initiatives in the current political climate seems unlikely, proponents acknowledge. The Trump administration’s plan to cut billions of dollars from Medicaid “has moved the needle backward on the accessibility of long-term care,” said Taylor Harvey, a spokesperson for the Senate Finance Committee.

So “are looking at what Washington is doing with a lot of interest,” said Norma Coe, who is an economist at the University of Pennsylvania and is tracking long-term care programs. Legislators have introduced bills in Illinois, Hawai‘i, and West Virginia; other states have task forces studying the issue.

“Long-term care is one of those conversations around every dinner table,” said Bea Rector, assistant secretary for the Department of Social and Health Services’ Home and Community Living Administration.

“Families step in,” she explained. Sometimes they can continue providing care, “but sometimes more formal care has to be put in place. That’s when people see the value of programs like this.”

Steven Russakoff knows the challenges of elder care, having provided years of support for his father, who died two years ago, and for his mother, who is now living in a nursing facility. “It’s brutal, it’s exhausting, and it’s extraordinarily expensive,” he said. The family has liquidated virtually all his parents’ assets to pay for their care.

Russakoff, who is 56 and lives in Shoreline, Washington, initially disliked WA Cares. He could handle the additional deductions (about $250 a year) from his paycheck as a director of university dining services, but he felt forced into a program he couldn’t use if he left the state to retire.

But WA Cares has already been amended several times and for many participants who move away, making him a convert. “It’s a good idea,” Russakoff concluded. “A necessary evil.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

So he didn’t know he had a bill to pay. After he and Tix returned home to Minnesota in April, they got a letter from Wellcare, the insurer that provided his drug plan, saying his coverage had been terminated after three months of unpaid premiums totaling $28.80. Under Medicare’s rules, he can’t enroll in a plan again until the fall, for coverage beginning in 2027.

Pare takes Xarelto, a blood thinner that reduces his risk of strokes, blood clots, and pulmonary embolism. “He could bleed to death without it,” Tix said. A 90-day supply of the drug costs about $1,800 using a coupon from GoodRx, a discount drug website, she said.

Pare is among tens of thousands of Medicare beneficiaries who were on Wellcare’s Value Script drug plan who will likely go without prescription drug coverage for the rest of the year because they didn’t pay premiums for three months.

Next year, thousands more people in 32 states and Washington, D.C., who are enrolled in zero-premium drug plans from Wellcare and other insurance companies may find themselves in the same situation if their premiums go up and they don’t realize it, according to a ³Ô¹Ï²»´òìÈ analysis of drug plan data. Premiums and other changes for 2027 will be unveiled in September.

Going without medication can be life-threatening, especially for Medicare beneficiaries. take one or more prescription drugs, according to the Centers for Disease Control and Prevention. Almost half live with four or more chronic health conditions that can cause functional or cognitive impairments.

Congress added prescription drug coverage to Medicare in 2003. But the coverage is administered by commercial insurance companies, which compete fiercely with one another for the business of about enrolled in drug plans.

Zero-dollar or very low monthly premiums have helped make Wellcare’s Value Script the bestselling stand-alone prescription drug plan in Medicare, with nearly 6 million customers across the U.S., according to government data. But in 26 states and Washington, D.C., some Value Script members who didn’t have to pay a premium last year were caught off guard by increases in 2026.

After a two-month grace period — which Wellcare extended to three — Medicare drug plans can drop customers who don’t pay their premiums, no matter how small the amount. Some members who lost their coverage in Nevada, for example, owed as little as $8.10 for three months, according to a ³Ô¹Ï²»´òìÈ analysis of Medicare drug plan data.

Wellcare terminated coverage for about 140,000 Value Script beneficiaries in April, according to a person with knowledge of the matter who was not authorized to speak publicly about it and feared reprisals at work for doing so. About 40,000 of the people who were dropped may be able to enroll in new coverage immediately because they have low incomes and receive financial assistance through a program Medicare calls “.”

Multiple state officials said they had heard the same disenrollment figures, including Nevada’s insurance commissioner, Ned Gaines, who chairs the National Association of Insurance Commissioners’ senior issues task force; Rebecca Gouty, director of the State Health Insurance Assistance Program in West Virginia; and Tim Smolen, director of Washington state’s Statewide Health Insurance Benefits Advisors. The West Virginia and Washington initiatives are part of the federally funded , or SHIP, which provides free, unbiased help navigating Medicare.

Surprise Bills

The Centers for Medicare & Medicaid Services, which oversees Medicare drug plans, declined to provide the number of Value Script members who lost coverage due to unpaid premiums. “The agency does not publicly provide plan-specific disenrollment figures or state-level breakdowns related to the non-payment of premiums,” Christopher Krepich, a spokesperson, said in a written statement to ³Ô¹Ï²»´òìÈ.

Centene Corp., Wellcare’s parent company, also declined to provide disenrollment numbers.

“We recognize how disruptive a loss of coverage can be and are committed to helping members understand their options,” said Sarah Baiocchi, senior vice president for specialty and prescription drug plans at Centene. She acknowledged that “some members in our Value Script plan experienced a premium for the first time, or for the first time in several years.”

Baiocchi said all Value Script members received a CMS-required annual notice of changes in September, before the premium increases took effect.

A sent to members in two states and Washington, D.C., is 21 pages long. The new premium is mentioned on pages 3 and 8, along with changes to out-of-pocket costs and how to find updates on covered drugs and network pharmacies.

The company also informed members about 2026 premium changes through phone calls, text messages, regular mail, or email, Baiocchi said.

People who are dropped are not able to reenroll or join another drug plan until the start of the open enrollment period this fall for coverage beginning Jan. 1, unless they qualify for an exception, Krepich said. And because they will have gone without coverage for at least 63 days, they could be hit with a permanent that increases every year for the rest of their lives.

“Medicare should be doing something about this so that we can go ahead and get coverage now,” said Wayne Bennett, 74, who lives in Durham, North Carolina.

In May, he found out that Wellcare had canceled his Value Script plan because he hadn’t paid his $3.60 monthly premiums. He takes nine prescription drugs to treat his blood pressure, glaucoma, chronic obstructive pulmonary disease, and other health problems. He filled most of his prescriptions — including several at no cost — before he lost coverage. He doesn’t know what he’ll have to pay when his supply runs out.

Gouty, the West Virginia program head, said many Medicare beneficiaries arrange for their monthly drug plan premium to be automatically deducted from their Social Security benefits, and that many likely thought that choice remained in place until they changed it.

“They didn’t realize that when the plan was a zero premium in 2025, that stopped the Social Security premium deduction and they would have had to reelect it for 2026,” Gouty said.

In other words, even if they mistakenly thought the premium was still zero, Medicare beneficiaries would have needed to somehow allow Social Security to make deductions — something the agency doesn’t do — or set up a payment plan through their bank or credit card in case payment was necessary.

“That sounds goofy,” Tix said.

Centene’s Baiocchi blamed the Social Security Administration for the problem: “We believe this was a key driver of non-payment disenrollments and subsequent complaints.”

Spokespeople for the agency referred questions about the matter to CMS.

Krepich said legal requirements for drug plan enrollment and disenrollment limit what CMS can do to help beneficiaries who lose coverage for not paying their premiums.

‘Pretty Upset’

Now that Pare has no prescription drug coverage, his doctor replaced his blood thinner medication with a much less expensive drug that should be just as effective. Pare paid $111 for four other medications that used to be free under his Value Script plan. He hasn’t had to refill four more prescriptions yet and doesn’t know what they will cost, Tix said.

If Wellcare members knew about the premium increases, they could have set up direct billing or an automatic payment plan early this year before the payment grace period ended April 1. But they would have been able to fill prescriptions during the grace period, so if they didn’t see Wellcare’s notices, they likely assumed there was no problem with their coverage.

Bennett, the North Carolina man, said Wellcare used to send him text messages with health tips and reminders when it was time to pick up a prescription. He didn’t know his premium had increased from $0 to $3.60 until it was too late.

“I was pretty upset,” he said, when he called the company. “The premium wasn’t that much, and I was ready to pay it right off the bat. I had my credit card out ready to make the payment.”

The customer service representative wouldn’t let him pay because his coverage had been canceled, Bennett said.

Hoping to restore it, Bennett called , a Durham nonprofit that advises Medicare beneficiaries and is one of more than 2,200 SHIP sites across the country. He was told he must wait until January to restart his drug coverage, said the group’s executive director, Gina Upchurch.

He doesn’t qualify for the “Extra Help” low-income subsidy or meet other CMS criteria for a , which would allow him to change drug plans during the year. CMS typically allows midyear switches for beneficiaries who, for example, move out of their plan’s service area, experience a natural disaster, or get help paying for drugs from a .

Senior PharmAssist was able to help one of its participants join another drug plan after she lost Value Script coverage because she is in North Carolina’s pharmacy assistance program for people with HIV/AIDS and has limited income, Upchurch said.

A further exception allows any Medicare beneficiary to enroll at any time in a drug plan that has earned five stars, the top grade in Medicare’s performance ratings. However, there are no five-star Medicare drug plans available to the general public. Only two insurers offer five-star plans, and only for retirees from certain employers. Their combined enrollment is about 8,700 as of June 1, according to the insurers.

But Upchurch, with more than two decades of Medicare expertise, doesn’t blame beneficiaries for not paying attention or for assuming Wellcare’s messages were bogus. Older adults are particularly vulnerable to identity theft and other scams and are often advised to ignore junk mail and calls from telemarketers.

Since Value Script members such as Bennett continued to get their prescriptions filled during the payment grace period, “why wouldn’t they think this was a scam?” Upchurch asked. “They are constantly bombarded by people selling them something that’s illegitimate or trying to scam them.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

We’re expecting our first baby boy in end of August. And when I think about what it’s going to feel like to take care of my wife and my new son and my mom, it’s a bit overwhelming.

If you are taking care of a child and you have a parent over 65, you’re among millions across the U.S. in the same life stage.

Nearly a quarter of all American adults — and half of all adults in their 40s — fall into this “sandwich generation” category, . And being in the middle of that sandwich can feel … intense.

“I have kind of prided myself on being self-sufficient. And in this season of life, that’s almost been laughable,” said Jason McAnally, a Nashville father of two who helps care for his aging dad.

HealthQ hosts Cara Anthony of ³Ô¹Ï²»´òìÈ and Blake Farmer of Nashville Public Radio, both in the sandwich generation themselves, are your approachable guides to an unapproachable healthcare system. In this one-hour special about navigating health and caregiving, they tap researchers, physicians, experts, and their own personal experience to explore:

• Identity: When to start calling yourself a caregiver, and why it matters.
• FMLA: How to start a conversation with your boss about taking federally protected leave from work.
• Kids and mental health: How to know it’s time to take an anxious child to therapy.
• Early-onset cancer: What you need to know about spotting diseases that are on the rise among people under 50.

The HealthQ team acknowledges the messiness, the humor, and the beauty of this season of life. Come on the journey with us.

Can’t see the audio player? Visit kffhealthnews.org to listen.

This installment is part of HealthQ’s reporting on caregiving among the sandwich generation. For more, check out the series archive.

HealthQ is a health series from reporters Cara Anthony and Blake Farmer, approachable guides to an unapproachable healthcare system. It’s a collaboration between Nashville Public Radio and ³Ô¹Ï²»´òìÈ.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Can’t see the audio player? Visit kffhealthnews.org to listen.

Cara Anthony tries to convince her HealthQ co-host Blake Farmer that there are benefits to embracing the caregiver identity when helping an aging parent.

When his father was diagnosed with gallbladder cancer in 2025, William Morrison immediately went into caregiving mode.

“We were in the hospital every day,” he said. “I was really playing the intermediary between the medical staff and our family and kind of helping have those conversations and push for those answers.”

One in 10 Americans say they are a caregiver for a parent 65 or older, . And many people in the sandwich generation — those who have both children and aging parents — start their caregiving journeys like Morrison: stepping up during a medical crisis and becoming a family caregiver essentially overnight.

For other people, taking on the role and identity of a caregiver happens more slowly.

Researchers and experts say the spectrum of caregiving is broader than many people realize and that embracing the caregiver title before there’s a crisis can make a significant difference in this phase of life.

Worry Comes First

Being a caregiver can start long before you go to a doctor appointment with a loved one or move your parents into your house. “Oftentimes what we see out in the world is a very limited definition of who a family caregiver is,” said Denise Brown, a caregiving coach and the founder of Caregiving Years Training Academy in Illinois. Being a caregiver is “not necessarily around defining caregiving by tasks and chores, but about that emotional impact.”

Brown created a framework that defines caregiving as a . She said the first stage — the “expectant caregiver” — begins the moment you start to feel concerned about a loved one.

“ You look into the future and you think, ‘Oh, I think someone’s going to need help in the family,’” Brown said.

When you start to get actively involved in a loved one’s care, that triggers the second stage, what Brown calls the “freshman caregiver”: “You’re learning the lay of the land. You’re learning the language of all the systems that you now manage. The best thing to do in this stage is to get comfortable experimenting.”

Caring for Parents Brings Different Stressors

The kind of care that Morrison provided — responding to an immediate medical crisis — catapulted him into the third stage of caregiving, the “entrenched caregiver.” By the time you hit this point, Brown said, “you can feel completely overwhelmed and swallowed up by the experience.”

that the stress is especially acute for people taking care of parents. The role reversal stresses the relationship: Caregivers who focus solely on children don’t deal with the tension linked to shifting power dynamics and other changes that happen when an adult child starts to care for a parent.

Burnout, defined by physical and psychological fatigue, was higher among caregivers of aging parents than among caregivers caring only for children. And for caregivers in the “sandwich generation,” who were taking care of both children and aging parents, personal burnout scores were even higher.

The Title Makes a Difference

Many people who perform care tasks don’t consider themselves caregivers, , but those who do are more likely to access support services and feel a sense of community with other caregivers.

“Anyone in a caregiving situation deserves support and help,” Brown said.

Embracing the role of caregiver early also allows you to have “really good conversations with people in your life” about their desires — and yours — as you enter this phase, Brown said.

Morrison, whose father died earlier this year, is about to enter his own sandwich generation era: He and his wife are expecting a baby boy in August, and he’s been stepping in to help his mom with housework and administrative tasks.

Morrison and his wife have already had conversations about making time for themselves and each other after their son is born. Morrison also wants to be more intentional with his own health, even if that means just going for walks.

People and Policy

Beyond the emotional strain, caregiving comes with substantial costs. On average, caregivers spend more than $7,000 a year on medical and other expenses to support a loved one, according to in 2021.

Some efforts aim to mitigate the financial burden. In most states, family members can get paid to take care of relatives who qualify for Medicaid. But state Medicaid programs face new pressure from federal cuts, and some states have pulled back funding for home-care programs designed to help residents with disabilities.

Meanwhile, a handful of states for unpaid caregivers. For example, starting in 2027, Connecticut will allow family caregivers who make less than $50,000, or couples who make under $100,000, to apply for a tax credit up to $2,000.

This installment is part of HealthQ’s reporting on caregiving among the sandwich generation. For more, check out the series archive.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

She spoke at rallies. With other members of the advocacy organization Compassion & Choices, she visited legislators’ offices. In 2024, as the state Assembly was debating the aid in dying bill, she helped unfurl a banner in the chamber gallery that read, “Stop the Suffering.”

Her activism was becoming difficult. Netherland, who is 59 and works for a nonprofit, was diagnosed with breast cancer in 2019. “I did a full year of aggressive treatment,” she said. “Chemotherapy. A mastectomy. Radiation treatment every weekday for five weeks. Six months of two oral medications.”

She recovered and felt well until the cancer returned a few years later. Although metastatic breast cancer is incurable, drugs are keeping her disease at bay for now. Netherland feels fortunate but also fatigued, and she contends with brain fog, gastrointestinal symptoms, and joint pain.

“My energy is really limited,” she said.

As she emailed and called legislators, Netherland feared she might die before the aid in dying bill — first introduced in New York in 2016 — could become law.

‘A Breakthrough Moment’

On June 9, 2025, after the Assembly approved the bill, Netherland was in the state Senate chamber, watching the aye votes mount, and seeing it pass.  an amended version in February; it is scheduled to take effect Aug. 5.

A similar law is  in September in Illinois, which would become the (plus the District of Columbia) where medical aid in dying is legal.

“A breakthrough moment,” said Kevin Díaz, president of Compassion & Choices, which has spearheaded the long campaign for such laws. After almost 30 years — Oregon’s law, the first in the country, was enacted in 1997 — the addition of two populous states means that almost a third of Americans will live in one where medical aid in dying is legally available. “It shows that there’s broad support for this model,” Díaz said.

Polls consistently back that claim. A  last spring found that almost two-thirds of respondents didn’t consider the practice “morally wrong,” either because they thought it was acceptable or not a moral issue. Support crossed many political and religious lines: A narrow majority of Republicans and 76% of Democrats both found “physician-assisted death” (also sometimes called “physician-assisted suicide”) permissible; so did most Catholics, Jews, and nonevangelical white Protestants.

In New York,  that 54% of respondents supported aid in dying, including majorities of men and women, of all age groups, and of city, suburban, and upstate residents. A plurality of Latinos supported it; Black respondents narrowly opposed it.

Passing these laws has grown somewhat easier, said Thaddeus Pope, a bioethicist and professor at Mitchell Hamline School of Law in St. Paul, Minnesota, who tracks such policies. “You can say, ‘We have 10 years in California, 18 years in Washington, and 29 years in Oregon, and nothing bad has happened.’ It becomes more accepted.”

‘You Need A, B, and C’

Yet legalizing medical aid in dying, or MAID, has been and remains a long, contentious process. Catholic leadership and many disability organizations staunchly oppose it. (Pope Leo XIV personally  not to sign the bill.)

The American Medical Association says that “physician-assisted suicide is fundamentally incompatible with the physician’s role as healer” and poses “serious societal risks,” although a number of state medical organizations have opted to remain neutral or, as in New York, to .

The Patients’ Rights Action Fund, through a sister organization, has lawsuits pending or on appeal in California, Delaware, and Colorado, arguing that aid in dying laws discriminate against people with disabilities by steering them toward physician-assisted suicide instead of treatment.

“This is a litigation strategy we’ve developed to ultimately get to the Supreme Court,” said Matt Vallière, the group’s executive director, who declined to say whether it would sue to block the Illinois and New York laws.

Even when aid in dying laws succeed, using them can prove challenging. In every state (except Montana, where it became legal through a court decision, so there is no statute governing eligibility), aid in dying is available only to people with incurable illnesses who are expected to die within six months.

It typically involves oral and written requests to two doctors, with mandated waiting periods between requests. Patients must have the mental capacity to make the decision, which disqualifies those with dementia, and they must ingest the medication without assistance. (An amendment Hochul insisted on adds a psychologist or psychiatrist to the process.)

All but two states require patients to be residents. Oregon and Vermont scrapped their residency requirements  brought by Compassion & Choices. ( a .)

Moreover, any doctor, hospital, or healthcare system can legally decline to provide aid in dying, and religiously affiliated institutions often opt out. Those that participate can add their own requirements.

“The state can say ‘You need A, B, and C,’ and Columbia-Presbyterian can say, ‘We also want D, E, and F,’” said Pope, the Minnesota bioethicist.

Hotly Debated, Seldom Used

Perhaps these restrictions, or a lack of public awareness, help explain why, despite the headlines and fervent debates, the number of people who actually use the law is tiny in every state — usually 1% or fewer of the deaths recorded annually. The support for giving patients this kind of autonomy at the end of life remains widespread, but the desire to personally exercise it apparently is not.

Still, after studies showed that many patients seeking MAID were dying , the trend has been to loosen restrictions. California cut its 15-day waiting period to 48 hours; New Mexico allows physician assistants and advanced-practice nurses to write prescriptions along with doctors.

“Most states have now amended their laws two or three times,” Pope said. “We have liberalized.” Telehealth can also facilitate access to participating doctors.

Compassion & Choices is planning legal challenges to end residency requirements in additional states, Díaz said. It is also considering how to “make inroads in jurisdictions with a much different cultural and political environment,” he added, mentioning Florida and other Southern states.

Medical aid in dying represents a shift in power, Díaz said. “The person who has to bear the burden of the suffering should have the ability to decide when it’s enough,” he added.

Anne Gurnett Bander, 72, a retired research scientist in Carmel, New York, cared for her husband for four years as ALS — the relentlessly disabling neurological disorder also known as Lou Gehrig’s disease — rendered him bedridden and dependent on feeding and breathing tubes. “By the time he died, the only thing he could do was nod his head,” she recalled.

So being diagnosed with ALS herself last year was “my worst possible nightmare,” Gurnett Bander said. She was planning to fly to Switzerland, where the nonprofit organization Dignitas provides medical aid in dying, when she learned about the New York bill and began speaking publicly in support of it, her voice faltering as her illness advanced.

Gurnett Bander and Netherland say they’re not certain they’ll use lethal drugs to end their lives as their symptoms intensify. Not infrequently, patients complete the necessary steps, secure the prescribed medication, decide they don’t need it after all, and die of their diseases. But both women insist that the choice should be theirs.

“It can offer so much peace of mind,” Netherland said. “I thought, ‘People should have this option.’ Now, they will.”

The New Old Age is produced through a partnership with .

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

She was in “reasonably good health,” and the risks of the procedure — bleeding, reaction to anesthesia, perforation of her colon — were fairly low. But she was 85. And she would need to briefly discontinue the blood thinners she took because of the cardiac stents keeping her arteries open; doing so could increase the risks.

Had Itzkowitz and his patient faced this decision five years ago, he might have scheduled the screening “without even thinking about it,” he said. But recent research has shown again that the benefits of a repeat colonoscopy .

Now, he said, “I’m saying to myself, ‘What are we accomplishing here?’”

He’s not the only doctor — or patient — having second thoughts. The risks and benefits of common screenings, procedures, and drugs add up differently at advanced ages, and research continues to point out fresh examples of some that may become unnecessary.

Recently, investigators have taken on questions about common skin lesions that probably don’t need to be removed, a widely used thyroid medication that many older patients can safely discontinue, and colonoscopies that reduce colon cancer mortality so slightly that the risks may outweigh the benefits.

Ugly but Probably Harmless

The reddened or rough patches on the skin are called, in doctor-speak, actinic keratoses. Because they result from long-term sun exposure, they usually appear on faces, scalps, forearms, and the backs of hands.

Such lesions appear most commonly on older patients. One large study of traditional Medicare beneficiaries found that over a five-year period, with an actinic keratosis. Then what?

“The vast majority of the time, they’re removed,” said Allison Billi, a dermatologist at the University of Michigan and an author of on the topic in JAMA Internal Medicine. That typically involves cryosurgery (freezing with liquid nitrogen), topical creams, or laser therapy.

The rationale: The patches could become cancerous. But “for the average patient with no history of skin cancer, there is less than a 1-in-1,000 chance of it progressing to skin cancer,” Billi said, citing . The lesions are far more likely to disappear on their own.

“The treatment may be more burdensome than the condition itself,” she added. Removal “is actually extremely painful, both during and after.” It can cause swelling, irritation, and lasting discoloration.

Besides, an actinic keratosis , or new ones will emerge. “This is a chronic condition,” Billi said.

She has proposed active surveillance, instead: Primary care doctors could observe the lesions annually for warning signs like bleeding, pain, or rapid growth, which might warrant removal. But “in many cases, it’s not necessary,” she said. “We don’t always need to do everything we can do.”

She does recommend using sunscreen, however.

Questionable Treatment

Patients take levothyroxine, one of the world’s most frequently prescribed drugs, when their thyroid glands can’t produce sufficient thyroid hormone.

With this condition, called hypothyroidism, “people gain weight. They have less energy. Their hair and skin are dry,” explained Jacobijn Gussekloo, a primary care doctor and researcher at Leiden University Medical Center in the Netherlands. “Everything slows down.”

Doctors also increasingly prescribe it for a borderline condition called subclinical hypothyroidism, which usually causes no symptoms but can progress to hypothyroidism.

Most patients take the drug for life — but do they have to? Gussekloo’s team has found that in many older adults with subclinical hypothyroidism, on their own.

The researchers have also reported that among older people with the condition, and “no apparent benefit.”

Like any drug, it can also cause harm. It may interact with other medications that older patients typically take. Moreover, “it requires frequent lab tests and follow-ups, more visits and expense,” said Maria Papaleontiou, an endocrinologist at the University of Michigan and an author of in JAMA accompanying the latest Dutch study.

“In high doses, it can cause hyperthyroidism, which can lead to cardiac arrhythmias and bone loss,” she added. Patients taking it also have to adjust their diets and meal schedules.

To determine whether some patients could stop taking levothyroxine, the Dutch researchers devised a protocol that gradually reduced doses over 30 weeks, with ongoing lab testing and consultations with doctors.

After a year, a quarter of the 370 participants, all over 60, while maintaining healthy thyroid function. Most had been on lower doses to begin with.

Patients shouldn’t stop levothyroxine on their own, Papaleontiou cautioned. Discontinuation requires tapering off gradually, with testing and monitoring. Some patients will always need the drug.

But it appears that “a select group of adults over 60 may not require this treatment lifelong,” Papaleontiou said.

A Screening With Risks

The question of when older patients can safely stop screening for colon cancer has prompted years of debate. The influential U.S. Preventive Services Task Force gives the screening a lukewarm , calling the benefit “small.”

Yet almost 60% of older patients who have had previous colonoscopies and face limited life expectancies (less than five years) are advised to undergo another screening, found.

As a gastroenterologist at the University of California-San Diego, Samir Gupta regularly encounters this issue with older patients. “I know they really have a low risk of colon cancer, and I’m putting them through more risk,” he said.

The risk of complications following a colonoscopy rise with age. One study found that nearly 7% of patients over 75 had within a month of the procedure.

Is it worth it? Gupta is the lead author of of almost 92,000 Veterans Affairs patients over 75 who had previous colonoscopies. In about 28%, the procedure had found an adenoma, a type of polyp that can become cancerous. Though only a small fraction do, gastroenterologists generally remove them.

The researchers found that after 10 years, veterans with a previous adenoma were more likely to develop colon cancer than those without one, though the rate was extremely low in both groups.

But just 0.5% — yes, one-half of 1% — of those with a previous adenoma died of colon cancer, compared with 0.4% of those without one. “A tiny difference,” Gupta said.

Both groups were dwarfed by the number of veterans — almost half — who died within the decade of other causes.

“Even if the procedure goes well, you’ll either find nothing or you’ll find something that’s not going to have real impact on your longevity,” said Itzkowitz, an author of published alongside the study.

Yet he has found that many patients who have had polyps removed want to continue colonoscopies.

It is hard to shift established medical norms. can meet with opposition from both patients and health care professionals.

Many older women past the point of documented benefit, and older men often beyond the recommended age.

Colonoscopies are less pleasant, so perhaps older patients will be glad to forgo them. “Even with polyps, the chance of dying from colon cancer is so low compared to everything else that can get you,” Itzkowitz said.

So he told his 85-year-old patient that she could skip another colonoscopy. She seemed pleased.

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