Call it the generational vise: canceling Father’s Day with my fast-declining 93-year-old dad because my 11-year-old came down with the flu. Stressful, definitely. Heart-wrenching, yes. Welcome? Of course. Despite all the juggling and hard choices that have to be made about competing demands for care, I’d rather be stuck in this vise than face the void of the alternative.

But it sure isn’t easy. “Caring for an aging and frail parent or disabled relative may be the hardest thing you’ll ever do in your life,” says Howard Gleckman, author of the newly published Caring for Our Parents: Inspiring Stories of Families Seeking New Solutions to America's Most Urgent Health Crisis. “But it can also be the most rewarding.” Gleckman, a senior research associate at the Urban Institute and former BusinessWeek senior correspondent, talks about the “silent society” of some 44 million Americans now caring for some 10 million elderly and disabled friends and relatives.

Our family is now a member of that society. Since September I’ve been commuting by car or plane at least once a month to see my ailing father 700 miles away as my brother, mother, and I face end-of-life issues head-on: Through episodes ranging from dehydration to surgery (at his request) to replace a broken hip joint so he wouldn’t be bedridden, my father has defied the odds and tenaciously journeyed through his 62rd year of marriage. Each crisis has weakened him, yet with his humor, logic, and longer-term memory mostly intact, he remains at core the kind-hearted man who raised me.

I consider our family to be among the fortunate: Years ago my father, a white-collar engineer, ensured that his wise investments would allow my parents to spend their later years in a highly rated, soup-to-nuts retirement community. But smart planning still doesn’t prepare a family for the reality of elder care. Decisions made long ago about interventions are no longer abstract—and are revised (no, now, to CPR; yes to antibiotics). Costs that can be pared (a private or shared bathroom?) are weighed; quality of life decisions often trump pocketbook concerns, at least for now. Even a caring staff seasoned in end-of-life care —doctors, nurses, chaplains, social workers, medical assistants—can’t predict how each individual will slowly fail.

Meanwhile, as President Obama takes the lead in an historic debate about reforming health care, questions abound about end-of-life care and its demands on caregivers and resources. Warning that “the weight of 77 million aging Baby Boomers will devastate our nation's already fragile system for funding this critical day-to-day assistance,” Gleckman provides ideas about how to repair the safety net essential to the nation’s aged and disabled, as well as resources. Organizations like the International Longevity Center take on such notions that putting limits on health care for the very old would save Medicare significant amounts of money. “Limiting acute care for the very old at the end of life would save only a small fraction of the nation’s total health bill,” said the center in a study debunking financial myths about health care for older adults.

Human dignity has no expiration date. That much has become clear to me as I sit in my father’s skilled nursing dining room while policy wonks in Washington debate their abstract questions. To outsiders, the bibbed, napping diners—many are former professionals—may seem lost to life as we know it. Spend meals with them, though, and the small gestures of pride (“Did I spill that?”), compassion (a resident helping another with her wheelchair), and companionship among the residents gently tug you into a world where time is irrelevant and human connections precious. My brother, who lives nearby and visits often, and I slip into the elder zone with ease. Using Styrofoam pool noodles, he engages in mock swords fights with our wheelchair-bound dad—at least for the few minutes that Dad has the strength to play the game.

And what about the generational squeeze? I find habits from not-too-distant child raising come back quickly, such as this past weekend when I was able to reschedule my visit. Singing “Hush Little Baby,” I massaged my father’s thin shoulders as he soaked up the sun on a patio. At lunch as I gently suggested he eat a few more morsels, I ran a mental search of feeding strategies (and rejected “open wide, here comes the airplane!”). But there’s no greater evidence of how welcome this squeeze is than seeing my dad’s thin face, most often nodding these days with his eyes closed, lift up and brighten with a wide smile when he hears my 11-year-old on the phone. “Hello,” he says in a voice muffled with age but suddenly stronger, “And how is my grandson?”

Reader, are you a member of that “silent society” of caregivers? And do you have advice about coping with elder care as well as the generational squeeze?

For information about long-distant caregiving, see the Web site of Caring from a Distance. "Whether you live across-the-world or an hour away," the site says, "you and your family face special challenges. Where can you find the local resources they require? How can you, family and friends communicate in an emergency? What can you do to help when you visit?" CFAD provides links to information and services.

More grim news on the obesity front. An annual survey of obesity in America found that adult obesity rates increased in 23 states last year, and did not fall in a single state. Adult obesity now exceeds 25% in 31 states, and two-thirds of adults are considered overweight or obese. Worst of all, the survey also looked at children age 10-17 and found that 30% or higher are overweight or obese in 30 states. 30 states! The rate of obesity in US children has more than tripled since 1980.

Study after study has found that overweight children are more likely to become obese as adults, and obese children are almost certain to remain that way. "There is a huge wave of obese adults coming that will bankrupt us as a nation unless we get this under control now," said Dr. James S. Marks, senior vice-president of the Robert Wood Johnson Foundation.

We might be inclined to blame the schools for filling them up with unhealthy lunches and cutting phys ed programs. But a 2007 study discovered that home may be far more dangerous to our children's waistlines. Body-mass index (BMI) gains were greater during summer vacation than during the kindergarten and first grade school years. We have met the enemy and it is us, the increasingly-fatter parents.

So what do we do? A New York City councilman, Eric Gioia, has proposed a bill banning fast-food chains from opening new restaurants within one-tenth of a mile of a school. He was inspired by a recent California study that found that when fast food outlets were in a short walking distance to a school the student obesity rate was 5.2% higher than those schools without such easy access.

In fact, according to the BusinessWeek story Alcohol, Then Tobacco. Now Fast Food? , consumer advocates are calling for regulations that would make children off-limits to fast food marketers, much as they are to alcohol and tobacco companies.

The food and restaurant industry needs to be responsible in how they market to children or else the government will step in and then require them to," says Dr. Margo Wootan, director of nutrition policy at the Washington-based Center for Science in the Public Interest.

Lots more could be done, according to the researchers who put together the state-by-state survey. Despite the fact that every state has some form of phys ed requirements for its schools, nationwide less than one-third of all children age 6 to 17 engage in vigorous activity for at least 20 minutes a day. Activity rates by state range from a low of 17.6% in Utah to a high of 38.5% in North Carolina. Perhaps we shouldn't count on the schools, and instead make sure our kids spend some time running around at home, instead of vegging out in front of a screen.

Parents can also agitate for healthier school lunches and a ban on soda in schools, although that won't do much good if they don't follow through at home. Does anyone else have suggestions on how to combat the obesity crisis swamping our children, and ourselves? Because we will all pay the cost, economically and physically, if this problem isn't addressed now.

If you want to see how your state stacks up on the obesity rankings, check out the full report, titled F As In Fat: How Obesity Policies are Failing In America, by clicking here or just roll your cursor over this interactive map.

As the debate over health care reform heats up in Washington, the rhetoric around health care rationing grows more vitriolic. Conservative commentators, such as those writing op-eds for the Wall Street Journal, paint a frightening picture of the world under "Obama-Care," a world where we would all stand in long lines to get whatever care the state deems reasonable. At the other extreme are the advocates for a massive healthcare overhaul who insist that a single-payer system would end the waste and inefficiencies now rife in our present system, leaving more than enough money to provide optimal care to all the people, all the time.

Let’s park our ideologies at the door and talk facts for the moment. Fact number one: The United States rations health care now, and anyone who doesn't think that's true has never come into contact with the medical system--or is very, very rich. But we ration on an ad hoc basis, with little to no honesty around the process. Has your insurer or doctor ever used the word “ration” when discussing the reasons why you should or shouldn't have a certain procedure? I didn't think so.

So let me ask you: How should we ration?

First, let's look at how the U.S. rations today. We start by limiting access to health care for the 40 million to 47 million Americans who do not have insurance. Many people insist that these uninsured do have access to high quality healthcare, in an emergency room or wherever; they just don't pay for it. Not true. Study after study has found that the uninsured get sicker, die earlier and get lower quality treatment than the insured, precisely because they can't afford to pay. From an Urban Institute report last year:

In 2002, the Institute of Medicine (IOM) estimated that 18,000 Americans died in 2000 because they were uninsured. Since then, the number of uninsured has grown. Based on the IOM's methodology and subsequent Census Bureau estimates of insurance coverage, 137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006.

Other researchers have estimated that the death rate could be reduced by 5% to 15% if the uninsured had the same access to care as those with coverage.

Those of us who are insured don't have to worry, though, right? Well, earlier this month three insurance executives testified before Congress that their companies routinely deny coverage to policy holders with pre-existing conditions, a practice called rescission, and they have no intention of stopping. From the LA Times:

An investigation by the House Subcommittee on Oversight and Investigations showed that health insurers WellPoint Inc., UnitedHealth Group and Assurant Inc. canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period. It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.

For a view from inside the rescission process, read the Congressional testimony of Wendell Potter, former insurance industry executive:

My name is Wendell Potter and for 20 years, I worked as a senior executive at health insurance companies, and I saw how they confuse their customers and dump the sick – all so they can satisfy their Wall Street investors. I know from personal experience that members of Congress and the public have good reason to question the honesty and trustworthiness of the insurance industry. Insurers make promises they have no intention of keeping, they flout regulations designed to protect consumers, and they make it nearly impossible to understand—or even to obtain—information we need.

There are other ways we ration. We limit the number of doctors that can be trained each year, and effectively limit the numbers of primary care physicians by reimbursing them at much lower rates than specialists, thus encouraging medical students to avoid that path. The result is doctor shortages and long wait times for appointments, often longer than Europeans and Canadians, the ones with universal health care, have to put up with.
Insurers also typically do not pay for preventive care, which might save money in the long run but not in the short term. And as New York Times economics columnist David Leonhardt points out, by allocating 18% of our gross domestic policy to health care we are devoting fewer dollars to salaries, savings and other social goods like college loans.

A 10% increase in health premiums leads to a 2.3% decline in inflation-adjusted pay. Victor Fuchs, a Stanford economist, and Ezekiel Emanuel, an oncologist now in the Obama administration, published an article in The Journal of the American Medical Association last year that nicely captured the tradeoff. When health costs have grown fastest over the last two decades, they wrote, wages have grown slowest, and vice versa. So when middle-class families complain about being stretched thin, they’re really complaining about rationing. Our expensive, inefficient health care system is eating up money that could otherwise pay for a mortgage, a car, a vacation or college tuition.

Then there is the way the U.S. chooses to spend the $2.3 trillion it will allocate for health care this year. We have decided that our top priority is to help the dying--studies estimate that 10% to 12% of U.S. health dollars are spent on end-of-life care. About 25% of Medicare's budget is spent on patients in their final year of life, and almost half that amount is spent on the final 30 days.

That makes little sense to me, and I speak from experience. When my grandmother was a frail 96-year-old, she fell and broke a hip. Despite our family’s better judgment, doctors talked us into hip replacement surgery, from which she never fully recovered. She did not walk again, she quickly fell into dementia, and died with six months. I doubt very much she would have had that wasteful operation in a European nation. Then there was my mother, who died of an asthma attack at age 64. But first, the hospital was able to revive her enough to put her on a ventilator. Although she had a living will, and her family wanted the machinery disconnected, she lived in a deep coma for another five weeks, unresponsive, essentially a vegetable. I cannot imagine the financial cost, and I am all too aware of the emotional cost. Again, I do not think that would happen in a European nation. But take a look at England, home of “socialized medicine.” My husband died of a brain tumor in London despite the uniformly excellent care he received, all free thanks to the National Health Service. In his final month cancer was found in his liver, but the doctors felt there was no point in putting him through any more painful treatments. We agreed and he died peacefully in hospice.

So, how would you like to die, and live? Should our health care dollars be spent on prenatal care or end-of-life care? How about preventive care, mental health care, dental care--how much are they worth? Should we insure everyone, or just those who can afford the premiums? Be upfront about rationing, or continue on an ad hoc basis?

It's time for an honest and open debate, don't you think?

For some great insights into how America rations, bookmark The Covert Rationing Blog by DrRich, a former cardiologist and medical professor who now works as a consultant.

Also, if you want to learn about one model under consideration for lowering health care costs, read my story on patient-centered medical homes: The Family Doctor: A Remedy For health Care Costs?

Do you wish your parents would help with babysitting, financial support or even picking up your dry cleaning?

Growing Old in America, a just-released study by the Pew Research Center, shows that parents and their adult children are relying on each other in many ways. Aside from the interesting retirement data in the study, what caught my eye is that 36% of respondents ages 65 and older say they help with their children with childcare. In addition, 51% of them say they have given their children money in the past year. And 32% of respondents 65 and older have provided help with errands, housework, and even home repairs.

Housework and financial support is definitely nice, but I’ve always been envious of the working parents who can rely on their own parents for childcare (and work-life balance). This week my son’s sitter is away on vacation, and because school is finished but camp hasn’t started, we had a problem. It would be so wonderful if one of his many grandparents could step in. But they are all at least two hours away. Luckily, our neighbor is watching him, which is arguably the next best thing to family.

Even so, I’m envious of the strong bonds children have with the grandparents who babysit for them on a regular basis. For example, a colleague’s mother-in-law just came to visit from the Czech Republic for two months, which made caring for his daughter, who is almost 2, a lot simpler. In the beginning, his daughter wouldn’t go to her grandmom, but, by the end of the visit, she was calling out her grandmother’s name (Baba) from the moment she woke up. Even more amazing: Baba got her potty trained.

Another editor here at BusinessWeek has what seems like an ideal set up: her mother-in-law is her daughter’s primary caregiver, and the mother-in-law does it for free. By now everyone in America knows that Michelle Obama’s mother Marian Robinson (pictured here) is helping out with caregiving for first daughters Sasha and Malia.

I realize the grass is always greener. Indeed, family tensions can flare up When Granny is Your Nanny, according to the Wall Street Journal’s Sue Shellenbarger. In her newspaper article and a follow-up piece on the Juggle blog, Shellenbarger writes about the complicated cross-generational child-rearing dynamic. Parents and grandparents may have conflicting views on food, sleep, homework, TV and computer use. For example, one grandparent lets her grandson eat ice cream while he is watching TV. Although his mother doesn’t let him do that, she often looks the other way.

Despite the potential for family clashes, it seems like more households are opting for what is considered an “old world” childcare solution.

The proportion of preschoolers cared for primarily by their grandparents while their mothers work rose to 19.4% in 2005, the latest data available, from 15.9% in 1995, the Census Bureau says. A wave of closings and cutbacks in child-care facilities suggest the trend is continuing.

Do you think your parents or in-laws can provide ideal childcare? Why or why not? Feel free to air your clean (or dirty) laundry here.