The Caregiver & Dysfunctional Families: How are you doing?

My dysfunctional family story...My sister is 62 and has metastatic cancer. A little backstory, my only sibling has had mental issues her whole life. She is 6 years younger than me and all I remember as a kid is her yelling and screaming and slamming doors when she would not get her way. My parents never sought out psychological help for her and enabled her as long as I can remember. After she graduated from college, she worked for five years then said she didn’t want to work anymore. So, she moved back home with my parents and stayed on their health insurance because they made her an “employee” of their small business they ran. She still lives in the family home. Over 20 years ago, my mom got cancer and died after six grueling months. My dad and I took mom to all of her appointments and chemotherapy. My sister “could not handle it”. That was fine because my dad and I did ok. Then 9 years ago, my father developed liver failure and my sister called me up and said "you have to take in dad, I can’t deal with this". My husband and I took my dad in till he passed away five months later. My husband and I took over the family business 18 years ago along with the enabling of my sister by keeping her on the company’s health insurance. Fifteen months ago, when she got sick with stage 4 cancer, I took her to every appointment, bought her all her food/prescriptions and paid all of her bills. Honestly, I thought she would pass away after six months to a year due to how far her cancer spread. I decided to help her even though every time I was with her she would scream (literally) about how she did not want to die and how young she was and life is not fair. I calmly listened to her at the beginning because Lord knows how I would react to that diagnosis. She refused mental health help and stopped talking when I would bring it up. So, here we are 15 months later, immunology is shrinking her tumors and she feels good. I started to bring up the subject of her driving herself to appointments because I have a lot on my plate running a business and taking care of my family’s needs. Then came the tantrums of “You are my sister you have to take care of me, I have enough pills to kill myself, you have to let me move in with you", and on and on and on. I was desperate because I was doing everything my parents did for her and I did not know how to step off the crazy train. I even hoped to break a leg or something to get out of seeing her because I felt like throwing up every time I was with her. Again, I begged her to talk to someone better equipped than me to deal with her emotions, no luck. It is very difficult to provide care for someone that is both physically and mentally ill as many of you on this forum know. Last month, my whole family got Covid-19…I called her and said you are on your own because we are all sick and cannot be near you for two weeks. Wouldn’t you know it, she is now driving herself everywhere without my help. This made me stronger where I terminated her “employment” and got her on Medicaid in our state so she does not have to deal with the monthly payments and deductible which she would have handed to me to take care of anyway. It took getting Covid-19 to get me to say no. I will be there for her when she physically needs my help if or when her cancer starts to grow again but not any sooner. In the last 15 months, my blood pressure has been a bit out of control and I had Shingles last October, so I knew that my health had to be addressed. My advice? Say "no" and set boundaries BEFORE you start wishing to get sick yourself in order to get out of the situation.

RMS, what a great story! Thank you for sharing it.

TG, did you read RMS's story? It is the kind of thing that a lot of us here are talking about--YOU make a change and the situation changes.

Stop trying to let stuff "roll off your back". It doesn’t work.

along the family enabling line…

My BFF sister is living in So Cal alone after her DH passed five years ago. The sister was married to an older man for about 40 years. They developed a gambling problem (lottery) and became estranged from extended family. At one time they had good jobs and bought a condo in a retirement community. They had taken the equity from the condo more than once so there is a mortgage and a HOA that takes a third of her SS. Sister has no friends or children and while she is able to drive, shop for food, manage her diabetes, she is basically a hermit.
Sister was nearing foreclosure after her DH passed. BFF made several trips from New Mexico to California to help. Sister was living in a filthy home with her aging cat. BFF helped her clear her home, took her around to look at alternative housing and finding nothing for less, finally made a deal with sister that she would pay her mortgage if sister would walk 10,000 steps daily and attend therapy weekly. Sister complied but has not improved. With the pandemic sister was able to stop paying her mortgage for over a year. Now the moratorium is over and the mo mortgage is once again due. BFF has decided that she has only enabled her sister to remain stuck in her mental illness (learned helplessness) by paying the mortgage. She traveled to Ca again and found her sister in even worse condition than before and in spite of the walking (done in her home) she has gained another 30 lbs, has stopped cooking, has broken appliances and basically spends her days watching tv. Hygiene has all but stopped. The therapist has been pushing sister to move to her birth home in Texas where the cost of living is less. There is one brother still living in Texas. He has poor health of his own and can’t care for his sister although he has agreed to let her move in while she looks for an apartment. So my BFF is in So Cal where the weather is beautiful and the grounds are gorgeous but the condo is filthy. BFF is having it cleaned, painted and made ready for sale while her sister is struggling to organize her few belongings to move. She plans to call an elder attorney for advice on how to safeguard the proceeds from the sale of the home so that sister can’t gamble them away and to be repaid for the mortgage payments she has made without jeopardizing sisters ability to qualify for Medicaid should it become necessary. She has told sister if the equity isn’t protected that she won’t help her sell the home or move. She expects the equity will be gone in five years.
She is going to call the psychiatrist who writes the prescription for the anti anxiety/depression meds and let him know the meds aren’t working. I suggested a geriatric psychiatrist.
BFF doesn’t think she can both manage sister and get the home ready for sale. She is looking for another family member to drive sister from So Cal to Texas as she is afraid sister can’t manage the drive alone. BFF is sick since arriving. Although the cat has passed, the house has not been cleaned in years. She said she had to wash dishes for two hours after arriving and another two hours were spent cleaning the bathroom. Her immediate goal was to get all the flat surfaces cleared. She has a cleaner coming on Thursday. BFF is a minimalist who finds all the clutter and filth especially stressful. She does not want to be her sisters keeper/caregiver. Neither does the brother. She is convinced the sister will let the condo go into foreclosure if she doesn’t help her sell it first. The sister is willing to do whatever BFF asks although she is clearly stressed at just having BFF in her home. Sister was sweating profusely and physically ill the first few days after BFF arrived. Panic attacks?? Sunday she made a slight improvement and was able to clear some paperwork. BFF expects her sister to be a recluse in her apartment after the move. She plans to encourage her to find a housekeeper. Thoughts or feedback appreciated.

So come home last night after visiting friends for 3 hours, dad was out at church then lunch with his friend. I take my dog out and bring her back in off the driveway she starts licking something. I look down and it is poop. a long strip of runny poop. Not an animal I knew it was human.
Long story short after getting my dog off it. I come into the hose and I can smell it, the bathroom was a disaster, poop everywhere. Apparently, he has another poop attack. 2nd in a couple of months. My wife was through the roof, he threw his clothes in the washer on top of our clean sheets. The smell was horrible. Paper towels, the toilet the door. Everything has to be decontaminated. Of course, he is sound asleep. We were not quiet at all. cleaning everything. I don't know where he put the clothes, he is good at hiding things. The last time I had to hose everything down in the driveway.
He stayed in his room all evening only coming out once to go to the bathroom. I have to have a talk with him today to get a full workup. He goes out has lunch and the second time that he has had an issue. Of course, he went to lunch for a nice Italian meal, most likely fried I guess.
My neighbor had a similar issue and it turned out to be colon cancer. Untreated he passed away. I had to help his wife a few times when the same thing happened to him.
Too many times I am cleaning his crap up, off the bed, the toilet or he is clogging the toilet (alto lately) I think he is using too much paper.
I try to feed him appropriate food but he goes out and eats whet ever he wants and we pay the price.
My wife is buying new bed sheets today over this. She is a saint to deal with this but it is really getting to me. I know he will lie about what happened. Getting tired of cleaning off the toilet, the walls, the piss all over the place. We bought the house my wife always wanted. Now it is turning into a nursing home. Does anyone else have experience with the loose bowels issue? He always wants a stool softener, tells me his is too hard then this happens.

TG, gross! My mom had chronic D for many years. Her geriatrician suggested we try a probiotic and it worked very well. Check with his doc to get thoughts.

It has been a day. I am helping care for mother who is in her 90's and has vascular dementia. She still lives with my stepdad in their home. He is a ...? Jackass? Know it all? I don't even know where to begin. Their house should have been torn down or declared unsafe YEARS ago. As my mother has gotten older and the dementia has progressed, she has turned over her entire life - from what she eats and how much, to what she believes her doctors should be doing to take care of her - EVERYTHING to him. He is just stupid. I am sure he loves my mother, in his own way, but it is all about him. They eat when and what he wants, etc....and he is extremely impatient with my mother. He refuses to do ANYTHING positive/helpful for her unless it is convenient for him. He doesn't believe anything her doctors say (he knows better) and actively encourages her to be non-compliant. He criticizes my mother for drinking too much water!!! His reasoning is that "she will get used to having water." What??? He has no interest in helping with her daily medication reminders, or recognizing that she should not be driving anymore. Ahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh!
Talking to my mother is a non-starter as she defends him constantly and will always take his side. The main problem for me is not caring for my mother, it is how to work around my step-dad! Sigh. Thank you for listening.

NoTryDoYoda, long time no see. Are you and your wife doing okay?

RMS1965 I admire your strength. It's a tough spot we get put in and you seemed to survive it.
We put ourselves in these situations, I don't know how things would have turned out if I didn't take dad in. there was no one to help. Sister, nope, brother hell no (but he was willing to live off my dad's business), that left me. Dad asked to come live with me and I had no choice. He was out of money besides SSI and isn't the kind to take care of himself unless it is going out to dinner or spending money on himself.
This week I've had to clean the bathroom so many times, he can't seem to hit the toilet! So we clean the bathroom many times a day.
Friday I got my booster shot and I must have had something brewing. Friday night hit with a 101 fever, chills sweat, headache, etc. All-day Saturday into Sunday. Sunday AM, I'm laying on the couch yet again. He comes down for church and asks if I was feeling any better. I said the same... He asks if I can take him to church..... I said I guess so..... He goes into the kitchen and asks my wife how I am, She said "You just asked him." He replies, "well he doesn't always tell the truth...." So I am supposed to tell him I feel wonderful? Un friggin believable. Somehow I managed to cook breakfast before that for my wife and me that he seemed to be able to eat once he got up. He was expecting me to take him to a funeral in the afternoon but apparently changed that being that he needed a ride home so he went to church and had ice cream and pie and then went out for lunch with his friend.
What burns me is that I am supposed to do everything for him and yet he never reciprocates to us. he's not an invalid, trust me when food is on the docket for the day he is up and ready to go.
With his crapping himself at places, I had him make an appointment with the Dr who was on the phone and he didn't tell me until days later. The Dr. said he gets constipated so that makes for his blowouts. And to not eat grape and oranges (that I buy him) because there is too much suugar. Guess there is no sugar in ice cream.
No, I cannot send him to an NH, he's not ready, No he cannot live on his own even with medicare. no, he has no other place, his entire life he has been taken care of.
Just tired, beaten down mad, angry, and just plain miserable. Othere than that, whoopie!
Thank for listening.

gladimhere, thanks, he had a call with his Dr and now he is taking medimuscile, of course, if he ate healthier that might work, but he doesn't like what I cook much, like green, lean meats, nothing fried etc... I made him oatmeal every morning until he threw it out one day to go to lunch with his friend. Well that ship sailed...
if he ate whole grains, fiber, and on a regular basis things would work better, but he does not listen to me. I cook one meal a day for the 3 of us. I cook breakfast for my wife and me at 6 AM, he doesn't get up until 11 most days, unless there is a lunch to go to. I cook dinner every night mostly pretty healthy. we pack my wife's lunch every day and I eat leftovers, I don't cook 3 meals a day for him. he can certainly find food in the fridge if there was a pie, a cake, or something good he would find it in a heart beat and he does. If I buy something new he finds it 10 minutes after I bring it home like a little kid with toy in the cereal box.

So I just have to comment here. Not complain. Just the fact with my family. Now, this is coming from my dad. My family tends to make stories more than what they may really be.
My sibling has cancer which is being treated, we are not close at all due to a whole lot of crap from childhood that will take many psychologists to figure out, but that is my problem.
My other sibling has been helping him even though she has to drive many hours to help him. That's on her as I won't (see above). So last night at dinner my wife asks dad how my sibling is doing. He only reports that when he was with social services with my sister trying to get assistance for income and medical needs that he has $1,000,000. of artwork. So there ended the story of how my sibling was.
He has artwork but I really don't think that artwork you bought at the store in the mall in the 70s is worth that kind of money, and if it really was would you think to sell it to pay for your medical care and since you are not working help care for yourself?
This is how my family rolls..... Ask dad how someone is and he tells a headline or a story. He can't hold a conversation or show compassion about others. Ask how someone is and he tells a grandiose story. This is how I have listened to things my entire life. Insert eye roll every time a story is told.

tgengine,
Can you make your Dad oatmeal again?
Give him another chance?


 You said he has always needed taking care of:
"I made him oatmeal every morning until he threw it out one day to go to lunch with his friend. Well that ship sailed..."

tgengine,

I can totally relate to your family dynamic. There's not a million dollars in artwork. The grandiose stories and the blatant lack of empathy for anyone or anything that isn't directly related to the elderly parent. I get you.
With my mother the grandiose stories are replaced with martyrdom about her having the hardest life in the world and all the sacrifices she made for us.
What sacrifices? My mother and father really did the very bare minimal for us. Yet to hear her talk about how hard she worked. Then in her old age I do a hundred times what she ever did, but I dont anything.
I live like a slave. No privacy, no breaks, no nothing. My mother thinks it's absolutely fine to enter the bedroom when I'm getting dressed or the closed bathroom door. Slaves aren't allowed privacy. Then she expects tender, loving care from me. I grew up in abuse and she's lucky I even still speak to her because I took the brunt of the abuse growing up.
So, I Gray Rock her big-time. I got a job. All she gets from me is food and meds and a clean environment. Nothing else. There are now locks on the bedroom and bathroom door. I do not tell her where I'm going when I leave.
If she complains I tell her she can go into a nursing home then. When she starts instigating a fight because she's bored, I ignore her even more.
My sibling does absolutely nothing. I totally get your family dynamic.

I really like the idea of this thread. I am struggling quite a bit. I am in therapy, but it goes beyond a 45 minute session every 2 weeks. Also, I do therapy via telehealth, so I can't speak openly anyway because I am almost never alone. I am 29 years old and feel **so** tired all of the time trying to care for 2 households (grandmother, great grandmother and mentally ill father) while working and attending graduate school. My friends can't relate to where I'm at. There's very little escape and the loyalty in a dysfunctional (VERY NEGATIVE) family makes me feel guilty about complaining about it anyway. I am a planner, but my family isn't. Even trying to plan for Thanksgiving... No one has a plan to the end of the week! Let alone what is to come over the next few months/upcoming years. What's funny is... Even with all of the self-care in the world, which I do so many things daily and consistently, when you're in a situation like this, it'll still drag you down to hell.

I absolutely love the dysfunctional families idea. Let's face it who's family is fully functional... mines not

I haven't read all the comments, and mine are addressed only to Nicola's comments of dysfunctionality, and who really is functional.  I think dysfunctionality isn't unique and that many if not all of us have some level of what could be considered dysfunctionality.   I think sometimes they're considered quirks.

However, I believe there are scales of dysfunctional levels (haven't checked the psychology manuals to see if this is a scaled "disorder").   Perhaps the only totally, completely functional people w/o any quirks really don't exist.  I've thought for years that dysfunctionality is used too frequently and too loosely, without parameters. 

Second hwever, I'm not denying that many of the threads here describe situations which aren't positive, are aberrant, and/or aren't conducive to healthy living.

I think you're right, GardenArtist -- both in the informal sense and formal diagnoses. There are many things are described as "dysfunctional" when perhaps they are more personality traits that conflict, or something else. It's tough to draw a hard line. The important quality to consider is: Is this detrimental to my physical, mental, or emotional health and well-being? If the answer is yes, then I think it's dysfunctional (a relationship, or personal habit) for that person.

The official disorders are being expanded, too. The DSM-5 that lists the medical/psychiatric criteria for disorders has come under criticism for being too vague, too broad. I think many people have traits that are borderline or narcissistic but wouldn't meet official diagnosis criteria. It's an interesting topic to me right now, as I'm studying psychology but with a different emphasis from mental disorders or any psychoanalysis or mental therapies.

Got a call from my mom a couple hours ago. She started asking me questions, like are you still working, are you still in school, etc. I'm answering these things with mostly monosyllables, thinking it's strange that my mom calls me up just to check how I'm doing, even if it's her usual closed-ended question style that seems more like interrogation than conversation some times. lol Then she interrupts my first slightly longer reply with "I SUPPOSE YOU WANT TO KNOW WHY I'M CALLING YOU."

lol Well, she's right about that, but for a second there, I thought she might actually just want to talk to me.

Turns out my dad's not doing so well (not taking meds, has had some falls) and also he talked about my grandmother's revocable life trust (for his benefit) with the subsidized senior HUD managers during a re-de. They have concerns about his eligibility and I get that. I went over this exact issue with an Elder Attorney before I filled out his application there and left that information out based on her expert advice.

My mom had a lot of questions about my dad's trust, HUD regulations, whether or not he would owe retroactive fees, etc. I told her the best thing she can do is go speak with the expert elder attorney that she refused to see before (I didn't say that last part out loud) because "she's too expensive." The atty fees are something like $450-500/hr and WELL worth it, especially considering that twice this attorney billed me for 1/4 hour when we specifically met up to discuss different qualifications and application questions. I've never seen such an honest billing practice from an attorney! lol

It's too goofy a situation to feel even a little smug here. I emphasized to my 72yo mom that all I want is for her and my 83yo father to protect themselves. That means she does not take any money from him without a caregiving agreement (which she's been doing every month for several years, as "caregiving fees" but no formal agreement) and protects both their need for future services. My mother has no savings, and a very modest house she bought with her retirement settlement check 10 years ago. My father only has the fed-minimum SSI plus a VA benefit that is like $100/mo, and this small trust that is not his asset/not in his name. Getting expert input is the right way to proceed. The risk to future care is so much more important than any few hundred being spent or saved each month. They're two entirely separate households, been divorced since I was an infant, and I'm not sure exactly what they're both risking here but I know they're both extremely naive about it.

I'm not getting roped back into any caregiving duties, no worries there, but I foresee some discussion during holiday time about all this. I'm frustrated that my mom hasn't taken this situation more seriously but I'll give her support and input, if that's what she wants. I told her that if she moved my dad in with her I'd never talk to her again. lol I was half joking, but she agrees... thankfully... which is a different approach than what she's said in the past. As my mom said, she can't even move into her own house that she purchased 10 years ago and never finished moving into. (That's another story and best told through the show Hoarders.)

This short conversation tonight brought back some feelings. I do not know how to help them, nor if anything other than some general support would even help. It's going to be frustrating to witness at times. I need to be ready for that -- to offer the support that I can and step away.

I'm leaving out a lot of details but my mom does caregiving for other elders from her church, too. She's a helper type, which is nice I guess, but never seems to realize she needs to help and protect herself, too.

Ali,
Shake it off, don't go there in your mind.
It is obvious your Mom thinks she knows better than you.

Re-focus on your finals.
It is all you can do.

Talk to Mom after finals if you want, maybe that will help get your mind off
today's conversation.

Your studies are very interesting.

Too late, Send! I already went there mentally, now bringing myself back around. lol

Today was the easiest schedule I've had in awhile. I finished the previous week's stuff and I thought I'd make hot chocolate and watch a movie. I've printed off my finals and will start them tomorrow. Then my mom called me.... 🤷 I'm glad, actually, that it happened tonight and I had time to work through it mentally and put it here. Good timing, all things considered! Thank you! 💚

Hey everyone! I have some questions and concerns regarding my health and who and where can I get help without going into debt! I feel trapped because I can’t apply for any anything without use my husbands income. Hey my husband tells me he can app,y for anything without usu for my income. I don’t understand that. ….why do I have to include his when he doesn’t have to use mine?

Sharyn, hi!

What does your husband mean by what he says? What is HE applying for without using your income?

This is highly state specific. Are you talking about applying for medical insurance?

There are SHIP counselors in every state that can help if you are talking about Medicare plans: https://www.shiphelp.org/

For ACA: https://www.healthcare.gov/income-and-household-information/how-to-report/

Hi Sharyn! Fun times figuring out all that Medicare carp isn't it? I have retired from the crappy public sector, just last Friday. It had gotten really ugly and corrupt! I will not go along with the crap! My mom did not raise a brown noser.

I too need to figure out Part B, sure as heck am not going to take cobra at about 900 a month!

Thanks for that info Barb, I needed it too. Any other hints?

Sharyn,
There are differences in insurance coverage for spouses.

Is it perhaps your husband is of retirement age (65 +) and you are not there yet?

I don't think that I will have an answer for you regarding the disparity between the requirements for husband and wife to qualify. But I can acknowledge it does exist.

Hello everyone! Christmas is very close now and yes I have shopping to do but can’t do until Wednesday, my payday. Most is easy as we get gift cards for adults. We now have 3 grandchildren with oldest being an eleven years granddaughter as a result of our sons recent marriage. She is a very intelligent young person who is also very artist. We look forward to getting know her as time goes by and if she feels comfortable enough to spend some summer time with us.

I got my booster Covid vaccine today as well as a diabetic check. Yes I am now considered diabetic but I’m on the very low end that qualifies me to be there…6.5 is my Daily glucose level. It’s just over the boundary between being pre-diabetic and actual diabetic so I don’t qualify for a meter. October and November have been hard for me as I have been diagnosed with diabetes and COPD. I’m adjusting to life style changes as you can imagine.

because I have already had an occlusion in my right eye as far back as my mid thirties, developing more is most likely because of diabetes. If you don’t know, an occlusion resulted because the retina only has one main vessel that feeds it, in my right eye, the vessel burst back in my 30’s. They could not explain why it happened since I was not diabetic nor did I have high blood pressure. I have a big black spot dead center in my right eye. I don’t see it anymore because left eye over compensates for it. My goal is to get a tired mill as exercise is important to controlling diabetes and I have a good opportunity to control it better since I’m low end on the spectrum. I don’t want to loose my eyesight from diabetic rentinopathy.

in the meantime….I’m getting a hip x-ray tomorrow as my right hip is causing chronic pain, down my leg into my knee plus when I stand I have tingling down my thigh to my ankle which is probably sciatic nerve. So… my dr wants to document everything we do to help this pain in case I need a hip replacement. As some of you may remember I had severe sciatic pain about 6 -7 years ago and the chiropractor told me the x-rays show considerable scaring in my hip socket which may result in a hip replacement. My dr agreed to let me try using Gabapentin for the pain as it is non narcotic and non addictive.

im using an inhaler for the COPD and I’m on the patch to quit smoking which is very effective.
I wish everyone a good December. I realize that with our dysfunctional family histories, Christmas may not be Merry, but I hope you can carve out some “you” time that all of you deserve. Caregiving in dysfunctional families is the hardest and I certainly know how much you all need some quiet time or a half day for yourselves.

much love to everyone.
SharynM

Hi Sharyn,

I just finished a long day and night of school work stuff (it's finals) and I was a little slaphappy as I read your post. I giggled at "tired mill" because it seemed like it could be a slang term for treadmills -- if you weren't tired when you started on one, you should be when you're done. My goofy brain loves a dumb pun, the dumber the better. :-)

I hope you can get some improvement for the pain and your other symptoms. I'm Rx'd gabapentin but I don't take it every day because I find it doesn't do much for my pain or anxiety symptoms. It works well for many people, though! Nerve pain seems like what it's best for. I hope it helps.

I never tried a nicotine patch but have tried lozenges and also gave them to my dad. They didn't help either one of us, so it's interesting to consider that a patch might be a better option. I'm glad it's helping you. I've picked up a bad vaping habit during the past year I'd like to cut down/quit.

I hope you get some answers about health needs stuff, and why you need hub's income if he doesn't need yours.

It's great to see your posts here and Happy Holidays to you and yours! It will be nice to get to know your new gd. She sounds neat.

Barb, my husband says he has not used my income to get medical insurance. Yes, he is on Medicare so maybe that makes a difference. I can’t afford tge affordable care act because it will be around $800 a month. I have 2 1/2 years to go before I can get Medicare. Hopefully it will be easier then.

Ali, lol! It was suppose to be tred mill lol! Autocorrect keeps changing it and yes I should be tired when done using it.

I like the patch and it works well for me but others tell me they didn’t like it. Good luck with stopping vaping. You did it once before so you can do it again.

Sharyn, Medicare is completely separate--confused the heck out of me when we first turned 65, as DH had always been on my insurance.

Health insurance is a tough issue to deal with in this country, for sure.

Send, it does seem to be a bit of a disparity especial when trying to get the affordable care act. What I mean is my husband may have to include my income too if he were to apply for it but it does seem unfair if a person is paying out of their income alone and not combined income.

Sharyn,
All I know is, before we were married, I had full coverage with health insurance.
And after we were married, I did not, but he did. All his needs were met. I just stopped seeking medical care to compensate, even though I had Medicare.