Health Affairs.org ‘s recent study on the near-term future of American middle-class seniors reports about 7.8 million will lack wherewithal for housing and healthcare within a decade, swelling the growing ranks of the impoverished, for whom available programs and services already are too little too late,
Reviewed by Kerry Dooley Young for Medscape, in The Forgotten Middle: Many Middle-Income Seniors Will Have Insufficient Resources For Housing And Health Care, authors Caroline Pearson, Charlene Quinn, Sai Loganathan, A. Rupa Datta, Beth Burnham Mace, and David C. Grabowski* found this dilemma confronting
...more than half (54%) of the 14.4 million Americans age 75 years or older who are likely to be in what Pearson and colleagues defined as the middle-income range in 2029. For people ages 75 to 84, that would be those with $25,001 to $74,298, in 2014 dollars. For those 85 or older, the range would be $24,450 to $95,051.
"We still have a lot to learn about what the emerging 'middle market' wants from housing and personal care, but we know they don't want to be forced to spend down into poverty, and we know that America cannot currently meet their needs," said Bob Kramer, founder and strategic advisor to the nonprofit National Investment Center for Seniors Housing & Care, in a statement about the study. The nonprofit group funded the research presented in Health Affairs.
For clinicians, the findings are a reminder of the need to consider broadly what's happening in their patients' lives, according to experts who served on a Health Affairs panel about the study.
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Columbia University professor John W. Rowe, MD, a former Aetna CEO, rates SOCIAL DETERMINANTS as HousingFirst does — a ‘vital sign’ usually unrecognized by conventional medicine. His classes instead teach that if there’s one question to ask older patients in the exam room, it’s “how many friends and family members do you see per week”, to extrapolate what the implied life circumstances signify for health prognosis.
Health Affairs editor-in-chief Alan Weil, JD, MPP calls this understanding rare due to the insurer influence of rewarding physicians for focus on narrow issues, such as tobacco habits.
...That's partly because physicians can easily offer advice to tobacco users about how to tackle this problem, while aiding them with bigger social issues such as housing may seem more daunting…
"The insurer says, 'Boy, if I can pay for this, there are long-term benefits, but there actually are immediate health benefits as well...'
"For most of the social issues, the healthcare system is still just at the early stages of learning what the interventions might be..."
There's certainly going to be a need for these kind of interventions. As several panelists noted, people in general would prefer to age in their own homes, an option that also can prove less costly.
Yet, in the near term, many senior citizens will be coping with conditions that make activities of daily life difficult; at the same time, a traditional base of assistance for the elderly in the United States is shrinking...
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Today, social determinants exert increasing effects on more and more Americans struggling to build against a dark future.
Aging in their own homes may be the most affordable positive choice, unless they’re already mired too deep in adverse conditions.
Or are on the brink, yet don’t see it coming.
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Pearson and colleagues note that about 60% of middle-income seniors in the future may have mobility limitations … about 20% may have three or more chronic conditions and one or more limitations [on] their ability to carry out activities of daily living.
In many cases, these seniors are unlikely to be able to remain in their homes without "meaningful support" from family or paid caregivers…
"Spouses and middle-age daughters constitute the bulk of family caregivers," the researchers write. "However, the availability of these caregivers has declined as a result of changing marriage patterns, lower birth rates, and where adult children live and work."
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In theory, Medicare Advantage programs supply benefits beyond plain Medicare that support senior independent living, such as in-home safety devices — stair rails, grab bars, temporary mobility ramps, etc. In practice, practice varies due to multiple factors, not least because many physicians are overwhelmed by the scale of a problem outside their training and expertise.
This has always been a hazard for low-income and poor Americans. So, The American Academy of Family Physicians‘s EveryONE Project created an online resource:
to help clinicians —and community agencies, and volunteers, and all of Us — enter your zipcode at that webpage to explore how — to quickly identify community resources that can make "aging in place" safer for seniors.
"...there are many low-cost, low-effort interventions that can have positive effects and if [the American healthcare fields would] build on those, we would see tremendous progress." [Weil said, citing] as an example a test program [see JohnsHopkins video at that link] called Community Aging in Place, Advancing Better Living for Elders/CAPABLE which was described in a 2016 Health Affairs article [“Home-Based Care Program Reduces Disability And Promotes Aging In Place”].
The program teamed a nurse, a handyman, and an occupational therapist in an effort to help people better manage their daily lives at home. [It] recruited people age 65 and older who had some difficulty performing [very basic] tasks of daily living, defined as walking across a small room, bathing, dressing the upper body, dressing the lower body, eating, using the toilet, transferring in and out of bed, and grooming.
In the CAPABLE program, the handyman undertook tasks such as lowering kitchen shelves, repairing wobbly railings, and installing lighting or grab bars in the bathroom. Spending on devices and home repairs and modifications ranged from $72 to $1398 per participant.
In addition, the nurse brainstormed with study participants about ways to live more safely. Changing the timing of diuretic, for example, could make an elderly person less likely to incur a risk of falling while rushing to the bathroom at night.
CAPABLE appeared to make a difference in the lives of the 234 participants, many of whom lived alone. At baseline, participants had difficulty with an average of 3.9 out of 8 basic activities of daily living, compared with 2.0 out of those 8 activities after 5 months. In addition, symptoms of depression and the ability to perform other tasks of daily living, such as shopping and managing medications, also improved….
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Now in twelve states with 27 cites, the CAPABLE program reaches about 1000 people, according to lead author Sarah L. Szanton, PhD, ANP, Johns Hopkins (see her video linked 5th paragraph above), this is, as a concept in the US, "still very much in its infancy," because certain American views about “need” lead to various kinds of ‘deservingness’ standards being applied, often contradictorily, often with moralistic limits, often over-focused on screening out fraud to the point that fraudsters are the best equipped to surmount the hurdles, with Americans at catastrophic level the least equipped.
By these standards, elders who seem able at speak for themselves may also be presumed physically able to deal with everything on their own, and infantilizable elders’ lives may be taken control of … making it a question whether either are better off from these kinds of “help”.
Contrariwise, elders whose energy suggests capacity for medical improvement may rate higher than those who are seriously disabled, for whom service is imagined to be a hopeless, thankless, exasperating waste.
The result of these catch-22s: very few programs like CAPABLE, and those few at much higher cost because, as Szanton notes, the cost-effective preventive and pro-active approach is, as usual, only available to the wealthy,
"The medical system doesn't address 'function' usually, but function is what you need to be able to age in place," Szanton said.
"If someone needs a hip replacement or a valve replacement in their heart, we're all in," she added. "But if what they need to do is be able to take a bath or get down their front steps, that's considered a private matter."
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The US is just one among advanced nations with longer-lived citizens eager, anxious, even desperate to function capably for themselves, their families and communities as long as possible, and be safe after that.
In some places, the first step is achieved by simply expanding to all seniors the kinds of resources proven effective for the disabled, and vice versa. This is akin to the argument decades ago, that a drinking fountain at accessible level for an adult in wheelchair is accessible for a thirsty kid, too. Such unifying approaches create a larger, safer, synergistic community from fragmentary ones, using as building-blocks what’s proven functional for everyone — the parade only goes in one direction, after all, and we’re all in it eventually.
A related article from Israel last month addressed an approach overlapping with CAPABLE: the “home hospitalization concept”, which finds that suitable equipment and “house calls” by professionals are more cost-effect and better morale support after all:
... It’s convenient, results in fewer infections and is what patients prefer. But what is really likely to push health maintenance organizations to adopt [this concept] are the huge financial savings.
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Wherever there’s little or no accommodation for elders and the disabled, that IS exclusion. And where accommodation divides and pits against one another the elderly, the disabled, and the poor, cost-effectiveness is so minimal as to gives the false appearance that help is as unaffordable to society as to the individual — financing may be imagined as charity for bestowing on moral basis, rather than recognized as investment in enhancing productivity for all of society that returns its dollar value to the taxpayer — the stitch in time that saves nine.
It can save even more via the taxes from wages of more care-workers employed in delivering services. Their paychecks spent in local communities help sustain local economy against the vicissitudes of industries of more commercial kinds. (And jobs like these can loosen the political and environmental stranglehold on communities that some harmful industries exert.)
Short of draconian condtions, the aging, the disabled, and the impoverished are a constant demographic. The more that life-saving skills and technology prevail, the larger that demographic grows, and societal ramifications along with it. Coldly put (as persuasion sometimes requires), the bottom line is about decreasing the costs and amplifying the advantage to larger society.
The society that maps out how to get pro-active with social determinants of health, to maximize capability, will optimize the physical and financial independence and productivity of low-income fragile elders, and correspondingly of their neighborhoods and communities. The emotional, professional, and material costs will be the lesser.
The society will be the richer.
In every way.
Commenters are more than welcome to link more news reports and diaries on this and related topics. Lists of additional diaries by kosaks can also be found by clicking on the tags at the top left margin.