BY RUTH E. KATZ
Illustration by: Jon Lezinsky
It has become abundantly clear that the long-term care "system" in one of the richest countries on the planet is not a system at all, but rather a patchwork quilt of solutions that have evolved to accommodate changing demographics. Even if the system had been fully functional and available to all who need help before the coronavirus pandemic, it is facing some tough challenges now. Why, and what can be done to get the country on track with an aging services system consistent with increasing numbers of older people?
Nursing homes, assisted living and other residential communities see heartbreaking losses of life, declines in the well-being of residents and staff, and gaping holes in federal and state support. Community providers shut down or significantly adapted their services. A false narrative emerged in some media coverage and amongst the public that blamed aging services providers, assuming COVID deaths in nursing homes were the result of malfeasance on the part of the nursing home or its staff. The Centers for Medicare and Medicaid Services and state policies restricted visitation in long-term care settings, yet providers were blamed for isolating residents and restricting family visits.
Policy makers have largely neglected long-term care services for decades, treating them as an optional add-on to health care. (A long-term care proposal known as the CLASS Act or Community Living Assistance, Services and Supports was originally enacted as Title VIII of the Affordable Care Act, the component that helped make the financing of the ACA work. The CLASS Act was repealed before it could be implemented.) So now it's hard when a global pandemic strikes the people living and working in aging services to see several media reports and the attitude of some Americans blame or even demonize the provider community.
Few people want to think about aging — their own or that of the population as a whole — and even fewer want to contemplate needing help with basic daily activities like eating, getting out bed or using the bathroom. Meanwhile, right under our noses, whether we pay attention or not, like most of the developed world, as a nation we are growing older. It's not all bad; there are some distinct opportunities awaiting each of us, our loved ones, and American society — if we can only get it right.
The pandemic provides a wake-up call. Our financing systems, policies, and social and community attitudes need to catch up. It is time to confront the reality that if we are going to live well into our 80s and 90s we are going to have to build and finance the capacity to provide older people with the help they need to live their best lives, even if they experience functional impairments.
WHY HAS LIFE EXPECTANCY GONE UP?
Getting old is a relatively new concept. Americans have nearly doubled their life expectancy over the past 120 years. At the turn of the last century, the average American lived to the age of 47. We've come a long way. Mid-century, life expectancy was 68 years and now, it's close to 80. By 2060, the U.S. Census Bureau estimates it will be closer to 86. 1 To what do we owe this widespread longevity?
The most significant benefits come from public health — efficient waste disposal, widely available clean water, vaccinations against deadly diseases, antibiotics, and the effectiveness of prevention programs for smoking and alcohol consumption and the promotion of physical activity.
Technology and science have played a big part. We all gain from the widespread use of electricity and refrigeration to keep food safe and improvements in transportation and communication. Medical research has given all of us more time; better cardiovascular treatments and widespread access to them may be responsible for decreasing prevalence or incidence of Alzheimer's disease and related dementias.2
When most Americans died in their 40s and 50s, a few short generations ago, they lived compressed lives. They were born, lived short childhoods and launched into adulthood by age 18. The concept of the "teenager" emerged in the middle 1950s, with the post-war economic boom, the emergence of better education and leisure time, and the longer lives people were starting to expect. 3
Just as the concept of the "teenager" was created because we found ourselves enjoying longer lives, the idea of a demographic group of people beyond retirement is emerging. As Americans and the world craft this new generation, some advantages that support aging well accrue more easily to those with more resources, including abundant food supply and reduced food insecurity, better access to health care and secure housing.
As a whole, the United States is not doing as well as it should be worldwide. In 1960 we had the 20th highest life expectancy. By 2060 we're expected to drop to 43. There are likely many reasons for this, starting with unequal access to health care, housing and education across racial and economic groups. But across all groups drug overdoses were six times higher in 2017 than in 1999; and everyone faces the triple threats of obesity, heart disease and diabetes — the leading causes of preventable and premature death.
Pervasive attitudes of ageism, in addition to the physical declines, social isolation and loneliness that often accompany aging, also shorten lives. A recent review of research in 45 countries found that structural biases such as denied access to health care and negative stereotypes induce stress, increase depression and shorten life expectancy. 4
COVID-19 THE MASTER TEACHER
And then along came COVID. Coronavirus is a danger to all generations, but it has been particularly deadly to older people. COVID-19 has sharpened the nation's focus on aging and the services and systems that are in place, or not, to support aging lives.
The pandemic offers all of us — individuals and providers and policy makers a great opportunity to see what must be done and do it. As a nation, like the rest of the world, we have paid dearly for these lessons; we must not squander them. We need to evolve personally, culturally and in our policy zeitgeist.
BEGINNING WITH THE INDIVIDUAL
In the landmark Harvard Study of Adult Development, begun in 1939 and now in its second generation, researchers identified the psychological factors and biological processes in earlier life that predict health and well-being in late life (80s and 90s). 5
They found that genetics was less important than physical activity, absence of alcohol abuse and smoking, having mature mechanisms to deal with life's stressors, and being at a healthy weight. But by far, they found that the key to healthy, happy aging is satisfaction with relationships in midlife.
The importance of relationships, in addition to clean living, is confirmed in other major studies. Researchers at the Stanford Center on Longevity in their 2016 Sightlines Study summarized scientific evidence that "living long and living well is most realistic for those who adopt healthy behaviors, are financially secure, and are socially engaged."6
Consider the reasons older people offer for why they move into life plan communities (also known as continuing care retirement communities). Beyond just safety, many are seeking social connections. Ironically, one of the deepest cuts from COVID has been social isolation, both for those in residential settings and senior communities and for those living alone in the outside community.
In his search for the secrets of longevity, in 2004 Dan Buettner set out on a National Geographic expedition that turned into a discovery of five places in the world where people consistently live to be older than 100; he called these places the "Blue Zones."7
The common denominators in the Blue Zones that are believed to slow the aging process are:
- Move naturally, live in environments that constantly require movement
- Have a sense of purpose
- Have routines to shed stress, like prayer, naps, or happy hours
- The Okinawan Hara hachi bu rule, stop eating when 80% full
- Eat more plants
- Drink one or two glasses of wine per day, with friends and food
- Belong to a faith-based community, any denomination
- Put families first, take care of aging parents, invest time and love in children
- Live in communities with social circles that support healthy behaviors.
We also know a lot more about living better with chronic illness and functional impairments. In part, health care and pharmaceuticals have a huge impact. Equally important, the Americans with Disabilities Act, a disability civil rights law signed by President George H.W. Bush in 1990, has systematically reduced the impact of functional impairments and turned disability to ability through advances in technology and the built environment (e.g., more curb cuts, ramps).
In addition to taking charge of our personal behaviors, we have a cultural obligation to make change.
HOW WE LIVE, WHERE WE LIVE, ATTITUDES, AND AGEISM
Looking at older adults, the Stanford team found that there are "signs of progress and reasons to be concerned about the ways Americans are preparing for longer lives." By 2030, people over 65 will outnumber those under 18. It is essential that our practices and cultural values keep up with the demographic shift.
In particular, looking at 26 factors associated with longer lives, there are big disparities. Non-whites are more likely to live in or near poverty, have less access to insurance and health care, are less likely to have retirement savings plans, and have lower educational achievement. Financial insecurity, they conclude, is associated with increased susceptibility to illness and shorter lives. It's no coincidence that COVID has hit these groups the hardest. Other studies have found that those with lower incomes and non-white people have higher rates of obesity and are more likely to smoke.8
The other big cultural disparity issue is ageism. Ageism across our culture fosters loneliness and isolation. Outdated attitudes of what older people can and cannot do — or should and should not do — are cemented deeply into media/social media and part of our everyday assumptions and language. We have to build communities that welcome older people into the very fabric of everyday life.
Our cultural evolution will have to include:
- Communities with built environments that support intergenerational living.
- Education approaches based on assumptions and with intentional focus on awareness of aging. As the population gets older, any jobs or careers young people pursue will involve interacting with older people. For example, all doctors will care for older people, not just geriatricians. All Starbucks managers will serve older customers.
- Working together, with three or more generations potentially on work teams, sharing work projects and spaces.
- Playing and exercising together.
- Celebrating and marking life events together, including grieving together and being ready to accept death as part of life.
- Having meaningful conversations about diversity, equity and inclusion – in communities that include people of different races and ages.
Alongside changing attitudes and behaviors, policy must respond and keep evolving. COVID has taught us that for their entire lifetimes, people need income, health care, housing and the guarantee of safe long-term care supports if needed.
IT'S TIME TO MODERNIZE GOVERNMENT'S ROLE TO SUPPORT HEALTHY AGING
Only once before in American life was aging such a universal focus. The early 1960s were such a heady time, when the country had recovered enough from the big mid-century wars to think beyond preserving the status quo. Leaders were taking a closer look at the diversity of our population.
In 1965, when Medicare was enacted after more than two decades of discussion, the average American lifespan was around 70 years. One of the rationales for Medicare was that older Americans' hospital spending was more than twice that of those under age 65. Today, when we can expect to live well into an older age, there is little argument that health coverage through Medicare is one of the reasons.
In the 1940s President Truman tried to establish a program to cover health care but failed. His plan was branded un-American and "socialized medicine." President Kennedy undertook a public relations effort to promote what the press had started calling Medicare, saying "We are behind every country, pretty nearly, in Europe, in this matter of medical care for our citizens."
Among others, people of color and older people emerged as growing segments of an enriched American population. The Civil Rights Act and the Older Americans Act were two sweeping legislative responses. The idea that policymakers could do something about economic disparities produced the War on Poverty. Congress established rent supplements and low-income housing. Of course, health care was an essential part of the equity equation; Medicare and Medicaid gave older people and those with low incomes access to health care.
Preserving the progress policymakers have made in forging a competent context for aging in America means continuing forward motion in health care, housing, economics and ensuring equal access for an increasingly diverse population. We must keep the hard-earned growth we've worked together to earn and address newly emerging challenges with the same forward focused spirit.
LONG-TERM CARE AND A PLACE TO LIVE: THE NEXT FRONTIERS
Now that we are routinely living longer, it is time to follow the forward thinking leaders who saw a future where older people would need health supports and took bold policy steps by building Medicare.
It is unacceptable in a country as rich as the United States that two out of three people eligible for low-income senior housing do not receive it because the supply is so limited.9 The housing options that do exist provide only limited services to help older residents maintain their independence in the community, even if they develop impairments. Regardless of their income, older people should be able feel secure in having a safe place to live.
ACCEPTING THE COVID CHALLENGE
No one can stop time; we are all aging every day. But we can ensure that every life — and every year of every life — lived in the United States can be a good life. The researchers in the Harvard longitudinal study recommend that the most important thing is to connect — and do it with joy.
Let's reach across generations, across race and economic class, into homes, schools and communities. Let's make sure Congress and state legislatures are on board with policy and financing to support the richness this country has to offer an aging population.
COVID has done a great deal of damage, stolen too many lives and so much of the way we live. We can't be done with it soon enough, but we can appreciate the spotlight it has shone on aging, racial diversity and aging services. Let's take our hard earned COVID lessons and turn the pandemic on its head. We have the opportunity to emerge stronger.
RUTH E. KATZ is senior vice president, public policy/advocacy for LeadingAge, the Washington, D.C.-based nonprofit focused on education, advocacy and applied research for older adults.
- Jennifer M. Ortman, Victoria A. Velkoff and Howard Hogan, "An Aging Nation: The Older Population in the United States, U.S. Census Bureau, May 2014, https://www.census.gov/prod/2014pubs/p25-1140.pdf.
- "Dementia Trends: Implications for an Aging America," Population Reference Bureau, Today's Research on Aging, no. 36, July 2017, https://assets.prb.org/pdf17/TRA%20Alzheimers%20and%20Dementia.pdf.
- Derek Thompson, "A Brief History of Teenagers," Saturday Evening Post, Feb. 13, 2018, https://www.saturdayeveningpost.com/2018/02/brief-history-teenagers/.
- World Health Organization, Aging and Life-Course, https://www.who.int/ageing/ageism/campaign/en/.
- Harvard Second Generation Study, Study of Adult Development, https://www.adultdevelopmentstudy.org/grantandglueckstudy.
- The Sightlines Project, https://longevity.stanford.edu/the-sightlines-project/.
- Dan Buettner and Sam Skemp, "Blue Zones: Lessons from the World's Longest Lived," American Journal of Lifestyle Medicine 10, no. 5 (September 2016): 318–21, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4948154/.
- Raees A. Shaikh et al., "Socioeconomic Status, Smoking, Alcohol Use, Physical Activity, and Dietary Behavior as Determinants of Obesity and Body Mass Index in the United States: Findings from the National Health Interview Survey," International Journal of MCH and AIDS 4, no. 1 (2015): 22-34, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6125071/.
- Worst Case Housing Needs Report to Congress, U.S. Department of Housing and Urban Development, Office of Policy Development and Research, https://www.huduser.gov/portal/sites/default/files/pdf/worst-case-housing-needs-2020.pdf.