Middle-Class Seniors Will Struggle With Housing, Health Costs, Study Shows

Kerry Dooley Young

April 30, 2019

WASHINGTON  — Many Americans may find themselves in the "forgotten middle" as they age, meaning they are too well off financially for federal or state assistance but unable to pay for adequate housing or needed healthcare, according to a new study.

In a study published online April 24 in Health Affairs, Caroline Pearson from NORC (formerly the National Opinion Research Center) at the University of Chicago in Illinois and colleagues examined the fiscal outlook for middle-class Americans as they age.

Within a decade, about 7.8 million older Americans will not have annual financial resources needed to cover their housing and medical costs, Pearson and colleagues found. 

That represents 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.

So-called social determinants, such as housing, play a much larger role in healthcare than the medical community has appreciated to date, said John W. Rowe, MD, a professor at Columbia University in New York City and former chief executive officer of health insurer Aetna.

"When physicians are evaluating older persons, it's important to expand the notion of the vital signs" to include social determinants, Rowe told Medscape Medical News after the panel discussion. "Too frequently, medical education neglects those elements."

But these social determinants can have more of an impact on the lives of patients than do traditional biological determinants, Rowe said.

"I tell my medical students that if there's an older man in the exam room and you are going to get to ask him only one question, you're better off asking him how many friends and family members he sees per week than if he smokes cigarettes," Rowe said. "It's a better predictor of how that individual is going to do."

At this time, though, insurers often reward physicians for checking on patients' tobacco use, with questions about these habits seen in performance measures. 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, said Alan Weil, JD, MPP, editor-in-chief of Health Affairs.

"With smoking, we know what to do. We have smoking cessation programs and frankly, they are relatively low cost," Weil told Medscape Medical News. "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," Weil added.

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.

Pearson and colleagues note that about 60% of middle-income seniors in the future may have mobility limitations. And about 20% of them may have three or more chronic conditions and one or more limitations that hamper 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, according to Pearson and colleagues.

"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."

That may push more responsibility onto the healthcare system to find workarounds to help senior citizens in need of help.

Medicare has allowed its insurer-run Advantage programs to offer additional benefits intended to help senior citizens preserve their independence. People enrolled in this form of Medicare are allowed access to safety devices to better prevent injury in the home, including stair rails, grab bars, and temporary mobility ramps.

The American Academy of Family Physicians has created an online resource, the Neighborhood Navigator, to help busy clinicians quickly identify community resources for their patients. These include many programs that can make "aging in place" safer for seniors.

"It's easy to be overwhelmed by the scale of the problem" with helping senior citizens live independently in the years ahead, Weil said. "But there are many low-cost, low-effort interventions that can have positive effects and if we build on those, we would see tremendous progress."

Weil cited as an example a test program called Community Aging in Place, Advancing Better Living for Elders (CAPABLE), which was described in a 2016 Health Affairs article. The program teamed a nurse, a handyman, and an occupational therapist in an effort to help people better manage their daily lives at home.

The study recruited people age 65 and older who had some difficulty performing 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.

The CAPABLE program has been expanded to 27 sites in 12 states, but it has only reached about 1000 people, lead author Sarah L. Szanton, PhD, ANP, Johns Hopkins University, Baltimore, Maryland, told Medscape Medical News.

"It's still very much in its infancy," she said. 

In general, Szanton said, the United States does not have enough programs in place now to help senior citizens maintain their independence. There often are wait lists for the programs that are available. She also said many of these have income limits that would exclude the very people Pearson and colleagues call the "forgotten middle."

"As a country, we're really vastly underprepared for people to be able to age in place, except for the very wealthy," Szanton said.

Addressing this shortfall will require a shift in how the United States prioritizes and allocates spending for care of the elderly, she continued.

"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."

The National Investment Center for Seniors Housing & Care (NIC) provided a grant to NORC at the University of Chicago to fund this research. Study authors reported having served as adviser to NIC, as a paid consultant to Vivacitas and CareLinx, and as a member of the scientific advisory committee of naviHealth.

Health Affairs. Published online April 24, 2019. Full text

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