Building a World Where People Thrive as They Age Requires a Whole New Way of Thinking
By Suzanne Weiss
Life’s too short, we like to say.
Or is it?
Most everyone knows or has heard about people in their 80s and even 90s who live on their own, still drive and enjoy activities ranging from travel to golf to volunteer work.
But the ninth and 10th decades of life are far from golden years for the vast majority of America’s “oldest old”—numbering 6.4 million today and projected to surge to nearly 15 million by 2040. Roughly 4 in 5 people over age 85 are housebound or in assisted-living facilities, struggling or at risk financially, coping with several chronic health problems and increasingly dependent on family, friends and a hodgepodge of supports whose capacity, accessibility, affordability and quality vary widely across and within states.
The fact that this vulnerable age cohort happens to be the nation’s fastest growing has broadened attention to the effects of longevity: on individuals, families and communities; on the workplace and the economy; and on the well-being of the nation.
The immensity of the future shift in demographics has helped put the issue on the radar for many lawmakers. Some states have shown notable initiative and commitment in areas such as retirement security and home-based and institutional care.
But states aren’t moving fast enough for James Firman, president and CEO of the National Council on Aging. “We see what is coming, but we are not prepared as individuals, as communities and as states,” he noted in a recent NCSL “Our American States” podcast, “Living to 100: The Policy Implications.” “This needs to rise quickly to the top of the legislative agenda before it’s too late.”
And “too late” is just around the corner, says Elaine Ryan, AARP’s vice president for state advocacy and strategy integration. Baby boomers, the generation born between 1946 and 1964, are retiring at the rate of 10,000 a day, and the oldest boomers will begin turning 80 just six years from now. The aging of the baby-boom generation, Ryan points out, coincides with several other potent and converging demographic trends: steady declines in birth rates, fertility rates and household size, along with a continuing rise in average life expectancy.
Rethinking the Life Span
Advocates believe that much of the legislation being enacted is piecemeal, amounting to little more than tinkering at the margins. They call for a top-to-bottom rethinking of the life span itself, in all spheres. “Long lives are not the problem. The problem is living in cultures designed for lives half as long as the ones we have,” wrote Laura Carstensen, director of the Stanford Center on Longevity, in a recent op-ed in the Washington Post. “Retirements that span four decades are unattainable for most individuals, education that ends in the early 20s is ill-suited for longer working lives, and social norms that dictate intergenerational responsibilities fail to address families that include four or five living generations.”
Firman agrees. He noted that we invest enormously in every state to prepare young people for adulthood, but very little in educating adults on how to control their health, choose wisely where to live, save enough money to last throughout retirement, and stay engaged and productive in their communities.
Firman and others call for greater public investment in job retraining, health education and retirement planning programs, and in new forms of support for the estimated 41 million spouses, children and other family members who provide the lion’s share of unpaid caregiving—an estimated 34 billion hours (worth about $470 billion) in 2019, according to AARP.
Comprehensive strategies for easing the burden of family caregivers are crucial, Firman says, because “typically, it’s when the caregiver collapses, and they can no longer care for that older adult, that a person has to go into a nursing home, spend down their assets and go onto Medicaid. And this is a huge drain on the state budget.”
Burden on Family Caregivers
Roughly half of people over age 65 enter the latter stages of life with little or no savings, and the resources they do have—Social Security checks, pensions, equity in their homes—are stretched ever thinner with advancing age. Medicare doesn’t cover the kind of intensive long-term care required by those with the most severe physical and cognitive difficulties, and only a small portion of those in their 80s and 90s have private insurance that covers such care.
The high cost of institutional care—upwards of $7,500 a month for even a shared room in a nursing home—forces many families to assume the caregiving responsibility. And that can be difficult. Not only do caregivers help their loved ones with meal preparation, dressing and bathing, housekeeping chores and financial responsibilities, they often must perform complex medical or nursing tasks, with little to no training.
Caregiving also takes a financial toll. Many caregivers report high out-of-pocket costs associated with caring for a loved one. Additionally, most caregivers have other jobs and report having to take time off work because of their caregiving responsibilities.
“Every day, families provide invaluable care for their loved ones so they can continue to live at home, where they want to be,” says Hawaii Senator Rosalyn Baker (D). “It’s a tough job, and we need to support them.” In 2017, Baker led the fight to pass a groundbreaking initiative that establishes a dynamic state-funded continuum of home- and community-based services tailored to the needs of frail and vulnerable adults over age 60.
When relatives and friends cannot provide the care needed, however, families turn to other long-term services and supports, the costs of which Medicaid covers, if the older adult’s family member has no more than $2,000 left in assets.
The federal government covers at least 50% of states’ Medicaid bills. And long-term services and supports are a big slice of the Medicaid pie in most states. How big varies greatly because states set their own eligibility rules, what services to cover and reimbursement rates. The total portion of Medicaid spending that goes toward long-term services and supports averages 50% nationwide but varies widely by state.
Long-term care insurance can help when faced with the costs of caring for someone for years. But only about 10% of adult Americans have it.
Washington lawmakers passed the first public long-term care insurance program in 2019 “to help seniors and their families pay for long-term services and support while protecting seniors’ retirement savings and assets,” wrote Washington House Speaker Laurie Jinkins (D), a prime sponsor of the bill, in a Seattle Times op-ed.
Those opposed to the bill raised concern over its costs.
Too Little, Too Late?
Historically, public policy for the aging population “has been very low on the radar screen,” says Karen Brown, a Denver-based advocate for older adults who served on a panel on aging created by the Colorado General Assembly in 2015. “But now we’re seeing more and more governors, legislators and other state officials saying, ‘Wow, things are about to change and we really do need to take a look, longer term.’ ”
The U.S. Census Bureau estimates that by the mid-2030s, older adults will, for the first time in our history, outnumber those under age 18. By 2060, the bureau says, nearly 1 in 4 Americans will be 65 or older, the number of 85-year-olds will triple, and the country will be home to a half million centenarians.
The latest of AARP’s annual 50-state reports on the infrastructure of services and supports for older Americans paints a grim picture. But caregiving, along with advocating for new policy approaches in areas ranging from retirement security to telemedicine, Ryan says, is among the organization’s top priorities in its work with states.
“State leaders are changemakers,” she says. “I believe we’re going to see a lot of innovation at the state level, including taking greater advantage of technology.”
AARP Drives Change
Over the past 20 years, AARP—with 38 million dues-paying members—has emerged as a powerful voice for redesigning traditional models of education and work; social and intergenerational relationships; and health care and financial planning to better support longer lives. The organization has set in motion an array of projects aimed at challenging attitudes, behaviors and norms related to aging.
AARP’s latest effort is called “Disrupt Aging,” a multiyear global initiative that calls for seeing “older people as contributors to society, not burdens.” Using a variety of platforms and targeting a variety of audiences, the initiative will address four key issues for adults from middle age on: taking control of their health, choosing where they live, making their money last and putting their experience to work.
Elsewhere, the Stanford Center on Longevity’s “New Map of Life” initiative includes a multidisciplinary team of experts in medicine, education, behavioral science, finance, philanthropy, engineering and climate science working to envision what it will take to create century-long lives filled with belonging, purpose and worth.
“Longevity demands a rethinking of all stages of life,” Carstensen says. “It would be a mistake to replace the old rigid model of life—education first, then family and work and finally retirement—with a new model just as rigid.”
Instead, she says, there should be “many different routes, interweaving leisure, work, education and family throughout life, taking people from birth to death with places to stop, rest, change course and repeat steps along the way.”
Thirty years were added to the average American’s life expectancy in the 20th century. But, Carstensen says, “rather than imagine the scores of ways we could use these years to improve quality of life, we tacked them all on at the end. Only old age got longer.
“If we do not begin to envision what satisfying, engaged and meaningful century-long lives can look like, we will certainly fail to build worlds that will take us there.”
Suzanne Weiss is a freelance writer and frequent contributor to State Legislatures.
Sidebar: 4 Ways to Prepare for Aging Populations
The aging of America will cause a societal metamorphosis. The “oldest old”—those in their 80s and 90s—number 6.4 million today but are projected to surge to nearly 15 million by 2040. Here are four ways state lawmakers can prepare.
1 | Strengthen the Direct Care Workforce
States use various titles for “direct care” workers and often define them in statute. They include personal care aides, home health aides, home care workers, long-term care aides and nursing assistants.
Each profession has a slightly different scope of practice depending on the number of training hours required and varying state regulations. Personal care aides generally assist with social supports and daily activities, while home health aides and nursing assistants may perform certain clinical tasks under the supervision of a licensed professional. Together, these health care professionals play a critical role in helping older adults and people with disabilities remain in their homes and communities; however, they are hard to find and even harder to keep.
Generally, direct care jobs don’t pay well and provide few benefits. The turnover rate is high—between 45% and 60%.
- Some efforts may also boost the perceived value of direct care jobs, which could improve recruitment and retention rates. Examples of recent state actions:
- Arizona established a state-funded training system following recommendations from the Direct Care Workforce Committee.
- Colorado increased its hourly minimum wage for direct care employees.
- Illinois and Oregon both created training requirements for employees who serve people with Alzheimer’s and other dementias.
- Maine and New Mexico created task forces to consider ways to strengthen the direct care workforce.
- Maryland increased the rate of reimbursement for community service providers, including direct care staff.
- Minnesota created a statewide job board that helps consumers and direct care workers find the right fit.
- Oregon, Illinois and Nevada passed “Domestic Workers Bill of Rights” laws, which extend protections against workplace harassment and required overtime.
- Texas’ Health and Human Services Commission issued a report required by the legislature to improve recruitment and retention rates among state Medicaid-funded personal care aides.
- Washington expanded learning objectives, increased training hours and introduced certification requirements for personal care aides.
- Wisconsin increased funding for direct care workers’ wages, bonuses, time off and benefits.
2 | Support Family Caregivers
Lawmakers are also expanding the availability of telemedicine, funding respite care, increasing home-based services, providing paid and unpaid leave for caregivers who are employed, and more.
- Hawaii passed Kapuna Care, a dynamic state-funded continuum of home- and community-based services to support aging in place to delay the need for institutional care. The program costs $7 million annually and currently serves about 6,000 older adults. A companion program, Kapuna Caregivers, provides a daily stipend of up to $70 for people who work at least 30 hours a week while caring for an elderly family member.
- Thirty-eight states, the District of Columbia, Puerto Rico and the Virgin Islands have enacted the Caregiver Advise, Record, Enable (CARE) Act. The law, based on model legislation from AARP, requires hospitals to instruct caregivers on the medical tasks they will be asked to perform before a patient goes home.
- Several states are considering income tax credits of up to $5,000 a year.
3 | Promote Long-Term Care Insurance
Last year, Washington created a public long-term care insurance program, funded with a payroll tax of 0.58%. It will pay benefits of up to $36,500 to cover the costs of both institutional and home-based care. Self-employed workers may choose whether to participate.
- California established a task force to examine the possibility of creating a statewide long-term care insurance program.
- Illinois and Michigan are studying similar programs, and Minnesota is considering options that include the private sector.
4 | Increase Retirement Security
In 2017, Oregon became the first state to establish a state-facilitated retirement-savings program for small-business employees who don’t have a retirement savings plan at work. OregonSaves lets workers save their own money for retirement via payroll deduction and is being phased in gradually based on the size of the employer. OregonSaves accounts are portable and stay with workers throughout their careers.
Currently, 10 other states and one city have enacted similar programs to help private sector workers save for retirement.
Samantha Scotti is a senior policy specialist in NCSL's Health Program.
Sidebar: Preying on the Elderly
Along with more seniors comes more abuse.
Approximately 1 in 10 Americans 60 and older have been abused, according to the National Council on Aging. But it’s hard to know because so few cases are reported. Elder abuse can be physical, emotional and sexual, but can include exploitation, neglect and abandonment, the council says. Offenders range from the elders’ own children and relatives (60% of the time) to staff at nursing homes and other facilities.
All states have some kind of adult protective services program, and all have passed legislation specifically to protect the elderly from various forms of abuse.
Minnesota lawmakers, for example, recently approved the Elder Care and Vulnerable Adult Protection Act of 2019 to protect vulnerable senior citizens from abuse.
“This is bipartisan legislation that comes out of many months of meetings with facility residents and families, advocacy groups, and other stakeholders. There is widespread agreement that this needs to get done—and it cannot wait,” Senator Karin Housley (R), chairwoman of the Senate Family Care and Aging Committee and author of the legislation, said in a press release. Among other provisions designed to protect the elderly, the bill requires the state’s assisted-living facilities to be licensed. It had been the only state without that requirement before this legislation, according to the Minneapolis Star Tribune.
With the number of elderly growing, many expect abuse to increase as well.
By the Numbers
50/50—Odds that an American 10-year-old will live to 100
10,000—Number of baby boomers turning 65 every day
3 to 1—Ratio of women to men who live into their 90s
40 million—Number of Americans providing daily care for older adults
61%—Percentage of family caregivers who work full time
$7,000—Average annual out-of-pocket expense facing family caregivers
75%—Percentage of adults over 85 who have at least three chronic health problems
30%—Percentage of adults over 85 with dementia
$9,100—Average monthly cost for a private room in a skilled-nursing facility
95%—Percentage of Americans over 40 who don’t have long-term care insurance
Sources: U.S. Census Bureau, AARP Public Policy Institute, National Council on Aging