The Bipartisan Policy Center’s Senior Health and Housing Task Force recently released Healthy Aging Begins at Home, a report and set of policy recommendations centered on integrating health care, supportive services, and housing to support the nation’s rapidly expanding older population. As the 65 and over population is projected to soar from 48 to 74 million over the next fifteen years, the report brings into focus some core challenges.
Surveys show that most older adults prefer to age in place; indeed, a 2014 AARP survey found that nearly 90 percent of those 65 and older agree or strongly agree that they would like to remain in their current homes for as long as possible. Yet as the incidence of mobility and other disabilities rises with age, only 1 percent of existing housing units have five key universal design features (no-step entry, single-floor living, lever-style handles on doors and faucets, wide halls and doorways, and accessible electrical controls) that can allow those with disabilities to live safely at home. Millions will also need support with homemaking and personal care, but costs of in-home assistance can be substantial.
Indeed, the Joint Center’s Housing America’s Older Adults report has shown that the typical renter 65 and over can afford just 2 months of homemaker or home health aides before depleting all assets. And while the physical and financial barriers to aging in place are high, the nation will also have to contend with rising Medicare and Medicaid expenditures.
The crux of Healthy Aging Begins at Home is that the challenges of aging in place, as well as rising health care costs, can both be moderated by better integration of health care and housing. For example, relatively small investments in grab bars, lighting, and other modifications can help avert falls among older adults that can end or severely impair an individual’s independence, and that cost an estimated $34 billion in health care costs annually. Helping older adults modify their homes for safety and accessibility can help them remain independent in their own homes longer, precluding moves to more costly congregate care. Similarly, the task force’s report finds Medicare, Medicaid, and hospitals should look to homes as a site for preventive health care as well as supports and services that help older adults age in place while also reducing costs. Among a number of examples, the report points to the Independence at Home Demonstration program, created under the Affordable Care Act, which uses home-based primary care for Medicare holders with multiple chronic conditions, saving over $25 million in the program’s first year.
While healthy aging indeed does begin at home, for a host of reasons the best home may not be the current home. As the BPC report notes, “[I]t may be the case that living alone, socially isolated, in a single-family home is not the most appropriate or healthiest living situation, particularly for a frail senior. America needs a broader perspective: the aspiration should be to help seniors not just to age in place but to age with options.” In a recent report from the Milken Institute on The Future of Aging, Joint Center Managing Director Chris Herbert echoes this point, noting the importance of aging “in the right place.” This may mean a home that is smaller, more physically accessible, more affordable, or less isolated. Since one size will not fit all, a range of housing choices is needed, including in older adults’ existing communities, which would allow for a move but help people retain social and family ties. With three-quarters of older adults residing outside of central cities, this means new options in suburbs, small towns, and rural areas.
We particularly need options for the millions who pay too much for inadequate, inaccessible, or otherwise unsuitable housing. Recent Joint Center analysis shows that older adults aged 75 and over have the highest incidence of all ages of severe cost burdens, paying more than 50 percent of their income for housing. While there’s a higher incidence of cost burdens among older renters, with the older population’s high homeownership rate and low incomes, greater numbers of older owner households face severe burdens (Figure 1). Unfortunately, we expect cost burdens among older adults to worsen as the population grows: a recent reportby the Joint Center and Enterprise Community Partners projects that severe burdens are expected to rise by 39 percent among those aged 75 and over and 42 percent among those aged 65-74 by 2025.
Indeed, while Healthy Aging Begins at Home calls for integrating health care, supportive services, and housing, it makes the compelling argument that this is not possible without housing that is affordable:
One thing is clear: all bets are off in bridging the health-housing divide if seniors lack access to affordable housing. Affordable housing is the glue that holds everything together: without access to such housing and the stability it provides, it becomes increasingly difficult, if not impossible, to introduce a system of home- and community-based supports that can enable successful aging.
Toward this end, Healthy Aging Begins at Home calls for the expansion of the Low Income Housing Tax Credit program to finance and preserve affordable rental housing, including units for low-income older adults. In close alignment with this recommendation, on May 19, Senator Maria Cantwell and Chairman Orrin Hatch of the Senate Finance Committee introduced a bill, the Affordable Housing Credit Improvement Act (S 2962), to increase support for LIHTC by 50 percent. The report also recommends a host of other policy changes including support for senior supportive housing through the US Department of Housing and Urban Development’s Section 202 and new programming, coordination of federal resources for home modifications, expansion and creation of new state and local efforts to support the financing of home modifications, integration of health care and long term services and supports for Medicare beneficiaries who live in publicly-assisted housing, a focus on fall prevention within Medicare and other federal programs, and greater reimbursement of telehealth and other technologies that make it easier to monitor and coordinate care for people living independently. Some of these policies require additional investments but have longer-term payoffs in terms of reduced health care costs.
The Joint Center’s own Housing America’s Older Adults report concludes that though the challenges are vast, the largest impacts on healthcare and housing are still a decade away, giving the nation time to begin to make needed changes to our housing stock, communities, and health care systems. That too was the message at the release of Healthy Aging Begins at Home: with so much at stake, the time to act is now.