Are We Ready to Care for Our Aging Population?

Our aging population will need more medical care and resources. / Illustration by Matt Harrison Clough

Of all our fears about aging, the greatest may be our fear of losing control. Having your driver’s license revoked, being forced into a nursing home — it’s unspeakably depressing to contemplate relinquishing agency over your most basic activities and independence, even when it’s for the best. In Being Mortal: Medicine and What Matters in the End, Atul Gawande describes philosopher Ronald Dworkin’s observation about autonomy and how it applies to the aging process: “Whatever the limits and travails we face, we want to retain the autonomy — the freedom — to be the authors of our lives.”

This human instinct for authority over our own lives will soon be tested by more Americans than ever. Have we taken the necessary steps to prepare for this graying of the nation? Not only do we have an unprecedented cohort of Americans entering their golden years with associated medical needs; we also have increasing life expectancy. Is Philadelphia, one of the poorest cities in America, ready to take care of its growing numbers of aging adults?

It’s been referred to as the “2030 Problem.” That’s the year, only seven from now, when all baby boomers (76 million Americans born between 1946 and 1964) will be over 65 and account for about 20 percent of the population. (As a point of comparison, in 2000, there were only 35 million people 65 and over, constituting 12.4 percent of the population.) By 2060, 95 million Americans will be 65 and up, representing 23 percent of the population. And people don’t need less care as they age, so this demographic shift presents some troubling realities about a massive impending need that will require equally massive resources. Unprecedented funding will have to be directed toward health care. Along with increasing longevity will come a sharp rise in the number of Americans living with Alzheimer’s disease. The Alzheimer’s Association estimates that those afflicted will increase from seven million now to almost 13 million by 2050. So how do we provide necessary care and ensure appropriate funding for the long-term health services of this age group? The burden of care against the backdrop of skyrocketing medical costs, inflation, ever-increasing health-care workforce ­shortages, and political skirmishes over “sunsetting” entitlement programs such as Social Security (which in 2020 began paying out more than it was taking in and could be depleted by 2035 without Congressional action) and Medicare (which also faces long-term financing shortfalls), should leave all of us worrying.

“The 30,000-foot view is that we have three fundamental issues in our system that are the genesis of our problems,” says Amol Navathe, a health policy professor and internist at the University of Pennsylvania, where he is co-director of the Perelman School of Medicine’s Healthcare Transformation Institute. Navathe identifies the first problem as the smaller share of Americans footing the bill for Medicare than when it was conceived in 1965, when senior citizens were only nine percent of our total population. Financing for the entitlement comes primarily from payroll taxes — about 90 percent, in fact. So there is vastly more need on the immediate horizon, along with a sharply diminishing number of working Americans paying into the pot. Don’t forget to factor in the long-term implications of our country’s declining birth rate. “Financing-wise, we can see that’s a problem, along with care getting more expensive,” says Navathe.

Problem number two, says Navathe, is thinking of Medicare insurance in the same way we think of private health insurance. The issue is that typically, insurance is taken out by the policyholder as a protection against unexpected incidents (and their costs) in the future. So you pay a small premium now to protect yourself from having to foot the entire bill later if your luck changes and you get sick or have an accident. This construct works for health insurance companies because with a relatively healthy group of policyholders, they take in more than they pay out. The problem with Medicare insurance and an aging population is that the majority do need care — a lot of it, and only more as time goes by. “With chronic long-term or degenerative conditions, the typical diseases of the elderly,” Navathe explains, “insurance doesn’t work the way it’s designed. If I diagnose a patient with dementia, they will require more and more resources and care. The whole construct of insurance as a hedge evaporates.” For example, according to the Center on Budget and Policy Priorities, Medicare’s Hospital Insurance Trust Fund, which pays for hospital and post-acute care in rehab facilities, is predicted to be unable to provide 100 percent coverage as soon as 2028, dropping down to paying only 90 percent of benefits.

The third problem, Navathe explains, is that Medicare was never created to pay for chronic or preventative care: “The 1965 statute that established Medicare specified it was to diagnose and treat disease, not to prevent or manage the degeneration of people at the end of life.” So Medicare doesn’t pay for long-term nursing-home stays, which many older adults need. The Medicaid program, the benefit for low-income qualifying people, is the primary payer for long-term care and residential nursing homes, for which Medicare doesn’t provide coverage. Navathe suggests that this coverage disparity could be fixed if policymakers created a Medicare long-term care benefit.

It has never been an issue for the wealthy to pay for long-term care, despite its whopping costs, and our area is dense in assisted-living and retirement communities for those who can afford them. For low-income people who have the safety net of Medicaid funding, long-term care is also accessible. But for the vast majority of Americans in the middle, there are tough questions to face. Do you “spend down” the financial security acquired via a lifetime’s work to qualify for Medicaid? Those who don’t must figure out a complex system and worry about what’s covered with Medicare or MedicareAdvantage and what’s an out-of-pocket expense. Even those on the extremes of the financial continuum must navigate a confusing patchwork system of services, agencies, entitlements and waiting lists. This is especially true because most of us don’t begin to address these issues until we’re forced to by a sudden medical crisis — either our own or that of an aging parent. Figuring out medical care for a parent in the midst of a medical crisis is like flying an airplane while trying to repair it mid-air: stressful.

Fortunately, for those of us in the Philadelphia region, a coalition of aging advocacy groups can point us in the right direction. Philadelphia Corporation for Aging’s president, Najja R. Orr, says, “You’re not alone. We are here to help problem-solve, whether you’re the consumer, the caregiver or a neighbor. We are here as a resource to help connect the dots.”

“There’s no wrong door,” says Nora Dowd Eisenhower, the executive director of the Mayor’s Commission on Aging, when it comes to which agency to call. “We all know how to refer someone to the right advocate.” Eisenhower recommends starting with the Philadelphia Corporation for Aging’s helpline but includes her organization as well as ­CARIE — the Center for the Advocacy for the Rights and Interests of the Elderly — and the SeniorLAW Center as excellent resources to help aging adults or their family members find answers for a myriad of issues, from how to sign up for Meals on Wheels to legal support to prevent eviction or deal with elder scams or even untangle medical reimbursements from providers.

Josh Uy, a geriatrician at Penn Medicine’s Ralston-Penn Center and the medical director at Renaissance Healthcare & Rehabilitation Center, says a lot of his work is intended to allow patients to focus on living rather than on managing their living, “Aging is going to suck,” he says. “There’s just no way around it. You don’t control aging. Somebody said life isn’t about making the waves stop, but about learning to surf.” He adds, “I want to take the feeling of crisis out of aging and make life as full and meaningful as possible.”

In the face of ever-increasing precarity around care across the country, our region does have some glimmers of hope. Besides having strong university medical systems that provide care and medical advancements, Uy says, “Even with the closing of the Philadelphia Nursing Home, we have enough facilities here in the city.” Curiously, we do have empty beds in area nursing homes, according to Eisenhower. But she also points to staff shortages within those homes and adds that state nursing-home regulations are being updated to align more with federal ones that will mandate lower staff-to-­resident ratios.

Nursing homes are vital to patients who have arrived at that level of care, but there’s wide consensus that the goal is to keep older adults independent and out of them for as long as possible. Eisenhower puts it this way: “We are all aging, and that’s a success story. I refuse to think about it as a catastrophe.” She believes we have enough time to create better, more livable communities for our aging adult community. And she points to adaptive strategies already in place, such as PCA’s Senior Housing Assistance Repair Program (SHARP), which fixes up older people’s homes or modifies them to make them safer and more functional for aging bodies. Besides the network of area senior centers that offer places to socialize and stay connected to the community, there are other innovative models, such as “virtual villages,” to offer support. This nonprofit concept began in Boston’s Beacon Hill and has popped up around the country; we now have three virtual villages in Philadelphia —  Penn’s Village, East Falls Village, and Northwest Village Network — as well as one in Springfield. Those who pay an annual fee can “age in place” and receive a range of useful services, such as transportation to appointments, technology assistance, educational workshops, social outings and even cat care. Another option to prolong “aging in place” are senior daycares, such as InnovAge, where seniors in moderate decline — who can’t be left unattended during the day while adult children are at work — can go for care and socialization. These types of facilities can provide a welcome respite for maxed-out adult children in the “sandwich generation.” AARP estimates that more than 53 million adult children currently shoulder the burden of providing unpaid care to family members.

I asked our local experts: If they had a magic wand, what would they fix when it came to eldercare? They all said a commitment to long-term investment from policymakers is critical, to support programs that keep seniors leading healthy, meaningful lives. This means supporting health-care workers — and incentivizing more people to choose the profession. Seniors want to “age in place” even if that means aging solo, so access to in-home care should be prioritized, as should access to affordable and safe housing. There’s no avoiding the obvious need for the government to find ways to fund the looming needs of our aging population. Whether through borrowing money or raising taxes, some government action is required. The advice Uy gives his patients might be something we should all heed as we look to a future with more elderly than ever among us. He tells his patients: “It’s better to have a plan you don’t need than need a plan you don’t have.”

Published as “What to Expect When You’re Expecting … to Get Old” in the May 2023 issue of Philadelphia magazine.