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The Health Perils of Aging: Lonely and Sick

Published: May 13, 2012 | Comments (2)

By Matt Perry

The grim effects of smoking, drinking, and poor eating are commonly cited by doctors as appalling and expensive health scourges. Yet for aging Californians, an often hidden health plague can be just as deadly: loneliness.

Social isolation and its common offspring – loneliness – became a political hot potato when California recently cut back on its adult day health care program, disqualifying 20% of the state’s older and disabled citizens from its attendance rolls. Families who depended on the centers for medical supervision and social interaction suddenly had to scramble to find new programs to care for these relatives.

For seniors with or without families, this often meant more time home alone.

“They’re just going to go home, watch TV and decline,” predicted Katya Hope, acting director of the Golden State Adult Day Health Care Center in San Francisco’s Tenderloin district, of the approximately 7,000 clients cut from the state program.

Research linking social isolation to poor health is abundant.

“It’s as large a risk factor for mortality as cigarette smoking,” says Laura Carstensen, director of the Stanford Center on Longevity.

Loneliness can increase depression, neuroses, pessimism, alcoholism, and suicidal thoughts. It can also disrupt sleep and reduce self-esteem.

Its physical effects are equally disastrous. It can increase blood pressure, limit the body’s ability to fight off illness, and has been linked to higher death rates. Social isolation can increase obesity and speed the progression of Alzheimer’s disease.

From a public health perspective, the most damning effects of social isolation are that it prevents older adults from living independently and exercising.

Long-term, all of these factors can cost the state money in chronic disease management and skilled nursing dollars.

Because funding for programs – like adult day health care – can end abruptly, creative local initiatives to address social isolation dot the state.

Some of these programs use the phone to reach seniors who are shut-ins or lack mobility.

The Senior Center Without Walls, based in Oakland, holds nearly 70 free classes a week for isolated seniors who call a central number to join a telephone classroom.

Classes include health information, poetry readings, brain games, cooking, gardening, and a popular travel club.

Director Terry Englehart, who started the program in 2004 with six women to tell jokes, said last fiscal year the center had 667 participants.

Many have lost their spouses or confidantes.

“They have found a community they belong to,” she says. “They have something to look forward to. They have friends.”

Every day of the year, the center hosts a 9 a.m. “Gratitude” call.

On one day, there are 15 older adults on the long-distance teleconference. Some are chronically ill. Although they have never met in person, the sense of community, friendship – even love – is palpable.

They give thanks for phone calls from children, medicine reminders, electricity, reality TV, museums, casinos, dogs, cats, fog, sleep, and blooming spring flowers.

“I’m just very grateful that I went for a walk this morning and they weren’t narrow hallways,” said one man recently discharged from the hospital.

In Northern California, volunteers at the Eskaton senior living community’s Telephone Reassurance call 550 older adults in a three-county area in and around Sacramento.

Callers socialize with clients, check on their health, or remind them to take medicines – even to eat and drink. They can also set up home visits or suggest social services, including financial advice.

“A lot of the folks we call live totally on their own,” says Terri Becker, director of the telephone reassurance program, which is one of many around the state. Becker says many are women who have outlived their husbands. Others live in poor neighborhoods, are financially destitute, or suffer from dementia. All crave personal contact.

Becker says the phone calls provide a sense of security in a confused world.

“Their anxiety goes way down,” she says. “Medicines can only help so much.”

Indeed, some experts decry the modern medical model that depends so heavily on pharmaceutical drugs.

Walking outside with a neighbor does “more good than all the friggin’ pills in the pharmacy,” says Dr. Walter Bortz, a “robust aging” expert and author of the book “We Live Too Short and Die Too Long.” Bortz currently teaches the Stanford course “Exploring the Human Potential.”

Former Harvard University president Derek Bok in his book “The Politics of Happiness” writes that good health and happiness are clearly intertwined. Yet Bok says that a clean bill of health from a physician is only “roughly correlated” with happiness.

The leading factor in being healthy and happy according to Bok: social connections.

A 2010 study by AARP of 3,000 people 45 and over found a whopping 35% “chronically lonely” – up significantly from 20% a decade earlier. Surprisingly, the loneliest age groups were in their 40s and 50s.

Peter Szutu, CEO of the Oakland’s Center for Elders’ Independence, says that older adults bounce back from sickness and stress with four factors: a community they belong to, meaningful activity, hope, and a confidante.

Yet in aging California, social isolation is expected to grow right with its population.

By 2030, an estimated one in five Californians will be 60 and over, says Mariko Yamada, chair of the state Assembly’s Aging and Long Term Care committee.

Yamada says a revolution in aging services is needed to survive a future often termed “the silver tsunami.”

By contrast, she says fellow legislators have oversimplified a complex issue.

‘There’s a fundamental flaw in the way we look at services in general,” says Yamada, who has worked in social services for 38 years. “We try to define them as either social or medical… It’s really both.”

One program that blends good health and social interaction is offered in San Diego county, where the Sharp Rees-Stealy Medical Group conducts six-week chronic disease management classes for patients.

A hallmark of the group’s Healthier Living program: the buddy system.

“Everybody gets a buddy,” says Kelly Dutcher, a wellness education specialist and class supervisor. At the end of each session, patients create an action plan for the following week.

“When they call their buddy mid-week it’s really to check in on those action plans,” says Dutcher. “So much of why people are successful is accountability.”

“I liked exchanging phone numbers and have (sic) a partner,” wrote one participant. “It motivated me.”

Dutcher says the program indirectly addresses social isolation: “Coming to this class may be the only time they get out of the house that week.”

Statewide, the PEARLS program treats older adults at home who are suffering from mild depression. Developed by Dr. Ed Wagner, who has developed models to treat chronic disease, PEARLS emphasizes an increase in physical and social activities. There are five programs in California, with two more in development.

Older adults who maintain or increase their social connections can slow both physical and cognitive decline, according to a study last year by the Population Research Center at the University of Texas in Austin.

In Fremont, two ethnic groups wracked by social isolation are Pakistanis and Afghanis – the latter suffering high rates of PTSD.

The city’s Pathways to Positive Aging – Fremont’s collaboration with the Tri-City Elder Coaltion – has built bridges to seniors in both ethnic communities. After creating the Afghan Elder Association and the Muslim Support Group, health programs were then introduced to address obesity, diabetes, and other health concerns.

Older adults in these communities were heavily isolated and not getting proper healthcare, says Ray Grimm, project coordinator for Pathways to Positive Aging. Creating these social organizations played a major role in improving health outcomes.

“Once you get them linked you keep them out of the emergency rooms, and hopefully out of the hospitals,” says Grimm.

In the city famously called “The Happiest Place in the USA” – San Luis Obispo – Wilshire Community Services offers both “senior peer counseling” (peer advice for those 55 and older) and Caring Callers (all-ages volunteers who make free weekly in-home visits to older adults).

Heartened by such community programs around the state, Yamada nevertheless anticipates a bleak future unless radical service improvements are made for aging Californians.

“It’s kind of like watching the Titanic approach the iceberg, and knowing that a lot of people are going to die or be hurt.”

First of two parts. In Part 2, Matt Perry will profile the Senior Center Without Walls, which connects older adults with new friends via telephone conference calls.

 

“Meet the pharmacist” event helps seniors manage medications

Published: November 2, 2011 | 1 Comment

Letty Santos Bustria, 72, of National City, meets with pharmacist Stephanie Mastorakos of Crocker Drugs, also in National City.

By Michele Clock

Some fill up Ziploc bags, others stuff carryall bags. Still others use big plastic boxes.

For years, California seniors have been toting their pharmaceuticals into “Meet the Pharmacist” events for one-on-one help with their daily medicine regimens. The events offer seniors a chance to sit down with a pharmacist and get free advice outside the sometimes busy, sterile pharmacy setting.

Demand for the events is on the rise, organizers say, as the state continues to struggle with a sluggish economy, high unemployment rate and budget cuts. Nearly $2 billion in pending slashes to Medi-Cal could put low income residents, including seniors, at further risk. The cuts call for increases in patient co-payments for doctors’ visits and caps on doctors’ visits each year.


This article is one in an occasional series on aging with dignity, independent living and public policy that affects both. For a complete archive of the articles, click here.

These cuts could put patients with complicated medical issues and medication regimens “in a bind,” said Maxine Fischer, manager of state operations for AARP, which helps organize the events.

As people are living longer, the number of chronic illnesses such as asthma, depression and congestive heart failure, have increased, said Stephen Shortell, Dean of the School of Public Health at UC Berkeley. What’s also risen is the number of daily medications people are taking.

“Many have 10, 15, 20 medications they take at different times of day,” he said. “It’s become a huge new public health challenge.”

As a result, pharmacists have taken on a more important role in people’s lives, Shortell said.

Concerned about unsafe prescription drug and drug-food interactions, the county of San Diego’s Aging & Independence Service agency created the “Meet the Pharmacist” events about seven years ago, said agency spokeswoman Denise Nelesen.

Too often, people decide to not take their prescribed medications after learning the cost or after becoming sick, Fischer said. Some don’t take their medications at all. Language barriers can also add to the confusion. A quarter of adults aged 65 and older skip doses of medication or don’t fill prescriptions because of the costs, Fischer said.

The events, which are organized by a network of groups focused on senior-related issues, offer participants a chance to ask vital questions and review their medicines in familiar, neighborhood settings. Over the years, the events have caught on and been repeated around the state, including in Los Angeles, San Francisco and Fresno, Fischer said.

At a Meet the Pharmacist event in south San Diego County late last month, in walked Letty Santos Bustria, 72, pushing a walker and clutching a plastic bag full of prescriptions.

Bustria, a spunky, outgoing Filipino-American who wears pink rhinestone studded eyeglasses, said she suffers from diabetes, hypertension and gout. She survived a heart attack and triple bypass surgery six years ago and now lives in a National City senior housing facility near where the event was held.

“I’m still alive,” Bustria said, smiling. “I like to live.”

Bustria is enrolled in both Medi-Cal and Medicare. She said she came to the event, held at National City’s Kimball Senior Center, to talk with a pharmacist and make sure her seven daily medications were “OK.” Sometimes she goes to pick up her refills. Other times, she has her son or a friend get them.

Volunteer Michelle Bautista, who works as pharmacy manager at a Walgreens in Chula Vista, said that at busier pharmacies patients may feel “like they don’t want to take a pharmacists’ time.”

“A lot of the patients are intimidated,” she said.

In addition to the sit-downs with pharmacists, the event offered presentations on fall prevention and wise use of medications. Vision, depression and blood pressure screenings were also available. Participants got free food and reusable shopping bags full of fliers and other goodies.

“We spoil them rotten,” joked Anabel Kuykendall, a county of San Diego Aging & Independence Services employee who helped organize the event.

Last month alone, the San Diego region hosted four of the events—in National City, Santee, San Diego and Escondido.

National City’s senior services coordinator Maria Wright said she’s seen an overall jump in demand for free services for seniors. Attendance at the Meet the Pharmacist events in her city rose from 100 to about 300 people over the past three years, she said. This year, about 160 participants attended the event, but Wright and others attribute the lower number to less publicity. If more knew about it, more would have been there, she said.

National City’s commodity food distribution program aids nearly 400 seniors a month, up from 75 last year, she said.

And while seniors like Bustria got the all clear on her medicines, Judy Gunn, of Bonita, got some tips on her daily medicine regimen.

Gunn, who declined to give her age, said she takes 12 daily medications for three chronic conditions. A pharmacist suggested that she take one of her over-the-counter medicines—Citracal—both in the morning and at night. He also recommended that she speak with her doctor about reducing a cholesterol medication.

“I’d been having sore muscles but I thought it was a side thing from the condition,” she said. The advice “will be helpful.”

 

Minority nursing home residents increase, whites decline

Published: October 13, 2011 | 1 Comment

By Jessica Portner

As the nation’s elderly population balloons, nursing homes across the country have seen a demographic shift in their residents. More Hispanic, black and Asian elders are moving into nursing homes while white residents choose other options.

A recent study by Brown University researchers published in the journal Health Affairs found that this nationwide trend is driven in part by changing demographics, such as the rapid growth of elderly minority populations.

But the study, released in July, also found that the increase in the proportion of minority nursing homes residents indicates a lack of access to home and community-based alternatives, which are generally preferred for long-term care. Whites, who have greater economic resources on average, are finding better housing alternatives as they reach old age.


This article is one in an occasional series on aging with dignity, independent living and public policy that affects both. For a complete archive of the articles, click here.

“We know those alternatives are not equally available, accessible, or affordable to everybody, certainly not to many minority elders,” said Zhanlian Feng, assistant professor of community health at Brown University’s medical school and the study’s lead author. “Most elders would rather stay in their homes, or some place like home, but not a nursing home unless they have to.”

The researchers found that between 1999 and 2008, the number of elderly Hispanics living in U.S. nursing homes climbed by 54.9 percent while the number of Asians increased by 54.1 percent. The number of black residents rose 10.8 percent. During the same 10-year period, the number of white nursing home residents in the U.S. dropped by 10.2 percent.

In the Los Angeles/Long Beach region, the residency increases were also significant with a 56 percent increase in the Asian population and 41 percent rise among Hispanics. The increase for blacks was slight, only 1 percent.

Patricia McGinnis, the executive director of California Advocates for Nursing Home Reform, agreed that minorities as a group tend to be less able to afford Residential Care Facilities or home care aides who charge about $15 to $20 an hour.

California currently has more than 7,600 residential care facilities, up from about 5,500 a decade ago, she said. The average rate for those facilities, which generally offer more freedom and personal attention to residents, can cost $5,000 a month.

“Lets face it — money issues and a disparity in income and assets in minority communities is still there,” said McGinnis. “Unless you have savings, people are priced out of the market.”

To conduct the study, Brown researchers used data from a federal survey, which collects periodic information on nursing home residents, their race, ethnicity, the size of their population, and where in the U.S. they live. They used information from the Census Bureau’s Metropolitan Statistical Areas to gather information on the racial and ethnic mix of nursing home residents and the demographic shifts in urban areas.

These demographic shifts in the composition of nursing home populations are taking place within a rapidly shifting long-term care landscape. There are currently 76 million baby boomers in the nation; the oldest of them will turn 65 years old in 2011. The Census Bureau projects by 2030, 20 percent of the U.S. population will be sixty-five or older. Today that figure is 13 percent.

The population of older racial and ethnic minorities is slated to grow particularly swiftly. The number of older Hispanics, for instance, is projected to jump from under 1.8 million in 2000 to over 8.6 million by 2030. The number of elderly Asians is expected to balloon from 0.8 million to 3.8 million.

At the same time, elderly people don’t have the support at home or the social structures of previous generations. People don’t live as close to their relatives as they did in the past. Couples are having fewer children and often both have to work outside the home and are unable to provide full time care to their elderly or ill parents.

These dramatic societal changes have prompted the government to alter certain policies and priorities. There has been a shift in support from nursing home care to favoring home-and community-based services, the study said, which cost significantly less than institutional care. A significant change was the passage of the Medicaid “waivers” authorized in 1981 in the Social Security Act. It allows recipients to use their Medicaid dollars to pay for personal care and other supportive services, enabling more beneficiaries to live at home or in a residential setting.

Older adults and those with disabilities prefer living independently at home or in community-based alternatives, according to a related study published in Health Affairs that examined what people want from long-term care. Assisted living allows people to have more freedom; a skilled nursing facility is more confined and has more supervision.

The Brown University study cites earlier research, which shows that minorities, even if they had the means, have other disadvantages when it comes to finding quality care. Nursing homes in largely minority areas are often of lesser quality and are more likely to close, while assisted living facilities are more likely to proliferate in high-income areas.

Eli Quinones, President and CEO of Alliance Nursing Centers, Inc., operates three nursing homes in El Monte. But he said the residents of his nursing homes, 90 percent of whom are Chinese, tell him they feel safer and more comfortable in his facilities. But Quinones said that in his industry in general, he sees how the cost of care can be a factor in the demographic makeup of a nursing home population.

“Assisted living has become quite popular and it’s also very expensive,” he said. “When it comes to economics, white folks are able to afford a different level of care.”

 

Home help affected by cuts to Medi-Cal and Medicare

Published: October 6, 2011 | No Comments

Programs for supportive services, in-home healthcare impacted by state, federal changes

By Melissa Flores

Low-income families in the Salinas area who are in need of home healthcare or support with daily activities due to a disability may have a harder time getting that help as state budget cuts and cuts to Medi-Cal and Medicare reimbursements continue.

“It would really be a disaster,” said Fe Stallworth, the director of business development and patient care planning of the Central Coast Visiting Nurses’ Association and Hospice, if reimbursements continue to be cut for home healthcare.

CCVNA is one of two agencies that offer help to those who have limited functionality – CCVNA through skilled medical professionals who can help people recover from surgery or illnesses at home rather than in a hospital and In-Home Supportive Services, which provides help for residents with limited functionality on day-to-day chores.

The main concerns for CCVNA are that it has become harder for clients to qualify for home healthcare and the reimbursements have gone down. The nonprofit agency is funded through grants, bequests, individuals and organizations, and government contracts.

In the 2010 annual report, Steven A. Johnson, the president and CEO, noted “There have been many challenges during 2010 including severe economic downturn, reduced government reimbursement and increasing governmental regulations.”

Changes in Medicare requirements include the new Health Care Affordability Act, which requires patients to have a face-to-face meeting with a home care certifying physician within nine months prior to starting services or within 30 days of starting services.

Stallworth touted the benefits of using home healthcare instead of staying in a hospital or skilled nursing facility.

“The cost of outpatient is probably half the cost of in the hospital,” she said. “It improves your well being.”

She said that patients can have medication administered, receive physical therapy or other medical services at home.

“They don’t have to drive to outpatient (clinics) every day,” she said.

CCVNA accepts patients with private insurance, but they also work with Medi-Cal and Medicare patients.

The services include skilled nursing services, rehabilitation services, certified diabetic educator, cardiac program, a wound care program, enterostomal and wound care, medical social workers, dietary and nutritional counseling and palliative care.

In-Home Supportive Services provides longer-term help to people with a functional impairment who need help with day-to-day activities. Services include assistance with light house keeping, cooking, laundry, medical transportation, and personal care such as dressing, bathing, and grooming.

In-Home Supportive Services received a 3.8 percent cut in the state budget, according to Sam Trevino, the public information officer for Monterey County’s Aging and Adult Services, which services Salinas clients. He said that an additional 20 percent cut is still a possibility.

Trevino explained that the types of activities that are allowed through IHSS have remained the same, but the number of hours available to each patient has been cut by 3.8 percent.

“The scope of the activities covered include daily living – chores and housekeeping,” he said. “There was some reduction of hours, but the initial 3.8 percent was absorbed (by the clients and homecare providers.) We didn’t get much in the way of calls coming in. I think they are doing their best to accommodate it.”

To qualify for the program, a resident must be low-income and have some kind of functional impairment. The impairments can be physical or developmental, and clients of all ages are eligible for the program. Through an interview with a social worker, the staff determines how many hours a client needs, from 20 hours a month up to 9 hours a day of care.

“We are concerned about the trigger cuts of 20 percent,” Trevino said. “It would be a challenge to respond to that if that were to occur.”

He said that he expects to know if the additional cut will come through in mid-December when the state completes its second-quarter reports. The “trigger cuts” refer to possible $601 million in cuts that will be implemented if state tax receipts come in lower than anticipated. If projections fall below estimates by more than $1 billion, the cuts will be enacted, including an additional $100 million to IHSS.

“It’s a threat that is actually looming on worker’s minds and recipients who rely on this service,” he said.

In Monterey County, about 4,000 employees are working with 4,000 recipients. The rate of pay is the same for all IHSS employees, though the number of hours they work varies by the clients’ needs. In 2010-11, employees made $12.10 an hour.

Statewide, 438,000 residents are expected to use IHSS services for the 2011-12 fiscal year, according to The SCAN Foundation, a nonprofit group that focuses on issues affecting seniors.

In March, state officials adopted several measures to save money that impacted IHSS. They included eliminating hours for recipients who do not have a physician certification that personal care services are necessary, for a savings of $67.4 million. They also eliminated an advisory committee that county boards of supervisors were mandated to establish. Counties can still continue with the advisory committee with $3,000 provided from the state.

The legislature is also banking on keeping some services through the federal Community First Choice State Plan Option, which provides community-based attendant services and IHSS for consumers who meet nursing facility eligibility.

Trevino said the IHSS program is funded through state, federal and local funding. A large amount of the money comes from Medicaid and Medical reimbursements.

Residents don’t have to come into an office, as social workers can visit them to determine their needs, with input from a physician. Residents can select their own IHSS worker, if they have a family member, friend or neighbor who wants to assist them. But Trevino said the staff can also pair residents with a provider through the IHSS Public Authority.

“The majority of recipients, about 80 percent, have one already,” Trevino said. “Having a family member can be good because they know the person intimately.”

Trevino noted that the program does help family members who are struggling, who have lost a job or have limited time to work due to caring for a loved one.

“If they have disabled family or aging parents, they might be struggling to stay employed,” he said. “This is trying to maintain the family, financially and be independent.”

 

Homeless for Years, Older Women in Los Angeles Find a Good Home

Published: September 26, 2011 | Comments (4)

Francine Andrade in her room at the Downtown Women's Center in Los Angeles.

By Jessica Portner

On Skid Row, the downtown hub of the homeless population in Los Angeles, transients ask passersby for change, slump against concrete buildings, and mumble obscenities at bus stops. The Downtown Women’s Center’s beautiful new building, sitting in the middle of the mayhem, is a standout. The DWC’s Day Center serves hundreds of homeless women in its facilities every day and 71 lucky ones live in permanent residences, or efficiency apartments.

The Center is a particular refuge for older homeless women who have lived in shelters, with family or on the streets for longer stretches of time. Of the 50,000 homeless people in LA County, 30 percent are women, and that number is increasing. About 47 percent of the women at the DWC are 51 years or older, the age that the AARP designates as senior citizen.

Women like Francine Andrade have struggled for years to find a home.

“To me, this is paradise,” said Andrade, 61, a teen runaway and abuse victim who slept on the cement sidewalk in Hollywood for two years. “Finally, at last, I don’t have to keep moving, not knowing where I am going to be.”


This article is one in an occasional series on aging with dignity, independent living and public policy that affects both. For a complete archive of the articles, click here.


Women often become vulnerable to homelessness if they have lost a spouse who was primary source of income for the family. They may not be easily employable because they have little experience in the workforce. Some older women, however, chose to be homeless and give up rent so their child could finish college or they could help support their grandchildren with their Social Security check.

“The philosophy is to create a sense of home,” said Patrick Shandrick, the Center’s Director of Communications and Public Education. “The first thing when you become homeless is you lose your dignity and sense of self worth, so we really try to provide comfort.”

The Center was the first organization in the nation to provide permanent supportive housing for women. Founder Jill Halverson started a center in 1978 following the closure of psychiatric hospitals statewide in the early 1970s, which led to a ballooning of the homeless populations. At the time, homeless women in the city had few options because shelters were only accessible to men. Halverson withdrew her life savings, bought the furniture and opened the center that served hot, healthy meals to women and offered a respite from a life on the streets.

The Center’s newly renovated facility was funded by a variety of public and private sources, including $8 million from the California Department of Community Development, $3.5 million from the city’s Community Redevelopment Agency and $7 million from foundations.

Stepping from the grimy street on Skid Row into the Center’s clean, airy space is a dramatic shift in ambiance. There’s a nicely decorated reception area, an open cafeteria, and couches in a flower-filled waiting area as quaint as a nice hotel’s. Design firms have decorated the spaces for free in the building, which is split between the quiet residential apartments and the bustling day center. There’s a Women’s Health Center that offers medical treatment, mental health and case management services for residents. Women receive gynecological health care, family planning and mammograms. The Center paired up with a clinic to provide physicians and nurse practitioners that conduct blood pressure monitoring, STD and HIV testing, cancer screenings, and diabetes tests.

There’s an impressive roster of physical and mental wellness activities that would rival some holistic health clinic. The women can take exercise stress reduction workshops and meditation. A nutritional specialist conducts cooking classes and prepares well-balanced meals for about 150 women who eat in the cheery cafeteria daily. They are introduced to healthy foods not generally served in shelters or soup kitchens, like quinoa, kale and couscous.

A team of mental health specialists at the Center offers psychological and psychiatric services for the women in the center, most of whom have experienced abuse, been victimized, or have a mental illness.

Jennifer Ma-Pham, the Director of Clinical Health Services, said the staff is attentive to how complicated diagnoses can be for older patients. Older residents go through the same issues any older person living in independently or in a nursing home might experience. They may need assistance with more intensive things like personal hygiene and dressing. Because the older residents are often less mobile, the staff always bring a plate of food at mealtime to women who can’t easily leave their room.

“People brush off that an older client forgets things and might not screen for dementia or Alzheimer’s disease,” she said. “They also might brush off the fact that they might be going though depression.”

Julia Perry, 65, a resident of the center, feels very well taken care of and keeps up with all her various annual screenings. For years, Perry supported herself and her sons by working as a maid, for All State Insurance Company, and as a nurse’s assistant. She traveled back and forth from Mississippi and California living with family, friends, and sometimes in rescue missions and hotels.

“This is wonderful,” Perry said. “I love the fact that it’s affordable and safe.” In the single room occupancy hotel, she said, “you never knew who could be entering the building while you are sleeping.” To stay at the Center, residents contribute 30 percent of the income they receive from Social Security. The average length of stay at the center is 13 years, but they can live there as long as they like.

Andrade, sitting on her cozy quilt in her own efficiency apartment, said it’s definitely worth it. “I got my kitchen and got my microwave and I got a real bed,” she said. “I never I had a place I could call home.”

 

Long term care program faces big hurdles

Published: September 14, 2011 | 1 Comment

By Herbert A. Sample

As the U.S. population ages in the coming decades, the need for some sort of insurance to cover long-term health care expenses – such as in-home support services – will also rise.

With this in mind, Congress and the Obama Administration last year included in the controversial health care reform act a little-discussed provision to implement a government-run long-term health care insurance program known as CLASS in October 2012.

Yet with a year to go before that deadline, officials with the U.S. Department of Health and Human Services are finding it difficult to devise a mix of benefits and premium levels that both would make such coverage attractive and affordable for consumers, and ensure the program is actuarially sound. That struggle may delay the program’s start until the fall of 2013, if not later.

At the same time, the private market for such insurance, once robust, has declined in recent years. And average premiums that hover in the hundreds of dollars a month are a hard sell to workers in their 20s and 30s – in the midst of a recession — who may not see a need for coverage that they aren’t likely to use for two to three decades down the road.


This article is one in an occasional series on aging with dignity, independent living and public policy that affects both. For a complete archive of the articles, click here.



Nonetheless, the need exists and will grow larger in the coming years, both advocates and critics of the fledgling CLASS program agree.

“If you just look broadly at all adults, only 3 percent of the population has any sort of private long term care, and if you look at just older people, people over 65, I think it’s about 10 percent,” said Joe Caldwell, director of Long-Term Services and Supports Policy at the National Council on Aging, which backs CLASS.

“So people aren’t really prepared at all. And like I said, it really ends up being Medicaid that provides a lot of those services, but we make people become poor to qualify for long-term care through Medicaid,” he added.

The Community Living Assistance Services and Supports Act is a relatively short 20 pages of the huge Affordable Care Act, which was enacted in March 2010. It mandated a voluntary long-term care insurance program, to be implemented no earlier than October 2012.

According to the law, employers who sign up for the program would automatically enroll their workers unless individual employees opt out. After a five-year vesting period of consistent premium payments, a beneficiary would be eligible for average benefits of no less than $50 a day to help pay for a range of services at home or in a nursing facility, such as eating, bathing, dressing and using the toilet.

Advocates say the program was not envisioned to fully cover such services, which tend to cost much more than $50 per day, but more to supplement whatever other resources beneficiaries can draw on. It also, they contend, would help patients avoid becoming destitute to qualify for Medicaid, which requires states to cover nursing home expenses but does not mandate coverage of in-home services.

In a February speech, HHS Secretary Kathleen Sebelius noted that some 10 million Americans currently need long-term services, which could rise to 15 million by 2020. She also said one out of six people who reach the age of 65 eventually will spend more than $100,000 on long-term care.

According to a July survey of almost 1,500 registered California voters age 40 and over by the SCAN Foundation and the UCLA Center for Health Policy Research, two-thirds of the respondents said they could not afford more than three months of nursing home care. About four in ten could not afford a single month of care, and only 14 percent said they’ve purchased long‐term care insurance.

One major sticking point for CLASS, which by law cannot be subsidized with taxpayer funds, is the cost to consumers. Average monthly premiums could be in the $160 range if the average daily benefit reaches $75, according to a 2009 estimate by the American Academy of Actuaries, a 16,000-member professional group that takes no position on the law itself. The Academy stressed, though, that major changes in the law are needed to make the program sufficiently sound to offer premiums even at that level.

Richard Foster, the chief actuary of the Centers for Medicare and Medicaid Services, an arm of the Health and Human Services Department, reported last year that average premiums would have to be set at $240 per month to adequately finance the program.

Back in 2009, when Congress was considering the CLASS proposal as part of the larger health reform bill, Foster and other administration officials privately raised concerns about its viability, according to The Associated Press. William Marton, who still heads the HHS Division of Disability and Aging Policy, wrote in an email that CLASS “seems like a recipe for disaster” because it would not attract sufficient numbers of healthy subscribers, AP reported Wednesday.]

These concerns center on the concept of “adverse selection.”

With auto insurance, for example, the state requires everyone who operates a car to buy coverage. The private companies that offer such insurance theoretically pay out less in payments for accidents and other covered events, and administrative costs, than they collect in premiums from a large pool of insured drivers.

But the worry with CLASS is that, being voluntary, the pool of persons who enroll will include too many individuals who currently suffer from health problems or who anticipate a need for coverage in the future, and too few persons who pay premiums but subsequently collect little or no benefits.

Further, setting the premium at a rate sufficient to cover CLASS benefits “further discourages persons in better health from participating, thereby leading to additional premium increases. This effect has been termed the ‘classic assessment spiral’ or ‘insurance death spiral,’” Foster said.

But while CLASS faces hurdles getting started, the private long-term care market is retrenching. According to LIMRA, an industry research group, 11 firms that once were among the top 10 long-term health care insurers no longer offer individual coverage, including MetLife, Unum, Allianz, CAN and IDS. Others have asked state regulators for big premium increases.

Nationally, a LIMRA spokeswoman said, the number of carriers has dropped from more than 100 a decade ago to fewer than 50 now. In California, that number has dropped from 28 in 2003 to 17 this year, according to state Department of Insurance records.

The last few years have been particularly disappointing to the industry as fewer policies were purchased despite the public’s greater awareness about the need for such coverage, a LIMRA report from June 2010 noted.

Some advocates contend CLASS, once it’s up and running, will improve public knowledge about and willingness to buy long-term care insurance, whether from private firms or the government program. But politically speaking, CLASS’ future faces tough sledding. The so-called “Gang of Six,” a bipartisan group of U.S. senators that tried earlier this year to devise a plan to reduce the national deficit and debt, called for its repeal. In 2009, the Democratic chair of the Senate Budget Committee called CLASS “a Ponzi scheme of the first order, the kind of thing that Bernie Madoff would have been proud of.”

Some opponents contend the program as currently structured is so financially unviable that Congress eventually will have to bail it out. But as a philosophical matter, they simply don’t think the government should be offering long-term health care insurance.

“We certainly agree that there’s a significant policy concern with regards to long term care. It’s something that most Americans don’t prepare for adequately,” said Kathryn Nix, a policy analyst at The Heritage Foundation, a conservative think tank that opposes CLASS.

“The right way to approach this is to … encourage individuals to save for their anticipated needs. But it’s not for government to intervene in the market. Government intervention has a place and this is not it,” she added.

The actuarial issues that critics have identified have led even the administration to agree that major alterations are necessary, most of which they contend can be handled administratively. Nix disagreed, saying the administration will have to approach Congress for most of the changes it’s seeking.

In her February address, Sebelius said her staff is exploring ways of raising awareness of the program, closing loopholes, making it more flexible for employers and indexing premiums to inflation, just as benefits are now tied.

“It would be irresponsible to ignore the concerns about the CLASS program’s long-term sustainability in its current form,” she said. “But it would be unconscionable to ignore the likelihood that without a CLASS Act, countless Americans will have to clear out their savings or leave their homes and loved ones in order to get the services and supports they need.”

A HHS spokesman declined to comment on the status of the administration’s deliberations. The Congressional Budget Office currently assumes a one-year delay in implementation.

“Trying to get some healthy people in and having a good mix of people in there is going to be the challenge,” said Sean Coffey, at the Family Caregiver Alliance in San Francisco, which supports CLASS. “If they can do that, then it should be sustainable.”

Coffey noted that the CLASS law requires the HHS secretary to certify that it will be solvent over 75 years before it can be implemented. “At least my sense of Secretary Sebelius is that she’s not going to do the program if she can’t get it to work within the parameters of the law of being self-sustaining,” he added.

Herbert A. Sample is a freelance writer based in Los Angeles. He can be reached at has ample@mac.com.

 

Merced seeks to improve public transit options for seniors

Published: August 23, 2011 | No Comments

Merced's The Bus, one public transit option for seniors.

By Minerva Perez

California’s population is getting older, and advocates say seniors will be unable to easily remain mobile, active and independent if policymakers don’t make public transportation a priority.

In the Central Valley town of Merced, seniors are already feeling the pinch of too few options.

“I have a car but gas prices are too high. I use the bus, my walker and this,” said Gloria Gonzales, 61, clutching her motorized wheelchair which she maneuvers through traffic every day to make it to the free lunch program at Merced Cherish Senior Center.


This article is one in an occasional series on aging with dignity, independent living and public policy that affects both. For a complete archive of the articles, click here.


A recent report by Transportation for America titled “Aging in Place, Stuck Without Options” ranked the city of Merced the fourth worst amongst cities its size for transportation services now and in the near future. The study estimates that in 2015, 86 percent of the population in Merced between the ages of 65 and 79 will have poor access to transit.

The study defined poor access to transit as the average number of bus, rail, or ferry routes within walking distance of their home. In Merced and other metro areas with fewer than 250,000 residents, a typical senior with poor transit service has access, on average, to less than .8 bus, rail, or ferry routes. Riverside-San Bernardino was the other California city on the top-four-worst list, coming in second-worst in the nation for metro areas with a population of 3 million and more.

The report attributes the source to rapidly aging baby boomers who are choosing to stay in place creating “naturally occurring retirement communities” in regions that are largely car-dependent.

Merced County’s transit system is looking to improve its transportation services for seniors like Gonzales by making it more affordable to ride public transit and providing options to the more rural parts of the county.

Recently, the half-fare program required by the federal Department of Transportation for individuals over 60 was expanded from four hours a day to all day on all urban and fixed routes. Seniors will now pay 50 cents per bus ride instead of a dollar.

That’s an alternative to the county’s more expensive dial-a-ride – a curb-to-curb public transit service that requires advanced reservations – which can cost anywhere from $2 to $6 one-way depending on destination.

“This provides options to people gives them an inexpensive way of getting around, encourages the use of the fixed-route system,” Rod Ghearing, the county’s transit manager, said.

In the past 10 months, 63,000 rides have been taken on TheBus’s dial-a-ride service and 570 people have used it as a source of transportation at least 20 times. Senior citizens usually take half of all dial-a-ride trips, Ghearing said, which costs the transit system an extra $7.30 more per trip than to offering a half-fare all day for seniors.

To further accommodate the senior population that was not being served, TheBus also began a taxi scrip service program for people over 60 years of age. Under this program, seniors living in Winton can take a taxi to Atwater to visit the shopping center or clinic at an 80 percent reduced price.

The Winton-Atwater area was selected as a pilot site for the program, Ghearing said, because dial-a-ride service is only available to the ADA population in that part of the county. If it goes well, he said they would consider expanding to other areas.

These programs may provide an instant alleviation to some of the short-range barriers that keep seniors from using transit, but seniors and their advocates say the transit system and Merced have a long way to go if they want to keep up with the needs of the aging population.

The real barrier in Merced for most seniors is the cost of transportation said Rick Bungcayao, Ombudsman at the Area Agency on Aging. While a 50-cent bus ride might not sound like much money, for a person living on a fixed income – as many seniors do – it is an added expense.

Most of the seniors on the bus are lower income individuals, Bungcayao said, who cannot afford or their own transportation. Seniors who are financially well-off tend to drive their own car as long as they can, he said.

“The SSI rate is in the $800 range, so when you consider that when you factor in, if they don’t own their own house, there is rent and utilities then there is food,” Bungcayao said. “It goes pretty fast.”

For some of the seniors he works with, Bungcayao said, ability and place make it even more difficult to use the fixed route system.

“If they live in an outlying area it’s hard to have access, and if they have a physical disability, it makes it difficult,” he said.

While there are challenges in getting seniors on public transportation, Merced’s ranking as the fourth worse in the country was somewhat unfair, Ghearing said. The survey looked at how far a person had to travel for transit and the systems timetables, but did not take into account that Merced has dial-a-ride or that its fixed routes – all 22 of them – operate on a “flag down” system. A bus will pull over if a person is walking down the street and they signal to the driver to stop and pick them up.

“In effect we have infinite bus stops,” Ghearing said. County surveys indicated that buses stop at more than 500 locations, including housing complexes, the hospital and community health center, senior and shopping centers and recreation places.

According to Merced County Human Services Agency there are between 32,000 and 34,000 seniors (people over 60 years of age) who live in the county, a 16 percent increase from its 2000 Census numbers.

The report found that without access to affordable travel options, “seniors age 65 and older who no longer drive make 15 percent fewer trips to the doctor, 59 percent fewer trips to shop or eat out and 65 percent fewer trips to visit friends and family than drivers of the same ages.”

“Having access to transit is most important to get to and from medical appointments for some of them being able to have some type of activity being able to go somewhere socialization being able to get out in general,” Bungcayao said.

“I haven’t driven in years,” Joseph Thomas, 92, said finishing up his meal at Merced Cherish Senior Center. “Sometimes I stay with friends, sometimes I stay at home; there is no way for me to get around on my own.”

Thomas has his daughter drop him off at the senior center where he has lunch with other older adults like him and partakes in a movie or a bingo game with them. He sometimes takes the dial-a-ride back home. Although his peers swear by it, he said he has had some problems including long waits and not being picked up.

The transit authority is wrapping up its short-range transit plan for the next five years, around the same time 86 percent of Merced’s senior population is supposed to have poor access. Plenty of other agencies are involved, including the Merced County Association of Governments.

“We are taking a clean sheet look at the system,” Ghearing said.

 
 
 

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