Our longest, happiest lives
Health policy for older persons
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As Coloradans live longer and healthier lives, the older cohort grows, for which the health system is unprepared. Now COVID-19 has exacerbated gaps in health policy for older persons; health policy leaders must act proactively to find inventive solutions ensuring that everyone has the opportunity to live long, healthy, and happy lives.
EMERGING ISSUE IN HEALTH POLICY
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THE POPULATION OF OLDER PERSONS
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As Coloradans age the older citizenry grows. Colorado’s 65+ population is projected to grow 84% between 2020 and 2050, more than double the growth of the young and mid-age groups (Figure 1).[1] By 2030 older people will be a larger group than young people, growing from 15% to 20% of Colorado’s citizens, insuring greater demands on our health care system.
Figure 1[1]
A higher proportion of older people implies more higher-risk cases. Aging results in different health challenges hence the existence of a medical specialty addressing the needs of this population: geriatrics. The health risk for this group is evident from the tragic impact of COVID-19, where 1 out of 57 Colorado adults over 80 years old died of its effects.[2] The health care system will have to treat and protect a greater number of older people.
Also impacted is the Colorado state budget. Adults 65+ represent 4% of Colorado Medicaid’s population, but 18% of its expenditures.[3] As the older group grows, so will Colorado Medicaid’s 65+ population, as will expenditures.
ACCESS TO CARE
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Older people need varying degrees of assistance with housing, activities of daily living, and treatment. These are reasons why so many long-term care services exist, including home health, independent living, assisted living, and traditional nursing homes. Residential services are expensive and there is a shortage.[4] In the aftermath of COVID-19, there is an even greater chance of shortage – now 2 out of 3 nursing homes are at risk of closing.[5] Unless housing is addressed quickly, there will be more people than the residential service industry can accommodate.
Another challenge impacting access to care is that the number of medical professionals serving this population is small and diminishing. There is a shortage of geriatricians, home health aides, and nursing assistants in the U.S.[6],[7] Home and personal care aides are doing hard work at the lowest wages among health care occupations (lower than veterinary assistants), and nursing assistants are not paid much more.[8] “There has to be a change in our culture to respect these workers and hold their jobs in high esteem” says William Dombi, president of the National Association for Home Care and Hospice.[9]
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Rural Colorado presents particular challenges for access to care. These regions currently have the greatest proportion of older persons (Figure 2), and access to care shortages before COVID-19 have been intensified by the pandemic.[10] Rural residents are driving hours to receive a COVID-19 vaccination because there is no nearby pharmacy with vaccine availability.[11] When health policies are fashioned to improve access to care, rural areas must be considered.
Figure 2[1]
CULTURE
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The challenges to building health policy that ensures long and happy lives stem from cultural constructs. Everyone who lives ages - there is no “us” versus “them”, yet there are cultural perceptions of aging including dependency, incompetence, and deterioration. These negative and often inaccurate perceptions are stereotypes which result in ageism, a form of discrimination against older persons.
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Another aspect of the treatment of older persons is how people feel towards this population. The COVID-19 pandemic yielded yet another revelation of the nation’s apathy toward older persons. Had COVID-19 been equally deadly to all people, not just those at greater risk, would there have been similar resistance to efforts to squelch the spread?
In the field of health care, misperceptions and apathy may result in not treating an older person as a unique, valid human, but as a manifestation of age. This has major implications for patient care quality and may result in overtreatment. Recently a health system with Colorado locations, Banner Health, has been cited for overtreating Medicare patients.[12] The culture of the health system must change to ensure people receive appropriate care.
WHAT WE CAN DO
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Leaders should come together to discuss, plan, and build a new health policy so Coloradans can thrive as we age. People thrive and heal better at home; policy makers need to look at housing and health policy to see what opportunities exist for accommodating older people within their communities.[13] Policy must address shortages of residential and nursing services for long term care through incentives. Lastly, and most importantly, leaders must encourage a culture of inclusivity and forward-thinking about older people.
[1] Department of Local Affairs. (2021). Population: Data and Lookups. https://demography.dola.colorado.gov/population/data
[2] Calculated by combining demographic data and COVID-19 demographic data from the Department of Public Health and Environment’s Colorado COVID-19 Data dashboard (https://covid19.colorado.gov/data)
[3] Department of Health Care Policy & Financing. (2020). 2019-2020 Annual Report. https://colorado.gov/hcpf/publications
[4] Sitkin, Lisa. (2020). Is a Housing Affordability Crisis on the Horizon for Seniors? American Bar Association. https://americanbar.org/groups/law_aging/publications/bifocal/vol-41/bifocal-vol-41--issue-3/is-a-housing-affordability-crisis-on-the-horizon-for-seniors
[5] American Health Care Association/National Center for Assisted Living. (2020). State Of Nursing Home Industry: Facing Financial Crisis And Staffing Challenges. https://ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/State-of-Nursing-Home-Industry_Dec2020.pdf
[6] Lester, P., Dharmarajan, T., & Weinstein, E. (2020). The Looming Geriatrician Shortage: Ramifications and Solutions. Journal of Aging and Health, 32(9), 1052-1062. doi.org/10.1177/0898264319879325
[7] Gwynedd Mercy University. (2020). Healthcare Careers in 2020: Medical Field Jobs. https://gmercyu.edu/academics/learn/healthcare-careers-interactive-report
[8] U.S. Bureau of Labor Statistics. (n.d.) Occupation Handbook – Healthcare. https://www.bls.gov/ooh/healthcare/home.htm
[9] Woods, Bob. (2019). America’s $103 Billion Home Health-Care System Is In Crisis As Worker Shortage Worsens. CNBC. https://cnbc.com/2019/04/09/us-home-healthcare-system-is-in-crisis-as-worker-shortages-worsen.html
[10] Hauff, Bret. (2020). For Colorado’s Rural Seniors, Coronavirus Strains Access to Home-based Care — Just as it’s Needed Most. Colorado Sun. https://coloradosun.com/2020/09/16/rural-home-care-seniors-colorado-covid
[11] Finley, Ben. (2021). Open Spaces, No Pharmacies: Rural US Confronts Vaccine Void. Associated Press. https://apnews.com/article/health-coronavirus-pandemic-virginia-19884014220f3697889560f0027c200f
[12] U.S. Department of Justice. (2018). Banner Health Agrees to Pay Over $18 Million to Settle False Claims Act Allegations. https://justice.gov/opa/pr/banner-health-agrees-pay-over-18-million-settle-false-claims-act-allegations
[13] Levine, D et al. (2019). Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Annals of Internal Medicine. doi.org/10.7326/M19-0600