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There’s a Crisis Brewing in the Field of Elder Care

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There’s a crisis brewing in the field of elder care. That’s the sobering consensus reached by most healthcare experts and demographers, and the consequences should be of concern to every American senior and their families. We’re experiencing a perfect storm: a rapidly growing cohort of people living longer combined with a shrinking workforce of caregivers. The time to prepare for your future care needs is now.

This article from NextAvenue, published in late April, offers yet more evidence that elder care is in crisis. The analysis was written by Harry Margolis, elder law attorney and blogger about elder care. His observation couldn’t be clearer: the growing ranks of Americans aged 85 and older require a lot of care and caregivers, and we don’t have enough of either.

Crisis in Elder Care: Senior Population Increasing Dramatically

Margolis launches his report with basic statistics.  According to the U.S. Census Bureau, he writes, “the number of centenarians in the United States will quadruple over the next three decades from about 100,000 today to more than 400,000 in 2054.” After that, the number of those passing the century mark will “no doubt keep growing at a rapid rate,” since by 2054 only half the baby boomer generation will have reached 100.

Seniors (65 and older) as a percentage of the population will also grow, in this case by more than a third in the next three decades. “The Census Bureau also projects that during the same 30 years the number of Americans aged 65 and older will grow from 62 million to 84 million,” says Margolis, “increasing from 18 percent to 23 percent of the U.S. population.”

But are these the most pertinent statistics? As the article explains, maybe not. The real challenge lies a bit deeper.

Crisis in Elder Care: With Longevity Comes Demand for Care

Margolis is quick to explain that neither the number of 100-year-olds nor the number of those over 65 is very useful. The number of centenarians may be impressive, he says, but it’s a comparatively tiny number – projected to represent just 0.5 percent of older adults by 2054. Moreover, it’s neither helpful or accurate to consider all of those over 65 as one homogenous group. “The projections are overbroad in throwing all those 65 and over into the same bucket,” Margolis writes.

In fact, he argues, those over 65 “constitute two generations in significantly different situations. Most people aged 65 to 85 are healthy and able to live independently. The numbers change dramatically after age 85, with many more people needing medical care and assistance with their activities of daily living.” The real looming crisis, in other words, is seen in the growing number of those living longer, well past the age of 85.

Margolis cites a 2019 report by Urban Institute economist Richard Johnson. Johnson showed that, in 2014, 40 percent of adults ages 85 and older had a severe need for long-term care, compared with 8 percent of those aged 65 to 74. The Urban Institute report further noted that about one in eight of seniors classified as “the oldest-old” received long-term nursing home care, compared with only 1 percent of those ages 65-74.

“Skyrocketing Demand” as Those 85-Plus Numbers Increase

If those 85 and older will need the most care, then we have a tsunami approaching, Margolis argues. “The Administration on Aging projects that the 85-and-older population will more than double from 6.7 million in 2020 to 14.4 million by 2040,” his article states. “Since the youngest baby boomers won’t reach age 85 until 2049, the number of 85 and older Americans — and the need for elder care — will keep growing from 2031 through the early 2050s.”

The result, Margolis writes, is crystal clear. The data shows that “the number of Americans with significant disabilities will double from 7.6 million today to 14.7 million in 2065.” But where will we get the trained workers to provide care for that rapidly expanding cohort of need?

Crisis in an Elder Care System That is “Already Strained”

“We’re far from ready to take care of elders,” Margolis states emphatically. “Our elder-care system — and perhaps ‘system’ is a generous term for our myriad of uncoordinated services — is already strained.”

Millions of family members are caring for parents, spouses and siblings, but they “often struggle to find the necessary time, facilities and resources,” says NextAvenue. “Hospital discharges are extremely stressful as hospitals seek to open up beds to new patients and families struggle with decisions about how to care for loved ones or which inadequate facility to select.”  (This is a topic Rajiv brings up repeatedly on the radio and in his seminars.)

Margolis speaks from personal experience as an elder law attorney. “As I write this, I’m working with a family of a woman who has been hospitalized for a respiratory illness and needs continuing oxygen care,” he says. “The hospital sent out a placement request to 88 facilities and received responses from two saying they would accept the transfer, both an hour’s drive (each way) from her family members.” No wonder families are at wit’s end.

Care Crisis Made Worse by a “Patchwork” of Programs

Margolis expands on the theme of placement and care decisions families are called upon to make, using the example of his client cited above, a woman who needs continuing care. “Medicare will pay for her care at first, entirely for up to 20 days, after which there is a sizable co-pay for the next 80 days,” he explains. “But it’s not clear whether the patient will receive a full 100 days of Medicare coverage because it will stop before then if she stops needing skilled care.”

What happens next can get murky. “After the Medicare coverage ends, whether at 100 days or sooner, she will have to pay privately at a cost of hundreds of dollars a day, qualify for Medicaid coverage, or return home,” Margolis states. “This uncertainty adds to the stress for patients and families, as well as for facilities that must manage their caseloads and cashflow.”

Our Entrepreneurial Economy Creates Choices, Adds Complexity

In some cases, says Margolis, American capitalism can create helpful and innovative caregiving solutions, but our system can also make things even more complicated for families. In our entrepreneurial economy, he writes, “both non-profit and for-profit companies and organizations step in to fill unmet needs.”

This capitalistic system can be a double-edged sword. “In recent decades,” says the article, “we’ve seen a tremendous growth of assisted-living facilities and home care agencies. At the same time, we have seen the closure of many nursing homes, and seen many others move from a chronic-care to an acute-care model in pursuit of higher Medicare reimbursement rates. These are natural and flexible responses to needs and funding.”

But this landscape of continual change is hard to navigate. “The myriad options available for care make it even more difficult for families to assess what their family members need and to learn what’s available in particular communities,” Margolis writes. “Further, in the absence of planning, what’s really needed is often unavailable.”  (Emphasis added.)

Elder Care Crisis in a Period of Changing Needs, Preferences

Margolis writes that, over the years, both the needs and expectations of seniors have changed dramatically. Housing choices haven’t always kept up.

“Assisted living facilities are built on a residential model, often providing very limited care and forcing residents to move out when their needs grow,” Margolis writes. But where will these seniors move? Skilled nursing facilities are in a prolonged decline.

“Very few new nursing homes have been built since the 1960s and 1970s,” says the article. Many of those older facilities are hampered by shared rooms and poor ventilation, a devastating combination during the COVID-19 pandemic.

“No one wants to move to one of these facilities,” says Margolis, “but many older adults must, due to lack of affordable alternatives.”

In fact, he writes, families are the front-line caregivers today. “Most elder care today is provided by family members, often daughters,” the article states. “Few older adults can afford to pay for care, whether at home, in assisted living, or in nursing facilities, for any length of time.”

Medicaid Often Forces Seniors into Institutional Care

“Our elder care financing system is based on Medicaid, a safety-net health care program,” Margolis writes. But therein lies the problem. “Since Medicaid is designed to be only for the poor, in order to obtain coverage, older adults must become poor by spending down their assets.”

But even if they qualify, seniors will almost surely face severely limited care choices. “They still may not get the care they want,” says the article. “Medicaid pays for only limited assisted living or home care, though coverage of both has been expanding in recent years. As a result, many people have to move to nursing homes just because Medicaid will pay for their care in such a setting.”

System Will “Fracture” as Baby Boomers Reach Late 80s

The outlook is bleak, Margolis argues, unless we take action now. “This is the picture of today’s system,” he warns. “Its fault lines will totally fracture when the baby boomers begin reaching their late 80s in about 10 years, which gives us a decade to prepare.”

He offers several suggestions based on his work with experts in the field of elder care. We’ve had to shorten these due to space limitations but we encourage you to read the original article here. Margolis’s suggestions fall into four categories.

Create a National System to Finance Long-Term Care: “Very few people can afford private long-term care insurance and those who can need it least,” he writes. “Attempts at creating a public long-term care insurance program have largely failed because they have not been universal.”

He cites a portion of the Affordable Care Act which was designed to help cover long-term care. But the law was never implemented because its optional nature made it “actuarially unsound.” He also singles out the universal program here in Washington State called Washington Cares that uses a payroll tax to provide residents will receive up to $36,500 of long-term care benefits. “That won’t solve the need,” Margolis acknowledges, “but it can provide important assistance for many people.”

Still, Margolis argues that a patchwork of state programs won’t solve the problem. A national solution is likely to function better.

Workforce Development: “Despite the promise of technology to solve care challenges, most care will continue to have to be provided by people, one on one,” the article predicts. “Not only do these caregivers deserve to earn a living wage, but research shows that doing so raises the quality of care — not a major surprise.”

Obviously, higher wages and better benefits mean more expensive care. “But it’s money well spent,” Margolis counters, “since it helps both the caregivers and care recipients.”  It does seem clear that something needs to change to stop the loss of caregivers from the workforce.

New Models of Providing Care: “Where care is received has already changed significantly over recent decades, moving from nursing homes to assisted-living facilities and home-based care,” says Margolis. “This is a good trend, but much more can be done.”

New home-style care facilities are being developed around the country, and builders are creating multi-generational communities where caregiving can be shared. “Many housing developments for older adults are adding services that can be provided to residents on a more cost-effective basis than would be the case if they were geographically scattered,” Margolis adds.

But he does point out one big challenge. “While the cost of providing care is borne by these communities, the savings go to the medical providers and insurers who benefit from healthier patients,” he writes. Considering the power of the healthcare and insurance lobbies in Washington, this will be a difficult model to change.

Family Support: “Despite all the money spent on elder care, most care has always been and continues to be provided by family members, often at great personal and financial cost,” says NextAvenue. “We need to increase supports in order to ease the strain this causes.”

He cites several helpful possibilities. “These can include better assistance with coordination of care and discharge planning from hospitals, credit for Social Security contributions when family members must leave or reduce work to provide care, better family leave and easier qualification for Medicaid to provide supplemental care or to pay family members providing care. All these initiatives will take time to implement, test out and modify, as necessary. We have the next decade to experiment and get this right.”

(originally reported at

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