Working to find actionable solutions to the nation's key challenges.

The Health and Housing Nexus

By Henry Cisneros

Monday, December 8, 2014

Determining how best to care for an elderly loved one is a challenge facing millions of families throughout America.

With the size of our nation’s senior population expected to grow dramatically in the coming years – the number of Americans aged 65 or older will reach nearly 73 million in 2030 – this challenge will only grow in scope and intensity.

The fact that seniors will constitute an ever-larger share of the overall U.S. population, with the ratio of working-age people to those reaching retirement falling significantly, will complicate matters even further.

To understand what our nation is up against, consider these facts:

  • Seeking to remain close to family and friends, the overwhelming majority of seniors (nearly 90 percent, according to some estimates) will wish to “age in place” in their own homes and communities as long as they are physically able to do so. Unfortunately, many of our homes and communities lack the necessary structural features and support systems to make independent living into old age a viable, safe option.
  • Private and public resources are currently inadequate to support the home-based and community “infrastructure” necessary to enable aging in place. Millions of households headed by seniors spend large portions of their incomes on mortgage or rental costs, leaving little for basic maintenance that can impact safety in the house. The personal retirement savings of many Americans, a potential source of funds to help make aging in place more viable, is shockingly low. Funding for federal housing programs designed specifically to assist the lowest-income seniors remains very limited and fails to match the great need that exists.
  • Seventy percent of those who reach age 65 will eventually require some form of long-term supports and services (LTSS) to assist with the activities of daily living such as bathing, dressing, or medication management.
  • While most experts believe it is preferable to deliver LTSS at home and in the community rather than in institutions, how to finance LTSS is the subject of considerable disagreement. Public spending on LTSS currently exceeds $100 billion annually, most of it through the Medicaid program. In 2012, private long-term care insurance covered about $7 billion of LTSS, while individuals and families were responsible for tens of billions more in out-of-pocket spending. It is estimated that unpaid services from family members, friends, and other caregivers is worth more than $450 billion annually. These costs are expected to rise significantly as our nation grows older.
  • While the majority of LTSS is unpaid and delivered in the home, paid LTSS has historically focused on institutional care. State Medicaid programs are required to cover nursing-facility services, while coverage for home- and community-based services remains Many states offer home- and community-based care through Medicaid waivers or state plan options, but the current system remains biased in favor of institutionalization.

In the coming years, an aging population will impose enormous strains on both the housing and health care systems, challenging us to think more strategically about how to use existing tools and resources. Rather than operating in isolation, it is critical that policymakers and practitioners in both the housing and health care fields identify ways to work together to forge effective, cost-efficient solutions.

The key is to create a policy and regulatory environment, supported by adequate resources, that promotes the integration of these services.

Just as the U.S. military insists on cross-service cooperation or “jointness” in its operations to increase efficiency and effectiveness, here on the domestic front, responding successfully to the long-term care and aging-in-place challenges will require the sustained collaboration and focus of multiple agencies at all levels of government.

Within the federal government, the U.S. Departments of Housing and Urban Development (HUD) and Health and Human Services (HHS) have initiated efforts to support better integration of housing and health case services – the Housing Capacity Building Initiative for Community Living Project is one such example – but the level of collaboration could be even higher.

HUD and HHS must make it an urgent priority to identify and remove any barriers to the creative use of residential platforms for meeting the health and long-term care needs of the seniors they serve. They should also encourage providers throughout the health care system to partner with their housing counterparts to create more integrated systems of services that will enable aging in place.

As part of this effort, it will be critical to assess how residential stability can improve health outcomes and reduce the costs imposed on the health care system. Robust data collection will be essential to accurately measuring these impacts.

The good news is that America is finally waking up to the immense demographic challenge we are facing. Nothing less than “all hands on deck” response will be sufficient.

KEYWORDS: CO-CHAIR CORNER, DEPARTMENT OF HEALTH AND HUMAN SERVICES, DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT, HENRY CISNEROS, LONG-TERM SERVICES AND SUPPORTS