By 2029, the US will be home to 14.4 million middle-income seniors. Two-thirds of these seniors will have three or more chronic health conditions, 60 percent will have mobility limitations, and 20 percent will have high health care and functional needs.
The majority of these middle-income seniors will need the level of care provided in senior housing, but more than half will not have sufficient financial resources to pay for it.
Caroline Pearson and David Grabowski painted this picture of American seniors’ near future at a recent convening at Health Affairs, involving researchers from NORC at the University of Chicago and Harvard University. The discussion revealed that, although increased educational attainment and other factors will likely decrease the proportion of extremely low–income seniors, the “forgotten middle” also has needs we must address.
High-income seniors have greater financial resources, and low-income seniors may be eligible for Medicaid long-term services and supports or have access to subsidized housing (though this system is far from perfect). But middle-income seniors have too many financial assets to qualify for Medicaid and not always enough to cover housing and support needs as their health and functional abilities change.
As a result, middle-income seniors must rely on family members, if they have them, and on retirement savings that may fall short as they try to navigate a patchwork of paid services and private supportive housing options.
John Rowe, one of the Urban Institute’s trustees and the Julius B. Richmond Professor of Health Policy and Aging at the Columbia University Mailman School of Public Health, offered his perspective on this potential crisis in an accompanying Health Affairs perspective:
Many core societal institutions—such as education, work and retirement, transportation, the built environment, health care, and housing—were not designed to support a population with the age distribution of our future population. We must reengineer these building blocks so that they facilitate the opportunity for aging successfully.
Rowe’s incisive comments about our lack of whole-person supports for all people (not just this forgotten middle) were particularly invigorating for us—researchers devoted to investigating the lifelong impacts of the social determinants of health.
Housing as a social determinant of health
The layered, inextricably intertwined issues of housing and health are not new to us. Safe, quality, affordable housing is fundamental to a healthy life. Healthy homes can improve lives and provide a foundation of health for individuals and families, but unhealthy homes can just as easily undermine quality of life and even cause poor or substandard health.
A decent home is paramount to healthy aging, as Jennifer Molinsky, another panelist, laid out. Housing without proper accommodation can become a safety hazard, but renovation is not always economically feasible or even desirable. Additionally, adequate housing—and one’s sense of home and community—is critical to mental health. Depression and loneliness tend to spike in older Americans and can often lead to physical and mental deterioration.
What does successful aging look like?
For Rowe, successful aging should be measured against an index that applies a whole-person lens, rather than singling out any one assessment of health or economic stability. For him, and for other researchers at the Research Network on an Aging Society, five domains work in combination to shape the aging process:
- productivity and engagement
- well-being
- equity
- cohesion
- security
We were surprised to learn how well the US seemed to be performing against this index, landing at number 3 against 18 Organisation for Economic Co-operation and Development countries, whereas we typically bottom out on lists evaluating overall population health and well-being. A closer look reveals that the US performs relatively poorly on well-being and equity, but its high standing in productivity and engagement (people working longer) boosts its standing.
From a social determinants perspective, this index is telling. Although we know that later retirement can be beneficial for some populations, we suspect that for the majority of Americans working in blue-collar or minimum wage positions—and struggling to afford basic necessities like rent, food, and electricity—working longer does not necessarily confer the kinds of mental and physical health benefits we see in white-collar workers, and indeed, may even exacerbate or accelerate a poor aging process.
Partnership, not just policy
How to best address the housing and health needs of the forgotten middle is unclear. Pearson and Grabowski suggested expanding our country’s subsidized housing system as one policy fix. Yet a large proportion of those already eligible for subsidized housing can’t access it because federal housing subsidies are not an entitlement, and we lack enough units or vouchers to serve all those eligible.
Close to 40 percent of very low–income elderly renters are not residing in subsidized housing and have rents that account for more than 50 percent of their incomes. The quality of nursing homes for Medicaid residents can also be poor, and assisted living is not covered as an entitlement in all states.
Ultimately, the solutions for improving our country’s outcomes for older adults—especially for this middle-income group—are likely to require public-private partnerships. Addressing the needs of our aging population will require political will, community empowerment, and a recognition that successful aging is not just about health care, or housing, or savings, or family supports, or dignity. It requires all of that—and more.
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