EXECUTIVE SUMMARY

A QUIET CRISIS IS LOOMING FOR AMERICA'S SENIORS

Eighteen short years from now, 53 million Americans (one in six United States residents) will be aged 65 or older. Today, 12.4 percent of the U.S. population is 65 or older; in 2020, that figure will approach 20 percent. America needs to prepare for these changing demographics: this is the “Quiet Crisis.”

Senior Americans, whether rich, poor, or somewhere in the middle, face many barriers to an old age in which very basic human desires for physical safety, appropriate health care, and maximal independence are met. For some, crucial family supports will disappear as they outlive spouses or children move to distant places. For others, limited resources will prevent them from identifying and purchasing needed services. Many will lose their homes — long a symbol of their independence — due to rising property taxes and maintenance costs. Living alone, isolated from services and perhaps coping with disabilities that prevent social interactions, a large and growing number of seniors will face triple jeopardy: inadequate income, declining health and mobility, and growing isolation.

“There's a lack of affordable housing alternatives to meet the demand, and many…do not have options.”
Rene Rodriguez, Executive Director, Miami-Dade Housing Agency, at hearings before the Commission, January 14, 2002, Miami, Florida.

In the face of unprecedented growth in the proportion of the population who are seniors, we believe that this Nation has both a moral obligation and a financial imperative to establish a more rational long-term care system. A system that drives seniors to needless, premature institutionalization and expensive, preventable medical interventions will burden both seniors and those who must bear the costs for their care. Senior individuals who are able to remain in the community should receive the services they need to be as independent as possible. Those who must move from their preferred setting should have viable and affordable alternatives that ensure their well-being. Neither institutionalization nor neglect should be the only alternatives they must accept.

“…A lot of older persons live in housing without supportive features. Over 5 million older households have one member with a functional limitation. Over 1 million of these households report needing modifications. These are primarily old, old persons.”
Dr. Jon Pynoos, Associate Professor of Gerontology, Ethel Percy Andrus Gerontology Center, at hearings before the Commission, November 7, 2001, San Diego, California

In a Nation characterized by care and compassion for the least fortunate of its citizens, the stark reality is that many seniors, after years of contributing to their country’s defense and prosperity, find themselves seriously at risk of being ignored, forgotten, or destined for a room in a skilled care facility. The simple fact is that this country lacks a national policy that addresses humanely and cost-effectively the needs and preferences of seniors who have diminished abilities to care for themselves. All too often, seniors with chronic illnesses and declining mobility have limited care and financial alternatives, when what they want is to live in their homes with appropriate support.

How the Quiet Crisis Has Developed

The Commission found that the Quiet Crisis has been developing over time as a result of numerous trends and economic factors. Some of our key findings regarding this evolution are the following:

• In 1900, seniors accounted for less than 5 percent of the total U.S. population; numbering 35 million, seniors now represent 12.4 percent. By 2030, the senior population will double to 70 million, or 20 percent of the U.S. population.¹



• Nearly 20 percent of seniors have significant long-term care needs. In 1997, more than 5.8 million or 18 percent of non-institutionalized people age 65 and older required assistance with everyday activities, and about 1.2 million (3.7 percent) were severely impaired, and required assistance with three or more activities of daily living (ADLs).²



• Many seniors across the income spectrum are at risk of institutionalization or neglect due to their declining healthand the loss or absence of support and timely interventions. The risk is greatest for those with lower incomes.³



• There are nearly six times as many seniors with unmet housing needs as are currently served by rent-assisted housing.⁴ Waiting lists for many types of subsidized housing are long. For example, “in 1999, approximately nine elderly applicants were on waiting lists for each Section 202 unit that became vacant within a year” compared with eight applicants in 1988.⁵



• The Nation’s affordable housing stock is in danger of losing significant numbers of units. According to Commission research, 324,000 Section 8 assisted units in senior properties are currently at risk of "opting out" of the HUD program.⁶

What the Quiet Crisis Will Bring

The Commission found, based on the best research and forecasts available, that by the year 2020:

• The number of senior households will have grown by nearly 53 percent;



• More than 80 percent of senior householders will be homeowners;⁷



• Nearly three-fourths of senior households with unmet housing needs will likely be homeowners; ⁸



• Almost 44 percent of senior householders will be age 75 or older;⁹



• Even if current rates of disability continue to decline, the number of seniors with disabilities will have increased from 6.2 million in 2000 to 7.9 million;¹⁰ and



• The need for home- and community-based services (HCBS) will have increased due to the desire of seniors to age in place;¹¹

Current policies and programs for seniors are an accumulation of unrelated decisions and unintended consequences. Housing assistance programs are implemented with little reference to health care or supportive service needs. Medicare remains centered on acute care and episodic medical interventions, while the need to manage chronic care for the senior population has emerged as the most formidable challenge. Medicaid, which was designed to ensure access to health care for low-income persons, now provides an imperfect reimbursement mechanism for the Nation’s long-term care facilities and the skeleton of a payment system for much-needed home- and community-based care.

“For any older American to suffer after working hard all of his or her life is a national disgrace.”
Honorable Elijah E. Cummings, Member of Congress, Seventh Congressional District of Maryland, at hearings before the Commission, March 11, 2002, Baltimore, Maryland

This Nation, despite competing demands for national resources, must respond to the critical need for affordable housing and home- and community-based supportive services, with a substantial financial commitment and effective policies. First, seniors most at risk of neglect or inappropriate institutionalization must receive the care they need. Second, all seniors, no matter what their individual circumstances and resources, should be able to continue to live where they prefer regardless of income, with the services they need to maintain personal dignity and quality of life.

“We just had a tragedy in this country where … immediately, all the money that was necessary to deal with that problem was provided…. We’ve got Baby Boomers coming. If they don’t want to deal with it now, what do you think they’re going to do then? ”

Andrew Montgomery, senior and former Chairman of the Commission on Aging for the city of Oakland, California, at hearings before the Commission, November 7, 2001, San Diego, California.

A VISION FOR AMERICA

The Seniors Commission believes that all older Americans should have anopportunity to live as independently as possible in safe and affordablehousing and in their communities of choice. No older person should have tosacrifice his or her home or an opportunity for independence tosecure necessary health care and supportive services.

The Commission further believes that:

• An individual's final years neednot and should not be a time of fear, loneliness, and pain;



• Today’s exceptions of excellence in seniors’ housing and health care services must become tomorrow’s norm;



• Seniors should be entitled to a coordinated system of healthy, affordable, and ethical long-term care without needing to spend down to Medicaid standards of eligibility; and



• This Nation has the capacity not only to protect its most vulnerable citizens from the challenges associated with long lives, but also from the loss of dignity and independence that millions of seniors face.

CONVERGENCE: A CALL FOR COORDINATION OF SENIORS’ HOUSING AND HEALTH CARE

The most striking characteristic of seniors’ housing and health care in this country is the disconnection between the two fields. With few exceptions, seniors obtain their housing from one source and their health care and supportive services from a completely different source.

Witness after witness before the Commission testified to this problem and the consequences of its continuation. Through such exchanges, Commissioners came to appreciate that:

• Some policy disconnects have long histories and may not be easily reconciled;



• Poor communication, differing vocabulary, and few opportunities to share experiences separate professionals, policymakers, academics, and even the media in the two fields;



• Lack of coordination and integration between housing and health care is characterized by different and distinct financing systems and regulatory structures; and



• Most difficult of all, government is structured, at both legislative and administrative levels, in ways that inhibit coordination.

…“Even for long-time professionals, the current ‘crazy-quilt’ tapestry of services and shelter options make it difficult to fully grasp their complexities, let alone try to access them. The result [is] confusion amongst consumers, duplication of service delivery, government agencies not knowing who supplies what service or that some services even exist, reduction in qualified service workers, regulations that impede dedicated service providers from providing the service they were hired and want to perform…”
Janice C. Monks, Executive Director, American Association of Service Coordinators (AASC), at hearings before the Commission, September 24, 2001, Columbus, Ohio.>

A Call for Coordination

The Nation can no longer afford the inefficiency of the current disconnect between housing and health service systems for seniors. The time has come for coordination among Federal, state and local agencies and administrators. Coordination should begin in the halls and committee chambers of Congress and should spread through all branches of government and society.

The now distinct worlds of housing and health care must begin to acknowledge each other, listen to and speak to each other, and learn to integrate efforts for their mutual benefit and the benefit of their senior clients. Such understanding and coordination are essential underpinnings to the success of reforms proposed in this report and in many other forums.

Realities for Seniors Formed the Basis of our Recommendations

The Commission received its Mandate from Congress; however, its major messages come directly from seniors across America.

The world of seniors in America today is insufficiently reported in the print media or pictured on television — aside from the occasional special report. Advocacy groups speak well for the needs of seniors, academics detail the results of their research, and Congress and State legislative bodies contain several experts (many of whom are seniors) in the field. But public attention to the coming crisis is minimal.

Commission members resolved, therefore, to find out for themselves about the world of seniors in America today. We held public hearings in Baltimore, Maryland; Columbus, Ohio; Miami, Florida; San Diego, California; and Syracuse, New York; and we attended a community forum in Boston, Massachusetts. We heard formally and informally from many of the country’s leading authorities on housing and health care options for seniors — heads of advocacy groups, recognized experts in senior services and leaders of government at all levels. We talked with providers, consumers, financiers, and regulators. We commissioned some of the Nation’s leading researchers to conduct original studies and we listened to seniors themselves.

From this work, stretching over 12 months, we began to form the conceptual framework for our recommendations to Congress. We developed concepts that flowed from the hearings’ testimony, Commission meetings, informal conversations, and research. Five guiding principles emerged, illustrated here by testimony from hearings and supported by research and other documentation received by the Commission. The Commission’s five guiding principles are as follows:

1. Preserve the existing housing stock

   …“Currently, neither the Federal or State governments recognize the critical nature of preserving affordable senior housing. Estimates are that there have been 300,000 units lost between 1997 and 1999. It is easy to see that we are losing units faster than we are gaining them. Many of these projects could be preserved with … the infusion of dollars far less than the cost of new construction. We estimate that new construction costs in our 202 portfolio are approximately $70,000 per unit. We are seeing renovation projects only in the range of $20-$30,000 per unit. The difficulty is that there is little energy for preservation at the Federal and State level; however, there is often a great deal of energy at the local level...”
   Thomas W. Slemmer, president, National Church Residences, September 24, 2001, testimony before the Commission in Columbus, Ohio.

   First and foremost, the Nation must save what it has. Affordable senior housing is, like its occupants, experiencing an aging process. The challenge lies in both preserving seniors’ homes and simultaneously meeting their changing needs.

   Principle No. 1 is addressed by seven specific recommendations that encourage the preservation, renovation, and refinancing of existing affordable and public housing projects and their potential conversion to service-enriched housing. These recommendations seek to preserve the existing stock of Section 202 units, encourage the renovation and refinancing of Section 202 projects, and support programs for senior homeowners to maintain their homes, maximizing their ability to age in place for as long as possible. Manufactured housing is recognized as an affordable housing option, and reliable financial products are encouraged for this type of housing. In addition, they encourage utilization of HOPE VI modernization funds to build new independent and assisted living facilities for seniors and to retrofit existing housing stock to better serve seniors.

2. Expand successful housing production, rental assistance programs, home- and community-based services, and supportive housing models.




“Monies have to be allocated for senior programs…there should be a whole senior division from U.S. HUD. We're getting older; this Nation is getting older…every year, we see less and less money allocated…we opened our fifteenth building. It's located in the heart of Little Havana on 22nd Avenue and Calle Ocho.
We thought that we were going to have a lot of people applying for the building, so we decided to do a lottery and announced through the papers and television that we were going to give applications for a period of two weeks. People usually camp out from a month before to fifteen days to get these applications. Through rain, through storms, people get robbed in the streets.
So we decided to try to do something because we thought there would be a lot of people… Six thousand eight hundred and ninety-seven people showed up for applications. We spent another two weeks qualifying these persons.
We finally drew up a lottery with the press present and a hundred fortunate people got apartments...”
Jose Fabregas, executive director, CODEC, January 14, 2002, testimony before the Commission in Miami, Florida.

A housing crisis is on the horizon, and more housing units must be created in response. The Commission recommends the production of a variety of housing types, serving persons of low, moderate, and middle incomes, ranging from single-family home communities to service-enriched senior apartments to Continuing Care Retirement Communities.

Principle No. 2 is addressed by ten specific recommendations that include funding and modifying the Section 202 Program to keep step with the forthcoming growth in seniors population, increasing annual production to meet the needs of future generations of seniors, assuring Medicaid funding to support quality care and adequate payments across all settings. Recommendations also include modifying rural housing programs to provide ample funding to more appropriately serve seniors and assuring that home- and community-based services and supportive senior housing are available in rural areas.

3. Link shelter and services to promote and encourage aging in place.

   “How do we have this continuum of care and services and coordinate them? What this [Commission] will do for us…is help us to look at this holistically…you can’t just have housing…people have different needs, they have different resources, and…how important is this medical component as we wind up with 55 or 60 million people in this country who are going to need both pretty substantially.”
   Congressman James Walsh, Chair, House Appropriations Subcommittee for VA-HUD and Independent Agencies, July 30, 2001, statement before the Commission in Syracuse, New York.

   In the area of long-term care services, public programs must move away from institutionally based models of service delivery. Seniors want choices in the services they receive. Public programs must provide services that are based on the needs and preferences of the individual.

   Principle No. 3 is addressed by seven specific recommendations that include urging Congress to appropriately fund service coordination in all federally subsidized housing with senior populations and supporting demonstrations in assistive living technologies. The recommendations urge Congress to direct the General Accounting Office to evaluate interdepartmental operations between HUD and HHS and provide recommendations on how to coordinate their programs for seniors more effectively. These recommendations also urge Congress to help facilitate safe environments for grandparents raising grandchildren and call for improving transportation options and accessibility for seniors with limited mobility.

4. 4. Reform existing Federal financing programs to maximize flexibility and increase housing production and health and service coverage.

   “Although Freddie Mac and Fannie Mae have existing programs and have become very responsive to us, their target is a very narrow property type…their programs accommodate properties that are generally servicing the middle and upper middle-income population that is largely Brookdales’ clientele. An issue that we have grappled with at Brookdale over the years is how to create a more affordable product for the vast population of seniors that cannot afford an upscale retirement community, yet has too much income to qualify for Section 8 or tax credit housing.”
   Mark Schulte, Chairman/CEO, Brookdale Living Communities, September 24, 2001, testimony before the Commission in Columbus, Ohio.

   Government-Sponsored Enterprises are the backbone of a housing system that has led to 68 percent of all Americans’ owning their own homes. With HUD, they should be major players in expanding housing and care facilities, particularly for seniors with incomes between 30 percent and 80 percent of area median income — a market segment with far too few options. Joined with Medicaid and Medicare, they can help meet the housing and service needs of many of the most needy seniors, now and into the future.

   Principle No. 4 is addressed by ten recommendations that include calling on GSEs to develop and actively promote appropriate credit products to help expand private sector participation in senior housing, modernizing and redesigning FHA programs to work together seamlessly, and establishing higher HUD fair market rent standards for units in assisted living facilities.

   These recommendations call on Congress to increase the Medicaid matching rate for home and community based service (HCBS) waiver services and ask Congress to institute a Medicaid shelter allowance as a requirement in Medicaid HCBS waiver programs, with incentives for state implementation. In addition, the recommendations support worker training in long-term care and urge the modernization of Medicare to address the growing needs of seniors with chronic conditions.

5. Create and explore new housing and service programs, models, and demonstrations.




…“Council for Affordable and Rural Housing (CARH) … members own or operate affordable housing across rural America…. If there is one thing we have learned it is that there is no more effective method of delivering affordable housing than a public-private partnership between government and its citizens. We have also learned that too often the special needs of seniors and the disabled are not properly addressed...
Robert P. Yoder, Sr., past president, Council for Affordable and Rural Housing (CARH), July 30, 2001, testimony before the Commission in Syracuse, New York.

Yesterday’s demonstration and pilot programs often become today’s most successful approaches to the delivery of service-enriched housing for seniors.

Principle No. 5 is addressed by eleven specific recommendations that include creating a clearinghouse of information about state Medicaid programs that deliver home- and community-based services and a national database of senior housing, encouraging the broader implementation of the Programs of All-Inclusive Care for the Elderly (PACE) model, developing enhanced private sector and rural housing programs, creating an incentive for the purchase of long-term care insurance and establishing a prescription drug benefit for seniors under the Medicare program.

Challenges to Meeting Future Needs

The Commission also learned that national efforts to meet the future needs of seniors will face numerous challenges. Principal among those challenges is the need for resources. Committed investment in affordable housing has declined over the past three decades¹² and resources devoted to home- and community-based services pale in comparison to resources dedicated to facility-based, skilled nursing care. The Commission's key findings on the challenges to addressing the growing affordable housing and health services crisis are:

• One-third of senior households are expected to have housing needs;



• Almost one-fifth of seniors will likely have service needs, and existing programs are not well structured to meet those needs;



• Current production of affordable housing does not begin to meet demand;



• Subsidized rental units are being lost due to expiringSection 8 project-based rental assistance contracts and mortgage prepayments; and



• Federal housing and health policies are not synchronized, often leading to premature institutionalization as a more costly, yet practical option.

The Commission has developed more than 40 recommendations to address the health and housing challenges of a dramatically increasing senior population. A full Table of Commission Recommendations appears in the Appendix to this Report.

Though the Commission’s recommendations seek to respond to its Congressional Mandate, the Commission believes that these recommendations address the entire Nation on issues that many government leaders, providers, developers, advocates and consumers face. It is essential that these challenges be addressed proactively.

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