Part I.  SETTING THE CONTEXT: THE ELEMENTS OF CHANGE

A Quiet Crisis Is Looming for America's Seniors

As Baby Boomers Age, Millions of Seniors Will Lack Affordable Housing and Health Care Services

A crisis is looming for America's seniors. It is a quiet crisis and most people seem unaware of its dimensions. Those who will be affected are not talking about it. Little is being done to prepare for it. Time is running out.

When the first of America's Baby Boomers reach age 65 in a mere nine years, the number of older Americans will begin to increase dramatically. Numbering 35 million seniors today, by the year 2020, one in six Americans - 53 million men and women - will be age 65 or older.¹⁴ The Nation is not ready for this surge in the senior population.

This is the same generation that overloaded schools, challenged the health care system, and overburdened the transportation network. Many of these seniors will need housing and health care services that may be neither available nor affordable unless the Nation acts now.

Congress saw this crisis on the horizon and established this Commission with a Mandate as broad as the crisis itself. At the outset, the Commission recognized the size and scope of the challenge - to examine two of the largest fields in America, housing and health, in light of this dramatic increase in seniors. We hope that our report is a first step toward the development of a sound national policy for seniors, but we know that many more studies and explorations of options must follow. It is important that the task has been identified, that the problem has been defined, and that work on finding solutions has begun.

Challenges to Meeting Future Needs

The Commission also believes that a national effort to meet 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 decades 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 expiring Section 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, and consumers face. It is essential that these challenges be addressed before the Nation is overwhelmed with the needs of the retiring Baby Boomer generation.

The Causes of the Crisis Are Clear

In America today, most people are living longer and many are enjoying their later years more, contributing as seniors to their families, communities, and country in countless ways. The reasons are simple: advances in medicine and health care, broader public understanding of good nutrition and healthy lifestyles, and a major reduction in environmental pollutants have contributed to a steady rise in life expectancy.

Commission research based upon U.S. Census and American Housing Survey data shows, however, that almost half of seniors today are likely to have a low-income (under 50 percent of area median income) and one-third of those seniors pay more than 50 percent of their income for housing. Witnesses repeatedly told this Commission of long waiting lists for affordable housing, especially in growing urban areas. Families of seniors told of needing to move into costly institutional settings because of the lack of affordable and appropriate housing in the community. They told of the shortage of health care facilities or supportive services associated with their housing. The level of investment in this area has been inadequate for the past quarter century; neither market incentives nor political imperatives have generated sufficient private or public investment to meet even today's need. If the situation is dire now, it will be desperate in the year 2020.

Barriers May Tarnish the Later Years

Americans - poor or not - face many barriers to a secure aging process. In addition, a growing number of seniors are finding that they have to work in their "golden years" due to insufficient retirement plans, rising costs of health care/prescription drugs and lack of safe, affordable housing alternatives. For some, family supports disappear when they outlive spouses or when children move to a distant place. For others, old age is a time of discovering that, with a declining or fixed income, they are simply unable to purchase the goods and services they need. Rising property taxes and maintenance costs may make their home, long a symbol of independence and often their most valuable asset, too costly to retain.

Seniors may face declining health, including the loss of ability to care for themselves and to live independently. They may live alone, lack family support, be unable to drive, be isolated from services they need, suffer disabilities that confine them to home, or be unable to enjoy friends and the social interactions so vital to their sense of dignity and well-being. While medical advances continue to increase life expectancy, the cost of medical insurance, long-term care, medications, and other needs for later life need to be within reach of seniors' ability to pay. Many will spend what resources they have to meet their personal care and health needs until, impoverished, they meet Medicaid eligibility requirements.

For those fortunate enough to have caring families nearby, their caregivers may face more stress than they can endure. When family, friends or caregivers search for help, they often encounter confusing requirements and eligibility standards as well as exorbitant costs. Those in rural areas face a dearth of available services, and the high cost of travel inhibits the use of what services are available.

Seniors who live in private homes and require assistance could greatly benefit from the intervention of a professional who is able to facilitate service linkages, in the same way that resident service coordinators do in federally assisted housing. Furthermore, those seniors who are able to stay in their private homes may not be able to afford home modifications necessary for their safety and accessibility (for example, wheelchair ramps, wider halls and doorways, and grab bars). Even if they have the resources necessary to pay for nursing and personal care, labor shortages may make such assistance impossible to obtain. Premature and inappropriate institutionalization is also an inadvertent and very costly outcome of the current system.

Sound public policy at all levels of government is essential to the development of solutions to these problems.

This Nation Needs a Policy for the Elderly

The Commission believes that a comprehensive national policy for affordable senior housing, coordinated with health and supportive services, is urgently needed. A specific concern of the Commission is to ensure that the government - at all levels - promotes policies that allow for choice. Seniors who need affordable housing, want to remain in their home and community, need assistance in caring for themselves, lack the resources to keep their homes and maintain their independence, or desire to live in senior communities should be supported in these options by sound government policy. Remaining at home is a cost-efficient housing choice, thereby allowing the most needy an increased opportunity to access the limited supply of subsidized housing.

If there is inadequate housing, if what is available is not affordable, if health care or supportive services are too limited, seniors have little choice. If private and public resources are too few to provide for people who cannot provide for themselves, choice is an illusion. The Commission acknowledges that too many seniors find themselves at risk of being ignored, forgotten, or inappropriately housed in an institutional setting.

"If we fail to meet these challenges," Chairman, AARP Board of Directors, Keith Campbell testified to the Commission, "the likely result will be a crisis in both affordability and availability in housing, creating the possibility that we will see an America with a significant increase in underhoused, underserved older citizens. And a result of this could be a substantial increase in costly and premature institutionalization of older people."

Individual Americans are compassionate and care about the lives and welfare of seniors. National policy should be grounded on that caring and compassion, but, for this to be so, change must occur on many levels. Policies for seniors need to be coordinated and integrated, from the top levels of government to the service delivery level. Demand for existing facilities already outstrips supply, and the current pace of construction of new facilities will not meet future demand. Millions of seniors will face critical, yet bleak, choices unless the Nation acts soon.

The Commission offers the following Vision as a conceptual guide for a national policy in the 21st century, a guide that finds its origins in the many voices that we heard.

A Vision for America

The Seniors Commission traveled across America to listen to men and women of all generations talk about the housing, health, and supportive service needs of seniors. From coast to coast, we visited with seniors and learned about their lives. We also heard from leading researchers, housing, health, and service providers, and government officials at all levels and from all points along the political spectrum.

The picture of seniors in America that emerges is both inspiring and alarming. As individuals and as a Commission, we commend the vigor, imagination, and creativity that Americans are bringing to solve the problems of affordable housing and health care for the Nation's seniors.

We found, as we stated in the preceding section on problems, that current efforts are falling short of developing what will soon be needed - indeed, they fall short of providing what is needed today.

Based on what we saw and heard the Commission developed this Vision for America.

Ours is a land in which seniors should enjoy an array of opportunities for affordable housing, health care, and supportive services. By mobilizing its private and public sectors in a spirit of community, and drawing on its vast resources, the Nation has the capacity to enable seniors, regardless of economic status, to maximize their independence, promote their health and safety, and preserve their dignity.

Seniors should have access to quality care within a coordinated and comprehensive system that delivers healthy, affordable, and ethical long-term care. They should not have to impoverish themselves to be eligible for Medicaid.

Seniors want and should have the opportunity to exercise informed choices about their care and their caregivers, and to grow older in their home, community, or other setting they select. Seniors should not have to face fear, uncertainty, or loneliness because of their limitations of income, illness, or disability. Nursing facilities should be places that care for the very ill and not the only alternative for people who cannot afford to live elsewhere.

Special attention should be paid to those most vulnerable in society - the seniors who are poor, who live alone, who have lost their financial independence and perhaps even their homes, who may have debilitating health conditions, and who may have lost their very spirit. An adequate supply of community-based affordable housing and quality services can enable seniors to look forward to a safe, secure, and dignified old age.

Today's exceptions of excellence should become the norm, and flexible programs should be tailored to the needs of individuals. Greater Federal, State and local resources should be committed to affordable housing and quality care with a focus on wellness, not illness. Government at all levels should coordinate and consolidate funding and programs. A new flexibility in administration should be balanced by accountability to the taxpayers. Application and reporting requirements should be simplified and unified.

The private and public sectors should work together to ensure appropriate care and services for seniors. Private business, faith-based and other non-profit organizations, government, and private foundations should form powerful and goal-driven collaborations and enter into creative partnerships for the effective and efficient use of private and public resources.

Communities should develop a better understanding and appreciation for the seniors who live within them. State and municipal government should rewrite use and building regulations to encourage facilities and amenities for seniors resulting in, for example, walkable neighborhoods and town centers, expanded transit services, retrofitted homes, and essential services for seniors who live alone. In response, bold and exciting new design concepts for homes and other environments, focused on the special daily living needs of seniors, would emerge.

Americans have the foresight to support the initiatives and programs to implement this Vision. America has the means to achieve this Vision. We see an America that dedicates time, energy, and resources sufficient to address the housing and service needs of seniors in the 21^st century.

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