Field Hearing

Syracuse, New York July 30, 2001


Testimony
By Arthur Y. Webb
President & Chief Executive Officer
Village Care of New York Manhattan

To begin with, I would like to express my appreciation to the Commission for moving so quickly to get this effort off the ground. The issues that are before you are not only extremely challenging, but they are likely as important a national public policy issue as we will confront in the first quarter of the 21st Century.

I would also like to thank former Representative Rick Lazio for his efforts both for having the foresight to recognize the need for a special undertaking of this congressional stature, and for having the determination to make creation of this Commission a reality.

Satchel Paige was wrong, you know.

Paige, one of the greatest baseball players of all time and an off-the-field sage who spun aphorisms that hit the mark as often as his legendary fastball, once said:

Age is a question of mind over matter. If you don't mind, it don't matter.

The truth is quite the opposite: As we age, most of us are going to become frail and are going to endure cognitive losses along with physical deterioration, if not outright physical failings. No matter how steeled we are in our own heads to face this prospect, we can't overcome these facts through simple strength of will.

And we should mind. And it does matter.

We should mind, because we - as a society, as providers, as professionals and, simply, as people - know that it is within our grasp to help our frail seniors continue to live in ways that are productive, independent and cheerful.

And it matters because two years ago this month, the United States Supreme Court, in Olmstead v. L.C., upheld the "integration mandate" of Title II of the Americans with Disabilities Act, potentially protecting and entitling a significant portion of America's elderly.

Those are the issues confronting us - and particularly this Commission - today as we contemplate the current and future needs of seniors in terms of "affordable" housing and their health care needs. There is so much in front of you - problems, concerns, issues and needs - that I am certain your own strength of will is going to be challenged in the shaping and development of a national agenda.

Part of why I am here today is to argue that we need to find ways that will offer our older adults housing opportunities that give support, care and assistance, independence and choice. That's quite a bit to accomplish in the coming years, particularly when it requires bringing together two fields -- health care and housing -- which heretofore haven't shown that they fit together particularly well. Complicating this is that both fields are in the throes of turmoil.

But that gets a bit ahead of things.

One of the tasks the Commission faces is finding an answer to this question: What do we know and what does it mean?

This covers a wealth of information that is out there, much of it statistical, about the increasing numbers of older adults, about their current and projected health care needs and about their living situations. That will be a lot to sort out and make sense of. The Census Bureau last month, for example, noted that in 1999, 9.7 percent of persons 65 and older, had incomes below the poverty level. We can probably safely assume that for this population, the term "affordable" when applied to housing is much more meaningful than to some other groups of older adults.

The Census Bureau tells us, too, in another example, that the population category of those 85 and older is one of the fastest growing, expected to be 9 million by 2020, three times what it was in 1990; by 2050 the number will jump to 18 million. For sake of argument, let's read a couple of things into this besides the sheer weight of demographics: First, the marvels of modern medicine and health practice are allowing us to live longer and in better health than ever before, with this group representing the vanguard of those benefiting from these technological advances; and secondly, many, perhaps the vast majority of those in this age group, might not find the "institutionalization" of the nursing home model either necessary or, if they were to think about it, in keeping with the community integration precepts of the ADA and Olmstead.

Another of the significant issues facing us regarding seniors and their housing and health needs is that there is an abundance of reasons why seniors need services and why they need housing...just as there is a broad range of levels of service and type of housing they need.

There are seniors living in housing that does not meet their needs, but they cannot afford other places that do.

There are seniors living in housing that is simply deficient.

There are seniors living with caregivers who are burnt out and daily becoming less able to provide what is necessary.

There are seniors living in nursing homes who don't need to be there, but for whom there is no other choice because affordable alternatives do not exist.

However we go about resolving the problem in front of us, it is clear that no common, single approach will work and that we will need to be flexible and respond to a wide variety of concerns. Further complicating this is that housing alone is not the answer. Whatever our housing solution is, it involves a close working relationship with health care, and that will lead us to walk into the quagmire of the categorical, narrow and sometimes contrived processes of the health care field, especially those of Medicare and Medicaid financing.

Already, circumstances themselves have created two divergent situations. It is the classic "tale of two cities," once again, where one is populated with those seniors who have accumulated sufficient wealth and resources to afford whatever it is they need, and the other a place of the poor and moderate-income older adults who struggle to maintain their dignity and independence, often losing in the face of a dearth of affordable alternatives.

Let's briefly examine the current situation:

• Nursing homes are being pulled in two directions at once, being required to provide the highest level of skilled care imaginable for those with extraordinary debilitation, and at the same time becoming the repository for chronically ill persons who don't need nursing home care, but for whom there are no alternatives.

• There is no rational public/private financing method to encourage the development of affordable housing with supportive services for seniors of low and moderate incomes.

• Individuals who might otherwise be able to stay in their own homes often lack the resources to pay for the help they need and they are not eligible for governmental assistance.

• Many seniors living alone in substandard housing are beneath the radar screens of social service agencies and governmental help.

In Manhattan, where Village Care of New York provides the bulk of its services for older adults, we have for some time been trying to confront these problems with something we call the "Urban Village." We are not alone, of course, for every continuing care provider in its own way is taking on these issues at the grass roots level - undertakings that are the fruit of having an understanding born of being close to one's community, and are at the same time a labor of necessity born of the absence of any coherent broad policy initiatives by government.

Since the mid-1970s, Village Care's primary way of caring for seniors' needs has been Village Nursing Home, a 200-bed skilled nursing facility on Manhattan's West Side.

A decade ago, we began to recognize that we were taking into the nursing home individuals whose level of care needs might better be served in other settings, or with other services. Clearly, as we talked to those in our care, and to their families, we learned that they had turned to the nursing home because there were no alternatives available to them. It was in that process that we envisioned our Urban Village, where we would create an array of residential and community services that seek to provide the most appropriate service in settings that offer choice, safety and independence.

The vision of our Urban Village has led us to create a sub-acute care program, a short-term rehabilitation unit, adult day health care centers and most recently, The Village at 46th & Ten.

Our experience with that last effort, one that could be the subject of an entire presentation itself, is worth the Commission's note.

In Village Nursing Home's "catchment area" we have places where older adults are living in housing that either isn't meeting their needs today, or will soon not meet their needs. The places where we find these seniors may be Naturally Occurring Retirement Communities, or they may be individual residences sprinkled throughout our area of Manhattan. While NORCs may harbor a concentration of aging adults, they by no means are all-inclusive.

As people have aged in place, so has their housing. Many of the people we are discussing here are those with moderate and low incomes. If the health slips a bit, their first line of defense is their informal network of families and friends. But even the formal network is a loose one, often consisting of little more than meals on wheels. Ultimately, a number of the people we are talking about will become prisoners in their own apartments, homebound, and finally they will end up in a nursing home because it is quite simply the only place that will have them when they can no longer make it on their own.

At Village Care, we spend considerable time talking with our community, both informally and formally, including sponsoring a series of focus groups and conducting ongoing research, and the issue of housing keeps coming up. The issue is always expressed regarding the need for housing that offers help with areas such as personal care, meals and housekeeping. and which does so in a way that middle-income folks can afford and to which low-income individuals can apply entitlements.

As we set out to see what we could do to meet this pent-up community need, we were quickly struck, much to our dismay, by two things: One, there was no model whatsoever to guide us in such a development, and, two, there wasn't even a hint of a way to finance such an undertaking.

Just another symptom of the "senior problem" for which there is no policy direction or initiative.

We were left to our own devices to develop a model itself, to get government at the state and local levels to understand what we were trying to do and to work with us, to arrange for private financing, to seek tax exemptions and, even, to define what "middle income" means. Since we were breaking new ground - literally nothing such as this had been attempted before - we had to spend time to determine the nature of the services we would provide, what level of assistance we would offer and at what cost, and to come up with a way to set rent levels and to market this development.

It took a year and a half to develop a model and to arrange financing, including setting aside a considerable piece of Village Care's own limited resources.

Two weeks from today, the first resident will move into one of 84 apartments in the Village at 46th & Ten, which will provide apartments with support services. Of the 100 residents, 19 will be persons with low incomes who will be a part of New York State's Enriched Housing Program.

The fact that we have succeeded so far is a testament more to our determination to do so, because what this example ought to expose to the Commission is the woeful inadequacy of programs and guidance. This example of our experience with housing can offer you some insight. There are some specific tasks that the Commission could consider to promote a harmonious blending of the housing and health fields. These include:

• Creation of affordable models, with one possibility that of using existing federal programs, including those that are HUD-financed and Medicaid-financed and offering a waiver process. There are many issues, however, that crossover between HUD and HHS and those two entities need to share and invest in a shared vision of what needs to be accomplished as we move through the conceptual and practical stages. Ultimately, a single authority addressing the housing and health needs of aging adults may prove to be the most efficient route, sidestepping the dichotomous housing and health bureaucracies.

• Consideration of what we might do were we unfettered by current convention and current financing schemes: We could, for example, create a grant program that would provide incentives for providers to explore and devise innovative solutions. Perhaps we could examine the feasibility of a voucher program for consumers, empowering them to make choices consistent with their need from a menu of services whose development we have fostered.

• Development of an understanding of the types and levels of services that are needed to provide support.

• Giving guidance for common eligibility rules for services and income levels, along with regulatory oversight.

• Consideration of allowing tax-exempt status to senior housing undertakings and expansion of the housing tax-credit program to encourage development of senior housing.

• Promotion of consumer protection. Those are the very practical outcomes that this Commission could pursue from its work. Just setting your sights on these and achieving them - not an easy task by any means - would enable you to pronounce yourselves successful.

But let's go on for a moment about policy, and about Olmstead.

If we embrace Olmstead we arrive at the obvious conclusion that the nursing home model has to change, and that the nursing home is not the place for most of those who are currently there. Indeed, if we take Olmstead to heart we find ourselves not trying to fit what we have into the confines of the court's ruling, but instead looking to create anew that which meets the ADA's demand that we "administer services, programs and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities."

Many roadblocks exist between here and there, however. These include:

• The long-term care field is fragmented and in turmoil over confronting the need to change and preserving its investments.

• Again, national and state policies that specifically address the direction of long-term care, irrespective of Olmstead, have long been lacking. Perhaps the clearest enunciation to date in recognition of this void came just last month in an executive order from President Bush on community-based alternatives for individuals with disabilities. The President said that community-based alternatives "advance the best interest of Americans," and stated that the federal government must assist the states to implement Olmstead.

• Confusion about the definition of models that do exist: assisted living, continuing care retirement communities, lifecare communities, supportive housing, adult care facilities.

• Over-regulation in some areas, no regulation in others.

At this stage, we are still debating how to bring health and housing together, with some, like the Institute of Medicine, arguing for a chronic care model, where community residential care would be geared toward those with ongoing needs. Others, such as the National Institute on Aging, are looking toward a wellness model, in which housing would be geared more to independent living with supportive services.

We have some time, but not much.

We have a small window of opportunity in which to mobilize consumers, providers and government to address the health and housing needs of seniors.

The beginnings of the senior population crunch is still a decade away, and if current trends continue, it looks as if older adults may not need as much in the way of services as was once thought.

The Commission can help in the mobilization that is needed.

We should resist any temptation to let the marketplace alone choose by default our policy direction, because the market is not fair and equitable. The current situation regarding housing that offers care and services of a supportive nature demonstrates clearly that allowing only the market to drive decisions results in a situation where those who have can get, and those who have not get little or nothing. Today's market is a case of extremes, with the well-to-do having a variety of options, and others having perhaps at best adult care facilities, which are sad options when you compare them with what is at the disposal of the "haves."

This is not a problem that will be solved simply by government, but with a combination of private and public funds and with multiple approaches by non-profits and for-profits.

With Olmstead in mind, the Commission should work to promote a national policy for our frail seniors and those with chronic illness and disabilities - those who can no longer live on their own without some assistance or support.

• This policy should address Olmstead's precept of integration and it should:

• Embrace community-based care and services.

• Promote the greatest level of independence attainable.

• Offer the opportunity for aging in place.

• Encourage local systems of care that connect services addressing varying levels of need.

• Incorporate "person-centered" care.

• Promote wellness.

• Empower consumers.

• Allow flexibility in adapting existing financing plans to new, innovative concepts, and support creative use of existing federal programs.

If that is not a tall enough order, consider that such a policy will be driven by externals over which the Commission has no control: Workforce shortages, economic downturn, federal spending limitations and the decisions made in individual state budgets.

The Commission must truly understand the landmark implications of Olmstead and use them as a call to arms - use them to drive needed changes by articulating clear and realistic expectations and defining needed administrative change.

It isn't necessary for the Commission to resolve the many social issues and implications that underlie resolution of health care and housing for seniors in the 21st Century, a task for which the Commission probably has neither the wherewithal nor the inclination.

But what it can do is give us the framework to begin to get a grasp on the looming problem of providing adequate, community-based housing for older adults with chronic illnesses and frailties.

You can help define government's role, you can foster the dialog among the many sectors involved in this problem, particularly at the federal and state levels, and you can create a focus on the needs of our seniors.

You can help us break down the reliance on institutional settings as the place for our seniors with frailties and disabilities and help us look at alternative concepts of supportive living arrangements, smaller-scale congregate living and community-based housing.

What you can do is recognize that for all the problems before us, this is an opportunity...an opportunity to address the housing and health-care needs of seniors in a way that is respectful of their desires and needs and which assures that they will continue to live as independently as possible.

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