POPE FRANCIS

AGING AND LONG-TERM CARE

Happily Ever After

SR. JULIA UPTON, RSM, PhD, MPH

Years ago, a friend and I went to see the Broadway production of Stephen Sondheim’s musical Into the Woods. The first act ends with all the fairy-tale characters’ complicated situations resolved in a “happily ever after” style.

“It’s over?” my friend asked, surprised that the show was ending so soon.

“No,” I replied. “This is intermission.”

“But what could come next?” he further probed.

“Not so happily ever after!” I answered, to which he just groaned.

No one’s life journey is as smooth or simple as those fairy tales led us to believe. Throughout life’s ups and downs, twists and turns, we need support and encouragement to maintain health— physical, emotional and spiritual—particularly in our later years. Rather than “happily ever after,” we seek a more realistic and achievable goal: to live the best life possible all our days.

What does the “best life possible” look like? Most people, when asked, value health above all else. The World Health Organization Constitution (1946) defines health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” As a theologian, I would add spiritual well-being to that list. As people are living longer, often needing to move to long-term care residences, maintaining well-being can be challenging. Too often residences are designed to serve staff needs rather than residents’ needs. Resident-centered or, even better, resident-directed residences are more lifegiving for all. Residents report being happier and healthier with fewer hospitalizations and staff report a stronger sense of purpose.1

Public health has begun to focus more on well-being rather than the absence of disease or chronic conditions. There are several iterations of the “domains of well-being,” but the one developed in 2005 by The Eden Alternative, a nonprofit organization dedicated to improving the lives of elders and their care partners in all living environments, is comprehensive.2 Rather than relying just on the more traditional measure of “quality of life” or “quality of care,” which come from the biomedical model, the “domains of well-being” address the individual person as a whole. They include:

Identity — being me, well-known, having personhood, individuality.

Connectedness — being with, belonging, engaged, involved.

Security — finding balance, freedom from doubt, anxiety or fear.

Autonomy — seeking freedom, liberty, selfdetermination, self-governance.

Meaning — making a difference, significance, hope, purpose.

Growth — growing and developing, enriching, unfolding.

Joy — having fun, expressing happiness, pleasure, delight.

It is not difficult to envision how these pandemic times are having an impact on the wellbeing of us all, but it is possible to address each of the domains in spite of one’s physical health or living situation.

Much of society’s understanding of human psychosocial development is based on the work of Erik Erikson (1902-1994). In a series of essays published in the 1940s he began to work out what

we now know as the stages of psychosocial devel- ological and therefore they might misunderstand. opment.3 Erikson’s theory described the impact of Such implicit bias might result in discouraging the social experience across the whole lifespan, build- very aspects that indicate well-being among the ing one upon the other. Each stage was marked very old. by successfully resolving a conflict in a way that Whenever I have presented the concept of struck a balance between two poles. The last gerotranscendence to older adults, I see lots of stage in Erikson’s original construct, occurring head-nodding, and later conversations reveal that during “old age” (age 65 to death) is resolving the participants were actually relieved to have their conflict between Integrity and Despair. Erikson experiences validated. If staff and family memheld that when death is approaching, everyone, bers were aware that the characteristics of gerowhether consciously or unconsciously, enters a transcendence were not only normal, but actually life review process, balancing life’s successes and desired, they might alter their expectations and disappointments to arrive at a resolution, seeing life ultimately as mean- Make room in the conversation for ingful or meaningless or somewhere in between.4 thoughts about death. If an older Since 1950 when Erikson began publishing, life expectancy in the person leads the conversation in that United States has increased 17.7 direction, it is likely an important years.5 That would give a person almost an extra 20 years to resolve issue for them. the identity crisis. The Swedish social gerontologist Lars Tornstam pioneered another personalize their care. This could increase everyapproach to the last stage of life with his doctoral one’s sense of well-being. thesis on aging at Uppsala University in 1973. He One way to provide support for older adults theorized a more open-ended approach to the last would be to ask questions regarding their expestage of life which he named gerotranscendence. rience. For example, one could say to an elder, It was not Tornstam’s intention to nullify the work “Some people say that they their concept of time of other theorists, but he believed that some ele- has changed. The past is so strongly present that ments of their theories were not applicable to the they almost live in it at the same time as they live very old.6 in the present. Have you experienced something

Gerotranscendence provides a paradigm for similar?” While that might elicit a simple “No!” understanding the developmental process of it might also open up an important conversation aging, which is evident on three levels: the cosmic about the past, maybe how childhood memories level, the level of self, and the level of social and are more vivid than ever before. When I would personal relations.7 Tornstam’s construct notes visit my elderly aunt in her residence, I would take the following characteristics about the very old. along the family genealogy. Although my aunt was

There is an increased affinity with past gen- blind by that point, she helped me fill in the blanks erations and a decreased interest in superfluous on our family tree while relating wonderful famsocial interaction. ily stories I had never heard before. Well-tailored

There is also often a feeling of cosmic aware- questions can open up the cosmic dimension ness of being in both the past and present simul- while acknowledging and appreciating increased taneously, and a redefinition of time, space, life interest in the past. and death. Too often we rely on “How are you feeling?”

The individual becomes less self-occupied as the opening question with someone. Intended and at the same time more selective in the choice or not, that question immediately focuses on the of social and other activities. elder’s physical self, which leads too easily to dis-

The individual might also experience a cussion of decline and limitations. Choose some decreased interest in material things. other topic instead. Consider a conversation

Solitude becomes more attractive. beginning like this, “Some people say that as they

To younger people or even to medical person- age they discover sides of themselves they hadn’t nel these characteristics might be viewed as path- known before. Have you made any discoveries

AGING AND LONG-TERM CARE

like that?” Although that also might lead nowhere, revise their work, adding to their understandit could also open up an unexpected conversa- ing of the life cycle. The Life Cycle Completed – tion on self-discovery. Where there is life there is Extended Version (1998) includes final chapters growth and change on many levels. written by Joan Erikson, revising their schema to

Make room in the conversation for thoughts include a ninth stage whose focus is on transcenabout death. If an older person leads the conver- dence. She finds fault when gerontologists use the sation in that direction, it is likely an important term “gerotranscendence” without fully explorissue for them. Too often such conversations are ing the new and positive spiritual gifts it brings. aborted because the family or caregiver is uncom- “Perhaps they are just too young,” she suggests. fortable with the topic. As family and staff, it is “With great satisfaction I have found that `tranessential to listen to the elders and acknowledge scendence’ becomes very much alive if it is actitheir feelings. Fear of death generally decreases vated into ‘transcendance,’ which speaks to soul with age and questions about life after death and body and challenges it to rise above the dysemerge. Once I was invited to give a sermon at tonic, clinging aspects of our worldly existence evening prayer in an upscale continuous care resi- that burden and distract us from true growth and dence. In it I suggested residents might approach aspiration.”8 life’s next great adventure the way they had prepared for other travel adventures in their lives. While there Designing new types of activities is no Michelin guide to the afterlife, there is Scripture, the work of spirisuch as reminiscence therapy or a tual writers, the stories of others and meditation course could foster the even the daily news that can lead one to anticipate crossing to the next older person’s personal growth. world as an adventure. The third level of gerotranscenEncouraging and facilitating quiet dence, in which an elder’s attitude and peaceful times and places would toward social and personal relationships begins to shift, is too often also go a long way to improving viewed negatively as “social disen- residents’ well-being.gagement.” The need for positive solitude is not automatically a manifestation of loneliness. Out of choice some elders opt The concluding lines of Mary Oliver’s poem out of activities that lack content, preferring the “When Death Comes” reflect the thoughts of company of a few like-minded people to a large most of the elders with whom I have worked in crowd playing bingo. They might even prefer recent years: their own company or that of a good book. Designing new types of activities such as reminiscence When it’s over, I don’t want to wonder therapy or a meditation course could foster the if I have made of my life something particular, and real. older person’s personal growth. Encouraging and I don’t want to find myself sighing and frightened facilitating quiet and peaceful times and places or full of argument. would also go a long way to improving residents’ I don’t want to end up simply having visited this world. well-being.

In 1982 Erikson and his wife Joan Erikson (1903- This is the fullest life possible that everyone in 1997) published The Life Cycle Completed, but as the healing professions should be helping to prohe grew deeper into the eighth stage of his own vide to everyone in their care. Eternal life is ours life, Erikson began to rethink the completeness of now, today. Living fully in that reality is the chaltheir work. Shortly before he died, Joan Erikson lenge of using the gifts that have been given. Some found her husband’s copy of The Life Cycle Com- day we will slip across the road and know eternal pleted and saw that no page was free from under- life in its fullness, but for now we listen to the Holy lining, highlighting or annotation. She began to Spirit who is ours in Baptism, knowing that we are wonder what they all meant. Soon she began to beloved and sharing that love with the world.

SR. JULIA UPTON, RSM, is provost emerita of St. John’s University in New York and Distinguished Professor of Theology and Religious Studies (retired).

NOTES

1. Michael Lepore et al., “Person-Directed Care Planning in Nursing Homes: A Scoping Review,” International Journal of Older People Nursing 13 (2018), https://doi. org/10.111/opn.12212. 2. G. Allen Power, Dementia Beyond Disease: Enhancing Well-Being (Baltimore: Health Professions Press, 2017) 23-37. This model was developed by 12 experts in transformational care called together by The Eden Alternative. 3. These essays formed the basis for Erik Erikson’s first book, Childhood and Society (New York: W. W. Norton, 1950). 4. Simon Hearn et al., “Between Integrity and Despair: Toward Construct Validation of Erikson’s Eighth Stage,” Journal of Adult Development 19 (2012) 1-20. 5. Jochen Klenk et al., “Changes in Life Expectancy 19502010: Contributions from Age- and Disease-specific Mortality in Selected Countries,” Population Health Metrics 14 (2016) 20. 6. Lars Tornstam, Gerotranscendence: A Developing Theory of Positive Aging (New York: Springer, 2005). 7. Lars Tornstam, “Gerotranscendence—A Theory about Maturing into Old Age,” Journal of Aging and Identity 1 (1996) 37-50. 8. Erik H. Erikson and Joan M. Erikson, The Life Cycle Completed - Extended Version (New York: W. W. Norton, 1998) 127.

QUESTIONS FOR DISCUSSION

Sr. Julia Upton, RSM, is a theologian and public health specialist. She takes a particular interest in older people in terms of a person’s spiritual depth and their right to move into their final years with the best opportunities for fulfillment. Her article “Happily Ever After” discusses what elements of happiness are unique to the elderly and what interactions, memories, honest questions and preferences for silence might lead to a more realistic and peaceful transition to the Ever After. 1. Upton argues that “quality of life” is too vague a term and puts forth seven domains of well-being identified by the Eden Alternative that can explore the well-being of elders in a more holistic way. Of the seven, security, autonomy and meaning seem the most obvious. How important do you think identity, connectedness, growth and joy are in older people? How does your organization attend to these domains in the elders you serve? 2. Conversation about death is difficult for most of us. Yet Upton explains it is sometimes the conversation that older people often want to have. How does your organization train caregivers and family members to become comfortable when patients/residents want to talk about death? During the pandemic, how can such conversations take place without adding to the anxiety the patient might have? 3. Upton uses the term “gerotranscendence” to describe how an older person might begin to separate from some of the things, people and interests of their life in order to give greater attention to things that really matter. Have you experienced this in people you love or patients you’ve felt close to? Is your ministry able to offer activities like reminiscence therapy or meditation courses to support people in this personal pursuit?

THREE PROMINENT ORGANIZATIONS, ONE INNOVATIVE GRADUATE OFFERING.

Catholic Clinical Ethics

Distinctive online master’s degree and graduate certificate for leaders of Catholic health institutions.

The innovative program is offered through a distinctive partnership with Georgetown University Medical Center, The Catholic University of America and the Catholic Health Association of the United States.

NOW MORE THAN EVER! Catholic Clinical Ethics will advance Catholic health care’s leadership in the nation’s health and well-being by preparing highly skilled professionals who can address complex changes in biotechnology, clinical treatments and health policy within the framework of human dignity and the Church’s moral teachings.

It is particularly timely in light of rapid technological breakthroughs and shifting social trends in today’s transformed health environment. DESIGNED FOR BUSY PROFESSIONALS The online certificate and master’s degree programs are ideally suited for… ! Executives in mission, ethics, health policy, social services and management ! Physicians, nurses, clinicians and medical professionals ! Members of Institutional Review

Boards or ethics committees

L E A R N M O R E T O DAY ! See how Catholic Clinical Ethics can help advance your career and professional development at clinicalethics.georgetown.edu or email

CatholicClinicalEthics@georgetown.edu

MASTER’S DEGREE & GRADUATE CERTIFICATE PROGRAMS OFFERED IN PARTNERSHIP WITH

Biomedical Graduate Education

AGING AND LONG-TERM CARE

Pandemic Is a Tragedy, And a Chance to Rethink Long-Term Care

HOWARD GLECKMAN

The COVID-19 pandemic has been a tragedy for hundreds of thousands of older adults in the U.S. and their families. It has amplified and exposed the nation’s already deeply flawed system of long-term supports and services (LTSS). Yet it also has created a historic opportunity to rethink our model for caring for frail older adults and younger people with disabilities.

The COVID-19 crisis did not spring from nowhere. Indeed, while many close observers of the nation’s long-term care system have been shocked at the amount of illness and death among older adults, they were not entirely surprised.

The pandemic focused attention on questions that often have been ignored by policy makers and even by providers. Does the nation’s longterm care system provide care in the setting that is most appropriate for each frail elder? Does it provide the right person-centered care? Does it effectively integrate supports and services with medical treatment? Are there enough direct care workers and are they properly trained? Has the nation dedicated sufficient resources to finance the care older adults deserve?

The answer to each of those questions is “no.” And COVID-19 has exposed the consequences. The way we care for older adults in the U.S. is, self-evidently, not working. The Kaiser Family Foundation estimates that as of Oct. 8, 2020, there were least 537,000 COVID-19 cases and 84,000 deaths in long-term care facilities.1 At least another 83,000 older adults living in the community have died from the disease, according to the Centers for Disease Control and Prevention.2

The indirect effects of COVID-19 are severe as well. Millions of older adults have been isolated from family and friends for months. While data are limited, families and operators of care facilities report that residents are prematurely dying from the effects of social isolation.3

How can we prevent this from happening again?

Start with where frail older adults live.

Today, 85% to 90% of those with long-term care needs — or about 12 million people — receive care at home. Many get this assistance with the support of family members and some have the help of paid aides.

But that care often is built on a flimsy foundation. Spouses and adult children often provide care with great love — and little skill. Few communities have programs to teach family caregivers the skills they need, for example, to safely transfer a frail spouse from a bed to a chair. Many family caregivers have no idea where to ask for help with transportation. Meal delivery services such as Meals on Wheels are underfunded and suffer from long waiting lists.4

Without that solid infrastructure, those aging at home are likely to suffer from social isolation or require emergency department visits or hospitalizations. For example, many older adults who visit

emergency departments are found to be suffering where (pre-COVID-19) frail older adults who are from malnutrition.5 highly vulnerable to infection often shared build-

Another 700,000 older adults with physical ings, dining rooms, day rooms, and even bedor cognitive limitations live in assisted living or rooms with people just discharged from hospitals, other residential care, and nearly all pay out-of- where infection is common. pocket. Under limited circumstances, Medicaid The pandemic also further exposed the gaps will pay for services, but not room and board, in in the direct care workforce. About 1,000 longthese settings. Thus, assisted living is available term care facility staff have died from COVID-19.11 for those with the financial resources — at a cost It appears that coronavirus often was brought in averaging $4,000 per month.6 And they often are by staff, who either were asymptomatic or who not set up to provide the high level of personal assistance that Today, the nursing home business model many older frail adults require.

Finally, about 700,000 peo- is in jeopardy. Many facilities were ple live out their days in nursing homes.7 Roughly 80% operating on narrow margins before of those long-stay residents COVID-19.13 Now they are under even receive Medicaid.8 While they may need a high level of per- more intense financial pressure from sonal assistance, few need skilled nursing care. Thus, the both declining revenues and rising costs. vast majority have no clinical reason to live in such a facility.9 They are there came to work despite symptoms. Many were largely because Medicaid creates powerful incen- poorly trained in infection control. Many may tives for them to do so, even if other settings are have spread the disease by working in multiple more appropriate. This arises from four interre- settings. Direct care workers often work two or lated circumstances. more jobs to make up for low wages.

Medicaid pays for room and board in nursing Yet, the risks of viral infections in long-term homes, but nowhere else — a strong incentive for care facilities were well-known before the panrecipients to choose a nursing home over settings demic. Every year, nursing homes suffer outwhere they would have to pay their own rent. This breaks of seasonal flu or the intestinal norovirus.12 model also means operators overvalue real estate Today, the nursing home business model is in relative to the services they provide. jeopardy. Many facilities were operating on nar-

Medicaid eligibility varies by state, but row margins before COVID-19.13 Now they are financial requirements often are less rigorous for under even more intense financial pressure from a nursing home resident than for someone receiv- both declining revenues and rising costs. ing care in the community. On the revenue side, the pandemic accelerated

Nearly all states finance their share of Med- the shift of lucrative post-acute care to home or icaid in part by imposing provider taxes on nurs- other less costly congregant settings. This change ing homes. Those taxes generally are based on has been driven in part by changing consumer patient revenue. Thus, states have an incentive to preferences. But it also comes from the managed steer Medicaid beneficiaries to nursing facilities care plans that now insure one-third of Medicare because they generate significant revenues. beneficiaries and are looking to place members

Medicaid home and community-based ser- in less costly post-acute care settings. And those vices (HCBS) are available in each state, but often that still send members to nursing facilities pay are severely underfunded. That means long wait- an average of about 20% less than traditional ing lists or benefits that are insufficient to provide Medicare. quality care for those living at home.10 At the same time, state Medicaid budgets are

But because Medicaid payments are so low, under severe pressure because of COVID-19, and nursing homes have built up a second business — nursing home reimbursement rates are likely to post-acute care — that is funded much more gen- remain frozen or even decline. Facilities may also erously by Medicare. The result: A model of care lose revenue if, for post-COVID-19 regulatory or

AGING AND LONG-TERM CARE

market reasons, they will have to eliminate semi- tance. They currently must navigate two enorprivate and even quad rooms. mously complex and disconnected systems.

At the same time, facilities are seeing signifi- For example, physician offices rarely inform cant cost increases, including for personal pro- patients about sources of personal care. Hospitective equipment and coronavirus testing. Even tal discharge planners have neither the time nor before the pandemic, labor rates were rising due the knowledge to prepare a patient or her family to a growing shortage of aides, nurses and other for her care needs when she returns home. This is staff. COVID-19 has driven compensation even another reason why many families default to posthigher, at least temporarily. acute care in a nursing home.

Facilities face significant capital costs as well. In this enormously challenging environment, Many are more than 40 years old and need to be what could a new model look like? remodeled. And the effects of the pandemic may Frail older adults and younger people with disrequire significant redesign to reduce the spread abilities, with support from family and a case manof infectious disease among residents and staff. ager, would choose the care setting and supports

Not everyone with cognitive and physical limi- that would help them live the best life possible. It tations can stay in their own home, especially if could be a group home, traditional assisted living, they have no family members to care for and advo- a nursing home or their own home. But the decicate for them. But they could live in less costly, sion would be based on what is most clinically and less medical settings than a nursing home. socially appropriate, not on the constraints of an

For many older adults, small group homes and outmoded payment system. similar alternatives could be more appropriate. The vast majority of those receiving longBut they are inaccessible for many families who term care at home are getting their support from cannot afford to pay out-of-pocket. And state laws unskilled relatives. Health systems, insurance that limit the services aides can provide make companies or government could make caregiver creative staffing difficult. For example, in many training a benefit. Perhaps family caregivers jurisdictions, nursing assistants cannot adminis- could even be paid. ter routine over-the-counter medications unless Direct care workers need to be paid more they are directly supervised by a nurse. and should receive benefits such as sick leave.

The flaws of the current payment system affect more than care Direct care workers need to be settings. They also create perverse incentives for care delivery by build- paid more and should receive ing a financial and regulatory wall between medical treatment and benefits such as sick leave. Whether personal assistance for those with they are working in facilities or in chronic illness. Medicare pays for health care but generally not long- people’s homes, they are paid less term care. For those eligible, Medicaid pays for long-term care but not than a living wage for what, even health care. before COVID-19, was an extremely

This creates two problems. First, this model discourages dangerous job. states from enhancing their Medicaid long-term supports and services. To the Whether they are working in facilities or in peodegree that better LTSS could reduce emergency ple’s homes, they are paid less than a living wage department visits and hospital stays, it could save for what, even before COVID-19, was an extremely significant money. But today those cost savings dangerous job.14 Long-term care providers will flow to the federal Medicare program, not to the create a quality workforce only by paying comstates that expand their LTSS programs. petitive wages and benefits.

Most important, this bifurcated payment Those with chronic disease and physical or model acts as an impediment to families who need cognitive limitations should have services wellfully integrated health care and personal assis- coordinated and tailored to their individual needs,

not driven by an outdated and dysfunctional pay- of housing with services, where low-income resiment system. dents of subsidized housing could receive some

Long-term supports and services would be basic supports as well as routine nursing care. well integrated with medical treatment, with no Medicaid also needs to be flexible enough to regulatory or payment barriers, and through a provide non-traditional services. For example, the financial model that creates incentives for strong CAPABLE program, designed at Johns Hopkins chronic care management. This could be deliv- University School of Nursing, combines social ered through managed care plans, such as Medi- supports, physical therapy and modest home care Advantage (MA) or fully integrated models repairs, all aimed at helping older adults remain such as the Program for All-Inclusive Care for at home. The program lowers costs and improves the Elderly (PACE). They also could be provided participants’ quality of life.15 through expanded special needs plans (SNPs), State and local governments provide many of which are MA plans targeted to members with these services today, but in a disconnected way. specific needs. For example, Institutional SNPs Like specialist physicians, each program cares serve those who live in the community but who would need insti- But in some way, the U.S. needs to tutional care without the additional services offered by the plan, such as put more money into long-term care coordination, or nutrition or transportation. supports and services. Our system

Delivering fully integrated care never will provide adequate care for through traditional fee-for-service Medicare would be more challeng- frail older adults and younger people ing but still possible. The many value-based models now being with disabilities so long as it remains tested could create incentives for severely underfunded. primary care practices to partner with, for example, community-based organiza- for just part of a person, not her whole life. The tions to deliver fully integrated medical and social agencies that deliver these programs need to care. It might also be possible in traditional Medi- work with one another to provide flexible, holiscare through Medicare Supplement (Medigap) tic care. California is one state working to design insurance. such a model.

A public program such as Medicaid would While Medicaid would continue to assist those continue to support long-term care for those with with low incomes, everyone else would pay for very low incomes. But Medicaid would be far their long-term services and supports through a more flexible than today, and the default setting mix of private savings (including home equity) for care would be people’s own homes, not nurs- and self-funded, universal public insurance. It ing facilities. Medicaid HCBS programs would be could be operated through Medicare or as a sepamore generously funded, and long waiting lists rate government program. could be eliminated. But in some way, the U.S. needs to put more

States should better align Medicaid LTSS with money into long-term supports and services. Our other public services, such as low-income hous- system never will provide adequate care for frail ing, transportation, home delivered meals, adult older adults and younger people with disabilities day services and primary medical care. For exam- so long as it remains severely underfunded. ple, the asymmetry of using Medicaid funds to Where will the additional funding for all this pay for room and board in a nursing home and come from? The reality is that few Americans have nowhere else could be addressed by shifting all saved sufficiently for the cost of long-term care government housing support to a separate pro- in old age, few have private long-term care insurgram. This could free up Medicaid dollars to pay ance, and Medicaid does not have the resources to for services and supports. support this care for the fast-growing Baby Boom

Similarly, Medicaid and state housing pro- generation. grams could work together to build out a model A public long-term care insurance pro-

AGING AND LONG-TERM CARE

gram could supplement out-of-pocket spending, especially for those with true catastrophic costs that few private long-term care insurance policies cover. A cash benefit (with care management) would let older adults decide where to live and give them the flexibility to purchase the services they need. Such a program could supplement managed LTSS benefits delivered through a health plan.

Washington state already has adopted a modest public long-term care insurance plan. A halfdozen other states, including California, Minnesota and Illinois, are exploring similar ideas. And there is some interest in Congress.

Such a program would not only benefit older adults, but it also could save substantial Medicaid dollars. Over the long run, the Urban Institute estimated a mandatory public catastrophic LTC benefit could reduce Medicaid LTSS spending by as much as one-third.16

Long-term care in the U.S. was failing long before COVID-19. But now that this terrible disease has exposed its flaws, we have an opportunity to fix them. We may not get to an ideal model, but many intermediate solutions already are on the table. With the political will, we can vastly improve a failed system that is needlessly killing our seniors before their time.

HOWARD GLECKMAN is a senior fellow at The Urban Institute in Washington, D.C., and author of the book Caring For Our Parents.

NOTES

1. Kaiser Family Foundation, “State Data and Policy Actions to Address Coronavirus,” Issue Brief, https// www.kff.org/health-costs/issue-brief/state-data-andpolicy-actions-to-address-coronavirus/. The statistics on this site change because they are updated frequently. 2. Centers for Disease Control and Prevention, “Weekly Updates by Select Demographic and Geographic Characteristics,” https://www.cdc.gov/nchs/nvss/vsrr/covid_ weekly/index.htm. 3. Suzy Kim, “The Hidden Covid-19 Health Crisis: Elderly People are Dying from Isolation,” NBC News, Oct. 27, 2020, https://www.nbcnews.com/news/us-news/ hidden-covid-19-health-crisis-elderly-people-are-dyingisolation-n1244853. 4. Marie C. Gualtieri et al., “Home Delivered Meals to Older Adults: A Critical Review of the Literature,” https://pubmed.ncbi.nlm/nih.gov/29722706/. 5. Collin E. Burks et al., “Risk Factors for Malnutrition among Older Adults in the Emergency Department: A Multicenter Study.” Journal of the American Geriatrics Society 65, no. 8 (August 2017): 1741–47. https://doi. org/10.1111/jgs.14862. 6. Genworth Financial, Annual Cost of Care Study: https://www.genworth.com/aging-and-you/finances/ cost-of-care.html. 7. U.S. Department of Health and Human Services, National Center for Health Statistics, Long-term Care Providers and Services Users in the United States, 2015–2016, published 2019. 8. ATI Advisory, Senior Housing Data Book, https:// atiadvisory.com/2020-seniors-housing-data-book/. 9. Charlene Harrington et al., “Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016,” Kaiser Family Foundation, 2018. 10. From the AARP’s “Long-Term Services and Supports State Scorecard 2020 Edition,” http://www. longtermscorecard.org/~/media/Microsite/Files/2020/ LTSS%202020%20Short%20Report%20PDF%20923. pdf. 11. Kaiser Family Foundation, “State Data and Policy Actions.” 12. Louise E. Lansbury, Caroline S. Brown, Jonathan S. Nguyen-Van-Tam, “Influenza in Long-Term Care Facilities,” Influenza and Other Respiratory Viruses 11, no.5 (Sept. 2017), 356-66, https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC5596516. 13. Medicare Payment Advisory Commission, A Data Book: Health Care Spending and the Medicare Program. Washington, DC., Medicare Payment Advisory Commission, 2020. http://www.medpac.gov/docs/defaultsource/reports/mar17_medpac_ch8.pdf2017 14. PHI International website, “Direct Care Workers in the United States: Key Facts,” https://phinational.org/ esource/direct-care-workers-in-the-united-stateskey-facts/. 15. Sarah Szanton et al., “Home-Based Care Program Reduces Disability and Promotes Aging In Place,” Health Affairs 35, no. 9 (September 2016): 1558–63, https: //doi.org/10.1377/hlthaff.2016.0140. 16. Melissa M. Favreault, Howard Gleckman and Richard W. Johnson, “How Much Could Financing Reforms for Long-Term Services and Supports Reduce Medicaid Costs?” Urban Institute, February 2016, https://www.urban.org/sites/default/files/ publication/77476/2000603-How-Much-CouldFinancing-Reforms-for-Long-Term-Services-andSupports-Reduce-Medicaid-Costs.pdf.