A silver wave? California braces for elderly boom that could overburden state

June 14, 2019

Virginia Kidd has rented her apartment in midtown Sacramento for 12 years. The retired Sacramento State professor lives there with her cats and enjoys helping out at the local library.

At 78, she said she has been lucky to age with minimal health issues so far, but she sometimes worries about what she would do if she were to need care.

She thinks about it when she climbs up and down the two sets of stairs in her apartment, which she worries she may not be able to afford if rents rise. “It’s a little harrowing, and I regret not owning,” she said.

Kidd still drives, but she often walks to places around midtown. That would change if she had to move, and as people age, driving isn’t always an option.

“I had cataract surgery a few years ago, but I get my mail over in the post office on J Street,” Kidd said. “But when you can’t drive, I couldn’t get to it.”

The surgery put Kidd out of commission for only a few days, but it happened to be at the end of the month when she needed to pay her bills, so she had to figure out another way to get the mail.

Figuring out ways to get around without a car, affording housing in a city where rents are rising rapidly, living on a fixed income and finding affordable healthcare are about to be major problems for a large group of people in California.

The Golden State is about to get a lot older.

By 2030, the 60-and-over population will be 40 percent larger than it is now, according to the California Department of Aging. Seniors will be a larger share of the population than kids under the age of 18 by 2036, the state projects.

The number of Californians 80 and older will grow by about 65 percent, or about 960,000, in the next 10 years, a growth rate more than 10 times faster than the projected rate for the rest of the state, according to the Department of Finance. There will be twice as many Californians 80 and older in 2033 as there are today and three times as many in 2043, the state projects.

It’s the same story around the world. Last week, finance ministers from the G20 group of nations met and discussed for the first time how to deal with the shrinking workforce and health care problems globally. Worldwide, the number of people over 60 years old is expected to reach 2 billion by 2050, more than double the number now.

In Sacramento and around the state, public officials and other groups that work with seniors said California must make some significant changes if it’s going to age gracefully. Understanding baby boomers, the generation driving the state’s median age upward, is just the beginning of the challenge, they said.

The state will face shortages in the health care workforce as well as a fragmented system of services. It will also have to confront the biases that cause older adults to be treated as though they are “decrepit,” as Kidd described it.

Will Tift, assistant director of the Agency on Aging Area 4, which covers seven counties including Sacramento, said he is trying to make sure that officials understand how an aging population will change life in California.

“What has happened is that we increasingly move toward a state of triage where the people with the most extreme, immediate need are served and everybody else is just in line,” Tift said.

Now, Gov. Gavin Newsom has announced he is officially making aging a priority. On Monday, the Democratic governor signed an executive order that calls for a “Master Plan for Aging” to be created by Oct. 1, 2020. The plan will “serve as a blueprint for state government, local government, private sector and philanthropy to implement strategies and partnerships that promote healthy aging and prepare the state for the coming demographic changes,” the statement announcing the order reads.

“The Golden State is getting grayer,” the governor said, “and we need to be ready for the major population changes headed our way.”

Understanding boomers

Tift has been watching California and the Sacramento region since 2003, when he came to work for the Agency on Aging Area 4. The agency works with county supervisors to provide support services to seniors, mostly through nonprofit partnerships with groups like Meals on Wheels.

Boomers are not doing enough to prepare for aging, Tift said. They don’t want to feel old, so they avoid understanding what getting older means financially and legally, he said.

“In that regard it’s similar to making funeral arrangements,” Tift said. “It’s never a good time to sit down at the kitchen table and say, ‘Let’s pick out a plot this weekend.’”

But seniors are living significantly longer than they did when the boomer generation was born in 1946, and it has become more common for seniors to live into their 80s and 90s.

Older adults also now tend to have more chronic health conditions than before. So a lack of preparation leaves some boomers doubly vulnerable: They have a longer time span during which they need to support themselves, and they often have more conditions for which they’ll need to pay for medicine, physical therapy or doctor’s visits.

Already, 16.3 percent of California adults over age 60 live below the poverty line, and 20.7 percent live poor or near poor, according to the California Department of Aging. Inequality among the senior population will increase over time.

The majority of retirees want to be able to age at home and in their communities. A report by the AARP Public Policy Institute found that 87 percent of people age 65 and older want to stay in their current home or community as they age — known as “aging in place” — and 71 percent of adults between the ages of 50 and 64 wish to do the same.

But baby boomers are “more likely to be single or childless, live alone, and live in poverty,” according to an analysis of census data by the California Future Health Workforce Commission.

With fewer family members available to help with caregiving and less money to pay for the broad range of services that help seniors and the disabled live independently, seniors have few options for aging in place comfortably. Instead, they often fall into what Tift called the “Medi-Cal spindown.”

“People can’t afford to pay out of pocket for that kind of care, and Medicare doesn’t cover it,” Tift said. “Your choice is to impoverish yourself, enroll in Medi-Cal, then we’ll take care of you.”

Boomers are much more diverse than previous generations, and care systems aren’t yet good at reflecting that diversity.

The Public Policy Institute of California used Department of Finance data to calculate the percent change in the 65 and older population by race between 2012 and 2030. The calculations predict the Sacramento region’s white senior population to grow by 67 percent, while the multiracial senior population is projected to grow by a dramatic 205 percent.

There will be a 216 percent increase in Sacramento’s Pacific Islander senior population, a 183 percent increase in Latino seniors, a 132 percent increase in African American seniors, and a 137 percent increase and a 159 percent increase for Asian and American Indian seniors, respectively.

“There’s a professor down at Stanford that calls it the ‘silver-brown tsunami,’ ” as opposed to the more commonly referenced “silver tsunami,” said Joanne Spetz, a professor at the Institute for Health Policy Studies at UC San Francisco. She said California’s health systems aren’t ready to handle how much more diverse the state’s older population will be.

Health care systems in California are still largely designed for a majority population that was of European descent and catered to the cultural norms of that heritage, Spetz said. People across cultures may have different communication standards or different levels of family engagement in care, she said.

One of the most tangible discrepancies is in language. A study by the UCLA Latino Policy and Politics Initiative found that there were only 62.1 Spanish-speaking physicians for every 100,000 people who exclusively speak Spanish, whereas there are 344.2 English-only-speaking physicians for every 100,000 people who speak only English.

Shortages

The gap between the supply of seniors and the demand for services is likely to widen as the state’s population grows and ages, and historically vulnerable populations — rural, inner city and low-income people — will be hit the hardest.

One of the most glaring problems is the state’s deficit of doctors, experts said. In nearly every scenario estimated, California’s supply of physicians is expected to decline in the next decade, researchers found in a study that Spetz co-authored.

California would need close to 9,000 additional primary care clinicians by 2030 in order to meet demand, the research showed.

“There are not enough physicians going into the primary care field,” Spetz said, “and geriatrics is actually even more challenged because it’s more education, more time in training and often it turns out that geriatricians get paid less than general physicians.”

The nationwide demand for geriatricians, or aging specialists, is not being met, according to the American Geriatrics Society. By 2025, AGS predicts that there will be 6,230 full-time geriatricians in practice when 33,200 will be needed. As of 2017, California had 720 certified geriatricians.

Janet Coffman, who is also a professor at the Institute for Health Policy Studies at UC San Francisco, tracked geriatrician numbers across California. Using a 2015 survey, Coffman and her team found that the ratio of geriatricians who provide patient care at least 20 hours a week per every 100,000 persons age 65 and older varies substantially. Many rural counties have no geriatricians at all.

While San Francisco County had close to 32 geriatricians per 100,000 seniors, 19 counties had none. Northern counties including Del Norte and Siskiyou as well as inland counties like Inyo, Mono and Alpine are in the latter group. Tehama and Yuba counties also had no geriatricians as of 2015, while Sacramento County had close to nine for every 100,000 seniors.

Researchers said lack of equity in care coverage between urban and rural regions is a theme throughout all areas of health care. They said the key conversation should be about how rural counties — places where the population is often lower-income and more people are in poor health — are underserved.

More than 7 million Californians live in so-called Health Professional Shortage Areas, a designation given by the federal government. The vast majority of people living in those shortage areas are people of color in places like the inner city of Los Angeles and most rural areas.

The majority of people living in the underserved areas are Latino, African American and Native American, the California Future Health Workforce commission found.

Another kind of health service catering to seniors called palliative care, which similar to hospice except its long term, is struggling to keep up with demand as well, Spetz said. People with severe health problems that can be managed for extended periods often turn to palliative care teams for support. Teams usually include a physician, nurse practitioner, top-level clinician and ideally a social worker and chaplain, Spetz said, but right now it’s hard to fill the roster.

“Most of the hospitals do not have that complete team,” Spetz said. “And they’re very reliant on in-kind services. A lot are reliant on the community for chaplain services or social work services … from a workforce standpoint we’ve just got these huge gaps we need to deal with.”

A nationwide study by the AARP Public Policy Institute found there will likely be a shortage of family caregivers available to help seniors as well. In 2010, according to the study, there were more than seven potential family caregivers for every person age 80 and older. But by 2030, that ratio is forecast to fall to 4 to 1, and in 2050 it will fall to less than 3 to 1.

Family caregivers don’t get enough support as it is, Spetz said, and hired personal care workers aren’t much better off.

“People are treated as over-glorified maids when a lot of them have very important skills,” Spetz said. “There’s so little respect and pay. You have more of a career path at In-N-Out Burger than you do in health care.”

FRAGMENTATION
Karen Robison, 81, and Karl Bucholz, 82, moved to Sacramento from Milwaukee in 2009. Bucholz was a “reluctant recruit.” He wanted to age in place rather than move into Eskaton Village Carmichael, the continuing care retirement community where the couple now live.

“My husband is a very competent guy and really felt he could be up on an extension ladder cleaning gutters on the second floor,” Robison said. “I felt that after age 70 men did not belong on ladders.”

When the couple came to visit the facility, Bucholz found he liked the fitness programs, transportation services, meals, different levels of care to meet all needs and maintenance crews available to take care of issues like changing light bulbs.

Sure, Bucholz and Robison could have paid someone to clean out their gutters. But then they would have had to find someone else to help with changing a light bulb, and booked another service for the fitness programs Bucholz likes.

Gretchen Alkema, vice president of policy and communication with the SCAN Foundation, a public charity focused on improving quality of life for seniors, said that this is one of the biggest problems for older adults. Long-term care services are fragmented across different departments and organizations, and that makes getting help a confusing process.

“What we would say is they (services offered by the state) are not terribly coordinated,” Gretchen Alkema said. “They operate in their own unique silos. Needs are not about these silos, but about addressing the needs of the whole person.”

In 2015, a report from the state Senate Committee on aging and long term care called “A Shattered System: Reforming Long-Term Care in California” called fragmentation “the most critical issue” facing the state’s system of long-term care because it causes consumers to struggle to identify and access home and community-based services. This in turn leads to an increased likelihood of institutionalization, the report found.

Too much of the dialogue at the state planning level, according to Alkema, is focused on individual programs and neglects to address what an aging California should actually look like.

“The way that state government is set up is that it’s bucketed in concepts around health, social services, transportation,” Alkema said. “What we see as a value is thinking about aging across all departments and programs.”

Long-term supports and services need to be organized as well as given more resources, experts said. The “new normal,” according to Tift, is that there is one slot for every five or six people coming to the Agency on Aging Area 4 requesting services.

After the Great Recession hit in 2008, funding dried up on all sides, Tift said. Reductions from federal, state and local governments slashed budgets, and the nonprofits Area 4 contracts with couldn’t get as much money from private fundraising and grants, either.

“We’re advocating now to get back to the funding levels that we had 10 years ago, and 10 years ago we didn’t have enough and we weren’t ramping up and preparing” for a population boom, Tift said.

Last year, the California Association of Area Agencies on Aging, the organization that represents the Area Agencies, asked for a restoration of funding from the state for Community Based Services Programs, Tift said.

The request went unfulfilled.

Tackling ageism

One of Robison and Bucholz’s favorite parts of living at Eskaton is how social the community is. No one ever has to eat alone if they don’t want to, and there’s a “we’re all in this together” feeling about the aging process that makes growing older less isolating, they said.

“Living independently in a typical community, there’s some feeling of having a deficit in being older,” Bucholz said. “But here, there’s a wonderful feeling of acceptance.”

Bucholz said that aging sometimes causes people to lose sight of the fact that humans are naturally social. “When we get to an age where we are more in need of support in one way or another, the social part of life is very important, and people tend to underestimate how much that means,” he said.

Keeping up a full social calendar can be difficult for older adults who are slowing down, but living in a community where seniors aren’t being included makes aging isolating. Many Sacramento community members said that they don’t feel old — except when other people point out their age.

Tift said that part of the problem is that California’s youthful, adventurous and trendsetting reputation creates a bias against anyone who doesn’t fit that image.

One of the clearest ways ageism shows itself is in language. Phrases like “silver tsunami,” which is often used to describe the aging population, are problematic and affect the way policies are constructed, Tift said.

“When people talk about ‘silver tsunami,’ that’s actually an ageist thing to say because tsunamis destroy things,” Tift said. “Ageism is so baked in to our thinking that it’s hard to overcome that and see this challenge as one that holds opportunity for communities to be more inclusive.”

Therese Ten Brinke, who works as a project coordinator of strategic initiatives at Eskaton and is an adjunct professor at Sacramento State, said there is no widespread narrative in California that presents aging in a positive light.

For the past few years, Ten Brinke said Eskaton has been examining the culture around aging both within the organization as well as in the community and found it in need of a serious update.

“We had to take a critical view of ourselves and say, ‘How do we want to portray how we all want to live?’” Ten Brinke said.

Words like “facility,” as in “assisted living facility,” fail to acknowledge that people live in them. The “facilities” are homes. But these words are baked into policy and regulations and continue to dictate how care providers like Eskaton do business, Ten Brinke said.

Ageism forces the entire senior population into one bucket, as though once adults hit 65, they aren’t worthy of focused attention. But the “65-and-over” population spans a 40-year range of ages and a massive continuum of different needs, Ten Brinke said.

“That would be like lumping an 8-year-old and a 40-year-old in the same demographic, which to anyone sounds like a bizarre idea,” Ten Brinke said.

Moving forward

With the aging boom already here, elected officials in California have started to address the problem. For many, the question is whether it will be enough.

The governor’s executive order calls for a “Workgroup for Aging” to advise the secretary of the California Health and Human Services Agency to create the plan, according to the announcement. The agency will also create an advisory committee that will include older citizens, adults with disabilities and other stakeholders. The aim is for the state to become an age-friendly place.

Sacramento has already begun doing its part to become more livable. Both the city and county of Sacramento are in the process of becoming officially designated as Age-Friendly by AARP, which means they will join a network of cities working on livability as well as come up with a plan to make the area livable.

The county has expressed interest in joining the network, but the city officially submitted its application to join the network last month, according to Jennifer Berdugo, an associate state director at AARP California.

The city of West Sacramento is in the network as well, and it has already created its Age-Friendly Action Plan. Based on what it learned through the network, Berdugo said, West Sacramento established an on-demand shuttle service.

Buses weren’t coming quickly enough and there weren’t enough stops for seniors to feel comfortable navigating the system, according to Berdugo. Now the Via shuttle system makes it easier for people to access transportation and reduces wait times.

“Older adults, because of the shuttle, are now able to buy ice cream at the grocery store because they don’t have to wait an hour for the bus to come,” said Berdugo, noting that the changes came about because seniors were included in the planning.

A state Assembly bill moving through the Legislature would require California to join AARP’s age-friendly network, too. AB 1118 passed May 28 and was sent to the state Senate to review.

Another bill, Senate Bill 512, would help alleviate what Tift called the “Medi-Cal spindown” by creating a new program that would help Californians pay for long-term services and supports. It passed the Senate on May 21 and is moving through the committee process in the Assembly.

The American Medical Association also announced June 5 it would award UC Davis along with the Oregon Health & Science University a $1.8 million grant to expand the number of medical students and resident physicians at hospitals from Sacramento to Portland.

The trainees will work in rural, tribal and urban areas, UC Davis School of Medicine officials said in a press release, with the hope that they will remain and serve in these areas affected by shortages.

By incorporating the voices of seniors in planning processes, living in California could become more equitable for people of all ages and abilities, experts said, but that can happen only if people stop seeing aging boomers as a burden. Alkema said the master plan is the first step in the process.

“This perspective about aging as everybody’s business and the master plan as resetting the vision,” Alkema, “is really a big first step.”