Kilaru AS, Gee RE. Structural Ageism and the Health of Older Adults. JAMA Health Forum. Published online October 16, 2020. doi:10.1001/jamahealthforum.2020.1249
Heightened risks of the novel coronavirus for older adults have been apparent from the earliest days of the pandemic.1 Those risks translated to devastating outcomes. More than 40% of US fatalities have been residents and employees of nursing homes and other long-term care facilities.2 Strategies to mitigate infection in congregate settings have sought to fix deficiencies, including shortages of personal protective equipment and personnel. Yet an important question is less commonly asked: how many nursing home residents—more than 1.3 million US residents—could live in the community instead?
The default for funding institutional long-term care but not caregiving at home is one of many examples of structural ageism. A crucial yet often hidden source of inequity, structural ageism is the explicit or implicit bias against older persons arising from policies, attitudes, and actions of social institutions.3 This systemic discrimination has a synergistic effect with internal ageism, or negative beliefs that individuals acquire about aging, on the health of older adults.3
Most seniors, as well as their families, prefer to live at home or in community settings, such as assisted living facilities.4 Indeed, care for older adults has increasingly shifted from nursing homes to the community. Between 2012 and 2016, the number of US residents living in nursing homes did not change, while use of assisted living facilities increased by 14%. To live at home, many elders need long-term services and supports (LTSS). Unfortunately, the responsibility for LTSS often falls to family members who are unpaid (and untrained). Despite efforts to expand options for elderly individuals under the Affordable Care Act, Medicaid programs are mandated to cover nursing facility care but not home-based and community-based services, leading to variations in available resources for elderly individuals depending on the US state in which they live.4
Regardless of whether older adults live at home or in nursing facilities, public funding for LTSS is insufficient.5 Few US residents can afford out-of-pocket expenses for long-term care, and fewer (just 11% of adults older than 65 years) have private long-term care insurance. Medicaid pays for most LTSS, particularly for low-income populations.4 The value of LTSS can improve through evidence-based models, such as the Programs of All-Inclusive Care for the Elderly, and improving the quality of care in nursing homes, which remains variable despite efforts to increase oversight and transparency. More ambitious yet potentially necessary approaches include overhauling the current public insurance system to more directly support long-term care or creating a separate, publicly supported program to finance long-term care, with the goal of equitably expanding access to LTSS coverage.6
Structural ageism is not limited to long-term care policies; it is a component of nearly all current political issues. Efforts to suppress voting by mail are ageist, because they seek to either suppress political participation or expose older adults to illness. The absence of universal mask mandates reveals that some communities are willing to sacrifice the well-being of their elderly members for convenience. On returning to work, older adults who are employed may be vulnerable to discrimination if they are not provided with safe accommodations. Elderly individuals who are newly unemployed and seeking to work may not be given fair opportunities.
We must also safeguard against ageism in the new ways that health care will be delivered. The pandemic has ushered in a new era for communicating, monitoring, and improving health through technology. While these developments may increase access to care for older adults with limited mobility, these new services must be designed with elderly individuals in mind. Disparities may be exacerbated for older adults with hearing and vision disabilities, as well as those with dementia.
More fundamentally, the health care system is not designed to encourage the complex, integrated care that many older adults require.7 In addition to strengthening primary and geriatric care by appropriately compensating the difficult work of coordinating care for older patients, the health care system should place greater emphasis on prevention of illness and injury, such as falls.
Policies that perpetuate ageism may be difficult to undo because of longstanding negative stereotypes of aging. In fact, portrayals of elderly individuals as frail are increasingly false, because more Americans are living in better health and longer. Most people older than 85 years report no health limitations affecting their ability to work or perform housework.8 The misperception that all older adults are vulnerable, compounded by the pandemic, fails to recognize assets that should be celebrated: wisdom, independence, and resiliency. More positive conceptions of aging can overcome negative self-perceptions, which may contribute to worsened health.
Strategies for reversing structural ageism start but do not end with health care. Bold investments can accelerate the transition of elderly individuals from facilities to the community. All caregivers, including selected family members, should be trained and paid fair wages. Older adults should not be denied access to health care, even during crisis standards of care. The corollary is that elderly individuals should only receive services or interventions that are concordant with their goals for quality of life. Technology should improve rather than worsen access to care and social isolation. Elderly individuals should be included in health research, including trials for vaccines and therapeutics against coronavirus disease 2019. All of these efforts require a broader social conversation on how to optimize the lives of elderly individuals.
Valid criticism of the ageism concept may point to the wealth gap between older adults and younger generations and investment in social programs such as Medicare. The relative economic prosperity of older adults reflects many complex trends, such as home equity and student debt. However, countering ageism does not mean preserving the wealth of older adults but rather consideration of how social attitudes and policy designs unfairly exclude older adults from participating in society.
Complacency to the ongoing loss of life during the coronavirus disease 2019 pandemic may be the most unfortunate consequence of ageism. Popular accounts of younger patients at apparently lower risk having poor outcomes serve as reminders to maintain mitigation efforts, perhaps because the stories of elderly individuals dying do not have the same effect. Ultimately, the pandemic has forced us to see how we value or devalue the lives of older adults. If older lives were valued equally, arguments to compromise public health for economic reasons or resist small sacrifices of personal autonomy would ring hollow.
Aging is universal. All of us should celebrate this common journey. Recognition of the harms created by structural ageism is a necessary step toward a healthier and more equitable nation.
Corresponding Author: Austin S. Kilaru, MD, MSHP, Perelman School of Medicine, University of Pennsylvania, 421 Guardian Dr, 1303 Blockley Hall, Philadelphia, PA 19104 (email@example.com).
Conflict of Interest Disclosures: None reported.
Additional Information: The views expressed in this article are those of the authors and do not necessarily reflect those of the US Department of Veteran Affairs or the US government.
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