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An Aging America Continues to Face a Shortage of Care 17 Years After FRONTLINE’s ‘Living Old’ Documentary

When Maria Paunescu was 96, she was dealing with the ramifications of multiple shingles infections on her legs, severe arthritis and heart and vascular disease. She could no longer walk, and it was impossible for her to sit up or get out of bed without help from her daughter, Lucia Paunescu.

Committed to keeping Maria out of a nursing home and the hospital, Lucia cut back her work to about 10 hours a week so that she could care for her mother. But Maria was very frail, and her doctor didn’t think her condition would improve.

“I give her everything I have, but I don’t know what to do,” Lucia told FRONTLINE. “And that is the hardest part because I don’t like her to suffer.”

That interview was conducted over 15 years ago, for the 2006 FRONTLINE documentary Living Old. Today, as Living Old becomes newly available on FRONTLINE’s YouTube channel, America’s geriatric population is still growing and still facing many of the same challenges. People at their most advanced age continue to deal with many of the same chronic conditions that those interviewed in Living Old battled, with families grappling with similar difficult decisions and a shortage of care for their loved ones.

As the Population Gets Older, Caregiving Continues to Fall to Families

The geriatric population continues to balloon, even outpacing experts’ predictions. A doctor interviewed for Living Old said that the number of people over the age of 65 would become 20% of the U.S. population in 30 years. Just 14 years later, in 2020, Census data showed that people over 65 were already nearly 17% of the population.

A person leaning over to help an older person in a bed
Credit: PBS

This means there are more people in need of care, experts say, as older adults battle chronic illnesses like hypertension, diabetes and dementia. And as Living Old depicts, that care often falls to family members. A 2022 University of Michigan poll of adults between the ages of 50 and 80 found that more than half reported helping to care for someone over 65.

“The care is everything from feeding them, bathing them, getting them out of bed into a wheelchair, toileting comfort, [to] kind of reassurance, emotional care, spiritual care,” said Dr. David Muller, a geriatrician and the Dean for Medical Education at the Icahn School of Medicine at Mount Sinai in New York City, in a recent interview with FRONTLINE.

Muller, who was also interviewed in 2005 for Living Old, said families still face tough choices when their loved ones age, navigating a complex healthcare system and balancing treatment decisions with their families’ wishes and the quality of their last years of life.

At the same time, “85 in 2006 is very different from 85 in 2023,” said Susan Silberman, senior director of research at the National Council on Aging (NCOA). People are retiring later and living longer, she told FRONTLINE.

Data from the National Health and Aging Trends Study suggests that from 2011 to 2021, the number of adults 72 and older who are living with certain disabilities has declined, and that older adults are increasingly able to manage life on their own with assistive devices.

Fewer Older Adults Experience Certain Disabilities in 2021 Than in 2011, Survey Shows

The National Health and Aging Trends Study (NHATS) surveys a nationally representative sample of Medicare beneficiaries each year to understand the physical impacts of aging. The chart below shows the proportion of beneficiaries 72 years and older in the study who dealt with certain health conditions.

A graph showing the comparison of Hearing Loss, Vision Loss, Dementia, Difficulty Balancing, Difficulty Walking from 2011 to 2021

“Older adults are much more vital,” NCOA’s Silberman said. “They’re active. They’re exercising. They understand more about how to live healthfully.”

NCOA is a nonprofit organization that advocates for benefits and policies that support older Americans, such as expanding Medicare coverage or protections against age discrimination. Some of the improvement in quality of life for older adults can be attributed to the administration of federally-funded programs to support older Americans in areas such as managing chronic illnesses, mental health, diet and exercise, NCOA’s CEO Ramsey Alwin told FRONTLINE.

While implementation of these programs has been expanding for twenty years, Alwin said more funding is needed for them to reach all communities. That’s unlikely to happen in the coming fiscal year, as Congress considers budget cuts to the federal agency responsible for administering these services. Two bills impacting the funding are currently making their way through Congress and will determine how much funding is available for a range of programs for older Americans.

The Geriatric Care Shortage Persists

The number of geriatricians across the U.S. has stagnated. When Living Old premiered, FRONTLINE reported there were about 7,600 certified geriatricians; in 2021, there were about 7,450, according to the American Geriatric Society. A federal model projects that the gap between supply of geriatric physicians and demand will grow as the population of older adults continues to increase. That gap is more pronounced in rural areas.

That shortage of care and lack of resources means some older adults may never get off waiting lists for care. The impact is even greater on minority groups who confront income inequality or disparities in access to healthcare, said Angelica Herrera-Venson, an associate director at NCOA. That combination of factors can culminate in more chronic illnesses later in life.

“We still have minority groups — in particular, African-Americans and Latinos — that still, compared to non-Hispanic whites, are living their older years in greater disability,” she said.

Despite needing an extra year of training, geriatricians make a lower salary than most other kinds of doctors since many older patients have Medicare, which pays less than private insurance. Experts FRONTLINE spoke with were in agreement that ageism also contributes to the field’s lack of resources.

In addition to a shortage of practitioners, geriatricians told FRONTLINE that the current “fee-for-service” healthcare system isn’t set up to provide the more holistic, time-consuming care that older adults living with chronic illnesses require. Instead, it rewards providers for the volume of patients they treat and services that work to cure individual ailments.

“The reimbursement system also is set up to pay for individual pieces of the puzzle. They pay for procedures; they pay for physically doing something — putting a needle in a person, doing something invasive,” said Dr. Jeffrey Farber, a geriatrician, in an interview for the documentary in 2005.

But there are some signs that the system is gradually adapting. In a recent interview with FRONTLINE, Farber said that Medicare and some other insurance providers have adopted billing codes for chronic disease management and transitional care that have helped older adults pay for the type of care they need.

“You need the art of medicine in addition to the science,” said Farber, who is now the Chief Executive Officer of The New Jewish Home, a healthcare system for older adults in New York. “In isolation, for an individual disease, sure, you can follow the script. But when you’ve got eight of them and you have a limited life expectancy and you have some cognitive and functional impairments, you really have to navigate that carefully. And it takes time. It takes relationship building. It takes conversations.”

Experts are hopeful that more focus may be put on improving the quality of life for older adults after the COVID-19 pandemic brought increased attention to caregiving and the impact of loneliness and isolation on mental health.

“There are solutions to raising awareness and addressing ageism, embracing this gift of longevity,” said Alwin, the NCOA CEO. “There are opportunities to ensure it’s not just quantity of years, but quality of years with evidence-based health promotion and disease prevention programs.”

By Julia Ingram | August 8, 2023 | PBS