Aging Californians Challenge State Health Care System

California, like the rest of the country, is confronting what many have dubbed “the silver tsunami” — a rising wave of graying baby boomers who will need, and undoubtedly demand, a wide range of acute and long-term health care services.

According to the 2000 U.S. census, 3.6 million people in California — almost 11% of the state’s 34 million residents — were 65 or older. That number is expected to triple by 2050, to almost 11 million, with the fastest rate of growth likely to occur among those 85 and older. This rolling population bulge is creating a host of new concerns for the state’s already overburdened health care infrastructure.

“I don’t think anybody’s prepared — state, federal, local,” said Bonnie Martin, a nurse practitioner in Stockton and a board member of the California Nurses Association. “This aging of the baby boomers has been talked about for 30 years. Now it’s already happening, and it’s going to get worse and worse.”

Demographic Factors

California policymakers, like those in other states, face a host of thorny issues, such as addressing the costs of long-term care, creating more effective coordination between a fragmented menu of services and funding sources, and ensuring that the health care work force understands the specific problems confronting the elderly. Yet the state’s sheer size and its large immigrant population create challenges not faced by smaller and more homogeneous states.

“In California, there are simply more older people,” said Dr. William Satariano, an epidemiologist and specialist in aging at UC-Berkeley’s School of Public Health. “And one characteristic of the older population here that really distinguishes it from older people in other states is the racial and ethnic diversity.”

The state’s demographics are significant because rates of many chronic illnesses that worsen with age, like diabetes and heart disease, disproportionately afflict the socially and economically disadvantaged — the very people who have fewer resources at their disposal and less access to health care services.

Dr. Satariano was a co-author of the health and long-term care section of California’s strategic plan for coping with the needs of an aging population, which was released by the Health and Human Services Agency in 2003. The many recommendations included:

• Advocating for universal health care to increase access for the elderly;
• Expanding dental care services;
• Increasing funding for substance abuse programs targeting seniors; and
• Helping to empower older adults to manage their own chronic diseases and conditions.

The strategic plan for the aging addressed such issues as housing, transportation and the workplace, as well as health. Progress reports on aspects of the plan are expected next year.

Work Force Limitations

A major issue, in both California and the country as a whole, is the shortage of health care workers with training and experience in coping with elderly patients. Nationally, people 65 and older account for 23% of outpatient visits, 48% of hospital days and 83% of those in nursing homes, according to one estimate.

But only a handful of medical schools require a geriatrics course, and less than 1% of registered nurses have been certified in the field.

“Taking care of old people is not considered a glamorous part of the profession,” said Ms. Martin, the nurse practitioner in Stockton.

Some academic institutions in the state are making efforts to beef up training and research in gerontology. UCSF was one of five schools around the country selected by the Hartford Foundation to establish a Center of Geriatric Nursing Excellence, which was founded in 2001 and funds doctoral-level scholarship.

In the current academic year, 14 out of 130 UCSF nursing doctoral students are specializing in gerontological issues — an increase from previous years, according to Dr. Nancy Stotts, a UCSF professor and expert in nursing education.

“We have a limited number of people in the country with a gerontological specialization,” said Dr. Stotts. “People who had good experiences with grandparents are interested in gerontology, but the pay is less, so there’s some disincentive built into the system.”

Alzheimer’s Disease a Unique Challenge

Apart from any other factors, the projected increase in the need for services for patients suffering from Alzheimer’s is staggering. According to the northern California and/northern Nevada chapter of the Alzheimer’s Association, an advocacy group, there currently are about 500,000 state residents 65 and over suffering from Alzheimer’s and related disorders; nationally, the figure is about five million.

Like the overall elderly population, those numbers are expected to triple by 2050. One recent study calculated that the total price tag of caring for Alzheimer’s patients in California, including costs associated with both formal and informal care, would increase from $25.9 billion in 2000 to $75.4 billion in 2040.

Ruth Gay, director of public policy for the Alzheimer’s Association’s northern California chapter, noted that policymakers need to recognize that Alzheimer’s not only generates its own medical demands but also makes management of other ailments and health conditions much more difficult and expensive.

“When you overlay Alzheimer’s and what that does to people’s ability to be cognitively able to participate in their care, to make decisions that affect their safety and livelihood, they need extra support and services and supervision,” Gay said. “We’ve put money into preparing for West Nile Virus and other threats. But Alzheimer’s is a reality happening right now. And if the state doesn’t address it, we’re going to have a major financial catastrophe in the next 20 years.”

The Alzheimer’s Association supported a bill in the current legislative session, carried by Sen. Elaine Alquist (D-San Jose) (SB 321) that would require the state to develop a strategic plan to address the future course of Alzheimer’s.

The measure is currently bottled up in committee and has a “pretty dim prognosis” this time around, said Robert MacLaughlin, a consultant with the Senate Subcommittee on Aging and Long-Term Care. “There is going to be a continued effort to get this statewide plan, since it clearly is a priority of many people,” he said.

Long-Term Care Needs

A key issue for many elderly in California, including those with Alzheimer’s, is accessing an appropriate — and affordable — type of long-term care. With residential facilities generally costing tens of thousands of dollars a year, many older adults find they have few, if any, options other than to spend down their assets so that Medicaid will pay for nursing home care.

Many states have received waivers from the federal government allowing them to use Medicaid funds to pay for assisted living as well as skilled nursing facilities. In contrast, Medi-Cal does not pay for assisted living, forcing some elderly people to stay in nursing homes when they might actually benefit from a less intensive — and less expensive — level of care.

Through the Assisted Living Waiver Pilot Project, the state is currently investigating whether to place Medi-Cal-eligible patients in less restrictive long-term care settings. Participants in the project receive services while living in either a residential assisted living facility or in public housing.

The program is being implemented for a three-year trial in Sacramento, San Joaquin and Los Angeles counties; if it proves to be successful and cost-effective, the state could expand it to other counties.

In the end, however, the state’s efforts to address the health care needs of the aging will partly depend upon the outcome of major discussions about health care policy.

“The overall issue of health care and how we’re gong to fund it, and what about the uninsured, and are we going to have universal coverage — these are debates we’re having at the state and national level,” said Dr. Kathleen Wilber, a gerontology specialist at USC. “That’s front and center. Long-term care is waiting in the wings, and to some extent, it will depend on what happens with health care overall. But it’s further down the queue.”

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