ROCHESTER, N.Y. — A tiny Russian-language library in an upstate New York apartment complex is not a typical setting for a yoga class. But this was not your typical yoga. The participants sat on folding chairs, for one thing, and everyone was older than 65 years old. Personal trainer Sarah Lane-Ayers led five women, all immigrants from Russia and Ukraine, in a series of stretches and movements: squeezing a ball, leg kicks, boxing moves like hooks and uppercuts. She demonstrated a modified pigeon pose, which strengthens the hips. “This is important for rolling in and out of bed. And working your core is crucial to keep from falling!” she said. The class ended with the students giving their teacher a round of applause before bundling up in heavy coats and trudging through the snow to their own apartments nearby.
“I wish my own mom had this, because it’s so beneficial,” Lane-Ayers told me. “But these are my second, third and fourth moms. I see them four times per week.”
The word “retirement” in America often conjures up the idea of relocating, perhaps toward golf courses or beaches. But about half of Americans over 65, and 60 percent over 80, haven’t gone anywhere: They’re living in homes they’ve been in for 20 years or more, and most have no plans to leave. Demographers call this “aging in place.” The Ellison Park apartments here are full of people doing just that, staying where they are well past the point when some of their peers move to old-age communities in Tampa or Phoenix.
Across the country, the Ellison Park phenomenon is repeating itself over and over, in cities, suburbs and even far-flung rural areas. These distinct and unplanned neighborhoods of senior citizens have a nickname — NORCs, or naturally occurring retirement communities — and as America becomes a grayer nation, they’re going to present greater challenges for the health care system and for local governments. But as NORCs proliferate, they’re also creating opportunities for rethinking just how to care for people as they age. That need will become increasingly acute as the decades pass: By 2050, when the Millennial generation will be entering senior citizenship, the number of Americans over the age of 65 will have doubled, while the number older than 85 will have tripled. According to Census Bureau projections, today, 15 percent of the total population is older than 65; in 2050, nearly a quarter of the population will be.
The Ellison Park apartment complex in Rochester, an ordinary grouping of three-story brick buildings situated around green lawns, was never planned as a retirement community. But in some ways it has accidentally become one. Many of the residents are low-income Jewish refugees from Russia and Ukraine who clustered here in the 1980s and 1990s; some use Section 8 vouchers to help pay their rent. Built in 1948, the apartments have narrow hallways and no elevators, which means 80-year-old Noyema Averbakh, a former math teacher and one of the yoga students, has to climb up and down stairs each time she enters or leaves her second-floor home—despite the fact that she is a handicapped cancer survivor. Like most American cities and towns, Rochester lacks a sophisticated public transit system, and when Averbakh’s husband, Zigmund, had a dentist’s appointment that afternoon, he had to pay for a taxi to get there.
To address problems like these, nonprofit organizations and governments have established NORC programs that concentrate services within a specific geographic area dense with senior citizens. The most common include transportation, social get-togethers, assistance with arranging home health care and housekeeping, and mental health and bereavement counseling. The idea is to meet the needs of seniors where they are, instead of requiring the elderly to overhaul their lives and move to get the help they need.
High-density urban areas like New York City and Boston can be ideal for aging. There are plenty of neighbors for human contact, elevators to get in and out of buildings, and public transportation and services are close by. But currently, only a fifth of older Americans live in such areas, while the rest are navigating more challenging, lower-density landscapes. “It’s a concern in terms of isolation,” said Jennifer Molinsky, a researcher at the Harvard University Joint Center for Housing Studies. More than half of elderly people eventually give up driving. “How do we bring services to those people and get them where they need to be?”
American families are further flung and work longer hours than ever, and many elderly people can’t rely on younger relatives to help with daily needs like shopping or meal preparation. These physical and logistical stresses can lead to loneliness and depression, all of which hasten people’s move into assisted-living facilities and nursing homes. So there’s a big incentive, both societally and for old people themselves, to come up with a different model. Aging in place—even with professional care at home—can be more cost effective than aging in an institution. One 2006 study of Medicaid spending found that providing care in the community saved government more than $40,000 per participant, compared with moving the participant to an institution like a nursing home.
Noyema and Zigmund Averbakh emigrated from Ukraine to Rochester in 1992, and feel they are lucky to live at Ellison Park. More than 100 seniors in the complex participate in a state-funded NORC program run by Jewish Family Services of Rochester. The owner of the complex, Eastwood Management, has donated an apartment to the NORC, which houses the Russian library and the office of Talya Brea, an energetic social worker who serves this senior population full time. Brea helps people navigate the insurance and Medicare bureaucracy and apply for food stamps; she acts as a translator and accompanies residents to medical appointments. She arranges a full schedule of activities each week, from yoga and English classes to shopping and theater excursions.
Brea’s goal is to help the residents maintain a sense of independence and community. They tell her “a nursing home is the worst thing that can happen to someone,” she said. “They would rather die.”
Noyema Averbakh’s eyes glisten when she talks about Brea. “She is a daughter to all of us,” she said.
More affluent seniors, too, can benefit from the services a NORC program provides. Southeast of central Rochester, a 1.5-square mile patch of the suburb of Perinton is home to another state-funded NORC, run by Fairport Baptist Homes. (Both the Perinton and Ellison Park programs are nondenominational and open to any senior citizen, despite being organized by religiously affiliated organizations.) Perinton’s residential neighborhoods are bisected by highways, and very few people here can walk to a supermarket or doctor’s appointment, nor can they rely on public transit.
“The No. 1 need for older olds is a transportation program,” said Ellen O’Connor, who directs the Perinton NORC. Every weekday from 8:30 a.m. to 3:30 p.m., the program runs an Elderbus that picks riders up at home and takes them to and from the bank, post office, supermarket, pharmacy, and other destinations in town. With 48 hours notice, any senior living in the NORC service area can reserve a volunteer driver who will use their own vehicle to take residents to medical appointments.
O’Connor has found that the simple need for a ride can then connect seniors with a broader array of services they may not have realized they needed. She recalled one “very, very proud couple” who preferred to decline help. But the wife reached a breaking point when she needed to get her wheelchair-bound husband—who hadn’t left the house in two years—to a medical appointment. The NORC sent a caseworker and occupational therapist to the couple’s home, a split-level house with steps leading up to the front door. The professionals were able to devise a system in which the man could exit the house safely with assistance, by bumping down the steps on his bottom. The caseworker also saw that the couple’s home needed basic maintenance, like yard cleanup and new furnace filters, which the NORC was able to arrange.
The program is modestly funded, with $160,000 annually from the state and some additional philanthropic dollars that are raised locally. But with a weak job market pushing prime-age workers out of the area, O’Connor and her staff see more seniors living far from their adult children, and think the entire town would benefit from access to NORC support.
Of course, that would be expensive. There also are questions about whether the NORC model is broadly scalable. Both the Perinton and Ellison Park programs serve populations that are fairly culturally homogeneous. Some elderly people might feel less comfortable socializing across racial and socioeconomic lines. Would as many residents of socioeconomically or racially diverse neighborhoods be willing to volunteer to drive neighbors to their doctors’ appointments? In addition, not all NORCS are as effective as the two Rochester programs. Some lack a full-time staff of social workers or nurses stationed within the service area, which is key to providing daily help. More broadly, there are challenges associated with aging-in-place that are beyond the ability of NORCs to solve, such as the lack of affordable rental housing for low-income retirees and neighborhoods that lack sidewalks, a crucial environmental feature that aids mobility for the elderly.
Talya Brea, the social worker at the Ellison Park apartments, has devoted considerable time to advocating for safer neighborhood roads, and spends countless hours on the phone each week dealing with healthcare bureaucracy. “It’s a nightmare,” she said.
WE MIGHT NOT think of old age as occurring in pockets, but that’s exactly the picture emerging for the nation’s future. The graying of America will put massive pressure on public services—and that pressure will be unevenly distributed geographically. Demographer William Frey of the Brookings Institution has identified a trend he calls the “pulling apart” of the nation by age. All regions are experiencing growth in their senior populations with some of the fastest growth occurring in Sun Belt destinations like Houston, Atlanta and Raleigh. But in those cities, the growing number of seniors is balanced by the arrival of young families. The most extreme concentrations of the elderly are elsewhere, often in communities where the number of children is declining and younger working adults are leaving, creating a generational imbalance to add to existing economic challenges. This is the case across a gray ribbon that cuts through the post-industrial Rust Belt. Metro areas like Rochester, Buffalo, Scranton, Pittsburgh, Cleveland and Dayton are among the demographically oldest in the nation, all with nearly one-fifth of their populations being older than 65. (High concentrations of old people also occur in the age-restricted retirement communities of Florida and Arizona, which tend to attract upper- middle-class seniors.)
While Rust Belt cities and suburbs are fairly inexpensive places to live—a good thing for a retiree on a fixed income—they have other challenges that make them difficult places to age. Rochester, for example, is the fifth poorest city in America, with a local job market that has been hollowed out since the 1980s by drastic downsizing at companies like Kodak and Xerox. Fewer living-wage jobs means less family and taxpayer support for the elderly. That is where a NORC program can step in.
The NORC model began in Manhattan in the mid-1980s. Fredda Vladeck was a social worker at St. Vincent’s Hospital in Greenwich Village. She noticed the emergency room was filled with seniors who lived at Penn South, a complex of high-rise apartment buildings popular with retired garment industry workers. The health scares that brought those seniors to the ER were often minor enough, Vladeck saw, that they could be more effectively addressed by preventive care provided outside the hospital. She worked with Penn South residents and the apartment complex’s board of directors to develop a program in which she and a geriatric nurse practitioner were based at Penn South, organizing a range of health and social services.
The concept caught on, and in 1994, New York brought the NORC model statewide. In Washington, Sen. Barbara Mikulski (D-Md.) took notice, and championed adding NORC funding to the Older Americans Act. Between 2002 and 2008, Congress funded the creation of 45 experimental NORC programs in 26 states. There is no longer federal funding for those NORCs, but states and localities have used other revenue streams to accomplish some of the same goals.
ONE STATE WORKING on making it easier to age in place—Montana—couldn’t feel further from Manhattan. The highly rural, spread-out population is the nation’s sixth-oldest state demographically. “We have an agrarian society here in Montana. A lot of the kids are not sticking around to farm and ranch the way you used to,” said Audrey Allums of the Montana Department of Transportation. “The communities are getting smaller.” It’s possible to think of all of Montana as a NORC — hugely diffuse, and very challenging for old people in some regions, because of the vast distances between homes and businesses and services.
Since 2006, Montana has used federal and state health and transit funding to expand rural public transportation programs from three to nearly 40 counties. In fiscal 2016, the state provided 1.2 million free or subsidized rides to the rural elderly and disabled, many of whom are more isolated than ever. Colleen Pankratz directs the rural transit system in Valley County, Montana, which stretches from the Canadian border south to the Missouri River. The county is home to 7,000 residents spread over 5,000 square miles, and public transit here looks little like a traditional subway or bus system. “We operate almost like a taxi service,” Pankratz said. “You call for a ride, and we come get you,” often within five to 10 minutes. Professional drivers work between 7:30 a.m. and 11 p.m., every day of the year. On average, the program provides 145 rides per day. Residents pay $1 for rides within Glasgow, the county seat, and $3 plus 50 cents per mile for longer rides to outlying areas. The system takes seniors as far as Williston, North Dakota, 150 miles away, for outpatient eye surgeries, and Billings, Montana, 300 miles away, for other specialized medical appointments.
Four hundred miles west, Flathead County, Montana, dominated by Glacier National Park and Flathead National Forest, contains several residential areas that are even more remote. “It’s like living in a postcard,” said Lisa Sheppard, director of the county Agency on Aging. “That’s great when you’re a tourist, but a challenge when you’re trying to provide services. Ninety-four percent of the land mass is wilderness, timberland, or agriculture.”
Flathead County operates a bus system in its larger towns and, in outlying areas, offers home pickups and drop-offs for the elderly disabled and seriously ill, but only twice per week. “Because of the way we’re laid out, we’re still missing a whole lot of people who need transit assistance,” Sheppard said. “In Montana, there is a culture of people feeling very independent and feeling connected to and appreciating the wilderness and living away from other people. There’s a real value placed on that. The decision to move into town can be a very difficult one. But if you don’t have family who can help, that may be the best option.”
According to Allums, of the state Department of Transportation, some shrinking rural communities are hesitant to invest in elder care because of its high cost. “They say, ‘What are we getting out of it?’,” she said, “But seniors are staying in those communities and spending money.”
Transit might be the most pressing need in Montana, but there are many others—some of which illustrate problems that NORCs haven’t yet been able to solve. One is finding home health aides willing to work in the most remote parts of the state. “It’s difficult to find people who are able and willing to travel in the winter to those locations, because they don’t necessarily get paid for their travel time,” Sheppard said. In some cases, Flathead County is able to supplement private wages by providing a travel allowance. But the county and state still can’t meet the full need.
ONE OF THE BIG CHALLENGES as NORCs expand is familiar to anyone in health care: the labor force. Home health aide is the nation’s fifth-fastest growing occupation and among the lowest-paid, with irregular hours and few employee benefits. Nationwide, the median annual salary for a home health aide in 2015 was less than $22,000. In Rochester, home health aide Yolanda Manns-Brown, 52, began working for $8 per hour plus overtime, and five years later, earned a base wage of only $9.27. Given how difficult the job is, that salary makes it difficult to attract and retain high-quality workers.
Manns-Brown underwent specialized nursing training to deal with problems like cognitive disabilities and pressure wounds. She takes obvious pride in the expertise she developed on each of her client’s conditions. “Often, we’re the ones doctors go to to ask questions” about a particular patient, she said. Yet the job took a huge toll on her personal life. She sometimes worked 24-hour shifts caring for clients with traumatic brain injuries, and because she was considered a contract employee, did not have paid sick days. “The work is physically demanding,” she said, including moving and bathing adults. “But if you can’t come to work” because you are injured or ill, “you don’t get paid.” Manns-Brown wasn’t able to care for her sick partner, who ended up needing her own home health aide.
Last April, New York Gov. Andrew Cuomo signed a bill that will gradually increase the minimum wage to $15 per hour in New York City and its suburbs. But in upstate New York, only workers in fast-food establishments will be eligible for the $15 wage, while other low-wage workers, like home health aides, will earn a minimum of $12.50 per hour. In Rochester by 2020, working at McDonald’s could pay more than caring for the elderly.
“How you treat the workers is how the clients are treated,” said Bruce Popper, vice president of the Rochester division of SEIU 1199, the United Healthcare Workers. “You can’t have quality care from exploited workers.”
Home health care employers, for their part, say they’re squeezed and can’t raise wages unless they receive significantly more public funding. The New York State Association of Healthcare Providers, which represents home care agencies, has complained that some insurance companies are unwilling to pass state Medicaid funding on to home care agencies, even though that funding was intended to support wage increases. Home health aides could lose their jobs if government, insurers, and home care agencies do not reach a compromise on how to fund raises—even as demand for aides is higher than ever.
ANOTHER WAY TO SUPPORT aging in place is to allow the sick and disabled elderly to live at home, but to bring them to day centers where they can access health and social services. In San Francisco, a nonprofit called On Lok Lifeways—it means “happy, peaceful abode” in Cantonese—pioneered, in 1973, a new way to think about senior services. At the time, a growing number of older immigrants in San Francisco’s Chinatown realized they needed help. “When seniors became frail, they often had to leave the community,” said Eileen Kunz, chief of government affairs for On Lok. “They were away from families and in nursing homes” where staff did not speak Chinese languages or serve Chinese food. “It wasn’t the kind of care that people wanted.”
The community members, doctors, and social workers who founded On Lok based their program on British day hospitals. Today, On Lok operates seven day centers across the Bay Area, serving over 1,400 seniors annually. Ninety-eight percent are low-income, and all are eligible for nursing home services through Medicaid or Medicare. Because of the services they receive at On Lok day centers, the vast majority are able to continue living at home. Vans pick participants up and bring them to the centers, where they receive medical care and can take advantage of opportunities like art classes, support groups, exercise classes, and current events discussion groups. Participant councils help determine the programming.
“Our centers are a community,” Kunz said. “Even the van ride from home to a center is an opportunity for socializing.”
The On Lok model was replicated nationwide, and is now known as PACE, the Program of All-inclusive Care for the Elderly. Since 1997, local PACE providers have been eligible for Medicaid and Medicare funding. About half of PACE participants have dementia; other common diagnoses include diabetes, heart disease and depression. Studies from Tennessee and Texas found that because PACE helps participants avoid nursing homes and long hospital stays, PACE saved those states 17 percent and 14 percent, respectively, of the costs associated with serving the frail elderly.
Today, 31 states have PACE programs, serving 40,000 people nationwide—a small fraction of the handicapped elderly who could benefit from such services. For-profit entrepreneurs have recently begun to invest in expanding the model, in anticipation of the aging of the baby boomer generation.
IT ISN'T SURPRISING that the aging of America opens up new business opportunities. Money is always part of the equation when it comes to decisions about how to serve the old and infirm. Caring for seniors is, in aggregate, the most expensive thing government does: Forty-three percent of the federal budget is devoted to Medicare and Social Security. According to the Congressional Budget Office, if the current laws governing these programs remain in place, Social Security and health care spending (mostly Medicare) will account for half of federal spending by 2046.
American demographers often refer to aging as a silent challenge for both economics and health care, one that few people talk about. According to a 2013 Pew survey, just 26 percent of Americans identify the growing number of elderly people as “a major problem.” In Germany and Italy, however, where a third of the population is already over 65, there is broader public anxiety about the tradeoffs between paying for elder care and investing in services for other citizens, such as immigrants and working families. Fifty-five percent of Germans and 41 percent of Italians identify aging as a major national challenge.
Juliana Horowitz of the Pew Research Center said that one commonality is that in all three societies, because of a weakened job market, the elderly are more likely to be financially supporting their adult children than receiving money from them. “Some of it has to do with the economy,” Horowitz said. “Particularly in Italy and the U.S., younger people are moving back in with parents and the wealth gap between older and younger adults has grown.”
The financial challenge of America’s aging populace is now likely to be compounded by growing anti-immigrant sentiment. Though it’s not a big part of the immigration debate, in fact, immigrant workers are supporting, with their payroll taxes, the very social safety net on which retirees rely. Because immigrants are younger on average than native-born Americans and also have more children, they help keep the population balanced toward working-age people. “Without immigration, the U.S. population would have aged faster,” according to Horowitz. Even under current immigration restrictions, newcomers are not expected to keep pace with the graying of America. Today, there are 33 working-age Americans for every senior over the age of 85. By 2050, that ratio is projected to shrink to 13-to-1. That’s a huge shift, and if there’s a clampdown on immigration, it could happen even faster and become even more extreme.
The good news is that many of the public investments that best serve seniors have benefits for all of us. Aging in place with the support of a NORC or PACE program is more affordable than aging in a long-term care facility, leaving more money for government to invest in education and infrastructure. Montana’s rural transportation systems are open to everyone, not just the elderly; last year, about half of riders were members of the general public. Raising wages and regularizing hours for home health aides will mean they are better able to care for their own families, who will be less likely to rely on food stamps and other forms of public assistance. And the sort of landscape that is easiest for elderly people to navigate—a dense mix of residential and retail—is also increasingly popular with young adults in their ’20s and ’30s.
“All ages have the desire for walkability,” said Molinsky, the Harvard researcher who studies housing and senior citizens. Advocates for seniors know their issue area—packed with obscure acronyms like NORC and PACE—isn’t always the sexiest. That’s why, almost universally, they emphasize that helping old people thrive also helps the broader social good.
In short, a great place for a senior citizen to live is often a great place for anybody to live.
Dana Goldstein is a freelance writer who frequently reports on health, education and other social issues.