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Aging in America: How COVID-19 Will Change Care, Coverage, and Compassion

      While it is a smaller population that has survived the Great Depression (1929-1939), the Great Recession (2007-2009), and now the devastating financial impact of the coronavirus (COVID-19) pandemic, this group of older Americans has experienced tremendous stress and, at the same time, shown incredible resilience. I reflect on these monumental economic downturns as a concrete social determinant of health—directly impacting access to quality health care. As if the vulnerability for contracting the virus and suffering serious illness associated with SARS-CoV-2 was not enough, older adults are also having to navigate a world of considerable uncertainty in most aspects of life. Whether it be the ability to afford critical medications, concerns related to food security, social isolation and its impact on mental health, or covering the cost of medical bills, older Americans are extremely vulnerable during this pandemic.

      Care

      It is sobering that eight out of ten COVID-19 related deaths reported in the United States are individuals 65 years or older (). Once the virus has been contracted, older adults aged 65-74 are five times more likely to be hospitalized and 90 times more likely to die compared to 18-29-year-olds. Within the age bracket of 85 years or older, the rate of hospitalization is 13 times higher and the death rate is 630 times higher compared to the younger age group ().
      Nursing homes and long-term care facilities have been overwhelmingly impacted by COVID-19. According to data from the Kaiser Family Foundation (KFF), more than 40% of the total deaths related to the coronavirus pandemic have been residents or staff of these facilities (
      • Musumeci M.
      • Chidambaram P.
      Key Questions About Nursing Home Regulation and Oversight in the Wake of COVID-19.
      ). Despite our familiarity with these figures, the spread of the virus in these facilities has remained rampant. As a specialist in gerontology for many years, I knew that the pressure to address the longstanding challenges in these facilities would be paramount.
      The injection of federal funds to support these skilled nursing homes was addressed in the , through the allocation of $4.9 billion (
      • Musumeci M.
      • Chidambaram P.
      Key Questions About Nursing Home Regulation and Oversight in the Wake of COVID-19.
      ) to support facilities that had lost revenue due to the virus. In July of 2020, the Health and Human Services Administration (
      Centers for Medicare and Medicaid Services
      Trump Administration Announces New Resources to Protect Nursing Home Residents Against COVID-19.
      ) announced that an additional $5 billion would be dedicated to…“Medicare-certified long-term care facilities and state veterans’ homes (“nursing homes”), to build nursing home skills and enhance nursing homes’ response to COVID-19, including enhanced infection control. This funding could be used to address critical needs in nursing homes including hiringadditional staff, implementing infection control “mentorship” programs with subject matter experts, increasing testing, and providing additional services, such as technology so residents can connect with their families if they are not able to visit (para 3).”
      However, more is needed than simply funding. Advocates, policy experts, and researchers have called on the federal government for many years to address stricter regulations and oversight within nursing homes (
      • Musumeci M.
      • Chidambaram P.
      Key Questions About Nursing Home Regulation and Oversight in the Wake of COVID-19.
      ). In April of 2020, the Centers for Medicare and Medicaid Services announced the Independent Coronavirus Commission on Safety and Quality in Nursing Homes; two months later on June 19, 2020, the 24 members were announced and includes nine registered nurses, two of whom are senior expert Academy Fellows: Terry T.Fulmer, PhD, RN, FAAN; President, The John A. Hartford Foundation, New York and Patricia W. Stone, PhD, MPH, FAAN, RN, CIC; Professor of Health Policy in Nursing, Columbia University, New York (
      Centers for Medicare and Medicaid Services
      CMS Announces Membership of Independent Coronavirus Commission on Safety and Quality in Nursing Homes.
      ).
      While the federal government considers the funding and regulations of nursing homes, it is important to note that only a portion of the older adults needing support now and in the coming years after the pandemic reside in these facilities. As a long-time member of the American Geriatric Society, I have seen how the community of experts have been raising the alarm for improved care standards for all older adults within Congress and the Administration. I am proud to say that many of their recommendations for older adults mirror that of the American Academy of Nursing. From bolstering the public health infrastructure to expanding access to telehealth services and support for caregivers, agreement on the direction forward is coordinated (
      American Geriatric Society
      COVID-19 Response to Congress & Administration, AGS Calls for Access to Medical Supplies, Telehealth, Among Other Issues.
      ; ). What looms on the horizon, however, is coverage.

      Coverage

      For the older adult population, this critical healthcare insurance program is a lifeline. In 2019, Medicare covered in total 61.2 million people, this includes 52.6 million people aged 65 and older as well as 8.7 million disabled individuals (
      Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds
      2020 Annual Report of the Board of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
      ). However, like many of the distressing fallouts the pandemic has and will cause, what remains to be seen is how well or whether the program will be sustained in the future, knowing it is already frail. In July of 2020, the unemployment rate in the United States was 10.2%, accounting for 16.3 million unemployed Americans (). The link between payroll taxes and Medicare spending is important to note. As stated by Julie Rovner, KFF's chief Washington correspondent, “fewer payroll taxes are rolling in to fund Medicare spending, the numbers of beneficiaries are rising, and Congress dipped into Medicare's reserves to help fund the COVID-19 relief efforts this spring” (
      • Rovner J.
      Another Problem on the Health Horizon: Medicare Is Running Out of Money.
      ). At a time when more and more people are utilizing Medicare benefits, the revenue going into the program is significantly falling. The 2020 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds stated,“The Trustees project deficits in all future years until the trust fund becomes depleted in 2026. The assets were $194.6 billion at the beginning of 2020, representing about 55 percent of expenditures projected for 2020, which is below the Trustees’ minimum recommended level of 100 percent (p. 6).”
      And this deficit may come sooner than that. Independent analysis considering the impact of the COVID-19 pandemic conducted by the Committee for a Responsible Federal Budget estimates that the Medicare Part A Trust Fund will be unable to pay its bills in late 2023/early 2024 (
      Committee for a Responsible Federal Budget
      Updated Budget Projections Show Fiscal Toll of COVID-19 Pandemic.
      ). These numbers are shocking and give us a bleak insight into the massive impact that lies ahead.

      Compassion

      Throughout my career, I have been inspired by older adults and have remained steadfast in my commitment to innovation for how they experience and receive care. From my time in the Philadelphia Veterans Administration Medical Center developing a novel support program for older veterans to address both mental and physical needs, to helping to grow the University of Pennsylvania School of Nursing's All-Inclusive Care for the Elderly (PACE) program, I know the demand to consider the unique needs of older adults. The changes that I have seen over time also require policy work. As a senior advisor to the Centers for Medicare and Medicaid Services and having previously served on the American Medical Association's Specialty Society RVS (Resource-Based Relative Value Scale) Update Committee (more commonly known as RUC), I have seen the value of bringing the nursing perspective to these conversations. It is our unique blend of scientific innovation, political savvy, and commitment to patient well-being that make nurses the prime change agents to implement more equitable, empathetic models of care for older adults.
      As I think to the future of the Academy's work, I see the organization front and center of these policy conversations— how to ensure coverage for older adults, how to better maximize their care in new virtual platforms, how to address social determinants of health like financial standing, or how to ensure the right practices are in place for advanced alternative payment models or the merit-based incentive payment system. We have yet to fully uncover the true impact SARS-CoV-2 will have on the care and coverage of the older adult. However, if my career has taught me anything, older adults have a profound level of fortitude and have shown me that strength lies in compassion and community. The financial impact on health and health care can be abated with strong policy grounded in evidence. As we consider the challenges ahead in a year or two beyond the pandemic, I think about the Academy's presence in shaping care and coverage guided by compassion. The road ahead will be long, but nursing will be a leader in reshaping the system.

      References

      1. American Academy of Nursing. (2020, June 26). https://higherlogicdownload.s3.amazonaws.com/AANNET/c8a8da9e-918c-4dae-b0c6-6d630c46007f/UploadedImages/FINAL_AAN_HELP_Committee_Pandemic_Response.pdf

        • American Geriatric Society
        COVID-19 Response to Congress & Administration, AGS Calls for Access to Medical Supplies, Telehealth, Among Other Issues.
        (March 24)2020
        • Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds
        2020 Annual Report of the Board of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
        (April 22)2020
        • Centers for Disease Control and Prevention
        COVID-19 Hospitalization and Death by Age.
        (August 10)2020
        • Centers for Disease Control and Prevention
        Older Adults and COVID-19.
        (August 16)2020
        • Centers for Medicare and Medicaid Services
        Trump Administration Announces New Resources to Protect Nursing Home Residents Against COVID-19.
        (July 22)2020
        • Centers for Medicare and Medicaid Services
        CMS Announces Membership of Independent Coronavirus Commission on Safety and Quality in Nursing Homes.
        (June 19)2020
        • Committee for a Responsible Federal Budget
        Updated Budget Projections Show Fiscal Toll of COVID-19 Pandemic.
        (July 10)2020
      2. Coronavirus Aid, Relief, and Economic Security (CARES) Act, Publ. L. No. 116-136 (2020). https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf

        • Musumeci M.
        • Chidambaram P.
        Key Questions About Nursing Home Regulation and Oversight in the Wake of COVID-19.
        in: Kaiser Family Foundation. 2020
        • Rovner J.
        Another Problem on the Health Horizon: Medicare Is Running Out of Money.
        in: Kaiser Health News. 2020
        • U.S. Bureau of Labor Statistics
        Employment Situation Summary.
        (August 07)2020