Older Adults in Poverty Face Compounded Health Inequities

August 25, 2015|12:55 p.m.| Shaina Wedmedyk

The process of aging creates a unique set of circumstances that directly impacts overall health. Discussions about health disparities often include race, ethnicity, gender, sexual orientation, and socioeconomic status, but older adults face their own set of disadvantages, including decreased cognitive and physical capabilities, entering into a period of fixed income or having to work at an older age, and experiencing the onset of many diseases that generally come later in life.

Connecticut Department of Public Health Commissioner and ASTHO President Jewel Mullen, who has led ASTHO’s 2015 Healthy Aging President’s Challenge, “Living Longer Better,” has promoted healthy aging and researched health disparities throughout her career. “We have to take our time to think about who we’re talking about when we say older adults or elderly, and remember that we’re not just talking about one homogenous group of people,” says Mullen. “And if we’re able to acknowledge that implicit bias comes into play among other groups, we should consider where it’s also operative when it comes to age.”

Evidence of this “implicit bias” can be seen in the spheres of both policy and healthcare delivery. For example, although older adults comprise a large proportion of persons afflicted by disease, they are disproportionally underrepresented in clinical trials, favoring younger individuals. This leads to clinical recommendations that aren’t applicable to the affected populations. In addition, older adults experience disparities in disease screening and communication style, both by clinicians and at the policy level. “Sometimes screening guidelines just say to stop at the age of 75, based on an estimated number of years of life left, although an increasing number of adults are living almost four decades or more after the age of 65,” says Mullen.

Studies have shown that the effects of health inequities are greatly compounded for individuals who belong to more than one marginalized group. The state of being older, with its unique set of disadvantages, can therefore be multiplied by contemporary disparities, a legacy of historical inequities, and, for many, a lifetime in poverty. These combined factors may be creating one of the most vulnerable populations in the United States.  

The common indicators of health disparities are correlated with higher levels of poverty. The state of insecurity that poverty creates has been demonstrated to cause more mental distress than war, leading to higher blood pressure, increased levels of stress, and drastically higher levels of depression. Mental distress brought on by financial strain can then be passed on to children, leading to poorer health and education outcomes that occur even if an individual’s financial state later improves. This demonstrates that the experience of poverty at any stage of life may impact individuals’ health as they age.

These factors and others contribute to a so-called “poverty trap.” “As people age, if they’ve already been in groups that experience disparities, they have a harder chance of overcoming them as they get older,” says Mullen. Lower quality or limited education in youth is a determinant of poor or risky health behaviors later on. Older adults in poverty are less likely to be insured, have less access to clinical services and supports, have more difficulty affording transportation or appointments, and are less likely to adhere to prescriptions or treatments due to their financial burden. This vulnerability and lack of independence leaves older adults more likely to be socially isolated and susceptible to elder abuse.

In addition to these physical barriers, older adults also report experiencing psychological barriers to care, such as feeling that doctors do not take reported symptoms seriously, which leads to lowered perceptions of access to quality healthcare. Older adults may mistrust medications or healthcare professionals for cultural and historic reasons, and are more likely to “normalize” symptoms of dementia and ignore the onset of disease.

An estimated 14.6 percent of older adults are currently living in poverty when adjusted for cost of living and out-of-pocket medical expenses. It is crucial to address the challenges facing this underserved population. Beyond the unnecessary suffering that the aging poor endure, health disparities overtax healthcare systems as complex and chronic disease among marginalized populations puts pressure on social safety nets. In many cases, addressing health disparities will require innovation and drive to enact systems-level changes, and this burden may fall on states and localities. States can take several actions to address health disparities among the aging poor:

  • Remove financial barriers to care by supporting expanded insurance coverage and free clinical services, such as screening programs.
  • Work to strengthen safety nets and supports for caregivers to ensure long-term care, safe housing, and retirement security.
  • Increase access to healthcare services and recreation by improving public transportation and promoting safe, livable communities.
  • Develop community education programs led by culturally-sensitive community health workers that reach targeted populations.
  • Support policies that ensure livable minimum wages, equal hiring, and fair firing, especially as it relates to older adults.
  • Engage with academic researchers and organizations that highlight issues facing the aging poor, such as the American Society on Aging, Justice in Aging, and the National Association of Social Workers.
  • Implement research or utilize existing data sources that measure health disparities, such as the Elder Economic Security Index, to raise awareness and drive action. To motivate stakeholders and legislatures, Mullen suggests enacting actuarial analyses of Medicaid enrollment projections based on current poverty levels.
  • Educate others and broaden the conversation on health disparities to include healthy aging to influence systems-level change.
  • Implement policies or programs that fight income inequality and the effects of poverty.
  • Re-evaluate and tailor existing policies and programs according to what barriers may exist for reaching marginalized groups.

Many states and localities have already taken action to address health disparities among older adults. New Jersey’s Cancer Education and Early Detection Program and Georgia’s Breast and Cervical Cancer Program offer free cancer screenings for low-income residents. Vermont’s Support and Services at Home Program provides free care and support services that allow older adults to safely age in place. New York’s Caregiver Support Initiative plans to support older adults with dementia and their caregivers through family and fare consultations, support groups, respite services, and education and training programs.

The most important actions that public health practitioners can take are to identify inequity and to become cognizant of (1) how disparities are built into current systems and create barriers to care and (2) how existing programs may sideline marginalized groups’ needs. But the issue of health equity is broad-sweeping and built into the structures of established policies, and correcting for historical inequities will require thoughtful, dedicated work.

“It takes insight, it takes exposure, and it takes empathy,” says Mullen. “It’s one thing to sit down and imagine what life could be like for somebody, and then say ‘This is how I’m going to address equity.’ It’s another thing to actually talk to the people. That’s where I think experience is so important.”

In the coming years, the issue of health inequities should not be ignored. As our population ages and the depth of poverty and inequality in the United States increases, health disparities for the aging poor can only worsen. For the health and well-being of our older adult population, says Mullen, “We have to decide what our societal expectations are, and what we’re willing to abide.”

Shaina Wedmedyk

Shaina Wedmedyk is an intern for health promotion and disease prevention at ASTHO. She is attending American University in pursuit of a Master of Arts degree in international development with a focus on global health. Shaina supports ASTHO projects related to healthy aging and chronic disease prevention.