Elder Law Prof Blog

Aging Issues in the News

To me, it seems recently there are more articles  in major publications about aging than in the past. For example, yesterday in the Washington Post, there were three: 

‘Granny flats’ play surprising role in easing California’s housing woes

Seniors are flooding homeless shelters that can’t care for them; 

and 

an opinion esssay, My neighbor lived to be 109. This is what I learned from him.

The "Granny Flats" article notes that this popular name for accesssory dwelling units is someo thing of a misnomer today as the focus of the article is on the popularity of using  ADUs to help with the housing crisis:

The numbers tell the tale: More than 23,000 ADU permits were issued in California last year, compared with fewer than 5,000 in 2017 — which was around when ADU permitting began to take off thanks to legislative and regulatory changes in the state. The state now requires faster permit approval by localities, and establishes that cities must allow ADUs of at least 850 square feet — though many are much bigger. A number of other bills are being debated in Sacramento, including one by Assemblymember Phil Ting (D) that would allow property owners to sell their ADUs separately from their main houses.

The second article, also on housing, is more troubling, noting the number of elders who are unhoused.

Nearly a quarter of a million people 55 or older are estimated by the government to have been homeless in the United States during at least part of 2019, the most recent reliable federal count available. They represent a particularly vulnerable segment of the 70 million Americans born after World War II known as the baby boom generation, the youngest of whom turn 59 this year.

Advocates for homeless people in many big cities say they have seen a spike in the number of elderly homeless, who have unique health and housing needs. Some communities, including Phoenix and Orange County in California, are racing to come up with novel solutions, including establishing senior shelters and hiring specially trained staff.

...

“It’s just a catastrophe. This is the fastest-growing group of people who are homeless,” said Margot Kushel, a professor of medicine and a vulnerable populations researcherat the University of California at San Francisco.

The opinion piece is based on a forthcoming book about the author's 109 year old neighbor.  ("This essay was adapted from “The Book of Charlie: Wisdom from the Remarkable American Life of a 109-Year-Old Man,” by David Von Drehle.")

And these articles are in addition to articles about the debt ceiling negotiations.  Off to read more.

Arizona Feature: "Arizona Seniors At Risk of Harm"

Appearing on the front page of the Sunday edition of the Arizona Republic (5.21.23),  the first paragraphs of an extended feature article point to the potential for harm to residents and the consequences of staff shortages or inattention at Arizona facilicities caring for residents with dementia. Two women in their 90s  are residents of an elegantly appointed assisted living facility-- but as the article begins they are covered in blood -- and the investigation of what happened there is hampered by the inability of anyone to give clear explanations. 

The feature, based on the newspaper's review of "thousands of pages of police and state regulatory reports," offers multiple reasons for such injuries in "senior living" facilities, including a lack of clear reporting rules and the absence of investigation by state agencies, especially for facilities licsenced for "assisted living" as opposed to "nursing home" care.  From the  feature:

In memory care units, anything can become a weapon -- toilet plungers, shoehorns, electric razors, TV remotes, metal trash grabbers and walking canes. Hundreds of vulnerable seniors, particularly those with dementia, contend with violence at the end of their lives in the very places that promise to keep them safe. 

 

Shortages of staff-- brought on by companies looking to maximize profits or stave off financial losses -- lead to more harm. Assisted living facilities can keep resident clashes underwraps [in Arizona] because regulartors don't make facilities report incidents to their state licensing agency.  Federally regulated nursing homes have to report but little attention is paid to the problem.

 

The Arizona Republic combed through thousands of pages of policce and state regulatory reports to find more than 200 clashes at senior living facilities from mid-2019 to mid-2022. Residents punched, hit, pushed, kicked, poked scratched, bit, elbowed or spat on other residents or employees.

Experts consulted by the Arizona Republic noted that one "key [to reducing problems] is tailoring a [resident's] care plan to each resident's needs, equipped with activities that bring their lives a sense of purpose."  Further, "[a]ssisted living facilities commonly get in trouble for having inadequate, delayed or out-of-date plans for residents that outline their need or for failing to follow those plans."

The article cautions that if a problem is not tracked, "it doesn't exist":

The Arizona Department of Health Services licenses facilities and is responsible for investigating complaints but assisted living centers don't have to report nonfatal injuries to the agency.  

 

That's not normal.  Most states require facilities to report to their licensing agency when residents get hurt, according to The Republic's review of state laws.

The feature suggests that "Arizona lawmakers and regulators have prioritized the needs of assisted living and nursing home companies over their residents," comparizing Arizona to  "[a]t least 17 states [that] require assisted living facilities to get inspected about once a year, with a few even requiring two inspections per year. " 

For the full Arizona Republic feature published in its print version on May 21, 2023, look for  "Arizona seniors at risk of harm: Facilities experiencing staff shortage, residents with dementia enable violence," by reporters Caitlin McGlade, Melina Walling and Sahana Jayaraman. The extended Sunday feature appears to follow several shorter articles available online in May from the same reporting team. 

Undocumented Workers in the Caregiving World

Los Angeles Times journalist Steve Lopez has been writing recently on the financial costs of long-term care, whether in the home or a "senior living" setting.  It is part of his series of  "Golden State" columns on California's aging population.   Today, however, he has reversed the lens, and talks about the impact of the need for care on low-wage workers.  He writes: 

I’ve been in homes where the caregivers are U.S. citizens with decent wages and benefits, and I’ve been in homes where the workers are undocumented and paid less than the minimum wage  ($16.04  an hour in the city of Los Angeles)  in cash. It’s a wink-and-nod system, much like farm labor, in which cheap labor is prized over any other consideration.

 

“It’s very much a legacy of slavery and a history in this country of not valuing the work done by … people of color,” said attorney Yvonne Medrano, who heads the employee rights program at Bet Tzedek Legal Services.

 

Several weeks ago I reached out to the the Pilipino Workers Center, a Los Angeles nonprofit that has been educating domestic workers on their rights and leading a fight against a system in which labor laws are often ignored and workers — many of them old enough to be receiving elder care themselves — are cheated and exploited.

Aquilina Soriano Versoza, the center’s director, said research indicates a majority of clients appreciate the care they get and would be willing to pay more for it, but many can’t afford to.

For  a more complete picture, read They Take Care of Aging Adults, Live in Cramped Quarters, and Make Less than MInimum Wage from the Los Angeles Times.

Limited Nursing Home Beds Also Impacting Hospital Availability

On December 7, NPR had a short segment during Morning Edition describing the impact of lack of staffing -- and therefore lack of "beds" --  in nursing homes and rehabilitation care facilities, which in turn means hospitals are stuck keeping the patients. Further, Medicaid often won't pay for hospital care for individuals who "only" need nursing home care. 

Listen to the 3-minute segment that uses hospitals in Vermont as the focus:  Limited Nursing Home Beds Force Hospitals to Keep Patients Longer.

The story hints at several subtle issues, including Medicaid funding priorities, especially as Medicaid involves joint federal/state funding, and how health care handles "inability to pay" by residents.   This last semester I've taught a stand alone course on Nonprofit Organizations Law and students are often surprised to learn that the single largest -- and highest income -- segment of the nonprofit world is health care, especially hospital-based health care.   Students ask how a "charity" accounts for earnings and losses -- and we discuss the fact that no organization, nonprofit or for profit, can afford to operate very long without adequate revenues to stay solvent.    The NPR story reflects a theme that my course often raises -- what does it mean to be "charitable"?  

USA's Fastest-Growing Demographic Group? Consider the Implications of People Age 50+ Who Live Alone

The New York Times Sunday edition includes a feature article about a trend, "more older Americans living by themselves than ever before."  

Using graphs, interviews and research results, the article makes a clear argument, that "'while many people in their 50s and 60s thrive living solo, research is unequivocal that people aging alone experience worse physical and mental health outcomes and shorter life spans." 

Plus, the article implies that evidence that shows a growing share of older adults (age 55 plus) do not have children, means there is a public policy concern "about how elder care will be managed in the coming decades." 

For me, this article crystalizes two legal concepts I write about frequently:  "filial support" laws that can be used to compel adult children to care for or maintain their elders, and "continuing care retirement communities," that permit people with sufficient -- make that significantly sufficient -- financial resources to plan for how their care needs may be handled in a planned community.  

Law professors can probably use the article to stimulate waves of student projects about personal and collective responsibilities in American societies and beyond.  

For more, see  "As Gen X and Boomers Age, They Confront Living Alone," by Dana Goldstein and Robert Gebeloff. 

 

Economic Insecurity for Older Adults

Kaiser Health News ran a sobering article, ‘It’s Becoming Too Expensive to Live’: Anxious Older Adults Try to Cope With Limited Budgets.

Economic insecurity is upending the lives of millions of older adults as soaring housing costs and inflation diminish the value of fixed incomes.

Across the country, seniors who until recently successfully managed limited budgets are growing more anxious and distressed. Some lost work during the covid-19 pandemic. Others are encountering unaffordable rent increases and the prospect of losing their homes. Still others are suffering significant sticker shock at grocery stores.

The article goes on to focus on the circumstances of 3 individuals and the inpact of unexpected circumstances can have on the financial security of someone who worked hard all their lives.

Along the same lines, don't miss this article from the New York Times, Downsizing in Retirement: Expenses They Didn’t Expect. 

Focusing on unexpected expenses that arise from downsizing, such as making improvements in order to sell the house and closing costs related to the sale, the article also discusses the impact of the housing market and interest rates on the ability to sell the house, the costs incurred in finding a new home, and of course, who can forget, taxes associated with the sale of the home.

The Myriad Benefits Available to Older Persons

Kaiser Health News published a recent article that focused on the various programs and benefits for older persons that they may not know about.  While Inflation Takes a Toll on Seniors, Billions of Dollars in Benefits Go Unused offers these examples to make the point:

A few examples: Nearly 14 million adults age 60 or older qualify for aid from the federal Supplemental Nutrition Assistance Program (also known as food stamps) but haven’t signed up, according to recent estimates. Also, more than 3 million adults 65 or older are eligible but not enrolled in Medicare Savings Programs, which pay for Medicare premiums and cost sharing. And 30% to 45% of seniors may be missing out on help from the Medicare Part D Low-Income Subsidy program, which covers plan premiums and cost sharing and lowers the cost of prescription drugs.

And yes, the article acknowledges that for many programs, eligibility is based on a means test, while for others, it's just a priority.  The article offers tips to find out if an older person is eligible for any of these programs, starting with the local Area Agency on Aging.

Is Florida Still An Affordable Retirement Option?

That's the question that was asked in a recent article in the Tampa Bay Times. Is Florida still an affordable place to retire? Amid rising costs, some seniors are reconsidering. Let me set the stage with this excerpt:

Cheaper than Miami or Naples, with destination beaches and a city once nicknamed “God’s Waiting Room,” Tampa Bay has long been hailed as an affordable place to retire in The Sunshine State.

But it’s becoming untenable for many seniors to survive in the area.

While costs are climbing everywhere, Tampa Bay’s prices have outpaced the national average. Area prices rose by roughly 11% in the last year, according  to the U.S. Bureau of Labor Statistics, compared to just 9% nationally.

Retirees, who depend largely on fixed incomes, are feeling it.

Read the article and draw your own conclusions. I have.

Know About NORCs?

The Ocala Star Banner newspaper ran a guest column explaining NORCs.  Naturally Occurring Retirement Communities give seniors the help they need to age in place explains  that "Naturally Occurring Retirement Communities (NORCs) are self-help communities that started springing up in 1992 with the founding of Community Without Walls in Princeton, N.J. They are not a formal community, but occur naturally in neighborhoods in small cities and urban areas, and are not cohousing. " 

The article highlights the versatility of NORCs: "[w]hile NORCs were first identified in urban settings, they can be found in communities large and small. They can be geographically defined by such boundaries as an entire apartment building, a neighborhood or a more rural setting over a large geographical area comprised of one- and two-family homes. Sometimes a NORC is not a physically connected locatioh, , but loosely organized around a church, synagogue or fraternal organizations."

Thanks to Julie Kitzmiller for sending me the link to this article.

Do Federally Exempt Nursing Homes, Assisted Living, and Continuing Care Communities Also Qualify as "Institutions of Purely Public Charity?"

The latest in a series of senior-care related cases is making  its way through the Pennsylvania appellate courts, asking whether a federally tax exempt senior living facility -- one that offers a range of options including independent living, "supported" independent living, personal care, and skilled care, although it isn't licensed as a CCRC -- can also qualify for state property and sales tax exemptions. 

Pennsylvania, in ways similar to many states, allows a federal charitable tax exemption under Rev. Code Section 501(c)(3) to serve as the basis for state exemptions from income taxes, but a separate state statute sets tougher requirements to qualify as a "purely public charity" in order to avoid responsibilities to pay real property, sales and use taxes.  Nursing homes, intermediate care settings (such as personal care or assisted living), and continuing care retirement communities (CCRCs) often rely on federal revenue rulings that recognize historical grounds to exempt "homes for the aged" from taxation.  See e.g., Rev. Rul. 72-124 (also available at 1972 WL 30720).  But on a fairly regular basis, Pennsylvania taxing authorities have challenged such enterprises as not being "sufficiently" charitable.  Compare, for example In re St. Margaret Seneca Place, 640 A.2d 380 (Pa. 1994) (upholding state tax exemptions for a nursing home) with Appeal of Dunwoody Village, 52 A.3d 408 (Pa. Commw. 2012) (denying state tax exemption for a CCRC).   In September 2021, a panel of the Commonwealth Court of Pennsylvania, using a "totality of the circumstances" approach concluded that the facility failed to donate a substantial portion of its services, and failed to show it benefits a substantial and indefinite class of persons who are subjects of charity.  See  Friends Boarding Home of Western Quarterly Meeting v. Commonwealth, 260 A.3d. 1064 (Pa. Commw. 2021).

The case is now under  review for en banc consideration by the full Commonwealth Court, and there are indications the case might go all the way to the Pennsylvania Supreme Court.  Working with my former Elder Protection Clinic colleague, Douglas Roeder, Esq., we examine a series of cases and trends under Pennsylvania law, including those involving senior living enterprises,  as reasons to consider larger implications for federal and state exemptions based on charitable grounds.  See Putting the Charity Back in Purely Public Charities (July 2022). 

Multi-Generational Housing Article

Last week the Wt featured an article about an elder taking on a college student as her roommate. One roommate is 85, the other is 27. Such arrangements are growing. For these two roommates, they learned about each other through an agency, "Nesterly, an online home-sharing agency that matches young renters with not-so-young people looking to supplement their incomes and share their space."  The arrangement is more than just renting space. For these two roommates, "[the owner] would rent the first floor of her home to [the college student] for $700 a month in exchange for help with the housework and gardening and occasional grocery runs. And [the college student] would get a safe and spacious place to live just six miles from Boston and a 30-minute drive from her robotics engineering job in Beverly, Mass.

Is multi-generational housing growing in popularity? According to the article

About 18 percent of Americans live in multigenerational households — meaning two or more adult generations — according to a study from Pew Research Center published this year. Such arrangements have quadrupled in the United States since the 1970s, with about 60 million U.S. residents now living with adults who are of a different generation, according to the study.

Contributing to that trend is that more young people are priced out of the housing market and more seniors want to age in place, said  [the] executive director of Generations United, a D.C.-based organization that focuses on programs and policies that connect generations.

The article notes that some universities offer such intergenerational roommate matching programs.Seems like a win-win!

Podcast on Quality SNF Care

The National Consumer Voice for Quality Long-Term Care has a podcast on Pursing Quality Long-Term Care. Here is a short description of the podcast: "Long-term care is or will be a fact of life for many of us and our loved ones as we age. We all deserve care – whether in the home or in a long-term care facility – that meets the highest of standards, enhancing quality of life and ensuring the protection of rights."  You need iTunes to listen. This is one in a series of topical podcasts, which you can access here.

 

Planning Housing for Old-Old Age

My friend and colleague, Mark Bauer, sent me the link to this article, How to design homes for life well beyond 100. According to the article, 

The world is getting older. By 2050, the global population of people in their 80s will be three times what it is today. According to the Stanford Center on Longevity, half of all the 5-year-olds currently living in the U.S. can expect to make it into their 100s. Harvard Medical School aging researcher David Sinclair suggests that the first person to live to age 150 has already been born.

It’s too early to predict all the ways that longer lives will change society, but at least one industry is starting to make some guesses. The developers, designers, and operators of senior housing are thinking about and planning for how these demographic shifts will affect their businesses and the services they provide.

To get ahead of the curve, some are designing their facilities for people who will technically be seniors for more than 40 years. They’re learning from communities around the world where people tend to live the longest and reconsidering the golf courses and bingo halls that were once central leisure activities. They’re also trying to design features that enable people to be healthy and active as long as possible.

Here is an intriguing thought from the article-there could be 3 generations of elders from the same family living in the same housing complex! It's a thought-provoking and informative article!

New Article on Reverse Mortgages

CNBC ran an article last month  Here’s what you need to know about reverse mortgages. Here's what the article points out

With the stock market getting volatile but the housing market still hot, reverse mortgages have become a more attractive tool for older Americans who need cash for retirement but want to stay in their homes.

Home Equity Conversion Mortgage loan volume was up 26% in March, according to data from the U.S. Department of Housing and Urban Development reported by service provider Reverse Market Insight. It dropped 3.8% in April but remained well above 6,000 loans for the month — above the average in the last few years.

As the article notes, a significant number of elders have home equity, "about 66% of the average retired American’s wealth," although costs are higher as a result of  a 2017 HUD rule change. The article lists and discusses the pros and cons of reverse mortgages. 

Residents Are Asking a Lot of Questions -- Tough Questions -- about CCRCs

It is Sunday, and I'm looking at a long list of things to do next week, with grading exams at the top of my list.  Significantly, however, in the last six to eight months, at increasing rates, I'm hearing from current and prospective residents of Continuing Care Retirement Communities (CCRCs, also sometimes called Life Plan Communities).  Here are examples of some of the most often asked questions:

• "The company that runs my CCRC is about to engage in development of a new CCRC.  Is the money I've already paid in the form of an admission fee, or the money I continue to pay as monthly service fees, going to support this new development?"
• "During the lock-down associated with protecting residents and the public from COVID-19, we were asked to give up services that were the very reason we choose this community.  But now that we are no longer locked down, the services either are not returning or the fees we are charged are actually increasing.  Is there some effective way to object to this disconnect between the promises and the delivery of services?"
• "My parents are thinking about moving into a CCRC.  On the one hand, I like the idea of the active community they are choosing.  But on the other hand, the amount they are expected to pay in the form of an admission fee is astounding.  Why are some communities calling this a refundable fee and others are saying it isn't a refundable fee? What are the protections for the 'refundable' fee?"
• "We have just learned that our nonprofit CCRC is being transferred to a for-profit company as the owner-operator.  How is this likely to impact my wife and I as residents?"

Answers to many of these questions depend on the state's laws governing this form of senior living operation and, even more, on the particular contracts between the resident and the provider.  State regulators have concerns here too.  For those looking for legal assistance in their particular community, I sometimes recommend looking for attorneys in the caller's home state, someone who understands CCRCs from a resident perspective. I first wrote about the need for attorneys who understand resident perspectives in 2006.  

Sometimes "elder law" attorneys have this expertise, but not always.  Plus, it can be important to consult with an attorney who understands consumer protection laws, and not "just" CCRC law.  Finally, if litigation is actually on the horizon, the choice for legal advice can depend on whether the attorneys have expertise in litigation or dispute resolution and not "just" contract law. 

So, all of this is a short way of saying that even though, as an legal academic,  I often write about the importance of resident rights in CCRCs, and even though I believe the future of CCRCs is very much tied to the answers, I'm not in a position to respond to individual questions. The very fact that I'm writing this Blog Post is a potential indication that something important could be going on in the industry.  Perhaps that "something" should be addressed by the industry itself, especially if it wants the CCRC concept not just to survive, but thrive.  In my opinion, it is not enough for the industry to say that "every CCRC is different."  

RFP: Washington State Seeks Expert Consultation to Develop CCRC Regulations with Heightened Consumer Protections

I'm always interested when I start getting lots of calls or emails about a certain topic in aging.  Today I was hearing from a lot of people wanting to talk about Continuing Care Retirement Communities (CCRCs, sometimes also called Life Plan Communities or LPCs). It is safe to say that all forms of senior living operations are facing new challenges after being hit hard by the lockdowns and staffing problems of the last two years with COVID-19.

But one of the most interesting set of calls was from the State of Washington, where residents have been using their time together during COVID to think carefully about the need for certain key protections for consumers who put their money and trust into CCRCs.  The Washington Continuing Care Residents Association (WACCRA) has worked carefully, calmly and diligently to reach the ears of legislators and regulators in the state.  I had the pleasure of hearing from  members and residents of CCRCs in Washington last October and speaking at their annual meeting. 

Today, I heard that the  Office of Insurance Commissioner in Washington has initiated a Request for Proposals for a time-sensitive research project:

This project is designed to assess federal and state authorities regulating continuing care retirement communities (CCRCs) and provide a report with recommendations on creating a legal framework for shared regulatory oversight of CCRC products under Chapter 18.390 RCW, which may achieve heightened consumer protections.

Interested researchers -- with background in regulatory systems for CCRCS -- should act quickly as the deadline for submissions is May 23, 2022.   

Click HERE FOR THE FULL DETAILS!  

Smart Home Tech Makes Aging in Place Easier

The Washington Post recently published this article, Aging in place can be so much easier with smart home technology. "Supporting health, safety and security are important components of successfully aging in place. So are home management systems that maintain a comfortable environment, and communication and recreation systems that enable social engagement, stimulation and entertainment."  As the article notes, the type and amount of tech is vast, ranging from pretty simple types that do just a little, to more comprehensive setups that integrate into much of every day life.  The article focuses on two couples who added tech to their homes.  It also looks at the pros and cons, as well as advances and includes a list of recommendations.  The article also mentions concerns about privacy and how to mitigate that. I would also add the topic of consent, when family want to install the tech in the home of the elder.  Lots of good info in the article.

Reverse Mortgage May Not Be A Last Resort Any Longer

Professor Naomi Cahn sent me the link to this recent article in the New York Times, Reverse Mortgages Are No Longer Just for Homeowners Short on Cash. "Until recently, it was conventional wisdom that a reverse mortgage was a last-resort option for the oldest homeowners who desperately needed cash. But a growing number of researchers say these loans could be a good option for people earlier in their retirement like [those]  who are not needy at all."

The article offers the basics about reverse mortgages and offers some insights into the thinking about greater utility of reverse mortgages:

Homeowners in their 60s and early 70s could use cash from a reverse mortgage to protect investment portfolios during market downturns, to delay claiming Social Security benefits or to pay large medical bills.

“The best use of this tool is to provide and supplement income during retirement,” said ... the director of the financial planning program at the University of Illinois, Urbana-Champaign. “A younger retiree can stay in the house while turning equity into an income stream.” 

The article discusses downsides for folks to consider as well.  Read it!

 

 

Increase in Multi-Generational Housing

Pew Research Center recently released a report on multi-generational housing. In Financial Issues Top the List of Reasons U.S. Adults Live in Multigenerational Homes   consider this key finding:

A third of U.S. adults in multigenerational households say caregiving is a major reason for their living arrangement, including 25% who cite adult caregiving and 12% who cite child care. Among the other reasons given for living in a multigenerational household, 28% say it’s the arrangement they’ve always had, while smaller shares cite a change in relationship status (15%), or companionship (12%) as a major reason why they live with family members. About one-in-eight adults (13%) say the coronavirus pandemic is a factor in why they live with multiple generations under one roof.

Breaking it down by age, the report notes that

[A]mong the oldest Americans – ages 65 and up – 20% of women live in multigenerational households, compared with 15% of men. Older Americans are less likely to live alone than they were several decades ago, a change linked to the growing share of older women who live with their spouse or children. 

By broad age group, Americans ages 25 to 39 and those ages 55 to 64 are about equally likely to live in multigenerational family households (each 22%). But within the younger group, those ages 25 to 29 (31%) are far more likely to live with multiple generations under one roof than those ages 30 to 34 (19%) or 35 to 39 (15%). 

The full report is available here.

You Don't Have to be a Parrot Head to Retire to Margaritaville

As the New Yorker explains in Retirement the Margaritaville Way, this active adult community was a logical step, "[g]iven the age of Buffett’s fan base, and the life style he’s hawking—as well as baby-boomer demographics... . The development in Daytona [Beach, Florida} was a joint project of Margaritaville Holdings and Minto Communities USA, the American branch of a builder based in Ottawa. In 2017, Minto had bought roughly two thousand acres of brush and swamp, about seven miles from the coast... [with] a plan to develop a retirement community there called Oasis. [which then] became Latitude Margaritaville, taking its name from Buffett’s breakthrough 1977 album...."  The article describes a number of features of the community and interviews with various residents.   And although you don't have to be a parrot head to retire to Margaritaville, you might have more fun if you are.