By Jennifer M. McGivney
A new LTSS Center study defines a growing but long-neglected segment of the older population.
A growing number of older adults live in an economic gray area: They’re not poor, yet they can’t afford to pay for long-term care without significantly cutting into their everyday expenses.
Marc Cohen, co-director of the LeadingAge LTSS Center @UMass Boston, and many others now refer to this group as the “Overlooked Middle.” It’s a group that has received little attention from both policymakers and researchers—until a project this year brought their needs into sharp focus.
About the Research and its Benefit to LeadingAge Members
When the California Department of Aging contacted the LTSS Center @UMass Boston to lead research on long-term care financing, Cohen focused the project on the Overlooked Middle. Who are they? How much money do they have? What concerns do they have now—and in the future—as they age? What programs could help them?
“This research would give us a clear conceptual definition of who this population is,” Cohen says. “How you actually operationalize a definition of the Overlooked Middle is really important, because a group must be defined to create targeted policy solutions.”
Benefit to LeadingAge Members: The research also could benefit LeadingAge members in California and beyond, says Cohen.
“LeadingAge serves the overlooked middle; this is precisely their customer base,” says Cohen. “This research will give insights to providers about the population group that, by and large, they serve. On an aggregate level, providers can learn what these people care about, which programs they seem to like. It can help people prioritize current offerings and help develop new ones.”
The Research Team: Cohen and Dr. Gretchen Alkema of Wolf Eagle Enterprises assembled a group of highly regarded researchers to join a team that included his colleagues at University of Massachusetts Boston Gerontology and:
- The Urban Institute
- Harvard’s Joint Center for Housing Studies
- NORC at the University of Chicago
- Collaborative Consulting
- Community Catalyst
- ATI Advisory
The team collaborated to study the Overlooked Middle and present existing programs that could meet a critical need: helping people afford, find, and benefit from long-term care if they need it, while preserving their ability to pay for basic living expenses. The result is the comprehensive new report, Recognizing the Overlooked Middle: California’s LTSS Financing and Affordability Initiative.
An Interview with Marc Cohen
Cohen shared insights from the research process: what the team learned about the Overlooked Middle and how those findings can lead to change not only in California but across multiple states.
Who, exactly, is included in the Overlooked Middle?
Our research began with this question. Who is the Overlooked Middle? And how many people in California are part of the Overlooked Middle?
We used the Elder Economic Security Index, developed by the Gerontology Institute at UMass Boston, to determine how many people can afford basic living expenses: food, housing, medical care, and transportation. To be part of the Overlooked Middle, people need to meet two criteria.
One, they can afford basic living necessities but would need to cut back on those expenses if they needed a moderate amount of home and community-based services.
Two, they currently do not and likely would not qualify for Medicaid to help them pay for long-term services and supports.
Based on these criteria, the Overlooked Middle included people with incomes between 139% and 500% of the federal poverty level. Single people in California who make between $21,000 and $102,000 are part of the Overlooked Middle. Overall, 40% of the over-50 population is in this group.
What organizations contributed to this body of research?
The Urban Institute did population estimates and projections for the state and each county that captured socio-demographic characteristics: How many people in the Overlooked Middle are in each county in California? How many of them will have a long-term care need? They projected these figures out to 2050. Then our UMass Boston Gerontology researchers took that data to develop interactive maps that can easily display that information.
Harvard’s Joint Center for Housing Studies investigated home equity: What role could home equity play in long-term care financing? How much home equity do people in this population hold? Would they be willing to tap into it in order to age in place?
Among many other contributions, Wolf Eagle Enterprises conceptualized and defined the concept of “longevity assets” for this group that go far beyond the standard definition of financial assets, necessary for aging in place. In addition to wealth, these assets include social connectedness, housing stability, health, community resiliency, and autonomy over care choices. The Overlooked Middle views these assets as critical to assuring a successful aging path.
We felt strongly that we would learn a lot by listening to people’s concerns, so we did a statewide survey with NORC at the University of Chicago and listening sessions with Collaborative Consulting and Community Catalyst. At the same time, ATI Advisory inventoried innovative programs across the U.S. that already help middle-income older adults. They compiled 200 of these programs into a compendium. To complement this, UMass Boston researchers created a compendium of Medicaid innovations designed in some cases to expand eligibility or service offerings to help the overlooked middle – people who are not quite eligible but may be close enough.
What did your group learn about the concerns of people in the Overlooked Middle during those surveys and listening sessions?
Among other things, we learned that people in the Overlooked Middle want to have someone to call when they have questions about long-term care. They want the connectedness. If someone with Medicaid has a question, there’s an infrastructure that gives them someone to contact. But when something happens to people in the Overlooked Middle, whom do they call for advice? They don’t want to look at a website; they want a staffed phone line that allows them to talk to a human about their particular situation.
People also told us that control and autonomy over their health choices was very important to them. This was why many of them favored the idea of having home care paid by Medicare, rather than the social safety net program, Medicaid. With Medicare, they’d have control.
Would that be possible? Could Medicare be part of the long-term care financing solution?
An enormous piece of this project was exploring how to potentially leverage the Medicare program. Currently, Medicare does not provide home and community-based coverage for people with long-term care needs. But could there be a Medicare model that would save money in acute care costs and finance home care costs?
ATI Advisory and Milliman, the actuaries, worked together for over a year and came up with such a model. People are starting to look at this and consider it, and it’s really fantastic. It’s called the Medicare Advancing Home and Community Based Care Model.
In what other ways did this research contribute new insight into older adults’ long-term care needs?
First, this research gave us a clear conceptual definition of who this population is. Secondly, it catalogued this population’s unique concerns and challenges. Many of these are particularly relevant to California; different states will have different issues. For example, California has particularly challenging housing costs, and many people shared worries about housing stability. That might not be the same in Mississippi or Kansas, which could have their own particular challenges. While there might be differences, there are attitudes and concerns that will resonate across the country. There’s not a state in the union that wouldn’t love to see that Medicare model we developed.
What comes next? How can California use this research, and how might it extend to other states?
California now has a tool with county-level information that can help them plan for this growing population. They know what resonates with people. They also have a compendium of 200 different kinds of programs so that they don’t have to reinvent the wheel. This is a menu of functioning programs around the country, and they can connect with others to ask, “How’d you do this? What does it cost? What are the opportunities?” They can hear about real programs and real solutions to learn what might work for them.
My hope is that other states will do this kind of work, too – work that allows them to build basic information and knowledge about this population so they can address the very real needs that this population has. We have a lot of expertise in this area and can help states gather the information they need, assess their options, and develop plans to address the needs of the Overlooked Middle in their jurisdictions.
To see the final report, as well as population analytics, consumer perspectives, and policy analysis, visit: Recognizing the Overlooked Middle: California’s LTSS Financing and Affordability Initiative.