Four Challenges to Aging in Place

by Jennifer Molinsky
Senior Research Associate

Within 20 years, one in five Americans—almost 80 million people—will be older than 65 and, surveys indicate, they will want to remain in the current homes for as long as possible. However, the country currently lacks the accessible housing units and supportive social services needed to accommodate these desires.

Four challenges are particularly noteworthy, according to Projections and Implications for Housing a Growing Older Population, a recent Joint Center report which also projected that the share of households headed by someone over 65 will grow from 29.9 million today to 50 million in 2035. In particular:

• Most U.S. homes are not accessible for older people with limited mobility
• Many older Americans living at home will need long-term care, which is expensive
• Millions of older adults cannot afford their current housing units
• Older adults who live at home are often isolated

Challenge #1: Making Housing Accessible

A growing older population will mean greater numbers of households that include someone with a disability (Figure 1). Indeed, the Joint Center projects that by 2035, 17 million older households will include at least one person with a mobility disability for whom stairs, traditional bathroom layouts, and narrow doors and corridors may pose challenges, a 77 percent increase from today. Yet only 3.5 percent of US housing units offer a zero-step entrance into the home, single-floor living, and wide doorways and hallways that accommodate someone in a wheelchair.

Notes: Mobility disability is defined as difficulty walking, getting in and out of bed, and climbing one flight of stairs; self-care disability as difficulty eating, dressing, toileting, and bathing; and household activity disability as difficulty with meal preparation, food shopping, using the telephone, taking medication, money management, housework, and driving.
Source: JCHS tabulations of University of Michigan, 2014 Health and Retirement Survey.

The costs of improving safety and accessibility range from free (e.g. removing throw rugs) to costly (e.g. a new addition to enable single-floor living). Preparing ahead, at a time when the no one in the household has limited mobility disabilities, can help lower the financial and emotional cost of these changes—for example, during a bathroom remodel, adding reinforced walls can make the later addition of grab bars much simpler, while choosing a walk-in shower can eliminate the need to add one later. For some, merely identifying modification needs and finding a contractor or handyman to make changes can be daunting. Consequently, resources that can connect people to trustworthy sources to assess the home and find capable workers will be an important part of any efforts to support aging in place.

However, a sizeable share of homeowners will need financial assistance to make these changes. Today nearly 10 percent of all older homeowner households have less than $50,000 in total assets including the value of their homes. (Excluding the value of the home, 39 percent have less than $50,000.) Going forward, trends in income, wealth, and debt suggest that older adults may have even fewer assets in the future. Helping older adults with limited means finance modifications through tax credits, low- or no-interest loans, grants, or expanded Medicaid waivers for needed modifications will be important.

Renters, particularly those living in older, less accessible units, may be in more difficult straits. Even though federal law generally requires that landlords allow tenants with disabilities to make necessary changes to their units, renters—whose median wealth is only $6,000—typically must do so at their own expense. Furthermore, landlords may require the modifications be removed at renters’ expense upon leaving.

Challenge #2: Providing Long-Term Care 

The Joint Center projects that the number of older adult households in which at least one person has a self-care disability will reach 12 million by 2035; many of these households will require daily assistance with personal care if they are to stay in their homes. (This is consistent with an often-cited 2005 study by Peter Kemper, Harriet L. Komisar and Lisa Alecxih estimating that nearly 70 percent of adults who reach the age of 65 will need some form of long-term care later in life.) Indeed, this type of care is increasingly being offered in people’s homes. Nursing home usage has declined in the past two decades, a trend likely to continue as health and housing partners build partnerships to deliver care at lower cost to private residences. In addition to assistance with personal care, by 2035, we project that 27 million older Americans will need help with other household tasks such as shopping, housework, or paying bills.

Yet long-term care currently is expensive. The median monthly cost for a home health aide working five days per week is $3,813. The typical older renter could afford just two months of these services before exhausting their savings. While the median older homeowner is better situated, many have limited resources—and as noted above may need these to make modifications to their homes.

Today most assistance is provided by family members, including spouses, at least in part because of high costs. However, in the future fewer family members will be available to the next generation of older adults, because the number of households with few or no children, as well as single-person households, will rise. For individuals, factoring in the potential costs of paying for in-home support and care is an important part of planning for aging in place, but policy has a role as well in encouraging innovation of cost-effective care delivery in the home.

Challenge #3: Ensuring that Housing is Affordable 

Affordability is and is likely to remain a significant obstacle to aging in place. In 2014, 31 percent of older households were cost-burdened (i.e. they spent more than 30 of their income on housing). Holding cost-burdened shares by age, race/ethnicity, and tenure constant, the Joint Center projects that by 2035, 17.1 million older households will be housing cost-burdened, and 8.5 million of these households will be spending more than 50 percent of their income on housing.

Given lower incomes, older renters are more likely to be cost-burdened. However, with a homeownership rate approaching 80 percent for older households, owners are more numerous and make up the majority of cost-burdened older households. In particular, owners who carry mortgages into older ages—a trend that has increased over the past 20 years—are at higher risk of experiencing unaffordable housing costs. Households that are housing cost-burdened typically cope by cutting back on other necessities, such as food, healthcare, or transportation. These tradeoffs put older adults’ health at risk and limit their opportunities to engage in their communities and access needed services.

For homeowners, the challenge of high housing costs might be met with prudent and early financial planning, reverse mortgages or refinancing, relief from property taxes, or help increasing home energy efficiency and lowering utility costs. Renters have fewer options, as rental subsidies are in short supply. By 2035 the Joint Center projects that the number of older adults eligible for rental housing subsidies will grow to 7.6 million from just under 4 million today. Currently the nation provides subsidies to only about one-third of those eligible; simply maintaining this level for seniors in 2035 would require providing subsidies to an additional 1.3 million households, which would more than double the number of older people who are being assisted today.

Challenge #4: Reducing Isolation

Ensuring older households are able to connect with their neighbors and access services in their communities and beyond is as critical to aging in place as preparing one’s home and finances. One can be isolated anywhere, even in a city if streets are perceived as unsafe, or if friends or needed services are not nearby. There are, however, ways to capitalize on a localized population of older adults to deliver services, through organizations like “villages” or those that serve naturally occurring retirement communities (NORCs), such as large apartment complexes that are home to significant numbers of older people.

Isolation is a particular concern for those aging in low-density and rural locales. The new study found that that just under half of older households are located in areas of metro regions with less than one housing unit per acre, or outside metro regions entirely (Figure 2). When older adults curtail or give up driving—a share that exceeds 50 percent for those in their mid-80s and above—people living in these locations can be particularly isolated.

Notes: Areas are defined as census tracts. High-density metro areas have at least 2028 housing units per square mile; medium-density metro areas have between 644 and 2028 housing units per square mile; and low-density metro areas have less than 644 housing units per square mile. Connected and isolated non-metro areas are defined using USDA Rural-Urban Commuting Area codes.
Source: JCHS tabulations of 2010-2014 American Community Survey 5-Year Estimates and USDA Rural-Urban Commuting Area codes.

Alternative transportation, such as paratransit or car-share services, as well as technology that enables virtual medical appointments and social interaction, will be key. But individuals in these lower density areas, and the organizations and governments that serve them, will need to consider how to expand programs to ensure older adults can access services and remain engaged in their communities.

Moving Forward

These challenges do not mean that aging in place is an impractical or an unworthy goal, but rather that there is much planning to be done at both the individual and societal level. Educating households about the financial and physical challenges they might face if they remain in their current home and the options available to address them is an important first step. So is ensuring that local governments understand and plan for the challenges their older residents will likely face.

For some, though, alternatives to a current residence may prove to offer a higher quality of life. Therefore, we also need to create new housing options that offer accessibility features, are located near to shopping and services (or in a multifamily building that provides services), offer flexible space (perhaps including space that can be occupied by caregivers if needed), and are aimed at a people with range of incomes, including low-income renters. Developing housing with these features in the centers or downtowns of small towns and suburbs where older adults already live can provide alternatives that allow longtime residents to maintain ties to their communities. Since one in three US households will be headed by an older adult within 20 years (up from one in five today), we need to start taking these and other steps as soon as possible.

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Jennifer Molinsky will be a panelist at our March 6 event Housing and Policy in an Aging America. This event will be free and open to the public.

Disability Housing - Best Practices and New Solutions

Micaela Connery
2015 Research Fellow

This summer I’m moving. Again. It will be my sixth “residence” since graduating college. Over the last seven years, home has included a three bedroom apartment in Somerville, my parent’s basement (Cellar Dwellers Unite!), a grad school dorm where adults regress to freshman status, full-size bunk beds on the Lower East Side (full-size bunk beds are a real thing), and a bedroom that was actually a closet found somewhere deep in a Brooklyn craigslist. Despite all the quirks that came with each dwelling place—communal showers, head whacks on the top bunk, et cetera—each one was home in some special way.

But, for many adults with disabilities, a suitable home is hard—sometimes almost impossible—to come by. In the time that I moved five times, hundreds of thousands of individuals with disabilities across the U.S. have sat on housing waitlists. They’re waiting, often many years, to make just one crucial move, the move out of their parent’s home into community or independent living. The United States spends over $77 billion dollars annually on special education, often working to prepare individuals with disabilities to be successful, independent, and included. Yet those opportunities for independence inclusion are almost non-existent after exiting the school system. We spend billions in public funds preparing individuals with disabilities for opportunities they may never be able to have.

The most obvious issue here is funding and availability of housing offerings. Most state agencies who are on the front lines of addressing this need are finding there simply isn’t enough public funding to support placements and support services for the high number of individuals with disabilities who need it. As state developmental services budgets are cut and numbers of adults with disabilities increase, the challenge is only growing over time.

While increasing funding (or at least preventing budget cuts) is a key part of the solution, it will only incrementally address the growing waitlists for housing services. Absent an increase in the supply of suitable housing options, funding alone won’t likely fix the problem. Many providers, families, and organizations have taken it upon themselves to innovate new solutions to housing placements; experimenting with different operational structures, engaging private funders, rallying parent support, and innovating new housing models. By understanding what makes these innovative models effective, and where they face challenges, policymakers can better support new solutions for the disability housing crisis. With support from the Joint Center, I spent last summer examining a few of these approaches and what we can learn from them, and have reported my findings in the paper “Disability Housing: What’s happening? What’s challenging? What’s needed?”.

Perhaps the most obvious finding from spending time with consumers and providers is that one size does not fit all. While there are some common best practices—engaging families, supporting choice, linking to employment and transit, and retaining quality staff—there is not one single housing type or model that is right for all people with disabilities. As for people without disabilities, what people want their home to look like varies greatly. Some people desire an apartment in a city while other prefer a house with lots of land in a more rural neighborhood. Some people want to live alone and other want to be surrounded by lots of friends, family, and activity. Policies must support a range of options and choices for individuals with disabilities.

The second key issue in finding housing solutions is the right to risk, meaning that housing options shouldn’t be unduly constrained by concerns about residents safety. A right to risk would bring a willingness to innovate and provide support for experimenting with new models. Policymakers and regulators, perhaps wary of litigation, seem to be resistant to anything that may lead to failure or risk. They want to protect people with disabilities, sometimes at any cost. But people with disabilities should be allowed to take risks themselves and providers should be supported to innovate with new approaches. While we should protect people as best we can, we can’t let protection stifle new ideas. The only way disability housing can improve is if we give it space to innovate, and even make mistakes.

While providing housing and adult services for people with disabilities presents challenges, it’s also full of opportunities. It’s an opportunity to better integrate our communities. Thinking about these issues helps us reexamine what it means to support quality and affordable housing for all populations, not just those with disabilities. It’s an opportunity to re-evaluate and innovate around how we create communities, connect with our neighbors, and age within our homes. With the right program design and service delivery, we can start to change the predominant concerns of parents of children with disabilities. No longer will they worry, “Where will my child live after I die?” or “Who will care for my child?” Instead, they can wonder: “Which housing option is right for my child?” And most of all: “What community will be lucky enough to have my child as a member?”

Individuals with disabilities and advocates have been fighting for thoughtful supports, inclusion in communities, and independent living since the 1960s. The challenge isn’t new, but the solutions will need to be.

Micaela Connery was a summer research fellow for the Joint Center for Housing Studies. She is an MPP Candidate at Harvard Kennedy School focusing on disability, inclusion, and community development. She is a member of the inaugural class of New World Social Enterprise Fellows at the Center for Public Leadership at Harvard. She will continue with her studies as a Mitchell Scholar in the Fall of 2016, pursuing her MBA at the Smurfit School at University College Dublin.

She is presenting a Housing Studies Seminar on this topic at noon on Friday, April 27, 2016 at the Joint Center offices. See our calendar listing for more information.

Older Homeowners Want to Age in Place but Aren't Focused on Accessibility

by Abbe Will
Research Analyst

With many baby boomers reaching retirement age this decade, a major shift in the age distribution of U.S. households is underway. According to recent Joint Center projections, the number of householders age 65 and over is set to increase by 9 million from 2010 to 2020. Many of these older adults will choose to remain in their current homes and “age in place” while others will look to move into homes that are better suited to their changing needs. New survey data from The Demand Institute—a joint venture between The Conference Board and Nielsen—sheds light on homeowner attitudes toward aging in place and accessibility needs, including major motivations for upcoming remodeling projects. This extensive survey, fielded in the summer of 2013, asked households about their housing attitudes, household finances, major household purchases, community and commuting, future moving intentions, housing and neighborhood needs, and home improvement plans and motivations.

A preliminary analysis of the Demand Institute’s consumer housing survey data indicates that older homeowners do not consider aging in place and home accessibility as going hand in hand. Although the vast majority of homeowners age 50 and over report that being able stay in their home as they age is very important (88 percent ranked this statement 8, 9, or 10 on a scale of 1 to 10, where 10 is extremely important), less than 35 percent of older owners place the same level of importance on having a home that is accessible to persons with special health needs or disabilities.

Indeed, 7 out of 10 older homeowners do not have any plans to move in the future, meaning they intend to age in place. But even among those who do plan to move at some time in their later years, only 36 percent cite accessibility as an important characteristic of their next home. This is a meaningful statistic given that the 2011 American Housing Survey estimates that almost 30 percent of older homeowners have a disability or significant difficulties doing typical activities around the home without assistance, which would indicate some need for home accessibility features. The share of homeowners with disability or impairments rises dramatically with age to 46.4 percent of homeowners age 70 or older.

Unfortunately, older homeowners are largely not focused on accessibility needs as part of aging in place. While 45 percent of older owners report being somewhat or very likely to do a major remodeling project (costing $2,000 or more) on their primary home in the next three years, few of them are likely to list “accommodating health needs” or “making the home easier to live in as they age” as major reasons for their next renovations. Only 8.0 percent of homeowners age 50 and over who plan to do a major remodeling project in the next three years plan to do so to accommodate the health needs of someone in the household, and only 15.3 percent want to renovate specifically to make their home easier to live in as they age. Even those older owners reporting that accessibility is important to them are not much more likely to cite accessibility (16.0 percent) and aging in place (23.4 percent) as major reasons for upcoming remodels.

Notes: Major renovations are defined here as costing $2,000 or more.  Homeowners placing high importance on accessibility ranked having a home that is accessible for people with special health needs or disabilities as 8, 9, or 10 on a scale of 1 to 10 where 10 is “extremely important.” Source: JCHS tabulations of the Demand Institute’s 2013 consumer housing survey data.

Certainly as the number and share of older households increase significantly in the coming decades, the demand for homes with accessibility features for safely aging in place will also grow substantially. Yet, given the attitudes of today’s older homeowners, the remodeling industry will need to bridge a significant gap between owners wanting to age in place and being able to do so safely with appropriate accessibility features.

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On Tuesday, September 2, the Harvard Joint Center for Housing Studies and AARP Foundation will release a new report, Housing America's Older Adults—Meeting the Needs of An Aging Population, which will look at these and other issues affecting America's aging population.

Join us for the live webcast at 11:00 a.m. (Eastern) on September 2, and follow the conversation on Twitter with #housing50.

Crossing the Threshold: Problems and Prospects for Accessible Housing Design

by Wanda Katja Liebermann
Meyer Fellow

America is at the confluence of two opposing demographic tides. Land use law scholar Daniel Mandelker has called the movement of people with disabilities out of state institutions into communities, in the last few decades, “one of the great migrations in recent history.” At the same time, aging baby boomers, many of whom are gradually becoming disabled in housing inadequate to their changing needs, portend a national “forced migration” in the reverse direction—into nursing homes and retirement enclaves. 

As I write in my recent working paper, our aging population is increasingly the focus of new planning and policy initiatives. Their unprecedented numbers—by 2030 the population of people 65 and over will top 20 percent—and political influence create new concerns as well as opportunities to rethink the physical, social, and legal landscape of housing, infrastructure, and service provision. Because people are much more likely to develop physical and mental disabilities as they age, the visibility of the boomer generation is helping to draw attention to the fact that, according to the 2010 National Council on Disability report, 35 million households in the US in 2007 had one or more people with some kind of disability, representing 32 percent of all American households. Because elderly and disabled people share a number of these needs, concerns long considered the marginalized province of the disabled are expanding. 

Both the disabled and elderly overwhelmingly want to live in homes in “mainstream” neighborhoods, but the ability to participate in the community depends on how well the physical environment can accommodate them. A number of legal protections developed in the last few decades have shaped the possibilities for that. The most comprehensive, the Americans with Disabilities Act (ADA), covers primarily public accommodations, leaving the bulk of housing unregulated. As AARP has shown, most people with disabilities, including older adults, live in private single-family residences, the largest sector of the housing market. Yet except for a small amount of federally-funded units, single-family housing is not covered by disabled access regulations. This creates a big gap between the supply and demand for accessible housing of various kinds. 

The left shows a metal ramp kit retrofitted to a public building entrance—an example of unintegrated thinking about access. The right is an ADA-compliant hotel room bathroom, featuring the standard “beige melamine” of mass manufactured accessible components.

Sources: http://www.portawalk.com/
http://www.sleepinn.com/media/eBrochure/ebrochure/AZ/AZ805/AZ805B8.JPG

Partly because it is not regulated by the ADA, private single-family housing is an area where states and local municipalities are experimenting with policy and design approaches to create more accessible options. Without building code prescriptions for specific access requirements, programs based on ideas like visitability and universal design are cropping up around the country. Universal design is especially appealing because its approach differs from ADA-based building codes by not singling out the disabled in design but by making better functioning spaces and objects through a broader reconsideration of good design practice—“design for all.” A classic example of this is the curb-ramp, originally developed for wheelchairs, which benefits parents with strollers, travelers with luggage and delivery people. Local initiatives are becoming laboratories for developing strategies with broader application.

The curb ramp is considered a classic example of universal design: developed for wheelchairs but so practical for many other uses that it seems incredible that it wasn’t thought of earlier. 

Sources: http://wwbpa.org/2009/09/ http://www.fhwa.dot.gov/publications/research/safety/pedbike/05085/chapt8.cfm

While planners and policy makers are recognizing the important role that housing, including the private single-family home, plays in public health, homebuilders have been much slower to adopt accessibility. The history of bad design for disability, among other factors, has meant that developers and homebuyers don’t yet see the benefits of accessible features, like a no-step entry. The common belief is that accessible design is ugly, diminishes the visual appeal of homes, and is only targeted at a small, specialized segment of the market. Nevertheless, some homebuilders are recognizing the looming demand for “aging in place” and “flexible” residential design. Eskaton Livable Design, one of the most ambitious of the commercial projects, is a third-party certification system, similar to LEED (Leadership in Energy and Environment Design) for sustainable design, which packages accessible features as part of an overall practical and aesthetically appealing design. 

On the left is the Livable Design model home, built in Roseville, California, developed by Eskaton to accommodate a range of abilities associated with multi-generational households. On the right sits Mr. Blundell, who commissioned this residence built with the LifeMark certification system, developed by the New Zealand government to create new access standards for the national housing market. 

Sources: http://www.livabledesign.com/livable-design-tour/
http://www.lifemark.co.nz/the-lifemark/case-studies/case-study-blundell.aspx

There are still a number of obstacles to widespread acceptance of accessible design in housing. The current political climate makes consumer demand central to both regulatory and market reform. Yet, consumer resistance persists because of the negative perception of accessible design related to the continuing stigmatization of disability—a mutually reinforcing dynamic. While more creative and flexible approaches to improving the accessibility of housing may appeal to both homebuilders and designers, their very open-endedness may pose difficulties for implementation at a wider scale. 

And indeed, as some of the commercial initiatives evolve, they show signs of requiring similar levels of compliance with prescribed standards for certification. Real change, including the capacity to deal with the complexities of interpreting and evaluating more variable design solutions, will require a new mindset. Public officials, architects, builders, and consumers need to develop a more critical understanding of design and accessibility, away from the compliance-only approach. 

Nonprofits Play Key Role in Repairing U.S. Homes

by Abbe Will
Research Analyst

Private sector spending on improvements and repairs to U.S. homes is approximately $300 billion a year. Yet as a new Joint Center working paper shows, each year nonprofit organizations and public agencies are also investing resources into the rehabilitation and repair of the homes of America’s most vulnerable households—including the elderly, disabled, and those with low-incomes—who might not otherwise be physically or financially able to undertake critical home remodeling and repair projects themselves. Major nonprofits such as Rebuilding Together, Habitat for Humanity, Enterprise Community Partners, the Local Initiatives Support Corporation, and NeighborWorks America, as well as thousands of local community development organizations across the country, are filling a significant and growing need, largely unmet by the private sector, by investing considerable resources—financial, technical, and direct provision of services—to make homes safer, healthier, more energy efficient, and more accessible for disadvantaged households.

The recent foreclosure crisis and sluggish economy undermined years of efforts to stabilize and improve distressed neighborhoods in cities across the country, only adding to the need for nonprofit and public sector involvement. Until this past cycle, housing inadequacy—a measure of the physical condition of housing units—had been on the decline in the United States, largely due to the success of govern­ment housing policies and the growing affluence of the pop­ulation. Since the housing market bust, however, this trend has reversed with the number of moderately or severely inadequate homes increasing by 7% between 2007 and 2011 to 2.4 million units. Certainly the severe housing and economic downturn had a measurable impact on the quality of the nation’s housing.

While a comprehensive data source of home rehabilitation and repair activity by nonprofits and public agencies does not exist, this new Joint Center working paper provides some insight into the topic. Rebuilding Together, one of the nonprofits in the study, provides critical home rehabilitation and modification services to low-income homeowners through its extensive network of local affiliates. A member of the Joint Center’s Remodeling Futures Steering Committee, the organization provided support for an affiliate and homeowner survey that collected data on the various types of projects undertaken by their affiliates, as well as demographic and socioeconomic information about the homeowners served and their experience partnering with Rebuilding Together.

Recent spending on home repairs and replacements, as reported by participating households, suggests that many of the homes worked on by Rebuilding Together have seen significant under-investment over the years. While the average American homeowner spent $3,000 on home improvements and repairs in 2011, according to Joint Center analysis of the American Housing Survey, almost two-thirds of Rebuilding Together program participants reported having spent less than $500 on average in the past year—fully 80% less than the typical homeowner in the U.S. Indeed, according to estimates developed by Rebuilding Together affiliates and the Joint Center’s Remodeling Futures Program, the homes serviced by Rebuilding Together were so in need after years of deferred maintenance, that the average value of the rehabilitation and repair projects undertaken by Rebuilding Together was in excess of $6,000 per home, or twice the annual amount spent by the typical homeowner in the U.S.

Home improvement expenditures under the Rebuilding Together program in 2011 were heavily oriented toward exterior replacements and kitchen and bath improvements—projects that would produce the greatest gains in key program objectives such as health and safety concerns, accessibility, and savings in energy use. Typical projects included additions or replacements of steps, ramps, railings, grab bars, windows and doors, roofing, insulation, energy-saving appliances, as well as painting and plumbing and electrical repairs. In the end, Rebuilding Together participants reported significant improvements in health and safety concerns, improvements in accessibility, and energy use savings as a result of nonprofit involvement.

Source: 2011 Harvard JCHS-Rebuilding Together Household Survey

While a more precise estimate is unavailable, hundreds of millions of dollars are spent each year by nonprofits such as Rebuilding Together, community organizations, and public agencies. Their contributions not only improve conditions for residents, they also help preserve badly-needed affordable housing opportunities, stabilize and revitalize deteriorating neighborhoods—of special importance in recent years—and encourage neighborhood stability by helping long-term residents of the community to remain safely in their homes.