Many older people rely on assistance beyond medical care and Social Security, but governments are mandated to supply almost nothing else. When the mayor and governor look for places to cut spending, services for the aging are therefore especially vulnerable. The shortage of support services that could keep older people at home sends them to nursing homes instead, where the New York State average cost of $73,000 a year buys a greatly reduced quality of life.
OLD AGE IS DIFFERENT IN NEW YORK
Being old in New York City is not like being old in the rest of the United States: you are less likely to be getting Social Security and much more likely to be poor. The percent of over-65 New Yorkers living in poverty rose to over 17 percent during the 1990's, while nationally it dropped to 10 pecent. Within the elderly population, African-American, Asian and Latino elders are poorer than their white peers. As people of color form a bigger share of the aging population-they are now 43 percent of New York City's elderly-the overall income level of their age group falls. (For more information on the elderly population, see Gotham Gazette's "New York City's Elderly,")
MORE NEW YORKERS LIVE ALONE AS THEY AGE
New York City's elderly are more than three times as likely to live alone as their peers nationwide, even though more New Yorkers have disabilities. Half the senior citizens living alone in the city are surviving on $10,450 or less a year.
Researchers have found that impoverished elders who live in poor Manhattan neighborhoods are twice as likely to live alone as their peers in wealthy neighborhoods, according to a report by the International Longevity Center-USA. This is surprising, because low-income neighborhoods are home to more Latinos and African-Americans, who have traditionally relied on family members to care for their aging. It is possible that the gentrification of nearly all Manhattan neighborhoods is reducing options for low-income families to make room for elderly members. In the outer boroughs, nearly two-thirds of elders live with their families, as they do in the rest of the state, according to one report [pdf file].
THE HOUSING SHORTAGE CREATES A NEED FOR SERVICES
The shortage of affordable housing in New York City is responsible for much of the need for social services for the elderly. In many cases, apartments are too small for aging parents to move in with children, or for old people living alone to offer room and board to an aide in return for everyday assistance. As deteriorating health limits their ability to climb stairs, elderly tenants of walkup apartments can be cut off from shopping, socializing, and other activities taken for granted when they were younger.
Aging tenants can't always move to a larger apartment, or one in an elevator building. Rent regulation protects long-term tenants who stay in place, but penalizes those who move by sharply increasing their rent. Rent-controlled apartments, which are like gold in this city, require tenants to have lived in them since 1969 (or inherited them) in order to maintain their low rents. Most rent-controlled tenants are now old; according to the Eastern Paralyzed Veterans Association, such tenants have an average income of $15,000 a year.
SHIFTING COSTS TO THE MEDICAL SYSTEM
Services for the elderly are concentrated at the two extremes of health. For the healthy, there are group activities at senior centers. If you have a moderate income as well as good health, New York City is an ideal place to be over 65 and retired: you don't need to drive, restaurants deliver meals for no extra charge, and there are free cultural events nearly every day. For the very ill or frail, there are intensive medical care and nursing homes.
In general, people who are over 65 are healthy most of the time. They can usually recover from illness or injury, and go back to their homes, if they receive enough support. The help they need is largely what families and neighbors used to provide: keeping track of finances, cooking meals, buying groceries, and other tasks that require no medical training. A common pattern is for the needs of an elderly person to rise in gradual stages: every year, a few more hours of help might be needed each week.
People aged 85 and older form the fastest growing portion of New York's population of the elderly; they are also the age group needing the most assistance. For those who cannot be completely independent, yet don't need round-the-clock nursing home care, there are few affordable sources of assistance. Most of those are embedded in the Medicaid system, with financial and medical standards of need so arcane that it takes a specialist to fill out the application for services, which come in rigid packages not easily tailored to individual needs. For instance, in-home assistants may be authorized to only do certain tasks: helping with bathing, but not dishwashing; accompanying the client on errands, but not giving medicine. Aides generally work four-hour shifts, up to three days a week, even when clients might prefer an hour of help every day.
It is hard to determine how many people are winding up in hospitals or nursing homes for lack of simple help. Linda Leest, executive director of Services Now for Adult Persons, gives an example. "Transportation is key in eastern Queens," she says. Her agency's vans do more than a commercial car service would. "We'll not only walk people from the van to the door, but we also have an escort program. We'll send someone to go into the bank with them. It can make the whole difference as to whether a person can keep living at home."
SERVICES FOR THOSE WHO DON'T QUALIFY FOR MEDICAID
Assisted living facilities offer a combination of independent apartments with medical and social services. However, the only people who can use them are those who can afford to pay thousands of dollars a month, with no reimbursement from Medicare or Medicaid. Bobbie Sackman, of the Council of Senior Centers and Services, warns potential residents that "There's no legal definition of what they have to provide, no regulations, so people are getting ripped off. They don't know what their money is buying -- how long they can stay, what services they'll get.
"What's really needed is housing with services," she explains. This means funds for home-based care, like that mandated by state law under the Extended In-Home Services for the Elderly Program. This provides case management, housekeeping, personal care, shopping assistance, bill paying, medication management and other forms of assistance to older, frail clients who are not eligible for Medicaid. Governor Pataki has proposed changing state law to end this mandate, merge Extended In-Home Services with another program, and cut the funds for both. The program can't keep up with demand in its current incarnation: it has a waiting list of 6,000 applicants.
NOT GETTING WHAT THEY ARE ENTITLED TO
Like most social workers at senior centers, Edna Souels advises clients about how to get benefits that can solve their problems. "They don't always know they are eligible," she says. Almost half of the seniors who have disabilities making them eligible for Supplemental Security Insurance payments are not receiving them. Two-thirds of the elderly who are eligible for food stamps don't get them. Even the Senior Citizen Rent Increase Exemption is not claimed by two-thirds of low-income elderly tenants in rent-regulated buildings who could use it to avoid rent increases.
Reasons for this include not only lack of information about benefits, but also the stigma attached to programs for low-income people. In 1990, only nine percent of Latino seniors used senior centers, 12 percent used home care, and four percent used visiting nurse services. Only one-half of eligible Latino elderly receive Supplemental Security Income, and 41 percent use food stamps. They are more likely to use Medicaid --- 74 percent of those eligible do -- because there is less stigma attached to it, since family members often use public hospitals. This is much higher than the use of Medicaid by all eligible elders in the city, which is just 40 percent.
The 1996 welfare reform laws added a new complication: the need to prove citizenship or legal immigration status to qualify for most benefits. Older people born in the United States, as well as those who are naturalized citizens or legal immigrants, may not have the right kind of records and be unable to prove their status. Individual senior citizens may have lost vital papers over the years, or forgotten where they are stored.
OUT OF SIGHT, OUT OF THE BUDGET?
When the city proposes closing senior centers, most people think of lunchrooms and bingo games. These are the visible side of the centers' work; they also care for elders who cannot leave their homes to attend group activities. Meals on Wheels, a joint public-private effort, delivers food to the homes of 17,000 low-income seniors a year; most of its meals are cooked in the kitchens of senior centers. The New York Public Interest Group has estimated that for every two elderly clients receiving Meals on Wheels, another nine qualify for this service, but are not getting it. The waiting list consistently averages about 500 people.
Older people can easily become socially isolated. Edna Souels, of Crown Heights Senior Services, spends much of her time counseling troubled clients. "Some of them have family problems-; their children aren't so good to them. A lot of them have depression." They rely on Souels for the understanding that younger people might get from a psychotherapist. "They don't go to mental health services much," she says.
Some senior centers send volunteers to visit clients who are unable to go out; others offer "telephone reassurance". Linda Leest, at Services Now for Adult Persons, is making innovative use of telephone conference calls for the homebound elderly. "We'll get eight to ten of them on the line, and they'll have a discussion group," she says. "We also have specialty groups: one is for bingo, and another is a choral group. They sing songs from when they were in high school."
This kind of activity doesn't lend itself to counting and evaluation; it's not tangible, like a bed in a nursing home. However, the lack of a rational system of in-home care is responsible for much of the huge cost of Medicaid today. If the few services that have taken root are cut off now, we will soon feel their absence in higher medical bills, not to mention the price that will be paid by those who end up in nursing homes.
Linda Ostreicher, a former budget analyst for the New York City Council, is a freelance writer and consultant to nonprofits. She is currently on the staff of Bronx Independent Living Services.