Dear White House Conference on Aging: Inequality Is the Primary Concern

Today, advocates, government leaders and practitioners in the aging and long-term care field are gathering for the decennial White House Conference on Aging. Held every decade since 1961, this conference aims to pinpoint the key concerns facing a rapidly growing demographic of older people, while forecasting the aging landscape for the next 10 years. Already, aging advocates have responded to the four policy topics that emerged early on from the conference: healthy aging, long-term services and supports, elder justice and retirement security.

But there’s a profound issue that's being subsumed within these topics and the conference at large: the growing social and economic inequality facing significant segments of the elder population. Consider these recent developments: Low-income elders are facing higher rates of food insecurity than ever before while struggling to access care; an estimated 12 million out of 16 million low-income homebound elders don’t receive the home care services for which they are eligible, according to a new report from the Government Accountability Office. Access to affordable and reliable home care is becoming increasingly difficult: a new study from the University of California at San Francisco estimates that 2.5 million more long-term care workers are needed within the next 15 years to match the anticipated demand -- a serious challenge given that the fasting-growing sector within this group, direct-care workers, often leave their jobs within a year because of dismal wages and thin protections. Even family caregivers -- a bedrock of care for elders -- are increasingly strained to offer care as their loved ones live longer, grow frail and become sicker, a reality that's detailed in a new study from the National Alliance for Caregiving and AARP.

Addressing the economic needs of older people and the workforce is not enough -- socio-economic status and race are entwined, as are gender, sexuality, gender identity and more. In a recent keynote speech, Director of the Michigan Center for Urban African American Aging Research James Jackson called on aging leaders to move beyond generic discussions of race as a fixed, isolated variable to addressing the impact of structural racism on the life outcomes of elders of color. What are the consequences of looking only at race, and not structural racism, when it comes to improving a community’s prospects as they age? Racial disparities are understood primarily in intellectual, statistical terms and written off as the “bad” behaviors of people of color -- in turn, people of color continue to age in poor health with marginal support from an aging field that more readily studies than protects them. Our field needs aging interventions that take on structural racism -- as one form of large-scale inequality -- before it destabilizes the physical and financial lives of elders of color.

Social and economic inequality -- defined here as the unequal status in opportunity, power, access and well-being among older people who are low-income, people of color, LGBT and living with disabilities -- is the primary challenge facing the aging and long-term care field in the next 10 years. It should be elevated to a core concern that threads topics and galvanizes leaders across disciplines and sectors. We must tackle inequality at its roots, center this issue in our missions and core programs, and elevate the discussion to the forefront. We should move from reflection to action, heeding the recommendations that come from experts in socio-economic inequality. A system reformed for the most vulnerable -- as a history of policy change in this country will confirm -- becomes a system that’s ultimately stronger for everyone.

Social and economic inequality is widespread and growing. It nests in our personal thoughts and behaviors, regardless of intentions, and it shows up as bias, discrimination and violence. It's embedded in the frameworks and policies of institutions that steer our country: government, the media, a wide array of industries and sectors, even our nonprofit sector. Ultimately, it delineates how we live, age, work and thrive all along the life spectrum. It's historical, generational, and structural; no meritocracy ideology or individual-empowerment model can alone transcend it.

Take the four policy themes selected by the White House Conference on Aging. In regards to “healthy aging,” a growing body of research continues to demonstrate that people of color experience worse health outcomes across the board from birth to old age, have less access to care (even in a time of health reform), and routinely encounter health providers without the cultural or linguistic competence to provide true person-centered care. Organizations such as SAGE and the member organizations that comprise the Diverse Elders Coalition have long proposed an array of policy responses to address these inequities among LGBT elders and elders of color.

The “long-term services and supports system,” the conference’s second theme, has expanded significantly in recent years with mixed results. For example, new regulations on Medicaid Managed Care illustrate how this complex system often excludes people with limited English proficiency and people with disabilities, as two examples. In this system, the compensation and training needs of direct-care workers -- a largely female, people of color workforce -- are often pitted against those of elders and people with disabilities who fear cuts in care and, potentially, institutionalization. Imagine if we rooted the challenge of Medicaid reform primarily in the experiences of underserved elder populations and direct-care workers -- and then tackled the larger problem of transforming a fraught, severely underfunded long-term care system that’s cannibalized by the exorbitant costs of health care.

In regards to “elder justice,” elder abuse can be physical, emotional, sexual and financial, and while it can stem from long-term care professionals, it is most often perpetrated by family and friends who are close to the victim. At particular risk of elder abuse are people with small support networks, severely isolated people, people with stigmatized identities (such as transgender elders), people with disabilities and people with limited English proficiency -- traits that characterize many elders of color, LGBT elders and low-income elders. Contrary to the media’s fascination with anecdotes of home care workers as perpetrators of financial and physical abuse, a properly trained direct-care worker can help prevent abuse in the home and keep people safe -- as demonstrated in a recently updated curriculum from PHI (Paraprofessional Healthcare Institute).

Finally, any policy approach related to “retirement security” needs to contextualize the growing racial wealth gap, increases in poverty rates, the lifelong concentration of people of color into workforces with low incomes and fewer savings options, and the effects of a lifetime of discrimination in the workplace -- all of which collude to derail the financial security of millions of low-income elders of color and LGBT elders. For many marginalized elders, the focus is financial survival, not retirement.

These are the realities of our country’s most vulnerable elders as we approach this historic White House Conference on Aging. Our abilities to age in good health and with financial security will rest on the courage and imagination of advocates working in the aging field. We should reflect on how far we’ve come and anticipate the policy issues that will need significant attention in the decade that follows. But we should be honest that it’s far from a level playing field for elders, even among the most vulnerable. To effectively repair the inequities facing these segments, aging leaders must do more than report basic disparity statistics, craft one-time interventions or studies, or hide behind politically safe “diversity” frameworks. On the latter, it's true that our differences as people are beautiful and profound, but aging policy is a safety net, not a parade, and we should prioritize our efforts on catching those of us who fall repeatedly through it.

It's July 2015. Inequality remains the prevailing issue of our time, especially among older people. And as with our own personal aging, it’s becoming graver over time.