Dying in America is expensive, putting some patients at risk of losing their homes.
The issue of unstable housing has a direct impact on patients’ health care choices and outcomes, including a higher incidence of aggressive treatments in their final days. The depletion of a family’s financial resources is a greater predictor of aggressive treatment at the end of life than patient preferences or demographic factors, a 2016 study concluded.
Data are scarce regarding the number of terminally ill individuals who experience housing insecurity, but among seniors in general, the threat of homelessness is growing.
“In many parts of the U.S. older adults represent the fastest-growing age segment of the homeless population, with nearly half of all older homeless people becoming homeless for the first time after age 50,” a 2021 report from the advocacy group Justice in Aging indicated. “Older adults are at the center of our nation’s housing affordability and homelessness crisis, as our nation’s population is aging and income inequality continues to grow, especially for older adults of color.”
As health care providers, payers, and other stakeholders seek to address social determinants of health, they may need to pay more attention to the issue of housing. Nationally, seniors are spending more to keep a roof over their heads.
As many as 6.4 million renters and 11 million homeowners older than 65 will be spending more than 30% on housing expenses by 2035, according to the U.S. Department of Housing and Urban Development (HUD). For about 8.6 million of those, housing costs will eat up 50% of their total income.
The U.S. Centers for Medicare & Medicaid Services (CMS) as of 2020 allows Medicare Advantage plans to cover supplemental non-medical benefits, including those designated as “general supports for living,” which can include some forms of housing assistance.
However, the scope and availability of those programs are limited, and under CMS rules narrow subsets of beneficiaries are eligible.
As of 2021, 2.7% of Medicare Advantage individual plans offered the general supports benefit, as well as only 10.3% of special needs plans, according to the Kaiser Family Foundation.
Hospice and palliative care providers have a vested interest in assisting patients experiencing housing insecurity. Not only does this align with their mission to improve quality of life for the terminally ill, but because these financial barriers can also interfere with patients coming under their care.
For one, patients who lack a stable living environment are less likely to receive regular medical care and frequently delay health care appointments, according to the National Council on Aging. The lack of routine care can delay or prevent referrals to hospice.
Financial burdens on the family can also be a deterrent. Research has shown that patients who are faced with end-of-life decisions may be less likely to choose hospice unless they have a network of friends or family who can serve as home caregivers.
But even when those supports are present and willing, the cost of caregiving can create an unsustainable situation.
Roughly three-quarters of family members who care for seriously ill loved ones spend upwards of $7,200 annually for associated costs, AARP reported. For many caregivers, this amounts to 26% of their income.
These costs can include patient medical and non-medical needs or lost income due to missed work days. Around 30% of caregivers cover rent or mortgage payments for their loved ones, while 17% pay for medical costs, according to AARP.
Many providers are doing their best to help. A rising number of hospices screen for social determinants and connect patients with community resources if they can’t address the issue themselves. Some offer assistance through charitable foundations or operate hospice houses for patients who are homeless or whose own residences are unsafe or unsuitable for the care they need.
But ultimately, any health care provider can only do so much. A hospice can care for a patient, but it can’t cure a system that is not designed for the rapidly changing needs of its population.
When it comes to supporting the growing senior population, we as a nation have a lot more work to do.
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