Introduction
It would be an understatement to say that the COVID-19 pandemic has impacted the lives of people throughout the world, either directly, due to exposure to the virus, or indirectly, due to measures taken to mitigate the virus' health and economic effects. As May 2020 draws to a close, confirmed COVID-19 infections approach nearly 6,000,000 globally with close to 400,000 deaths worldwide (Johns Hopkins University School of Medicine, 2020), No nation has been spared but some countries have been hit particularly hard by the virus. Although just 4.3% of the world population (U.S. Census Bureau, 2020), the United States constitutes 29.5% of COVID-19 infections and 28.2% of COVID-19-related deaths (Johns Hopkins University School of Medicine, 2020). Other countries experiencing disproportionate impact, whether measured in terms of numbers of infections or deaths, include the United Kingdom, Italy, France, Spain, Brazil, Mexico, and Germany. Unprecedented actions have been taken to stem the tide of coronavirus infection. These actions include state of emergency declarations, shelter-in-place orders, travel bans, school and non-essential business closures, mandated use of face masks, visitor bans (in hospitals and long-term care facilities), and mass testing and distribution of personnel protective equipment (PPE).
The spread and response to COVID-19 has devastated national economies, pushing many into recession. A Brookings Institution analysis of 20 wealthy democracies found that by May 2020 5.7%, or 38 million of 660 million total workers, had filed for unemployment insurance since the pandemic began (Rothwell, 2020). In all, there have been more than 40 million initial unemployment claims in the U.S. since mid-March 2020 (Reiniche, 2020). At 13%, a higher proportion of workers in the U.S. than in other countries are currently receiving unemployment insurance (Rothwell, 2020), with four countries Canada, Israel, Ireland, and the U.S. - witnessing double digit increase in unemployment insurance claims during this time. Cross-national variation in unemployment reflects, in part, the relative mix of strategies used to mitigate the negative economic consequences of the virus (Rothwell, 2020). Some countries have weighted intervention more heavily toward enhanced unemployment and other individual or household financial support. Other countries have weighted intervention toward subsidizing businesses and stimulating the broader economy to head off large-scale layoffs. Still other countries have emploved a relatively balanced mix of these two approaches.
Notably, the intensity of the health and economic pain brought on by the COVID-19 pandemic has been stronger in some segments of the population than others. Exacerbating existing disparities, people from Native American, Hispanic and African American communities, as well as individuals with low incomes and those residing in urban areas, have been disproportionately impacted (Raifman & Raifman, 2020; Webb Hopper et al., 2020). A Harvard University analysis found that during the early weeks of the COVID-19 pandemic "deaths surged higher in Massachusetts cities, towns, and ZIP codes with larger concentrations of poverty, economic segregation, people of color, and crowded housing" (Ryan & Lazard, 2020). According to a May 2020 Kaiser Family Foundation survey, black and Hispanic respondents were more than twice as likely (at 48% and 46%, respectively) as non-Hispanic white respondents (at 23%) to report having trouble affording food, housing, utilities, credit card bills or health expenses due to COVID-19. Respondents with annual incomes below 40,000 USD were more than three times as likely to report having trouble with these expenses than respondents with annual incomes over 90,000 USD (47% v. 14%) (Kaiser Familv Foundation, 2020).
Older adults have been especially hard hit by COVID-19. In 2015, people aged 65 years and older constituted 15% of the population in the U.S.; people aged 85 years and older 1,96% (Federal Interagency Forum on Aging-Related Statistics, 2016). Yet, 22% of all COVID-19 cases and 81% of all COVID-19 deaths have occurred among older adults (Center for Disease Control and Prevention, 2020a, 2020b). Deaths per million from COVID-19 rises dramatically with age, increasing from 23.6, 66.6, and 159.1, respectively, among individuals aged 33-44, 45-54, and 55-64 years, to 377.9 and 969.8 among individuals aged 65-74 and 75-84 years, and an astonishing 2,670.6 for individuals 85 years and older (Girvan, 2020).
A large proportion of COVID-19 deaths has occurred in long-term care facilities that care for older adults with physical and cognitive impairments in need of assistance with basic activities of daily living such eating, bathing, and toileting. Just 2.1 million people accounting for 0.62% of the U.S. population reside in a nursing home or assisted living facility, yet, as of May 22, 2020, this population constituted 42% of all COVID-19 deaths (54% when excluding New York, which may be under reporting nursing home fatalities from the virus) (Girvan, 2020). Several states well exceed these national totals. In Massachusetts, for example, 62% of 6,547 COVID-19 deaths have been in long-term care facilities (Wasser, 2020). All but 33 of the state's 319 nursing homes and rest homes reported deaths from COVID-19, including 80 facilities with at least 20 deaths and 19 facilities with 30 or more. These figures are consistent with data reported in other countries where, for example, more than 50% of COVID-19-related deaths have taken place in care homes in France (51%), Belgium (53%), Norway (60%), Ireland (60%), and Canada (62%) (Comas-Herrera et al., 2020).
Local, regional, and national government actions taken to mitigate the spread of the virus have served, in part, to shield older adults from COVID-19, though not without increased social isolation, enhanced economic risk, revealed ageism, delayed medical treatment, and challenges getting basic needs met. These negative effects crosscut with vulnerabilities grounded in the social determinants of health to place older adults, families, and caregivers belonging to racial and ethnic minority and economically disadvantage populations at especially high risk for adverse outcomes. Specific vulnerabilities include underlying comorbidities (such as chronic lung and heart disease, diabetes, cancer and other immunocompromising conditions/treatments), inadequate housing, income and savings, resource scarcity, population density, poor health care access and quality, disproportionate employment in essential or forward-facing occupations, and structural racism and sexism (Raifman & Raifman, 2020; Webb Hopper et al., 2020).
This special double issue of the Journal of Aging & Social Policy, "Older Adults and COVID-19: Implications for Aging Policy & Practice," explores the myriad ways in which the COVID-19 pandemic has affected older adults and their families, caregivers, and communities. It proposes policies and strategies for protecting and improving the lives of older individuals during the pandemic. It draws lessons for aging policy and practice more generally, given underlying challenges brought to the fore by government, provider, community, and individual responses to the pandemic.
Issue content
The articles included in this issue, authored by leading scholars in their respective fields, focus on one of eight main areas affected by COVID-19: (1) delivering long-term services and supports (LTSS) in the U.S. (Gardner, States & Bagley; Behrens & Naylor; Shippee et al.; Dobbs, Peterson & Hyer), (2) financing LTSS in the U.S. (Feder; Blewett & Hest), (3) LTSS in other contexts (Beland & Marier; Comas-Herrera et al.; Lum, Shi, Wong & Wong); (4) high risk older adults in communities (Cohen & Tavares; Naylor, Hirschman & McCauley; Henning-Smith), (5) families and caregivers of older adults (Almeida, Cohen, Stone, & Weller; Hedo & Feinberg; Stokes & Patterson; Carr, Boerner & Moorman), (6) local government and community responses (Wilson, Scala-Foley; Kunkel & Brewster; Angel & Mudrazija; Hoffman, Webster & Bynum; Xie et al.), (7) economic risks for older workers and retirees (Ghilarducci & Farmand; Li & Mutchler; Tabor), and (8) documenting and combating ageism (Reynolds; Previtali, Allen & Variamova; Ehni & Wahl). A final, concluding article addresses the post-COVID-19 recovery (Morrow-Howell, Galucia & Swinford).
Delivering long-term services and supports in the U.S
Four U.S.-based articles focus on the delivery of LTSS during the COVID-19 pandemic, primarily in nursing homes but also in assisted living facilities and home and community-based services settings. Gardner, States & Bagely document heightened risk for older adults in long-term care facilities, both directly from COVID-19 and indirectly due to increased isolation and potential for abuse and neglect. The need for enhanced testing, infection control, stalling supports, and supervision in the context of the crisis are noted.
Informed by discussions with nursing home leaders, Behrens & Naylor propose a framework to facilitate decision making and collective action to address the COVID-19 crisis within the nursing home sector. The framework outlines the resources essential to mitigate COVID-19 as facilities seek to maintain or improve operations depending on their current stage of operations: standard, contingency, crisis, or catastrophic.
Shippee and colleagues point to marked racial and ethnic disparities in the quality of LTSS that have worsened during the COVID-19 pandemic. Recommended near term actions in recognition of these disparities include enhanced reporting of COVID-19 by race/ethnicity and prioritizing high proportion minority facilities for testing, PPE, and other supports. Long-term actions to address prevailing disparities affecting residents and frontline workers are suggested as well.
Finally, Dobbs, Peterson & Hyer focus on the challenges faced by assisted living facilities due to COVID-19, including with respect to family visitation, use of third-party providers as essential workers, staffing guidelines, transfer policies, and rural hospitalization. Recommendations include increased use of digital technology, limits on multi-facility visits by home health care workers, enhanced staffing through extension of the personal care attendant program to assisted living, hazard pay for direct care staff, and implementation of comprehensive emergency management plans.
Financing long-term services and supports in the U.S
Two U.S.-based articles focus on the financing of health care and LTSS in the context of Medicaid during the COVID-19 pandemic. Both articles deem Medicaid, the joint federal-state health insurance program for low income Americans, essential to state responses in light of the growing demand for coverage and services. Blewett and Hest observe that states have taken advantage of new authority granted to them by the federal government to streamline and increase the flexibility of Medicaid LTSS eligibility to help facilitate enrollment and prevent disenrollment. They caution, however, against subsequent cutbacks in Medicaid LTSS eligibility and services during this time of great need due to forthcoming budget shortfalls generated by the COVID-19 induced economic crisis.
Feder also cautions against funding reductions but views increasing the federal share of Medicaid spending during the economic crisis as only part of the solution due to the inadequate and inequitable nature of Medicaid LTSS funding across states. Recognizing these extant limitations, Feder suggests that Medicaid LTSS financing should be modified to either adjust federal matching funds by the age of each state's population, or fully federalizing the funding of long-term care expenses for dually eligible beneficiaries (i.e., Medicaid beneficiaries who are also eligible for Medicare).
Long-term services and supports in other contexts
Three additional articles examine LTSS-specific responses to COVID-19 but outside of the U.S., in Canada, England, and Hong Kong. Beland & Marier point to similar challenges and risks posed to long-term care facilities in Canada as the U.S. They argue that the devasting consequences of COVID-19 for long-term care facilities is a "focusing event" that draws attention to the issue, in light of existing policy legacies underlying devolution of funding and oversight to the provinces and a public-private dichotomy in ownership and oversight. Should a resulting "policy window" open up, a first step toward reform suggested by the authors would be to increase provincial and, potentially, federal funding for this highly stressed sector.
Comas-Herrera and colleagues describe challenges to the quality and availability of social care posed by COVID-19 in England, and policy responses made in light of those challenges. Responses noted include a successful call for volunteers in health and social care and measures to promote the financial viability of care providers. They also include provisions aimed at removing barriers to effective coordination between health and social care to provide services, facilitate transfers, monitor infection rates and deaths, distribute PPE, conduct testing, and bolster the provider workforce. The importance of achieving well-co-coordinated response across the central and local government, health services, and private and voluntary sectors is highlighted.
Lum, Shi, Wong & Wong report on Hong Kong's successful effort to manage and contain COVID-19, informed, in part, by lessons drawn from the 2003 SARS epidemic. Home and community-based services were severely restricted. The provision of resources to fund PPE and to pay for additional cleaning staff helped to contain the spread of COVID-19 in long-term care facilities. So too did the adoption of hygiene practices (e.g., remote family visitation, temperature checks, face mask use, and keeping residents in their rooms), combined with population-level behavioral changes.
High risk older adults in communities
Three articles examine the implications of the COVID-19 pandemic for high risk populations, including community-based seniors with respiratory disorders, older adults with COVID-19 transferring back to the community, and older individuals residing in rural communities. Cohen & Tavares document the large number of seniors living in the community with chronic respiratory issues. This already precarious position is further exacerbated by multiple additional health and social risks, including a greater likelihood of being unmarried or living alone, being in fair or poor health or depressed, having multiple chronic conditions and LTSS needs, and living below the poverty line. The authors conclude that current approaches to protecting this population from COVID-19 are inadequate; what is needed is improved testing, better assessment, increased social supports, assurance that basic needs are being met, and protection for home care workers.
Naylor, Hirschman & McCauley draw attention to the transitional care needs of older adults discharged from the hospital to the community with COVID-19. They argue that elements of the evidence-based Transi...
