Ageism: An Often-Overlooked Social Determinant Of Health In The Health Equity Equation

Most health systems, provider organizations, and health insurers have recognized the need to address how the social determinants of health (SDoH) can significantly influence patient health and drive up the cost of care. Health equity researchers have collected extensive data showing how failing to address SDoH has led to inequitable healthcare for the elderly, ethnic and racial subpopulations, and other underserved Americans. 

Research on levels of health equity for Black, Hispanic, American Indian, and Alaska Native populations shows people in these groups do not do better than their White counterparts for any examined measures of SDoH. Broadly speaking, these subpopulations may have lower health insurance coverage, may experience more challenges accessing care, and have worse health outcomes when compared with White people. 

Age-related SDoH place older persons seeking care at a disadvantage

Not only do certain social factors hurt ethnic and racial subpopulations in America, but SDoH research shows that Americans 65 years old and older of all races and ethnicities have experienced disparities in the quality of healthcare they receive. Further, as people of all demographic groups reached advanced age (meaning those 85 and older), they often experience still more bias when using the healthcare system simply because they are older and face challenges that can have negative effects on their health outcomes, thus raising the total cost of care.

Seniors face health inequities at a rate never previously experienced

Ageism in healthcare is prevalent but can appear subtle. For example, many older Americans face transportation barriers that limit their ability to visit a physician’s office or access other healthcare services. Such barriers lead to delays in care, skipped appointments, and missed medications, contributing to poor management of chronic illness, adverse health outcomes, and increased costs.

Older people may lack access to care for reasons that are difficult for the healthcare system to solve for because most physicians and other providers traditionally see patients in their offices, outpatient clinics, emergency rooms, urgent care centers, and hospitals, among other settings. As a result, it falls to the healthcare system to priorities reducing health inequities and address the transportation challenges that older populations face as demographic changes and lower birth rates cause the average age of all Americans to rise. 

Ageist SDoH is a call-to-action for the Baby Boomer population 

In 2020, the U.S. Census Bureau reported that the nation’s 65-and-older population had grown sharply since 2010. Driven by aging Baby Boomers born between 1946 and 1964, the 65-and-older population grew by 34.2% (or 13.8 million Americans), the fastest rise among all age groups. In addition, the nation is growing more racially and ethnically diverse as all other groups added more members at faster rates than Whites, census data shows.

What’s more, persons aged 65 and older represented 16% of the population in 2019 but are expected to represent 21.6% of the population by 2040, according to a report in 2021 from the Administration for Community Living of the federal Department of Health and Human Services (HHS). At the same time, those 85 and older are expected to more than double from 6.6 million in 2019 to 14.4 million in 2040 (a 118% increase), the agency reported. The implications of this dramatic subpopulation expansion? Without significant planning and investment in reducing health inequities experienced by older persons, poor health outcomes and cost of care will run rampant.

Ageism in healthcare via provider bias may affect senior mental health as well

Senior citizens experience negative stereotypes, prejudice, or discrimination feeding into implicit bias by society at large. When encountering ageism in healthcare, older patients may find themselves under treatment by providers who assume they are incapable of understanding and following care plans, are physically frail, and have unpleasant or difficult attitudes. Case in point: one study conducted in 2015 showed that one out of five adults over age 50 confronted discrimination in healthcare settings. 

A Frontiers in Psychiatry article discusses dignity as a table stake for delivering high-quality healthcare to seniors. “Implicit and explicit biases that negatively influence their [older persons] care include the triple jeopardy of ageism, mentalism, and ableism…Incorporating dignity in the care of older persons takes on greater importance, due to their multiple and interdependent vulnerabilities such as physical, psychological, cognitive, and social frailty, interacts with dependence on others, loneliness, social isolation, polypharmacy, medical comorbidities subjecting them to human rights abuses, loss of autonomy and poorer access to healthcare. Promoting their dignity and protecting older persons against stigma, discrimination, violence, abuse and neglect enhances clinical outcomes and quality of life.”

Bias and care disparities put the health of seniors at risk

Age-related discrimination can be found in explicit age cut-offs for treatment and age-related bias that create additional health care barriers, resulting in poorer health care, adverse outcomes, and increased mortality. Whether age-based criteria for treatment are implicit or explicit, they can limit seniors’ access to life-sustaining preventive care, such as mammograms, colonoscopies, and vaccinations. Ageist policies also keep seniors from getting more expensive life-sustaining treatments.

Ageism in healthcare leads to more hospitalizations, emergency room visits, and reduced medication compliance. Also, it can lead to inadequate, inappropriate, limited, or delayed care, all of which lead to decreased survival, poorer quality of life, and more cognitive and functional impairment. These factors drive up the costs of treating older Americans and promote continuing health inequities.

For some seniors, home is where they’re healthiest

In recent years, federal health agencies have recognized that older Americans need programs explicitly designed to shore up the weaknesses in the health care system where SDoH impact the care they receive. State Medicaid programs, for example, have added non-clinical services designed to keep seniors in their homes by paying physicians and other health care providers to deliver care to seniors and the disabled in their homes.

The CMS and state-federal Medicaid programs are investing in home and community-based services (HCBS) to support seniors and people with disabilities. Previously, states and managed care organizations serving Medicaid members were not allowed to spend federal Medicaid funds to pay the direct costs of non-medical services such as housing and food. However, state HCBS programs have received approval through federal waivers to add non-clinical services designed to keep Medicaid members in their homes with assistance for household activities such as cleaning, laundry, and meal preparation.

Programs to reduce ageism in healthcare

Two examples of successful programs assisting older Americans experiencing the negative effects of SDoH are the Community Aging in Place—Advancing Better Living for Elders (CAPABLE) program (developed at the Johns Hopkins University School of Nursing) and the Program of All-Inclusive Care for the Elderly (PACE) which the Department of Health and Human Services (HHS) developed for beneficiaries who are eligible for both Medicare and Medicaid. 

The Medicaid programs in Colorado, Connecticut, and Massachusetts are incorporating the CAPABLE program into their offerings, and the program is available at 30 other sites across the country.

The PACE program is designed to serve dual-eligible recipients of Medicare and Medicaid who wish to remain at home. Managed care organizations run 144 PACE programs in 30 states in part because research has shown that PACE programs reduce hospitalizations and emergency room visits and effectively keep PACE members at home and out of nursing homes. 

In a 2021 report, HHS said the PACE program effectively kept members out of the hospital, cut the number of visits to the emergency room, and reduced the need for nursing home care. The CAPABLE and PACE programs show that the federal Medicare agency, state Medicaid programs, and health care payers are interested in developing programs to address SDoH by keeping patients at home—and out of the more expensive nursing home and other long-term care settings. 

How to address health inequities among older people

While age itself may not be considered a SDoH, ageism (bias, prejudice, or discrimination based on age) is a strong candidate that justifies further evaluation and incorporation. 

If you would like to better understand the disparity and health equity of aging and older populations and sub-populations, turn to RTI Health Advance. 

We can help align your strategies, develop implementation plans, and execute relevant interventions (social, clinical, technical, and/or financial). We also assess the impact of these interventions on care quality, population health, and health equity and determine the economic value of these programs.