Local Government Efforts to Mitigate the Novel Coronavirus Pandemic among Older Adults

Abstract

As the coronavirus crisis spreads swiftly through the population, it takes a particularly heavy toll on minority individuals and older adults, with older minority adults at especially high risk. Given the shockingly high rates of infections and deaths in nursing homes, staying in the community appears to be a good option for older adults in this crisis, but in order for some older adults to do so much assistance is required. This situation draws attention to the need for benevolent intervention on the part of the state should older adults become ill or lose their sources of income and support during the crisis. This essay provides a brief overview of public support and the financial and health benefits for older individuals who remain in the community during the pandemic. It reports the case example of Austin, Texas, a city with a rapidly aging and diverse population of almost a million residents, to ask how we can assess the success of municipalities in responding to the changing needs of older adults in the community due to COVID-19. It concludes with a discussion of what governmental and non-governmental leadership can accomplish in situations such as that brought about by the current crisis.

As the coronavirus crisis sweeps through nursing homes, our nation is reminded that where we live and with whom we live matters, especially for those of advanced age. Death rates from COVID-19 are highest among older adults, especially among those with underlying medical conditions. During the global pandemic individuals in most countries are confined to their residencies if possible, but this may be challenging for older adults due to dramatic changes in family living arrangements for aging Americans over the past half century. According to the U.S. Census Bureau, the fraction of people ages 65 years and over living alone has increased substantially in recent decades, and it now represents about 30% of individuals in this age group (U.S. Census Bureau, 2019). Living alone no doubt increases with age due to the loss of a spouse. In the U.S., about half of older women (45%) age 75 and above live alone (The Administration of Community Living, 2018). European countries in large part mirror these trends (Mudrazija et al., 2020).

Given the shockingly high rates of infections and deaths in nursing homes, remaining in the community appears to be a good option for older adults in this crisis, but in order for some older adults to do so much assistance is required. This essay argues that while living arrangements depend on one’s circumstances and personal desires, the role of policies, both at the national and local levels, is also critical, especially in the context of promoting socially desirable outcomes and providing the resources necessary to achieve them. Communities in the U.S. – whether rural, urban barrios, or suburbs – may be ill-equipped to deal with aging populations and those at highest risk during COVID-19. The swift-spreading coronavirus public health crisis has caught many southern states off guard. These include Alabama, Florida, Georgia, Mississippi, and Texas, all of which have yet to expand Medicaid (Kaiser Family Foundation, 2020). Cities hit the hardest by the epidemic such as Atlanta, Georgia, and New Orleans, Louisiana scramble to mobilize resources to save lives, disproportionately in African American communities, amid already overwhelmed hospitals and public health services (Brooks, 2020).

We begin with a brief overview of living arrangements in the U.S. and the history of public support for keeping older adults within the community as long as possible in later life. We then take a close look at Texas, which, at 17.7%, had the highest uninsured rate in the country in 2018 (Keith, 2019). In many states, older residents – pre-retirement age, immigrants, and adult caregivers – lack easy access to a health care provider and thus, are unable to get tested for the virus during this crisis. By example, we present a case study of Austin, Texas, a city of almost a million residents with a rapidly aging and diverse population, to gauge the preparedness of the City in responding to the needs of older adults in the community during COVID-19. Austin is the first municipality in Texas to receive official approval for implementation of an Age-Friendly Action Plan, a World Health Organization and AARP initiative that enables people of all ages to stay at home for as long as possible (City of Austin Commission on Seniors Working Group, 2016). We end with a discussion of what the role of governmental and non-governmental leadership can accomplish in situations such as that brought about by the current crisis.

Living arrangements in the U.S

In the 20th-century, wealth generated by a vibrant post-World War II economy coupled with falling poverty rates made it possible for older adults to afford to live alone across most developed countries. Aside from having more income to support independence, many social norms associated with aging in recent years have altered the lives of older adults. Most individuals have developed an expectation of privacy, craving autonomy and independence when they reach old age. Similarly, most older adults prefer to continue living safely in their community and their home for as long as they can, as opposed to residing in a nursing home even in the event of cognitive decline (Evans et al., 2019; Portacolone et al., 2019). Home is not only an asset, but also a place to which a person is emotionally attached (Mudrazija & Butrica, 2017). The sense of belonging to a community where one lived for a substantial part of his or her life is generally very strong. Such values reflect an ardent preference toward living in one’s own home as opposed to moving in with children or an assisted living facility. For most home owners it represents a major fraction of a family’s total wealth and probably the largest portion of what they can leave to future generations (Mudrazija & Angel, 2014).

In the U.S., however, living arrangements are not uniform across racial and ethnic groups. Although currently only 20% of older adults age 65 years and over are members of a racial/ethnic minority group, projections show that aging African Americans, Hispanics, and Asians will account for 42% of the population by 2050 (Angel, 2018). Social scientists have long established that older minority American households are far more complex than the majority households. This complexity can be attributed to marked differences in marital dissolution and migration patterns, greater socioeconomic disadvantage, and a legacy of cultural preferences in kin solidarity (Himes et al., 1996). Low-income African Americans and Mexican Americans have a greater propensity than non-Hispanic whites to form joint households in response to changing needs for financial or health assistance (Cohn & Passel, 2016). In Europe, living in extended-family households that include relatives such as grandchildren, nephews, and adult children’s spouses are the most common arrangement for people 60 and older (Ausubel, 2020).

In light of the global pandemic, however, new pressing considerations related to living arrangements are emerging. The pandemic has shown how close quarters and institutional settings have not fared well, which will impact how we age in the future (Horowitz & Bubola, 2020). Growing old in a nursing home is now a grim but clear reality for some of the nation’s frailest, infirmed, and vulnerable older adults that places them at considerably greater risk from COVID-19 (Stockman et al., 2020), While shelter-in-place orders have worked to reduce the spread of the virus within the community, home has become a dangerous place for those who live with family in close quarters. Essentially, the family household has become a disease vector for many older adults alongside clusters of residents in nursing homes (Horowitz & Bubola, 2020). It is abundantly clear that the COVID virus outbreak is adding peril to the vulnerable populations already at-risk, sounding an alarm for aging policies that promote supportive services and programs that enable older adults to stay in their homes as the shelter-in-place orders linger.

Public support for aging in the community

A recent cross-national study compared the income and wealth profiles of the population aged 60 years and above for those living alone in the U.S. and 19 European countries. The data from the Health and Retirement Survey (HRS) and Survey of Health, Aging and Retirement in Europe (SHARE) revealed that living alone is far more common in old-age welfare systems like Germany, Sweden, Denmark, and Switzerland, partly because of generous social support and spending (Mudrazija et al., 2020). On the other hand, a lack of adequate public support in less generous welfare states such as the U.S., Greece, and Italy tended to constrain the ability of many low-income older adults without a partner to continue living independently.

In later years of the life course, where and with whom one lives greatly influences the quality of one’s life. Yet a person’s living arrangements are not solely the result of individual choices. The options from which an older person can choose are determined by his or her economic and social resources, as well as by his or her state of health. As a result, living arrangements and levels of independence vary greatly among the elderly. Gender differences in living arrangements magnify group disparities in care options as people age in place. For example, data from the largest and longest running study of older Mexican-Americans in the Southwestern United States show that women are more likely to live longer than other racial/ethnic groups of women and men. Consequently, they are at high risk of dependency on family and “fictive kin” partly because of limited options in formal community-based long-term care services and supports (Angel et al., 2018; Rote et al., 2017).

Many communities in the U.S. – rural, urban ethnic barrios, and suburbs – are underserved. Municipalities struggle fiscally in light of increasing demographic pressures to promote aging in place – with all of the services and supports that are needed – for their older residents while also attracting younger generations required to ensure continued economic prosperity and social vitality (Torres-Gil & Angel, 2019). In conjunction with the fact that many families face daunting challenges to provide care during COVID-19, other arrangements must be considered. These include semi-formal organizations consisting of community-based resources that family caregivers can call upon during the virus outbreak. Resources range from informal, unpaid care from family members and others, formal governmental agencies that provide eldercare services and, in between, non-governmental organizations. Examples of the latter include faith-based organizations, synagogues, and congregations that increasingly serve as vital sources of assistance to families caring for elders at risk for infection or who live alone and have no family support.

According to the Administration on Community Living, access to state-sponsored services like the state Area Agencies on Aging (AAA) and Aging and Disability Resource Centers is critical for older adults and their families. These local agencies offer an important support system for older adults 60 and over, including distributing information, providing assistance, helping to manage services, and giving access to publicly-funded programs like Medicaid. State AAAs may also receive grant funding, based on their share of the population age 70 and over, to administer the National Family Caregiver Support Program (NFCSP) program, which links services to caregivers 18 years and older, regardless of the age of the care recipient. However, few community-based programs have adequate funding to operate effectively given the need in low-resource communities. This lack of resources poses a challenge during regular operations but especially during crises like COVID-19.

Case example: Austin, Texas

Austin, Texas is the fastest-growing big city in America. Projections show that from 2015 to 2030 Travis County’s population (within which Austin is situated) will grow by more than 20% to 1.3 million residents (City of Austin, 2015). The city’s rapid expansion is the result of growth in every age group, but nowhere is that surge more pronounced than among seniors 55 and older (Angel, 2016). The Austin metropolitan area leads the nation in the growth rate of people ages 55 to 64, and has the second highest growth rate of those 65 and older (Aging Services Council of Central Texas, 2019). The population of individuals 65 and older in Travis County is projected to almost double between 2015 and 2040 (Neely, 2017). In ten years, one out of five Austin residents will be 65 or older (City of Austin, 2015). The needs of the older low-income population present unique challenges to policymakers in Travis County in light of COVID-19.

Austin is administered by an eleven-member city council consisting of ten council members elected by a geographic district plus a mayor elected at large who is Steve Adler. The City employs about 13,500 staff in more than 40 departments that offer a wide range of services (City of Austin, 2020). For example, Austin Public Health (APH) offers extensive public health services from health education programs to enforcing regulations that protect everyone from injury and illness (City of Austin, 2020).

After the declaration of the novel coronavirus global pandemic by the World Health Organization on March 11, 2020 (Branswell & Joseph, 2020), APH collaborated effectively with the Department of State Health Services, Centers for Disease Control and Prevention (CDC), and local and regional public health and healthcare agencies to develop a COVID-19 response plan in accordance with new CDC guidelines (Centers for Disease Control, 2020). APH is adjusting operations, modifying work schedules and programs, to continue providing services to residents while ensuring public health and safety in response to the coronavirus outbreak. As part of the strategy, senior residents are given special attention because of known sources of vulnerability to aging in place amid the crisis. Currently, APH’s epidemiologists are actively investigating clusters of COVID-19 cases in Austin-Travis County as part of efforts to contain COVID-19. On March 30th, Austin Public Health announced a new plan for nursing home residents that tested positive for COVID-19 but do not require hospitalization. To keep the virus from spreading, two “isolation facilities” containing 100 beds total were set up in Travis and Williamson Counties to treat older residents who typically reside in nursing or assisted living facilities.

In addition, APH created a Senior Task Force to mobilize interagency guidance to assess gaps in service delivery and housing supports. Austin City Mayor Steve Adler gives daily briefings to educate the public. These provide consistent public messaging regarding the goals to protect residents’ health by complying with stay at home and shelter orders that would contain the spread of the virus infection. Adherence to social distancing and washing hands have been emphasized as key mitigating strategies to save the lives of senior residents. Given the high risk among older adults in large public spaces, the City also issued a Mayoral declaration on March 16, 2020 closing all three senior activity centers. In addition, the City has partnered with local businesses and voluntary organizations to build capacity to produce more masks.

Led by APH, a cross-department Senior Task Force engages in daily dialogue to assess service gaps in changing needs for assistance and to identify unmet services and supports. Three of the ten members of the Austin City Council sit on this Task Force. In terms of public education and outreach, the City’s Information Technology Department created a new web page with links to provide updated and vital COVID-19 information linked to the Travis County Dashboard (TCD), fostering transparency of confirmed COVID-19 cases and deaths (see www.austintexas.gov/covid19). Up-to-date Stay at Home Order Information and specific requirements are available on the TCD. For other Corona-related questions that cannot be answered by what is on the TCD, residents can call 3–1-1, the exchange for police non-emergency inquiries (see https://www.austintexas.gov/department/311). Additionally, APH works alongside Austin-Travis County Emergency Operation Center’s newly created social services branch Task Forces in their ongoing COVID-19 response efforts to address the needs of the frailest and most vulnerable older adults in the community, including those with behavioral health problems and the homeless population (see http://austintexas.gov/news/austin-travis-county-creates-social-service-branch-emergency-response-efforts).

As the virus takes its course, the City of Austin uses the data report on the TCD to gauge benchmarks for containment of the virus, which is achieved after a sustained reduction in cases for at least two weeks. Importantly, the Dashboard’s home page also includes a self-assessment tool to assess COVID-19 symptoms. Seniors, caregivers, and others can pre-register for free testing, and schedule a no-cost, drive-through test at a local Austin Public Health facility. A Hotline number for the uninsured was set up by Central Health, a public entity funded by local taxes, for treatment at one of seven neighborhood health clinics (known as Federally Qualified Health Centers) in the City of Austin (Health Resources and Services Administration, 2018). A medical team triages all callers and makes appropriate recommendations while answering patient questions related to COVID-19.

Some City Council members also hold virtual Town Halls to assess the needs of District residents, provide updates posted on Facebook, and publish monthly newsletters. Senior issues are highlighted and panelists at the virtual Town Halls represent local grocery stores and nonprofit organizations, such as Meals on Wheels Central Texas, Drive a Senior West Austin, and the municipal government’s Aging Services Council of Central Texas. These organizations are adapting to serve senior clients in the midst of the pandemic. Like counterparts around the country, grocery stores are holding senior-only store hours to minimize older adult’s exposure to the coronavirus. Meals on Wheels Central Texas has adopted many programs, including the Pets Assisting the Lives of Seniors (PALS) service that supplies pet food and veterinary care (Texas, M. O. W. C., 2020). The Aging Services Council of Central Texas provides a list of special services related to COVID-19, opportunities to work for a nonprofit organization by volunteering at home or in the field as well as donate money to help support seniors age in place (Aging Services Council of Central Texas, 2020)

To facilitate aging-in-place, APH is working to align public and private organizations to address food insecurity. The Central Texas Food Bank, a nonprofit organization, currently serves around 1,600 seniors a month through the Healthy Options Program for the Elderly (HOPE) in partnership with Meals on Wheels Central Texas. In response to COVID-19, the Food Bank partnered with H-E-B, a Texas-based supermarket chain that offers food delivery service, and Capital Metro to deploy Help-at-Home kits that consist of pantry staples, such as peanut butter, rice, soup, and canned vegetables to the City of Austin’s Metro-Access, a shared-ride service for seniors and people whose disabilities prevent them from riding other Austin bus and rail services (CapMetro, 2020). H-E-B instituted senior grocery delivery through the Favor App or Website (https://favordelivery.com/) for those 60 and older. Same day delivery is available 11 a.m-7 p.m. (H-E-B, 2020)

Drive-a-Senior West Austin (DSWA) now offers free grocery delivery services and prescription delivery services for clients. Similarly, Randall’s Grocery gives the option of free delivery for prescriptions during this time. DSWA recently launched operation of an emergency food pantry delivery service to seniors 60 and older. The emergency response will be sustained until the end of 2020 and seniors, who are at the highest risk of death from the disease, will be encouraged to stay home much longer than the general public once orders are lifted (Drive a Senior Austin West, 2020).

While most state and local governments struggle to keep the outbreak at bay with shrinking budgets, the City of Austin shines a glimmer of hope on ways of doing this well. At the same time, the extent to which City officials, along with non-governmental partners, can manage the epidemic and economic damage alone has yet to be gauged. Current federal government efforts lag behind local municipalities in providing the real help low-income workers and their families need in the absence of adequate federal and state support. As the City of Austin has shown, it takes a smart deployment of resources by coordinating efforts of various agencies and departments that provide services to seniors. This coordination involves housing, social welfare programs, food access, transportation, and other supports critical for older adults to live independently. Such services are essential for those of limited and moderate means.

Notwithstanding these efforts, other vexing issues loom as COVID-19 lives on. According to the Aging Services Council of Central Texas, there are currently limited or no transportation services that will take seniors to testing sites. Many seniors worry about safe access to a local doctor’s office or hospital. Seniors also lack access to reliable technical devices, and many do not understand how to use devices if given access, nor can they afford the additional cost of Wi-Fi. Social isolation is a major concern, especially for seniors living alone. Our seniors need contact from the community, during the pandemic and beyond (Austin City Council, 2020).

Conclusion

The range of actions taken by Austin’s local government in partnership with nonprofits and for-profit businesses represents a successful example of how local authorities can facilitate life in the community for seniors. While these services have been introduced in response to the COVID-19 pandemic, at least some of them could and should stay in place permanently as they meaningfully improve the quality of life for seniors who live in the community.

Long-term, as the virus lingers, the pandemic accentuates in particular the risks for those seniors living without family and social support. This situation is avoidable with proper preparation. Austin, by example, is a template for a city’s preparedness planning for an aging population under extraordinary circumstances and are likely to be useful in the future. While young and hip, the City is rapidly becoming older and more diverse which demands effective implementation of aging-in-place policies. The City is confronting many new challenges in addressing the needs of residents aging and living alone during the Corona virus outbreak. Isolated seniors and those with no relatives and a fragile social network are particularly at high risk of disability and death without a safety net. The rising cost of living, lack of affordable housing options, and need for support in retirement is a major concern and has given rise to shared living arrangements – co-residence and multigenerational households – placing many seniors, especially among immigrant families, precariously at high exposure to the virus given the small spaces that are shared most. For many cities, strengthening social resilience is vital for recovery. With strong partnerships and civic leaders, cities and the nation can rise to the challenge of enhancing livability for all in these difficult times.

Key points.

• Helping older adults age safely in the community is far more important than ever in viral pandemic.

• Living alone is more common in municipalities that have generous old-age social support.

• Effective response to COVID-19 requires coordination among the local polity and private and not-for-profit organizations.

• COVID-19 presents fiscal and administrative challenges to sustaining livable communities for older residents who face the greatest barriers to sheltering in place.