Aging Latinos: Increasing diversity will increase challenges for aging network
Janice Lynch Schuster
By Janice Lynch Schuster
Overview: Disparities in Care, Strengths in Community
The age boom – the 77 million boomers reaching old age together – is already straining national, local and personal resources as the country tries to manage health care and services for the millions who are living longer, dealing with multiple chronic conditions or who require a continuum of care – beginning with assistance with the tasks of daily living and ending with palliative care and end-of-life services.
As stakeholders experiment with how best to redesign and deliver care that supports and engages older adults they also must account for changing demographics. According to the Census Bureau, the majority of aging boomers (72 percent) are white. Their experiences may prove less instructive in understanding the particular needs of racial and ethnic minorities, whose numbers will surge when today’s millenials reach retirement age. Today, Latinos are just 11 percent of the boomer generation, but comprise one-fifth of the millennial generation, and one in four of today’s children under the age of 18. This interactive infographic from CNN Money illustrates the shifting proportions over time.
By 2050, the Administration for Community Living projects that there will be more than 17 million older Latinos, or about 29 percent of the total U.S. population. Latinos will comprise the majority of non-Caucasian elders. According to a 2014 National Council of LaRaza report:
While Hispanics are a vital and expanding part of the U.S. population, there are troubling trends in their health and well-being. Chronic diseases – such as heart disease, cancer, diabetes, asthma, obesity, hypertension, arthritis and liver disease – are prevalent and burdensome among this community. For some of these conditions, including diabetes, obesity, and HIV and AIDS, Hispanics face significant health disparities.
Latinos are twice as likely as whites to be diagnosed with diabetes, and 50 percent more likely to die from it. Their higher obesity rates – 39.1 percent versus 34.3 percent – puts them at greater risk for developing diabetes and other chronic health problems. The CDC reports that 14.2 percent of Hispanics had two or more chronic conditions in 2010, and 2.7 percent had four or more. The U.S. Department of Health and Human Services has launched an initiative to address the needs of the burgeoning population of people who have multiple chronic conditions (MCC). People with MCC are at increased risk for mortality and function more poorly on a day-to-day basis.
In a recent Huffington Post article, William Vega, of USC’s Edward R. Roybal Institute on Aging, said that aging Latinos may “strain safety nets such as Medicare and Social Security because of lower incomes, savings and education levels.”
La Raza notes that until the implementation of the Affordable Care Act, Latinos were more likely than whites to be uninsured. As a consequence, they were twice as likely as whites and non-Hispanic blacks to report that they had no usual place of health care. The ACA may reverse this trend, by providing improved access to health care, along with increased coverage (in many cases, free) for annual screening and wellness visits. Such improved access to care, screening, and treatment will be especially important to improving care for older Latinos.
Key issues for aging Latinos
Latinos will face the usual challenges of aging, but theirs will be compounded by health disparities, as well as by cultural and ethnic traditions and practices that do not mesh with a traditional American focus on individual autonomy. For immigrants who did not work in the system long enough to qualify for Social Security and Medicare benefits, who are undocumented, or who live in households with undocumented people, the challenges will be even more pronounced.
Jaqueline L. Angel, Ph.D., a professor of sociology and public affairs at the University of Texas at Austin, said, “When we think about ethnic diversity of the aging population, people just aren’t focusing on it, but it is a reality, as is the question of who will care for elderly people who are living longer with serious functional impairment.”
She continued, “This is especially true for aging Latinos of Mexican origin: fifty percent of their time before death is spent with physical disability. Who will take care of this population, who have an aversion to nursing homes and who are the least likely to use nursing homes? There are variations, but the greatest tendency [among Mexican Americans] is to use nursing homes for short-term care only. Mostly, however, they are living with family, even though they are living longer than other ethnic groups.”
These longer lives, Angel said, come with a price.
“Longer lives are fabulous, but these are longer and sicker lives that create a dependency burden on society and on family members. At the same time, we have the ‘de-familyization’ of households, which are shrinking in size, have increased labor participation, and wider geographic residence. With the lack of jobs along the Texas-Mexico border, younger workers are moving away. And so you have the social dilemma too: Who is going to pay for Medicare and Medicaid?”
Multiple chronic conditions
Latinos begin to experience MCCs at an earlier age than whites and other racial groups. According to Adriana Perez, Ph.D., A.N.P.-B.C., of the Arizona State University College of Nursing and Health Innovation, “Cardiovascular disease and diabetes affect Latinos disproportionately. And so I see Latinos who are 60, who would benefit from Medicare because they are aging physically and aging quickly. I see women at 50 with worse problems than older white women at 65.”
Although the Affordable Care Act will enable younger Latinos to access preventive care and treatment, it will not have the same effect on “those who are old now, who have issues related to living longer while facing health disparities that lead to morbidity and mortality,” Perez said.
As this New America Media story explains, despite documented health disparities, Latinos may live longer than members of other ethnic and racial groups. However, Perez suggested that this “Hispanic Paradox” may not be as valid as some suggest. She notes that many older Latinos return to their country of origin when they become sick and old, and, consequently, the data do not reflect their experiences of illness and death.
Family caregivers are usually middle-aged daughters who also work full or part time. Caregiving has significant financial effect on women – a 2011 MetLife study found that the average woman who leaves the workforce entirely or reduces her hours experiences a lifetime earnings loss of about $142,000 in wages and income. The cost to her Social Security benefit is about $131,000. For those women who still earn pensions (increasingly fewer), an additional $50,000 is lost. Latino women are hit even harder. Many are employed in lower-wage work, so while the actual dollars may be less, these losses create an even greater overall effect.
Latinos also face the challenge of maintaining cultural traditions, in which families care for their members by themselves. In the face of socioeconomic changes and imperatives, that tradition may become harder to follow. Perez noted that there may be some mutual benefit to arrangements in which older adults live with younger family members, thus enabling families to pool and leverage their resources.
Perez pointed to the strengths within Latino communities, where, she said, “Family seems to be a protective mechanism. It is a very intergenerational culture of families working together and living together.” She added that in general, Latino communities foster respect for older adults, and values them as matriarchs and patriarchs who guide decision making.
However, many of those communities are not conducive to healthy living behaviors, especially for access to healthy foods and activity, such as walking. Florida’s Little Havana has one of the nation’s highest mortality rates for older Latinos. She added that diet and nutrition are a constant concern, and that while Latinos generally have healthier diets in their home countries (with diets based on vegetables and beans for protein), those deteriorate as they move to America and adapt American food and eating habits.
End-of-life care, hospice care and palliative care
Latinos face problems as they approach the end of life, particularly in selecting and naming a health care proxy, completing advance directives, accessing hospice care, and receiving adequate pain management. A nationally representative study found that Latinos are less likely than whites or non-Hispanic blacks to have a health care proxy, and are less likely to have someone who can serve as a proxy, according to Susan Enguidanos, Ph.D, M.P.H., of the University of California, Davis, School of Gerontology. Her research focuses on racial and ethnic variations in hospice and palliative care. Enguidanos has found that:
Latinos are less likely to be referred to hospice, and more likely to die in hospital.
Latinos tend to prefer a family-centered focus on care, with family members engaged in the care and in decision making. This is a more collective approach to care, one that is much more focused on the family unit. Because most models of care planning focus on individual decision making, this cultural preference may present another barrier to care.
Language barriers can intensify the usual roadblocks to end-of-life conversations – obstacles erected by physicians and patients, who find the conversation difficult and worry that they are “giving up.” Hispanic culture itself may present barriers to talking about death. Among Latinos the biggest barrier may simply be a lack of knowledge about end-of-life care, hospice and palliative care.
Distrust of the health care system is common among Latinos regardless of age, according to recent research and reports. A recent survey by Oregon State University finds that even younger Latinos are mistrustful and perceive discrimination within the U.S. health system.
A 2012 report from the California HealthCare Foundation provides further details on Latinos’ experiences and expectations about end-of-life care in that state:
Latinos (38 percent) were more likely than whites (15 percent) to say that they did not want to talk or think about dying.
Latinos were 16 percent of deaths in the state, but only 4 percent of these deaths occurred in hospice.
Latinos are more likely than whites to rate living as long as possible to be very important to them, which dovetails with wanting doctors to provide aggressive care (56 percent).
Enguidanos said that although repeated studies have found ethnic variations in hospice enrollment, her study of patients enrolling in hospice after receiving a palliative care intervention revealed no such variation. Because palliative care does not require patients to forgo curative treatment, patients may be willing to choose it.
In covering aging Latinos, reporters should bear in mind the vast differences within the population, which is not monolithic or homogenous. Hispanics come from many parts of the world, with many different traditions and experiences, and, among immigrants, with very different reasons for having come to America. The range of stories reported should reflect the diversity of the population being covered. Ideas for other stories might include:
The Latino experience of nursing homes: If they prefer not to use them, what are they using? What are they doing? What are the outcomes? What are the benefits and burdens to their family caregivers?
Latinos and Alzheimer’s: Latinos develop the disease at earlier ages than whites, but are often diagnosed at later stages. This reflects not only a lack of understanding of dementia, but some of the shame and stigma within the community, which views this as a mental health problem, and a shaming one.
Home care workers: Many direct care workers earn very low wages, and face a financially unstable future. What are the implications of this for Hispanic workers as they age. How will they ever save for retirement? How will they affect the safety net?
Healthy environments: Is your community safe for older pedestrians? If not, why, and how can it be made safer? Does the community promote healthy living strategies for Latino residents? Is there a food desert?
Health literacy and health insurance literacy: Perez is engaged in research to understand the level of literacy among Latinos, and how to improve it so that they can access the benefits of the ACA. One caveat: Individuals who are over 65 and not Medicare-eligible do not qualify for the exchanges. In addition, many Latinos are accustomed to using urgent care centers and emergency departments, and must learn to navigate the primary care system now open to them.
Workforce growth: Perez, a nurse, noted that fewer than 5 percent of registered nurses are Latino. The ACA includes provisions to expand the health care workforce and attract racial and ethnic minorities. It will also need to find ways to diversity that workforce.
Adriana Perez, Ph.D., ANP-BC, assistant professor and co-director, Hartford Center of Gerontological Nursing Excellence, Arizona State University College of Nursing & Health Innovation (firstname.lastname@example.org)
An Inside Look at Chronic Disease and Health Care Among Hispanics in the United States, Report from National Council of LaRaza
Medicare Chronic Conditions Dashboard by State (no ethnic breakdown)
Status of Aging Hispanics, National Hispanic Council on Aging
The Next Four Decades: The Older Population in the United States 2010 to 2050, United States Bureau of the Census
Aging Latino Resource Center, University of California, Davis
This tip sheet by Paul Kleyman on additional challenges facing ethnic elders.
A 2013 special report from the National Institute on Aging on Racial and Ethnic Barriers to Palliative Care.