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The United States is in the midst of an unprecedented demographic experiment. The achievements of the past century—lower poverty rates, improved environmental regulations, higher educational attainment—have led to a remarkable growth in life expectancy. The average life expectancy for an American born in 1920 was 54.1 years. As of 2017, that number had risen to 78.6 years. This growth in life expectancy has been coupled with a steep drop in birth rates. In 1960, the fertility rate in the United States was 3.65 births per woman. By 2017, that number had fallen by more than 50% to 1.76 births per woman.

This transformational change in our country’s demographic profile—a growing elderly population paired with a stagnant youth and working age population— raises important challenges from a public finance perspective with warning signs already flashing in other advanced liberal democracies. In France, where the ratio of active workers to retirees has fallen from 4 to 1 in 1960, to 1.7 to 1 today, the longest strikes in 51 years have brought segments of the country’s economy to a halt as the Macron administration has attempted an overhaul of its 70-year-old pension system, which it argues is headed for large deficits. The challenge presented by a changing demographic profile in the US is particularly acute in the healthcare sector, which currently constitutes almost one-fifth of the nation’s GDP, and where annual cost growth has outpaced inflation for decades. As we consider our public policy priorities as a nation for the next decade, at the top of the list should be the question of how we can provide high-quality, personalized, empathetic care to a growing senior population, and do so in a way that is cost-effective and financially sustainable.

In evaluating healthy aging from both a public health and economic perspective, among the most expensive and life altering public health issues for seniors is falls. In the United States, 30% of adults over the age of 65 experience a fall annually. Falls are the leading cause of fatal injury and the most common cause of nonfatal trauma-related hospital admissions among older adults.

In purely financial terms, this translates to over $50 billion a year in direct medical expenditures. The indirect costs of falls for seniors—increased social isolation, reduced quality of life, increased risk of future health complications, and skyrocketing caregiver costs—are exponentially higher. While fall prevention is an enormously important public health issue in its own right, it is intimately tied to the concept of “aging-in-place”—the preference of the vast majority of older adults to “live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level.” Because the majority of falls take place in the home, effective aging-in-place and fall prevention programs are deeply intertwined.

Our goal with this paper is to explore pathways to sustainably fund programs that significantly reduce falls among seniors, allow them to gracefully age-in-place, and impact a range of other public health issues—such as social isolation—that are reaching epidemic proportions among elderly Americans.

Authors and Contributors: Adam Halper, Green & Healthy Homes Initiative (GHHI), Nina Creech, People Working Cooperatively (PWC), Ruth Ann Norton (GHHI), Michael McKnight (GHHI), Kiersten Sweeney (GHHI), Will Klein (GHHI), Daniel Son (GHHI), Kelsey McClain (GHHI), Ron Henlein (PWC), Aaron Grant (PWC), Sara Bourgeois (PWC) and Brad Staggs (PWC).

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A comprehensive ‘Healthy Homes’ model, which aims to make a home healthy and safe from hazards that can lead to trip and falls among older adults, could be an even more effective approach to fall prevention.  This model includes:

1. An environmental assessment that identifies health and safety hazards such as lack of stairway rails and grab bars, obstacles and tripping hazards, and inadequate lighting that are present in the home.
2. The development of a scope of work that may include installing grab bars and sufficient lighting as well as removing obstacles and tripping hazards.
3. The execution of these home modifications specified in the scope of work that address the hazards.

However, developing and implementing this type of model requires extensive program infrastructure, cross-sector partnerships that include home environmental assessors, community-based contractors, and a sustainable business model with willing and reliable payers.  With no certifications currently required, the incorporation of assessors and contractors would be seamless.

Recruiting payers is more difficult.  To foster a successful “Healthy Homes” fall prevention program, there must be coverage for:

• the target population of older adults at-risk for a fall, which includes individuals who have already fallen and individuals who have not fallen but are at-risk.
• the environmental home assessment performed by an environmental assessor
• home modification equipment such as grab bars and toilet seats
• and the execution of the home modifications by a contractor

Currently, there are no entities that are both willing to and able to pay for a “Healthy Homes” fall prevention program that includes each of the above components.

There are several viable opportunities within the healthcare sector to support and sustain a comprehensive “Healthy Homes” fall prevention program.  Medicare is a good option with its role in covering care for adults over the age of 65, the age group that is the most at-risk for fall.  While the other components are largely not covered, there are several opportunities that could lead to coverage involving the potential expansion of the definition of durable medical equipment to include home modification equipment as well as the passage of the CHRONIC Act, which removes some of the barriers to implementation of a comprehensive fall prevention program.  There is also potential for coverage under Medicaid as the Medicaid Waivers, Medicaid Rule Change, and Medicaid Managed Care Organizations enable coverage of environmental assessors, community contractors, and the services provided in a comprehensive “Healthy Homes” program.  Still, there are some barriers to implementation that include eligibility criteria, the coverage of home modification equipment, and whether housing interventions are considered medical services.  There are a few other opportunities for coverage of certain components of a “Healthy Homes” fall prevention program including hospital investment, accountable care organizations, and value-based care, that are largely under-developed.

Still, home modifications are effective in reducing both the risk of falls, and their associated costs, among older adults.  In Baltimore City, the CAPABLE pilot program improved the ability to perform activities of daily living in 75% of participants, saving an average of $30,000 in healthcare costs.  More information on this program and the Habitat for Humanity of Greater Memphis Aging in Place Program” are included in this report as case studies.

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