The Old Old in Florida

The neighborhood clubhouse at Gold Key West Villas is empty. The canasta tables are deserted. The swimming pool is quiet. Some blue and white lounge chairs are overturned. The men's club at this retirement community disbanded a few years ago, and the women don't have enough active club members for real meetings any more. The social club expired last year. New Year's Eve went uncelebrated, no champagne, no noise-makers. 

"This used to be a real jumpin' place," says Irving Engelbert, 80, who came from Brooklyn to Gold Key West Villas in Sunrise, Florida, 12 years ago. "Now it's death valley." 

Peggy Graham, 65, agrees: "Every day I look up and down the street and just pray for a front door to open." But many of her neighbors are too frail to venture out alone. Twelve years ago Bob and Peggy Graham migrated to South Florida, like thousands of retirees. The Massachusetts winters were painful. Bob, now 69, had suffered a mild heart attack, and doctors ordered them south. So the Grahams left their daughters and big, old, burdensome house. They left with some money: Bob had a handsome pension from his job as a mail carrier in downtown Boston, and Peggy had saved some of her earnings as a supermarket cashier. They moved to Gold Key West Villas, a modest retirement community of 101 white one-story homes in Broward County. They bought a small house for about $17,000, only doors away from Bob's brother Vinnie and his wife, Florence. But times have changed since they moved into this once bustling community. 

"You can look out your front window all day and never see a fly go by," says Florence Graham, 72, who tends to the growing number of frail widows in the neighborhood by giving them permanent hair-waves or just checking on them. For thousands like the Grahams, the enchantment of retirement is giving way to the harsher realities and frailties of advanced old age and the expenses that accompany declining health. 

"Increasing numbers of the elderly outlive their good health and their resources than have ever been known in the history of the country," says Max Rothman, a former district administrator for Florida's Department of Health and Rehabilitative Services (HRS). "The state has traditionally been the payer of last resort. The state is finding more and more that it will have to pay." 

Life in Gold Key West Villas is no different than in hundreds of retirement communities across South Florida. Thousands of retirees, like the Grahams, moved to Florida during the early 1970s mostly from the Northeast. They came seeking healthy sun, easy housekeeping, and evergreen golf courses. But as they moved from the ranks of the "young old" and joined the "old old," those attractions changed to golden memories. Now many elders in South Florida find their savings exhausted and their bills mounting. They find themselves alone, often unable to drive, dust the house, or bake a potato. They confront the reality of old age. 

Policy-makers across Florida also are confronting the problem and discovering it to be colossal. "Our 'old old' population is growing immensely," says Candy Rechtschaffer, director of Broward County's Area Agency on Aging. "People move down here healthy and happy, and suddenly they are old and out of money. And that is a tremendous problem for the state." 

Florida policy-makers and politicians also realize that other states, with their smaller elderly populations, are watching to see how Florida copes. "All the other states are looking to us. We are the laboratory for the rest of the country for the next 30 years," says John Stokesberry, the HRS district administrator in Broward County and former head of the state's Aging and Adult Services division. "But the other states won't have nearly the same demand as Florida." 

It has not always been that way. In the past, for the most part, Northern senior citizens simply stayed home and were cared for by their grown children. But starting in the 1950s, after World War II, elders moved south in large numbers. During the 1970s, as later generations' incomes grew, the migration increased. Mostly, people came to Florida. 

A 1984 national study shows that nearly half of the total 1.7 million retirees who moved during the 1975-80 period ended up in just five states. Florida was the destination of 26.3 percent of all the retirees, according to this analysis of 1980 U.S. Census data. Second-place California received 8.7 percent; 5.7 percent went to Arizona, 4.7 percent to Texas, and 3 percent to New Jersey. 

The study, conducted by a team of four researchers including Charles Longino of the University of Miami, shows that 437,040 senior citizens came to Florida during that five-year period — a 66 percent increase over the number who migrated to the state in the 1965-70 period and a 110 percent increase over 1955-60. 

"It's a critical situation in the state today," says Candy Rechtschaffer. "Tomorrow will be disaster if we don't do something about it." 

Longino, a sociologist who is also director of Miami's Center for Social Research in Aging, attributes the dramatic population shifts to several factors. Medical technology has enabled people to live longer, and with less dependence on their children for long-term care, and Social Security benefits and pensions have made retirement easier. Longino also believes it became more acceptable after World War II for Americans to leave family and friends and strike out on their own. But more than any other reason, older people move to the Sunbelt states for the pleasant climates and leisurely lifestyles. 

Whatever the reason for the flight south, the mass movement has been a boon for Florida. The well-off retiree has been an important consumer. Developers turned seas of scrubby sawgrass into sprawling cities of retirement condominiums. The beachfront quickly became a wall of towers. Grocery stores, pharmacies, and hospitals followed. Retirees invested some of their pensions and savings in Florida banks, and the sheer numbers of elders, whether they own their homes or rent — and the construction that accompanied their arrival — have boosted the tax base in a state that relies heavily on property taxes for its income. At the same time, most retirees to Florida remain out of the labor force; thus they don't compete for jobs. Nor are they big consumers of the usual government services such as education and welfare. 

But the impact of elders on Florida's economy is changing. Until now, Florida's elders actually have been relatively young. But Florida policymakers are defining a new segment of the state's population who will need more expensive services: the "old old." 

Statistics compiled by Stanley Smith, a University of Florida economist, show what is happening. In 1980 the total number of Floridians over age 80 was 299,209. By 1990 that number is expected to reach 523,238. By 2000 it should be 775,867, according to Smith, who directs the population program in the Bureau of Economics and Business Research at the university in Gainesville. 

Policy-makers hear those statistics, politicians visit retirement communities like Gold Key West Villas, and they realize the enormity of the situation: as people grow older, they are more apt to become frail and their needs often multiply staggeringly. 

"When they first come here, they're young, mobile, married, and have means. There has been no slowing of the flow of elderly into Florida — 12,000 to 15,000 a month. Twenty years from now, those people won't be 60 years old,'' says Stokesberry of HRS. "Clearly, they need adequate and affordable and appropriate housing and health care, both long-term and preventive." 

Florida's policy is to discourage senior citizens from entering costly nursing homes. Instead, the aim has been to keep people living on their own. "Florida is making it possible for people to live independently," says Evelyn Glasser, head of a statewide committee studying long-term care for the elderly. 

And Florida elders are staying home. State population figures, compiled by Longino based on census data, show that 26.7 percent of those 85 and older are married and living with spouses. Only 10.6 percent of these very old people live in homes for the aged. Florida's elders may be staying out of nursing homes, but many still need help. "People have difficulty walking. They have difficulty doing things around their homes. These fitted sheets are very nice, but they're hard to put on the bed," says Margaret Jacks, the first director of the HRS division of aging, now a lobbyist for the Florida Council on Aging. "When you get to be shaky of hand and not too clear in sight, you put a kettle on for a cup of tea and you get burned." 

Today, Florida does provide health aides and housekeepers under its Community Care for the Elderly (CCE) program, which other states are eyeing and emulating. Started in 1978 as a pilot project, CCE provides basic services designed to keep the elderly living independently. While the programs are funded by the state, recipients also pay fees based on a sliding scale depending on their income. Other services include home-delivered meals, transportation to doctors' offices, and home health care in which a nurse comes to an elderly person's home. 

One CCE service is a 24-hour emergency alert/response monitoring system. Frail elderly people, living alone, can press a portable help button electronically connected to a hospital to get emergency assistance. Hospital personnel call a neighbor or friend who can then check up on the person. 

Another CCE program is homemaker services, in which an older person receives help with light housekeeping, cooking, laundry, and shopping. Under the personal care program, someone will give an older person a bath or shampoo; and the respite care program offers relief to a spouse or sibling caring for a sick elder, permitting that person to leave the house for a while. CCE also provides day care centers offering meals, programs, and rehabilitative therapy for senior citizens. 

Still, the needs outrun the program. Governor Bob Graham asked the legislature for $30 million for the community care program for this year, but only $22 million was granted. That will serve 21,660 people a day, officials say. In Broward County alone, 700 people are on the waiting list for homemaker services, and seven day care centers serve 343 senior citizens, with 160 on the waiting list. 

"There's tremendous need," says Margaret Lynn Duggar, head of the HRS division on aging. "There are so many waiting lists. And these are the critical services people can't really wait for." To meet that need, Graham has asked the Florida legislature to increase state dollars for CCE by $14 million over the next two years. 

Besides expanding the CCE program, Graham wants to create a new Community Services System (CSS), a central clearinghouse which would help disoriented older people get access to medical and social services. While it is still rough, the idea is to help seniors find their way through a maze of different government agencies. "Most older people get bounced around from one agency to another. They feel lost," says Cathy Kimbrel, a Broward County social service division supervisor. "If there was a single entry point, like they are suggesting with CSS, that would help." 

The plan for CSS is just part of the 99-page report developed by Graham's 20-member Committee on Aging. In June 1984 Graham appointed the body to study the future needs of Florida's 1.7 million elderly residents. Released in January, the report — entitled Pathways to the Future — suggests state policies for coping with the burgeoning elderly population. 

The recommendations are sweeping, dealing with issues ranging from health care to crime to media perceptions of the elderly. In an attempt to improve the image of the elderly, the state will try to educate people about them. Specifically, the committee recommends legislation requiring the Department of Education, the Post-Secondary Education Commission, and others to have courses on aging in kindergarten through college-level classes. The committee also suggests that the state challenge public and private personnel officers to hire more retired workers who want to work part-time, and that school districts employ retired teachers as substitutes and teacher aides. 

Another proposal is financial aid to people who have elderly relatives living in their homes, along with social services needed for their care. The bulk of the committee's report deals with health care, perhaps the single most important and expensive issue for the elderly. 

The Florida Consumers Federation has pushed for lower health costs. The statewide organization lobbied for a hospital cost containment bill passed last year by the state legislature, especially demanding sections requiring hospitals to submit their budgets to a state board regulating cost containment. These sections were included, but the willingness of the board to be more than a paper tiger is in doubt, according to Karen Clarke, state director of the Consumers Federation. 

The federation is now preparing a patients' bill of rights for the legislature to consider. It would cover a patient's right to receive full disclosure about proposed treatment, the right to participate in making decisions about her or his own treatment, and the right to fair billing practices, to quality care, and to confidentiality. It also would set up a grievance procedure whereby patients could protest hospital practices. 

Better consumer education is also built into the CSS proposal — to help clear up elders' questions about confusing Medicare regulations. Many such questions concern new Medicare regulations implemented in 1983, which were designed to curb costs but created problems of their own — including premature hospital discharges. In the past, Medicare reimbursed hospitals for the actual cost of treatment. Now, however, the rules specify 470 categories of medical conditions, known as diagnostic related groups (DRGs), and each DRG has a price tag, a flat fee. This cash limit tends to determine the number of days a person will be kept in the hospital, regardless of whether the patient's condition warrants discharge. 

"You have all these weak, impaired seniors coming out into the community, usually before they are completely well," says Glasser, who studied long-term care for HRS. 

Sometimes, when medically necessary, a nursing home with round-the-clock care is the only answer. And this option may become more frequently necessary if the trend to discharge elders prematurely from hospitals continues. Going into a nursing home depletes an elder's personal savings. Usually, she or he starts out in a home by paying the bill — typically $1,500 a month — with private health insurance and savings. But, as a HRS report points out, over an 18-month period, it is common for insurance coverage to end and for the elder to run out of financial resources and become a client of Medicaid, the program that pays for health care for indigents. Even though Florida has a very low ratio of nursing home beds per elderly resident — 22 per 1,000 senior citizens — more than three-fourths of HRS's $389 million budget for long-term care is spent on nursing home care for only 1.3 percent of the state's over-60 population. 

A recently released HRS report, Targeting for Change, emphasizes the need for improved Medicaid reimbursement methods for nursing home care. Reasonable ceilings are essential, the report says, but they still must ensure that nursing homes provide quality care. The report also recommends possibly eliminating the least-intensive level of nursing home care, designed for people who might be able to live in an adult congregate living facility. 

There's not a lot on nursing homes in Graham's report — because the state philosophy that a retiree should try to live at home or in an alternative facility is firm. The report recommends the creation of incentives for local communities to change their zoning codes to allow such alternative living environments. It also suggests that the state encourage the private sector to develop group homes and congregate housing through tax relief and fair rental agreements. 

Low-income housing for the elderly is another looming issue. Historically, the state has not received much in federal funds for such projects. In September 1984, however, the Department of Housing and Urban Development opened a new door for Florida: it granted millions of dollars for 18 projects in the state, the first outlay in six years. 

State officials are applying for more federal money to provide additional badly needed apartments. But given President Reagan's recently announced budget request for 1986, state officials don't expect any money after this fiscal year. "You can forget any more money after October and probably until the end of Reagan's term and probably long thereafter," says Rechtschaffer of Broward County's Area Agency on Aging. 

Graham's committee does make some recommendations for affordable housing: the state should provide housing assistance to those with low and moderate incomes and should encourage the private sector to build affordable housing through tax breaks. 

Florida's advocates for the aged, who usually are pleading with the state for more money and attention, greeted the governor's report with smiles. Although Consumers Federation director Clarke is disappointed that the Graham committee failed to make recommendations about the need to ensure access to appropriate medical care for the uninsured poor, she believes that the committee recommendations are a step in the right direction. Now she and other advocates hope that the state legislature will appropriate the money necessary to put the proposals into effect. "This is the first time Florida has done something like this," says Rechtschaffer. "And it's about time. The need is so critical."