Earlier this week, the journal Health Affairs released new research highlighting an impending gap in the availability of supportive housing affordable to middle-income older adults. As baby boomers begin to reach their 80s in the next decade, coordinating health and housing will become more important, and many will need the more intensive supports of assisted living and similar models but, as configured today, these models are unaffordable to most who will need them. At the same time, however, many older adults will seek to remain in their homes and communities. As Chris Herbert and I discuss in our article in the journal, there are serious barriers to aging in place as well, in terms of finances, accessibility of the home, and supports in the community.

The authors of the new research (Caroline Pearson, Charlene Quinn, Sai Laganathan, A. Rupa Datta, Beth Burnham Mace, and David Grabowski) project that by 2029 there will be 14.4 middle-income people age 75 and over, 20 percent of whom will have high needs (three or more chronic conditions and at least one limitation in activities of daily living) that will make it difficult to remain at home. “Middle income” is defined as those in the 41^st through 80^th percentile of annuitized individual financial resources. Because this group does not qualify for Medicaid, and Medicare generally does not cover long-term care, those with high needs would have to look at market rate assisted living and other forms of supportive housing. Yet the authors find that, as they exist today, these options will be financially out of reach to 7.8 million middle-income older adults.

At our Center, we’ve seen anecdotal evidence of this gap: while wealthier older adults have access to a growing set of supportive housing options, and there are excellent models of subsidized housing that offer an array of supportive services to a portion of low-income older adults, there are few options affordable to middle-income households. In quantifying the potential gap between supply and demand for supportive housing for middle-income people, Pearson and her co-authors help policymakers and private industry think more concretely about how to serve this growing population.

But what of the remaining 80 percent of the middle-income market? This group may not have “high needs” but is still likely to experience health and functional limitations: the authors estimate that 60 percent of all middle-income older adults will face limitations in mobility, and 67 percent will have three or more chronic conditions. Still, given proper housing and access to services, many of this group could remain at home.

In our paper, Chris and I consider the challenges that remaining at home currently poses. Only 3.5 percent of US housing stock offers three basic features of accessibility: no-step entry, single-floor living, and wide hallways and doorways that can accommodate a wheelchair. Making modifications to a home can be expensive, particularly if extensive changes such as widening doors, installing ramps or chairlifts, or lowering cabinets are needed. For the many middle-income older households who own their homes, equity tied up in the home makes financing modifications more challenging.

In addition, about half of middle-income older adults are aging in low density locations where transportation options are limited, making it difficult for those who don’t drive to access services and remain engaged in their communities. At the same time, low densities can make meal delivery services or visits from health care aides challenging.

While programs to improve accessibility and provide services to low-income older adults are wanting in many ways, they offer models that might be expanded to the middle-income market. Older adults seeking to make modifications to their homes, for example, can benefit from tax credits and no-interest loans, but more programs are needed for those in middle incomes who do not have a disability. Communities can consider visitability programs, which typically require new housing to have basic accessibility features, or to be adaptable so changes can be made more easily later.

Programs like Supports and Services at Home (SASH) coordinate services and care for older adults living at home, improving health and saving health care dollars at the same time. The program began in Vermont, but expanding SASH to other geographies and a wider segment of older adults could help broaden this model of linked care and housing and also help to connect the many actors in the healthcare system. Age-friendly initiatives can also support older adults living at home, including those living in lower density locations. These seek to expand the livability of communities for older adults by focusing on transportation needs, the built environment, engagement, services, and other aspects important to health and wellbeing.

Even with attention to home modifications, service delivery, and “friendlier” environments, however, remaining in one’s home may not always be the best solution. For some, quality of life would be improved in more accessible apartments, denser housing in town centers, accessory dwelling units, shared housing, or multigenerational models, more of which are needed in all parts of the country.

Finally, while we think some of the options available to lower income older households might be made more available to those in the middle market, there are still serious gaps in meeting the housing needs of low-income older adults. Housing is not an entitlement, and only a third of very low income older adults who are eligible for federal rental subsidies receive them. While we draw attention to opportunities to address the housing and care needs of middle-income older adults, the needs of those with lower incomes persist as well.