Bioethics Forum Essay
The Place in “Aging in Place”: Housing Equity in Late Life
Health policy research demonstrates that housing and community are crucial determinants of safety, health, and well-being across the lifespan. The United States is an aging society, where more people are over age 65 than under 15. Most older Americans want to age “in place” – in the community, not an institution. This goal relies on housing. However, housing policy research reveals a poor fit between our nation’s housing stock and our aging demographics. Most older Americans have difficulty paying for both housing and care. The racial wealth gap contributes to fewer housing options and greater precarity for Black Americans. The National Academy of Medicine’s 2022 Global Roadmap for Healthy Longevity identified late life housing affordability and accessibility as key health variables, whether an older adult is living independently or with others.
Health policies aimed at reducing health care cost burdens for older adults may ease some housing cost burdens by freeing up limited income. Yet these welcome policy approaches alone cannot compensate for our society’s persistent failure to foresee, value, and support the experience of aging by zoning, planning, and building or remodeling housing stock that is affordable, accessible, and “livable”–a good fit, with proximity to transportation, services, and opportunities for social engagement. Housing policy research shows that less than 4% of the U.S. housing stock meets basic accessibility requirements, for example.
Housing equity for older adults is a bioethics issue. It is integral to health equity because housing is a powerful socio-environmental determinant of health. And it is integral to the capability to flourish in late life, a stage of life typically experienced at or close to one’s home. For older Americans to age in place and experience well-being despite foreseeably deteriorating health and modest or inadequate fixed income, the scope of bioethics should attend to a broader range of policymaking ideas and processes that support–or undermine–equity in access to a good life in late life.
Over the past six years, The Hastings Center, in partnership with a diverse array of researchers, practitioners, policymakers, and advocates, has explored ethical and societal questions arising from population aging that are not resolvable through mechanisms for medical decision-making or health care resource allocation–the traditional touchstones for bioethics work on aging–nor through appeals to concepts such as dignity or intergenerational equity. This line of research and public-facing work–Bioethics for Aging Societies–produced a report in 2018 that laid out the landscape of bioethics issues in this area and launched a series of collaborative projects funded by the Retirement Research Foundation for Aging, the National Endowment for the Humanities, the National Institute on Aging, and others. Jennifer Molinsky, a housing policy expert and community planner who directs the Housing an Aging Society program at the Harvard University Joint Center for Housing Studies (JCHS), a preeminent source of policy-relevant research and analysis, is a key partner in this work. Milestones in Hastings Center-JCHS collaboration include a 2019 public symposium on aging in place and housing inequality; the creation in 2020 of a multidisciplinary research network that includes policymakers; and an innovative empirical study of housing-focused responses to the needs of older adults during the Covid-19 pandemic.
Our study’s final report will be released on October 6 and explored through a webinar series, also beginning on October 6. The final report describes the bioethics standpoint–a “housing lens” –that we developed and applied in this study and offer for further use in age-focused policymaking and social innovation.
The housing lens is grounded in the ethical and social importance of housing to safety, health, and well-being and the moral imperative to balance private-sector options available only to the wealthy minority of older adults with far greater attention to housing equity in late life. As a tool for integrating bioethics considerations into policymaking, a housing lens highlights the importance of housing to security, health, and well-being in late life; focuses on the material conditions that make aging in place feasible, including inequities in access to homes and neighborhoods supportive of aging; and corrects distorted framing, such as the perception that being able to afford the housing one needs to accommodate aging and disability is a personal responsibility, despite a national shortage of affordable housing affecting millions of older Americans and others.
By foregrounding housing and de-centering health care as the dominant policy narrative about aging, the use of a housing lens encourages critical thinking about why age-focused policymaking should also incentivize housing development and related services and supports for aging in place. Our goal in sharing this new tool is to foster creative collaboration across policymaking domains and to sharpen media and public discussion of what it takes, in terms of public priorities, public and private investments, and community-level networking and advocacy, to create real options for all older Americans to age in place.
Nancy Berlinger is a research scholar at The Hastings Center and co-author, with Jennifer Molinsky and Bailey Hu, of Advancing Housing and Health Equity for Older Adults: Pandemic Innovations and Policy Ideas (Joint Center for Housing Studies and The Hastings Center, October 6, 2022).