How Has COVID-19 Changed Health Care for Older Americans?

GRETCHEN JACOBSON: There’s also the flip side of if they’re used to seeing their grandchildren every weekend or so, they may not be able to do that anymore if their grandchildren may be putting their health at greater risk.

SHANOOR SEERVAI: Hi everyone. Welcome to The Dose. You just heard from Gretchen Jacobson about one of the big challenges older people are facing because of coronavirus. The pandemic is impacting everyone, but the older you are, the more severe the health consequences. At a single nursing home in Washington, at least 35 people have died of COVID-19. Two-thirds of the home’s residents, older adults, their average age is 83, are infected. That’s scary, because all of us, regardless of how old we are, have parents, grandparents, mentors, neighbors, friends, who are at greater risk because of their age. So I asked Gretchen, who leads the Commonwealth Fund’s Medicare program, to talk about what the pandemic means for Americans above 65.

Gretchen, welcome to the show.

GRETCHEN JACOBSON: Thank you for having me here.

SHANOOR SEERVAI: So to get started, tell me what we know so far about the risk of death from COVID-19 for, say, someone who is above 65 compared with younger Americans.

GRETCHEN JACOBSON: Well, as everyone knows, we’re learning as we go with this, and the death rates seem to really vary depending upon how you look at it. It really depends on the number of people that have been tested, which is higher in some countries than in others, and it also really depends on the presence of other underlying conditions like asthma or heart conditions and the extent to which those really impact people’s ability to deal with the virus.

SHANOOR SEERVAI: Is it correct that if you’re older you’re at higher risk?

GRETCHEN JACOBSON: Yes, for many reasons, but also just simply people who are older also tend to have more chronic conditions, so more than 85 percent of people who are ages 65 and older have one or more chronic condition and more than half of them have two or more chronic conditions. So they already are more vulnerable than younger populations, simply because their system is already dealing with other health conditions.

One of the initial outbreaks of the pandemic in the U.S. occurred in the nursing homes in Washington state, and that’s when people were really alarmed and really noticed just what a toll it was taking on the older population.

SHANOOR SEERVAI: So let’s get into some of the challenges that the pandemic is posing for the older population.

GRETCHEN JACOBSON: There’s multiple challenges here. First, with social distancing, there is really the risk, particularly in older population, of it turning into social isolation, and people really not getting enough social contact that they really need to maintain their current underlying conditions, get the health care that they need, but also to prevent just loneliness, which can also exacerbate underlying chronic conditions. So those are mental health challenges that are layered on top of the current situation.

SHANOOR SEERVAI: What are the health risks of social isolation?

GRETCHEN JACOBSON: Some of the more obvious repercussions of social isolation are things such as anxiety or depression, but also it leads to people not being able to take care of themselves as much as they otherwise would and can affect their other chronic conditions that they may be treating in an ongoing basis.

SHANOOR SEERVAI: And the thing I keep thinking of is somebody who, let’s say is maybe like 70-year-old man with diabetes who’s able to take care of himself. He’s regularly picking up his insulin, he goes grocery shopping, and so he has a healthy diet, goes for a walk every evening. He’s doing great, and then the pandemic hits and suddenly this condition, diabetes, which of course it is a chronic condition, but you were able to manage it successfully, suddenly it’s so much harder.

GRETCHEN JACOBSON: Yes, that’s exactly right. And it’s just also mentally challenging for people too, to just not see people as much or have so much social interaction or be able to walk over to their friend’s house just to say hi. It’s much more challenging. In addition, there’s also logistical issues for people 65 and older, so they clearly won’t be able to see their doctor as often as they otherwise would, or they use telehealth or virtual visits. It may also be challenging for them to get their prescription medications that they need from the pharmacy or through mail order. They may need to figure out some other sort of system.

SHANOOR SEERVAI: Right. And you mentioned of course the impacts of isolation and not being able to see people, but I wonder for older people whom actually are seeing other people, maybe they live with their children or their children’s families, maybe they have a home health aide and that person is moving about in the world.

GRETCHEN JACOBSON: Yes, I mean exactly, so it’s everything compounded depending upon the number of people that they have coming in and out of their lives on a daily basis. So on the one hand, if they have a social worker or home health aide coming in to help them every day, that person is in effect putting them at risk for the virus by coming in. But they’re also, their health may be at risk if the person isn’t able to come in and help them. There’s also the flip side of if they’re used to seeing their grandchildren every weekend or so, they may not be able to do that anymore if their grandchildren may be putting their health at greater risk.

SHANOOR SEERVAI: That’s really heartbreaking.

GRETCHEN JACOBSON: Yes. I mean I think it leaves a lot of very difficult choices for people in how to manage their current condition, keep themselves healthy, but also be able to enjoy their lives, and it’s a real tug pull for a lot of people.

SHANOOR SEERVAI: Before we think about enjoying our lives and we look at just how people are getting by, I understand that older adults in the U.S., if you’re above 65, you get your health care through Medicare.

GRETCHEN JACOBSON: Yes.

SHANOOR SEERVAI: And Medicare, has it been adapting to face this new challenge?

GRETCHEN JACOBSON: Yes. I mean, the Medicare program has made several changes during this time to help make accessing health care much easier for people. One of the largest changes has been permitting people in the traditional Medicare program to have greater access to telehealth and they’ve greatly expanded that to not just video, face-to-face services over video, but also now people can access telehealth simply by calling their doctor on the phone even if they don’t have a smartphone. And this is a large change from where Medicare was prior to the pandemic.

Previously, the traditional Medicare program would only cover telehealth services for people in relatively rare conditions, if they were in rural areas and they needed mental health care that wasn’t available in their area, and then they had to go to an outpatient health clinic or some other similar clinic in order to then receive telehealth services. Now, people can literally call their doctor on their phone and have that count as a telehealth visit from their home and have that covered by Medicare, so it’s really quite a large difference that’s been made during this time.

Medicare program has also made other pretty substantial changes in effect by not requiring face-to-face visits for a lot of coverage decisions. For example, people no longer need a face-to-face visit to receive home health care or after a hospitalization or to receive other similar types of care. Another large change has been allowing people to receive three months’ worth of a prescription medication. Previously, they could only get it one month at a time, and so now they have greater access to their medications and don’t have to go to the pharmacy as often. These have been pretty large changes to the Medicare program over a relatively short period of time.

SHANOOR SEERVAI: Yeah, those do sound like pretty large changes. And I guess the first question that’s coming to my mind is why were these restrictions in place to begin with?

GRETCHEN JACOBSON: Some, such as telehealth, were put in place in order to help control the Medicare spending, federal spending, for the program. Many of the other changes were originally put into place to help control fraud and abuse of the program. There has been substantial fraud in the program over many years, and as a consequence the federal government put in these barriers to basically ensure that people were actually using care appropriately and getting only the care that they needed. That included limiting the amount of prescription drugs, for example, that people could get so that they or others weren’t selling the prescription medication that they weren’t using that particular month. And what the administration has essentially done during this pandemic has been deciding to trust the Medicare population that they’re going to use care appropriately and really expand their access and ease of access and services.

SHANOOR SEERVAI: Do we think it’s working?

GRETCHEN JACOBSON: We do know that this probably impacts people’s health care to a fair degree. So for example, even allowing people a three-month supply of medication really affects this population because about one in four take at least one prescription medication on a regular basis, so that means a large number of people not having to go to the pharmacy or figure out some other means to take their monthly medication if they’re going to be socially distancing themselves for longer than a month.

SHANOOR SEERVAI: So it allows for more effective social distancing.

GRETCHEN JACOBSON: Yeah. Similarly with telehealth, it allows people to some degree to the extent that they can receive care from their doctors on an ongoing basis without having to physically go to their doctor and put themselves at risk of getting the virus.

SHANOOR SEERVAI: Let’s talk about telehealth for a minute, because everyone is pivoting now to a digital universe, and kids are suddenly in virtual classrooms, but these are kids who have grown up trying to grab their parents’ iPads and iPhones all the time. For people above 65, I just imagine that there are a lot of obstacles to using technology effectively to get telehealth to an older population.

GRETCHEN JACOBSON: Yes. I mean, technical challenges are really amplified during this time as well, so one thing that the Medicare program did recently is allow people to receive telehealth services just via phone, so not having to be face to face. So for the large number of people that do not have smartphones, which tend to be poorer, more vulnerable populations and older populations, they can still talk to the doctor via phone.

But one really large question is really how effective is it really to just talk to your doctor on the phone and not have a face-to-face interaction? Or even if you do have video, how effective is it to really virtually talk to someone versus being in the same room and being able to show them really more how you’re feeling, and how effective is virtual mental health therapy compared to in-person mental health therapy, where it’s easier to read people and talk to someone face to face?

SHANOOR SEERVAI: Those are hard questions. We really don’t know what the answer is, how that will impact people’s health, even if they are able to get some amount of care via telehealth.

GRETCHEN JACOBSON: Right. We really don’t know in a larger picture of how having only virtual contact with people over a long period of time really affects your mental health. Is it really enough to have screen time with your relatives or do you really need more the face-to-face personal interaction? And we can speculate that you really do need to interact directly with people, but we really don’t know in terms of health care how large of a difference it makes.

SHANOOR SEERVAI: And as far as other things we can do to ease some of these challenges, what are other ways in which the Medicare program could be adopted to make this time easier for older Americans?

GRETCHEN JACOBSON: There could be some more consideration around ways to ease social isolation and loneliness for people on Medicare who may be experiencing it and also for ease of accessing mental health services for people when they just may be feeling the blues and depression and the beginning stages of severe loneliness. Some concrete examples might be reducing or eliminating the cost-sharing required for mental health services during this time for people on Medicare, and other ways of encouraging people to reach out to their doctor and reach out to others in case they are feeling very isolated.

The administration actually has made a lot of changes to the current program. And so that’s just worth underscoring that it seems as though they’ve tried to really roll back as many restrictions to access as they possibly could this time.

SHANOOR SEERVAI: What will happen when, and who knows when, but what will happen when we go back to normal?

GRETCHEN JACOBSON: That’s a great question, because on the one hand, the Medicare program has really been modernized over a very short period of time, over the past few weeks, and brought into the modern age of people actually being able to talk to their doctor on the phone and having that covered as a medical visit. But on the other hand, these restrictions were put in place to help control costs or prevent fraud in their program, so it’s really going to be a tough question as to whether or not to roll back these restrictions over the long term or whether to keep them in place. Right now it seems right now it seems that the administration has really chosen to put a lot of trust in people on Medicare and their caregivers and trust that they’re going to receive the care that they need and not take the opportunity to commit fraud and abuse in the program.

SHANOOR SEERVAI: And finally, Gretchen, before I let you go, I did want to ask, a lot of people right now, they’re feeling scared, they’re feeling vulnerable, they may be working from home, they may not have work, but a lot of people also want to help and want to know what to do to make things easier for the people who are having a really hard time in the pandemic. Do you have any advice for listeners who might want to help out older people in their community?

GRETCHEN JACOBSON: One of the agencies they may want to reach out to is the Area Agencies on Aging, which are federally funded and in every state and they really help to reach out to the population of older adults and help in cases outside the pandemic, for example of delivering meals, of reaching out to ensure that people are not socially isolated, and issues that really affect the older population. So that may be really one avenue that’s available to everyone to look for in their community.

SHANOOR SEERVAI: That’s helpful. Thanks, Gretchen, and thanks for joining me today.

GRETCHEN JACOBSON: Well it’s been a pleasure. Thank you, Shanoor.