By Robert B. Hudson and Judith G. Gonyea
Older women’s place in public policy has usually been delayed, derivative, and secondary. Their needs, when addressed, have often arisen in the context of another more pressing political concern, or as the result of some perceived gap or failing in the informal or private sectors. As a result, older women have become the unwitting beneficiaries of what can be characterized as residual social policies, of an after-the-fact, stop-gap character most frequently associated with public assistance. Recent years have seen impressive efforts to position older women more centrally in the social and health policy worlds, but today’s current events and political climate suggest a retreat from these endeavors.
The Marginal Standing of Older Women
Faced with ageist and sexist stereotypes, older women contend with a marginal social standing in contemporary life. The relevance of gender is ongoing and cumulative; the opportunities, challenges, and constraints that have occurred throughout women’s and men’s lives shape their standings in old age. Today, three out of every five Americans ages 65 and older are women. Yet, gender inequality influences older women’s experiences despite their majority status in the older population. Women live longer than men, but they often face greater economic, health, and social challenges. In later life, women are three times more likely to be widowed or living alone, spend more years with a disabling health condition or illness, twice as likely to reside in a nursing home, and more than twice as likely to live in poverty. About 11 percent of women ages 65 and older live in poverty, compared with 7 percent of men ages 65 and older (Federal Interagency Forum on Aging-Related Statistics, 2016).
Older women’s lower socioeconomic status and greater risk for poverty are due to multiple factors, including lower lifetime earnings because of the gender wage gap, longer periods of interrupted paid employment and-or earlier exit from the labor force primarily due to caregiving responsibilities, more limited access to pensions and other sources of retirement income, and greater need for long-term-care services at older ages (Institute for Women’s Policy Research, 2015). It is also important to recognize that older women are not a monolithic and static group; their diversity reflects differences, for example, in race and culture, sexual orientation, religious precepts, and political affiliation.
Currently, one out of every six older women is a member of a minority group—African American, Hispanic, Native American, or Asian American/Pacific Islander. These women experience the interactive effects of ageism, sexism, and racism. Among older women living alone, three out of five African Americans and two out of five Latinas live in poverty, compared to one out of every five non-Hispanic Whites (Federal Interagency Forum on Aging-Related Statistics, 2016).
The 5.1 million U.S. women who identify as LGBT (lesbian, gay, bisexual, and-or transgender) share the same concerns as heterosexual women in terms of finding well-paying jobs, caring for family members, and saving for retirement. However, anti-LGBT laws, coupled with inequitable and outdated policies, mean that LGBT women may experience reduced incomes and additional costs for healthcare and housing that affect their ability to accrue savings.
The Residual Policy World of Older Women
The marginal standing of older women is reflected in how their needs have been addressed and ignored in the development and evolution of broader aging-related policy. Title I of the original Social Security Act was Old Age Assistance (OAA), a public assistance (i.e., means-tested) program addressing the abject poverty facing millions of older people in the 1930s. Title II was Old Age Insurance (OAI), a non-means-tested, earnings-related insurance program designed to partially replace the income of the family breadwinner (the husband) in retirement. However, there was no protection for a deceased worker’s widow and children should the worker die. The (male) designers of OAI resisted any insurance benefit for individuals who had not worked and “earned” their benefit. Given the miserable fate of widows and orphans absent such support, in 1939 the Survivors Insurance program was added as an afterthought, albeit an important one.
The enactment of Medicare and Medicaid in 1965 makes clear the distinction between mainstream and residual policy. Medicare’s passage resulted from fifty years of periodic attempts to enact national health insurance in the United States. President Roosevelt withdrew a plan in 1935 as too controversial, and President Truman saw his follow-up legislation defeated in 1950. As recounted by Marmor (1970), bureaucrats and advocates tailored the 1960s legislation to elders only, which were considered a so-called deserving population. Even so, passage was far from assured; one result of this concern was the conscious omission from the legislation of long-term care for chronic illness or disability.
Acute healthcare is about doctors, hospitals, and medical urgency; chronic illness care is about informal caregivers and home health aides—two groups that are overwhelmingly female—and presumptively non-life-threatening conditions. Medicaid, enacted in the wake of Medicare, was designed to deal with the medical needs of public assistance recipients. At the time, these were understood to be mainly younger families receiving Aid to Families with Dependent Children (AFDC) but included coverage as well for OAA recipients, recognizing after thirty years of neglect that chronic care needs could not be meaningfully addressed by the relative pittance found in a state-determined OAA benefit.
As odd as it sounds, Medicaid—initially enrolling only OAA, AFDC, and low-income people with permanent disabilities—had more in common with 1930s public assistance income policy than with 1960s health insurance policy. In short, coverage for chronic conditions of low-income elders—again, overwhelmingly women—was an afterthought in a welfare program that was itself an afterthought. This is residual social policy.
Further evidence of the neglected place for needs central to older women is seen in the sad legislative history of the Medicare Catastrophic Coverage Act (MCCA). The MCCA was promoted by the Reagan Administration to assuage older adults who had been angered by an earlier attempt to limit Social Security cost-of-living increases. Reagan, Health and Human Services (HHS) Secretary Otis Bowen, and Sen. David Durenberger promoted a “catastrophic” benefit—lifetime caps on Medicare Part A hospital stays—that was arguably a benefit targeted more toward older men than older women. This was instead of spending on long-term-care costs, which was the catastrophe that most elders, especially women, were concerned with at the time (Tolchin, 1989; Himelfarb, 1995). In any event, the combination of the wrong benefit and a vociferously opposed Social Security surtax to pay for new benefits led to the legislation’s unceremonious repeal within a year of its passage.
Finally, Social Security’s treatment of women remains caught up in long dormant patterns of work and family life. The workings of the spousal benefit in particular can have negative consequences for younger and older lower income women. As outlined by Steuerle (2017):
- A poor or middle-income single head of household [usually a woman] will pay tens of thousands of dollars more in taxes and often receive tens of thousands of dollars less in benefits than a high-income spouse who does not work, does not pay taxes, and does not raise children.
- A one-worker couple earning $80,000 annually gets tens of thousands of dollars more in expected benefits than a two-worker couple with each earning $40,000, even though the two-worker couple pays the same amount of taxes and typically has higher work expenses.
- Because of the lack of fair actuarial adjustment by age, a man with a much younger wife will receive much higher family benefits than one with a wife roughly the same age as him.
More widely seen Social Security shortcomings for older women are found in the aggregate lower wages of women (particularly women of color), the years they may spend out of the workforce counting against the thirty-five-year working years benefit formula threshold, and the wage ceiling ($127,000 in 2017) that disproportionately advantages men, who are much more likely to have salaries above that cut-off.
Republican Domination: Making Things Worse for Older Women
While much remains uncertain in today’s Washington, there can be little doubt that new legislation will not advantage older women. At the broadest level, there is an “ideology vs. interest” battle unfolding, where conservative and nativist rhetoric fueled Donald Trump’s election, but where numerous constituencies and interests continue to vie for the maintenance or expansion of concrete government benefits. Most notably, the effort to repeal Obamacare energized a conservative base, but doing so and potentially costing 24 million people health insurance coverage generated fierce pushback, ultimately forcing Republican Congressional leadership to withdraw the proposal.
As Free and Cantril (1969) argued, voters are often “ideologically conservative” but “operationally liberal.” Or as the Harris Poll (2011) said of their respondents more recently, “they hated the forest, but they liked the trees.” To borrow from the President’s language, many constituents may like “the swamp” that he wishes to drain.
The Fiscal Year 2018 budget proposed by Mick Mulvaney, Director of the Office of Management and Budget, tacks closely to the ideological end of the interest-ideology spectrum. Its central purpose is to make government smaller and reduce federal debt. Should major elements of this proposal become law—an unlikely prospect—the negative consequences for older women, among many other groups, are not hard
to see. Most notable would be cuts to Medicaid, which in the budget and the House and Senate Obamacare repeal bills would amount to somewhere between $600 billion and $800 billion over ten years.
But the budget calls for cuts across a range of aging-related social programs: Senior Community Service Employment program (eliminated), Low Income Home Energy Assistance program (eliminated), Community Development, Social Services, and Community Services block grants (eliminated), Medicare State Health Insurance Assistance program (eliminated), Senior Corps (eliminated), Supplemental Nutrition Assistance program (cut by $194 billion over ten years), Centers for Disease Control and Prevention’s Falls Prevention (eliminated), Chronic Disease Self-Management Education (cut by $3 million), Older Americans Act and Elder Justice Act (FY 2017 budget increases reversed), and Amtrak’s long-distance train service (potentially eliminated due to major cuts to the Department of Transportation budget) (NCOA, 2017). While these cuts would affect elders across the board, older women—by virtue of their numbers and needs—are disproportionately the beneficiaries of each of these programs.
Bui and Chira (2017), employing “gender-based budgeting” have found that the deepest cuts in the Trump budget would be in programs that spend more on behalf of women than men (of all ages).
Both in size and centrality, Medicaid and Medicare command the most attention when addressing the challenges facing older women. Medicaid supports 1.4 million older adults living in nursing homes, more than 70 percent of whom are women, and contributes two-thirds of all nursing home expenditures. Nursing homes and other long-term supports constitute 40 percent of Medicaid expenditures.
The House and Senate bills debated during Spring and Summer 2017 efforts to repeal Obamacare would have ended Medicaid as an entitlement, that is, a program with open-ended funding required to enroll all individuals eligible for benefits regardless of cost. In its place, congressional proposals would have imposed a per capita cap, adjusted to some degree for population and inflation, but a cap nonetheless. Among other consequences, the cap would have directly affected the one-in-five older women who constitute 61 percent of “dual eligibles,” where Medicaid provides wrap-around coverage to Medicare. Premiums might be reduced for some enrollees, but would do so at the cost of higher out-of-pocket expenditures and plans containing fewer benefits.
Premium increases and co-pays would have been especially difficult for the 6.5 million enrollees ages 50 to 64, numbering 6.5 million individuals, 47 percent of whom have pre-existing conditions that might lead to coverage limitations in states seeking waivers around federal requirements. States also could have sought waivers to exclude one more of the eleven essential health benefits specified in the legislation, including chronic disease management. Both House and Senate bills would have phased out funding for the thirty states that expanded their Medicaid programs, program expansions that between 2011 and 2016 enrolled an additional 11 million people (Brenoff, 2017).
With one notable exception, Medicare has been spared the cuts and limitations imposed by congressional bills on Obamacare and Medicaid, although the Republican proposals would have eliminated major tax provisions included in Obamacare to prop up the Medicare trust fund: a 0.9 payroll tax on incomes over $200,000 and 3.8 percent tax on investment income.
While otherwise unaffected by the Affordable Care Act repeal efforts, the limitations in the Medicare benefit package as it affects older women remain substantial. Most notable are those associated with Medicare’s acute- and post-acute-care emphasis. Older women, especially very old women, experience high levels of chronic illness and disability, constituting 72 percent of Medicare beneficiaries living in nursing homes, and two-thirds living alone in the community. Especially for older women not eligible for Medicaid, out-of-pocket expenses are a major burden: these women have higher out-of-pocket expenses than men, they have lower incomes than men, and they have fewer financial assets.
As a stark illustration (Kaiser Family Foundation, 2017), 60 percent of women ages 85 and older with incomes of less than $20,000 have out-of-pocket expenses averaging $7,555; this contrasts with 35 percent of men at that income level, who have out-of-pocket expenses of $5,835. By virtue of very advanced age, health status, income, and living arrangements, older women and their needs are only marginally addressed by the Medicare program (Kaiser Family Foundation, 2013, 2017).
Conservative Pressures, the Politics of Aging, and Older Women
Beyond the disheartening policy landscape there exist larger political pressures that may also prove harmful to older women. One centers on the logic of conservatism and the other more broadly on the current stage of old-age politics.
A handy acronym that captures much about American conservatism is DIP: decentralization, informalization, and privatization. There is a lot of that going on these days, and it does not bode well for older women. The catch phrase that captures decentralization is “bringing government closer to the people.” It may well be that people know better what they want and need from a local rather than a distant government. Yet, it is not at all clear that local governments are more democratic or responsive than more distant ones. Minority rights of one kind or another are more easily ignored in small jurisdictions, and majorities tend to be more permanent. These patterns have long been seen in matters of racial and LGBT discrimination.
Older women may not be subject to these kinds of discrimination, but they often lack a powerful political voice in their communities. In the current context where decentralization may mean cutting federal expenditures and sending responsibility to states and localities, that lack of political presence is problematic. There are numerous other spending interests—schools, police, fire, and public works—that compete for state and local funds. It is also important to keep in mind that public funding for older adults is overwhelmingly federal (largely Social Security, Medicare, and Medicaid), whereas the majority of local revenues are allocated to education and state revenues to education and . . . Medicaid.
As an illustration of “interest” trumping “ideology,” the conservative Louisiana Sen. Bill Cassidy (R-LA) initially opposed the Senate’s attempt to repeal Obamacare because 47 percent of Louisiana’s budget is devoted to Medicaid, and, as a poor state, it does not have the resources to make up for the proposed federal cutbacks (which constitute three-quarters of Louisiana Medicaid expenditures). In short, older women may well find the workings of local politics not to be in their favor, yet their and others’ legitimate demands may be high if today’s decentralization essentially means the federal government pulling the budgetary plug on the states.
The second conservative mantra is increased reliance on the so-called informal sector—family, friends, and neighbors. Family and neighborhood have a hallowed place in the American psyche, and rightly so. Yet, there can be no question that the informal sector has more than held whatever might be considered its rightful share of the burden in the support and care of older women. Informal care constitutes three-quarters of all long-term care, its monetary worth has been calculated at more than $500 billion annually, it brings with it both the strain of care provision and the opportunity costs associated with lost wages and leisure, and it is increasingly provided by older women as well as being received by them.
Caregiving is centrally about age and gender, and undermining Obamacare support for 50 to 64 year olds and capping Medicaid long-term services and supports for those older than age 65 will profoundly impact the informal sector. Future population aging can only exacerbate these pressures. In order to resist, the informal caregiving sector—with its 77 million members—will have to assume a political presence it has never possessed (Levitsky, 2014).
Privatization is essentially about risk-shifting. In theory and usually in practice, public policy is about risk-sharing: programs mandating benefits and costs covering large populations are put in place, preferably where higher risk individuals cannot be excluded and lower risk individuals cannot opt out of participation. This coercive feature of government is controversial. Should younger, healthier people be forced to join and pay premiums to a program in support of older, sicker people? But the advantage of the public approach lies in the sharing of risk. It is these mandatory features that have been at the ideological heart of opposition to the Affordable Care Act.
A recent opinion piece by Republican Sen. Ron Johnson (R-WI; 2017) captures the appeal that conservatives see in healthcare privatization: “The private sector is much more effective in solving problems” . . . the private sector would not “separate patients from the direct payment of health care” . . . the health care sector needs “consumer-driven, free-market competition” . . . “Obamacare has largely destroyed an already struggling individual health insurance marketplace . . . “loosen up regulations and mandates, so that Americans can choose to purchase insurance that suits their needs and that they can afford” . . . . “we should return more flexibility to the states, to give individuals freedom and choice to buy plans they want.”
The contrast between private and public is clear here. The private sector is about individuals, choice, competition, freedom, and affordability. At least in the case of healthcare, the public sector response is that risks are unpredictably if unevenly distributed, that unconstrained individual choice will leave identifiable populations unprotected, and that effective competition requires informed consent of all parties, which can seldom be found in healthcare decision-making.
President G. W. Bush’s attempt to partially privatize Social Security in 2005 was based on his idea of the “ownership society,” but opponents argued that turning the program into one of defined contributions rather than defined benefits would pose undue risks on participants, many of whose level of financial literacy left much to be desired (Beland and Waddan, 2007). Pending proposals to turn Medicare into a “premium-support” program encounters the same difficulty: the government would subsidize premiums at a fixed level, and the risk of future cost increases would be transferred to patients or providers, with the government, having subsidized the premium, then being out of the picture.
Older women would run particular risks under privatized Medicare, as well as under a capped Medicaid program. Already facing income, health, and social challenges, they would be placed in a private insurance or support environment where competition—in the absence of regulation—might well lead to a race to the bottom. These women would lack the economic and political resources to counter programs that might involve marginal quality, higher costs, and disqualification, all dangers that public sector intervention can forestall.
“Dependent” Elders in a World of “Advantaged” Older Adults
Something of a parallel development to the rise of Donald Trump and a Republican Congress is seen in an evolving politics of aging. The origins of the nation’s aging-related social programs lay in a widespread and accurate understanding of elders as a group being singularly vulnerable to economic and health challenges due to the vagaries of old age. Advocates and reformers seized on this image in enacting programs that largely (Social Security) and exclusively (Medicare) benefited older Americans. More recently, the collective reality of older adults has become much more diverse, with some remaining highly vulnerable, but others enjoying fruitful retirement years with substantial incomes and good health. These “new elders” today also constitute a powerful political constituency, defending and promoting the major aging programs that have been central to this heightened well-being of many older people.
Borrowing from Schneider and Ingram (1993), Hudson and Gonyea (2012, 2014) have captured this evolution and the new political tensions that have accompanied it. Schneider and Ingram characterized political target populations along two dimensions: legitimacy (positive/negative) and power (high/low). In applying the four derivative categories, we argue that historically elders were considered “dependent” (positively viewed, politically weak), but by the turn of the century had achieved a presence that could be termed “advantaged” (positively viewed, politically strong). This newer status was captured by discussions of successful aging, productive aging, encore careers, and the Third Age.
This emergence has been widely celebrated by elders and advocates alike, yet it has also attracted skeptics who ask, “If older people are doing so well, do we really need to spend well over $1 trillion dollars on their behalf?” A combination of fiscal conservatives and generational inequity proponents has come to question these seemingly disproportionate expenditures directed toward older adults. As a result of these concerns, we see aging politics as having entered a more contested phase, one Schneider and Ingram labeled “contender” (negatively viewed, high power).
Understanding that these are population-wide characterizations applied to an increasingly diverse older population, we ask what becomes of those who continue to struggle with low incomes, poor health, and social isolation. Our concern lies in the possibility that the singular political standing older Americans have long enjoyed—and which has been the basis for enactment of generous programs benefitting them—will splinter. So-called successful elders will mount the political barricades in defense of major programs, but more vulnerable elders may be relegated to a more marginal and, if you will, residual political standing.
Older women would clearly be the core group of those who might be politically left behind. Suggesting this possibility a few years ago was perhaps an exercise in speculation. However, the developments outlined here speak to this splintering possibility actually unfolding. The Trump-Mulvaney budget leaves Social Security and Medicare alone for now but targets smaller discretionary and-or means-tested programs that assist elders: low-income energy assistance, subsidized housing, food stamps, public transportation, and, of course, Medicaid. The callous treatment of the ages 50 to 64 age group in the congressional Obamacare reform bills may be seen as a manifestation of this phenomenon as well—people of late middle age not yet Medicare-eligible facing rising premiums and potentially staggering out-of-pocket healthcare costs.
The numbers and needs of older women are rising inexorably as the last of the Silent Generation and the first of the baby boomer cohort enter advanced age. We are now seeing pressures to cut programs for vulnerable populations, and we may see efforts to means-test the major social insurance programs, Social Security, and Medicare. Borrowing from the academic literature on the welfare state, these pressures on the universal or “institutional” programs may partially transform them—and their beneficiaries—to selective, or “residual” status.
Robert B. Hudson, Ph.D., is a professor of Social Policy in the School of Social Work at Boston University in Boston, Massachusetts. Judith G. Gonyea, Ph.D., M.S.W., is dean ad interim and professor of Social Research in the School of Social Work at Boston University.
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