Advancing Health Equity: Reframing Aging

Steven Collens, CEO of MATTER (00:15):

Hello, and welcome to the second episode of MATTER's Advancing Health Equity podcast. My name's Steven Collens. I'm the CEO of MATTER, a healthcare technology incubator and innovation hub on a mission to accelerate the pace of change of healthcare. In addition to accelerating the growth of healthcare startups and helping large companies innovate more effectively, we highlight innovative thinkers who have important perspectives to share. In this podcast series, we invite leaders who have deep expertise in how various groups are served or not served by our healthcare system, and what we can do to change that. On our first episode, we hosted Brian Richardson, CEO of StartOut, and Kate Steinle, Chief Clinical Officer of Folx Health for a discussion on the health needs of the LGBTQ+ community. Today, we've invited two experts in the field of aging to explore the way we currently think of aging and how we can reframe that thinking to improve health for older adults and drive innovation in the aging space.

(01:13):

We're joined by Robert Espinoza, executive vice president at PHI and chair-elect of the American Society on Aging. Robert is a nationally recognized expert in aging, caregiving, and long-term care workforce issues. In 2015, he was appointed by the Centers for Medicare and Medicaid Services to its advisory panel on outreach and education, as well as by the National Academies of Sciences, Engineering and Medicine to its forum on aging disability and independence. Robert will be interviewed in this episode by Mary O'Donnell. Mary is the president of RRF Foundation for Aging, a national grant-making organization, and one of the few private foundations in the US devoted exclusively to aging issues and improving the quality of life of older adults. Welcome Mary and Robert, and thank you for joining us today.

Mary O'Donnell, RRF Foundation for Aging (02:01):

Thank you so much for that introduction. Steven. I'd like to start by defining ageism according to the National Center to Reframe Aging, an initiative that we at RRF Foundation for Aging are proud to be able to support. Ageism is discrimination or unjust treatment of older people based on stereotypes. So that's the definition. But Robert, can you begin by expanding on this definition of ageism and if you could, providing some examples of the different ways you've seen ageism manifested?

Robert Espinoza, PHI & American Society on Aging (02:41):

Yeah, absolutely. Thank you, Mary. I think when we think about ageism, it's important to think, remember that ageism is the ways in which we devalue people because of their age, and that can be because you're older. It can also be because you're younger. Um, and what we've seen in the older American context, the older adult context, is this idea that older adults are somehow not as valuable as younger people. And that plays out in cultural messages, in policy and in our everyday experiences. And so when we think about how do we frame aging, I'm gonna draw some lessons from the National Center to reframe Aging. Um, and the Frameworks Institute, which produced some really cutting-edge research several years ago, that formed the foundation of a lot of this analysis. Um, so one of the ways that ageism plays out is this idea of us versus them. So we think of older adults is this distinct population from everybody else, and we sort of relegate them into that space when in fact, that binary is quite simplistic and it's inaccurate. We are all aging, and hopefully we will all reach our sixties, our seventies and eighties. Um, and older adults are a big part of our families. They're a big part of our lives and communities. So the us versus them is a form of ageism that really ends up

Mary O'Donnell, RRF Foundation for Aging (03:59):

I like that. The Center to Reframe Aging. Sometimes I, I have a button that says aging's. So cool. Everyone is doing it. Which is true. We're all, to your point, we're all aging all the time.

Robert Espinoza, PHI & American Society on Aging (04:10):

Absolutely. And, and how much better it would be if we created more positive messages about being older. Um, another way is this idea of individualism versus collective responsibility. So there is, uh, an ageist myth that the conditions of which you age into, um, are somehow the results of the personal choices you made when you were younger. And if you're not aging as well, it's because you made poor choices. Right? In truth, people reach older age because of a wide range of structural supports, their environments, their experiences of everything, including the challenges they face, um, which then ultimately impacts what their aging is like. And this is where we see racial and gender disparities. This is where we see some challenges related to LGBTQ identity and that they're facing societal pressures and barriers. Um, the final point I'll make is that there is this reliance on terminology that's a little bit too easy when it comes to understanding older adults and also potentially harmful.

(05:13):

So words like tsunami or the silver wave suggests that this large growing number of older adults that are entering, that's entering our country, that's becoming part of our country and our world is somehow a threat to our society and to how our system is financed and, and, and run. Um, instead of seeing them as assets and opportunities for improving accessibility and, and really drawing on them, are there also terms like senior elderly or I hear this term a lot, our seniors as if they belong to us, right. It's patronizing or paternalistic, and it often invokes stereotypes about frailty and dependency on others, which is only true for a segment of the older adult population. So those are harmful messages.

Mary O'Donnell, RRF Foundation for Aging (06:00):

Yeah. And I think one of the things that I've just been increasingly attuned to, to, to your point, is that the way that we talk does really, and the way that we kind of frame our messages and the, and the statements that we're putting out really does impact how we all think. And, um, and that then impacts how we behave and the policies that we put in place and the structures back to your point about kind of the structural supports that might or might not be, um, in place to, to improve the quality of life of all of us as we age. So let's take that a step further then. Um, can you, uh, explain the ways in, in your view at least, um, those of us in the states are thinking about aging and, and why it needs to be reframed? So, um, maybe touch on some of the, the ways that, that we're seeing this come to life.

Robert Espinoza, PHI & American Society on Aging (06:59):

Sure. So I do think that because of the growing numbers of older adults and the fact that we are seeing a much older America and world, really, a more and more people are thinking about what are the implications for industries, for policymakers and for our culture as a whole. Um, and I think so far a lot of those discussions have been focused on the challenges that that will create. it will overburden our Medicaid system or long-term care system. It will impact, you know, the kinds of resources and supports that any kind of community can offer. And it's seen as a threat, again, as a tsunami or as a silver wave. Right. Instead of thinking, run away,

Mary O'Donnell, RRF Foundation for Aging (07:43):

Run away,

Robert Espinoza, PHI & American Society on Aging (07:44):

Run away. It's a

Mary O'Donnell, RRF Foundation for Aging (07:45):

Disaster.

Robert Espinoza, PHI & American Society on Aging (07:46):

<laugh>. Exactly. And it's harmful. I think that if we were to think about, um, the incredible strengths and opportunities that older adults bring to our society and our culture, that framing and that way of thinking would change. One example, I work in the direct care workforce sector where home care workers and nursing assistants support millions of older adults and people with disabilities all around the country. And it's a workforce that's rapidly growing because of that population that's also growing. And yet we're not able to fill all these jobs because of a variety of reasons. Mm-hmm. <affirmative> one potential for meeting demand and filling these jobs is to tap into the older adult population, because oftentimes older adults bring years of family caregiving and child rearing, and great wisdom and experience of what it means to support somebody who's older living with a disability. And because it's already a sizable number of older adults, we can certainly imagine the ways in which we could draw on that to fill those workforce gaps. But it doesn't mean that we need to rethink how those jobs are and how we recruit and retain older workers, because there are often different needs and different realities.

Mary O'Donnell, RRF Foundation for Aging (09:01):

It's so interesting. And I, I wonder, Robert, if we could just spend a one more moment on, on thinking about the direct care workforce, and certainly through your work at PHI, which is such a well regarded, uh, leader in the policy space and in the thought leadership that you've been able to promote around this important topic. I'm curious about what your thoughts are around how the direct care workforce might be able to also be, um, bolstered if we can shift the way we think about older adults. So I love the way that you just reframed for us how, uh, older wor older people themselves can be part of the workforce and all the assets that they would bring. I also wonder if there's a role that ages in plays in, uh, people of younger ages who might be turned off to being part of the direct care workforce if they think that they're caring for older people who are, oh, that would be so sad. They would just be so frail. Have you ever seen an, uh, come across ways where really that can be an engaging part of, uh, a workforce experience? So talk to me a little bit about the role that aging plays in that, in that side of the pipeline too.

Steven Collens, CEO of MATTER (10:23):

Hi, it's Steven Collens again. I hope you're enjoying the discussion at Matter. We help healthcare startups build business capabilities through one-on-one mentorship curriculum to help them navigate the complexities of today's healthcare industry and individualized support from our team. We help them raise capital and gain traction in the market, optimizing their business development strategies, and providing curated introductions to decision-makers across all sectors of healthcare. Our not-for-profit no equity model enables us to build a neutral platform for collaborative innovation. If you're a startup interested in learning more about our community visit matter.health/join.

Mary O'Donnell, RRF Foundation for Aging (11:07):

Have you ever seen and, uh, come across ways where really that can be an engaging part of, uh, a workforce experience? So talk to me a little bit about the role that aging plays in that, in that side of the pipeline too.

Robert Espinoza, PHI & American Society on Aging (11:21):

Yeah, those are all excellent points, Mary. I mean, I think that what we see in general is that there is an opportunity to look at younger adults as a way to meet demand and fill jobs in direct care. And yet what we don't have in this sector are kind of youth specific, uh, recruitment approaches, market research, and so much more that would tell us as kind of long-term care employers and as policymakers and others, what are the best ways to engage young people around this sector and around this career. Um, and that's something that really needs to be addressed, and it's probably rooted in ageism as well. in both directions. Yeah. Um, one of the most profound examples that I've seen in my career in aging around kinda ageism in the workforce, um, had to do with COVID-19. I mean, when we saw the pandemic, um, take root in this country and in this world, in the US it disproportionately impacted nursing homes and nursing home residents.

(12:17):

Yeah. And of course, there are medical reasons why older people, especially those living in nursing homes, were more at risk and are at risk of COVID-19. But there are also structural reasons why nursing homes were ravaged by this crisis. And some of it has to do with ageism. When you think about the nursing home sector and the direct care sector in particular, we're talking about some of our country's most marginalized populations as clients and as residents. We're talking about older adults and people with disabilities. And in nursing homes, it's predominantly people of color and all low-income. And when we think about the workers who are supporting older adults and people with disabilities and long-term care, it's primarily women, women of color and immigrants. And so those are populations that have long been not just ignored by public policy and oftentimes by industry, but also challenged and targeted by the kinds of ideas that are out there.

(13:14):

And we saw it all explode during the Covid 19 crisis. And that, you know, I think early on, one in two deaths were in nursing homes, and those were all the news stories. And yet when you would turn on the TV and you would see telethons, um, drawing attention to essential workers, you would see grocery store workers and nurses and police officers, all of whom are incredibly valuable. Yes. Overall, and within a crisis. Yet you would not see direct care workers or nursing home residents or older adults in general. And that to the disconnect between that is all ageism. How can we ignore a sector and the people who are most dying when the ones who are are, are clearly the ones who need the most attention.

Mary O'Donnell, RRF Foundation for Aging (14:00):

Right, right. Such good points. And I mean, again, it gets back to health equity, you know, and how can we advance health equity? And we know, as you just pointed out, we know that disparities can be compounded by all these different social factors at work, such as, as you said, race, gender, sexuality, socioeconomic status, education, all these things just to name a few. And, you know, I think after the pandemic, there also has been such a, a positive awareness around the intersectionality that different roles and identities can play. So if we think of an older person, but then an older person of color, or an older woman of color, or an older, uh, person from the LGBTQ community of color, you know, all these different aspects of disparities they can play out together in, in, in ways that, uh, amplify challenges to access health equity. So, um, I wonder how some of the stereotypes that we've talked about here are being heightened in, in different ways now that the pandemic has moved into a new phase. Are those, are those challenges still there? Have we overcome them? What work lays ahead of us?

Robert Espinoza, PHI & American Society on Aging (15:17):

Yeah, we certainly have not overcome them. And maybe they're even more complicated or more pronounced, and we're seeing them, for example, in election season where people are talking about, you know, the main candidates being too old to be president. Right, right. Without unpacking what that means. Um, and it, it's taken us for granted and, and in a way that, um, is unfortunately quite ageist. Think about some of the most dominant stereotypes or myths about older adults. You see, um, this entrenched thinking that really harms older people, and specifically people who live at those intersections of being older or being a woman and people of color and immigrants and so on. I, I wanna share a few examples. One is this stereotype that it is inevitable that older people will get dementia, for example. Great. Well, dementia rates are of course, increasing, and yet it's not necessarily a normal part of aging.

(16:13):

It's the, the risk of dementia grows as you get older, but it's not inevitable. Um, and many people live in their nineties and beyond without, you know, acquiring dementia. Um, we also can see, for example, that black older adults are twice as likely as white adults to develop Alzheimer's disease. And yet the research also shows that 36% of white people with dementia who are diagnosed, are diagnosed at baseline visits. Yet only 26% of black people in these same studies are diagnosed at baseline visits. Right. So even though black people are more likely to develop dementia, they are less likely to be diagnosed. And that has to do with the kind of biases that we see in the healthcare sector.

Mary O'Donnell, RRF Foundation for Aging (16:54):

Yeah. Um, this, this, and that would then mean that probably, uh, older African Americans are also less likely to get the level of treatment that their white counterparts might, uh, or the kinds of caregiver support systems that are in place. Um, and, and that might because of some of the implicit biases that we as a country have and that our healthcare professionals may have without being aware of it. Um, I hadn't heard that stick. That's startling to me.

Robert Espinoza, PHI & American Society on Aging (17:24):

It is startling. Um, another one that I think about when it comes to stereotypes and mi myths and misconceptions is this idea that older people are not sexual beings, right? And yet, the research shows that STDs and nursing homes, um, have increased by 260% from 2008 to 2020. Wait,

Mary O'Donnell, RRF Foundation for Aging (17:44):

Say that again? 260,

Robert Espinoza, PHI & American Society on Aging (17:47):

260%. Yes. That's jump STDs. Absolutely. STDs are preventable, and they can, but it requires education. It requires uptake, it requires confidence with negotiation and tools like condoms. Right. Um, from an intersectional perspective, I worked for five years in the LGBT aging world, um, where a lot of our work had to do with older adults with HIV. And what we found was that older people are often less likely than younger people to get tested. And that doctors do not always think to test older people for HIV. Right. And yet, HIV infection rates are incredibly high among older adults and specifically LGBTQ, older adults, right? So that's another way in which a myth around sexuality and aging is disproportionately impacting a very marginalized population.

Mary O'Donnell, RRF Foundation for Aging (18:41):

Yeah. 'cause if we're just writing off, if like, oh, we don't need to think about that, that of course isn't the case, and we're not seeing older people as whole, uh, whole beings, just like all of us at any age, we're not then, uh, thinking comprehensively about the, the challenges that might need to be addressed. Um, so I, I guess turning from some of those stark <laugh> distressing, but very real statistics to, to maybe more of, um, a, a forward-looking approach that, what do you think health equity would look like for older people?

Steven Collens, CEO of MATTER (19:25):

Hi, it's Steven Collens again. I hope you're enjoying the discussion. MATTER was founded based on the thesis that collaboration is the best way to fuel innovation in healthcare. In addition to accelerating healthcare startups, we help large organizations innovate more effectively. We help life sciences companies, health systems, insurance companies, and others find value in the entrepreneurial ecosystem, empower their internal innovators and work across healthcare sectors to advance their objectives. If you are interested in learning more about partnering with MATTER, email partnerships@matter.health.

Mary O'Donnell, RRF Foundation for Aging (20:06):

What do you think health equity would look like for older people?

Robert Espinoza, PHI & American Society on Aging (20:12):

Yeah. It's a great question. I wish it was a question that it was one that all of us started with, right? What would equity look like among older adults if it was achieved? I mean, equity from a definitional standpoint is really about being fair and impartial. So it's really saying that in the context of health, the disparities that we're seeing now based on race, gender, sexuality, and so much more that they would go away. And so healthcare access and healthcare outcomes in terms like conditions like heart disease, cancer, diabetes, that they would no longer be different people of color than for white and white people, right? Or for women and men or LGBTQ people and heterosexual and cisgender people. Um, everybody would be kind of experiencing health access and outcomes in the same way. And yet we're nowhere near that.

(21:02):

There is an extensive body of research showing that, for example, communities of color are less likely to afford care. They are often treated differently in healthcare settings and in long-term care settings. And there are higher rates of many of those conditions, heart disease, diabetes, and so much more. Um, and it's not because of personal choice. It's because our society has long been designed to create structural disadvantages for people of color, for women, for LGBTQ people, and it impacts their health. So I think we would see a society where those barriers that are rooted in history would be dismantled. Um, and we would be intentional as organizations, as policymakers, as anybody in this sector, um, to really dismantle them and, and support those communities so that the health profile of any one of us is not necessarily better than the next Right. That we are creating a, an ideal world in that regard.

Mary O'Donnell, RRF Foundation for Aging (22:03):

I so appreciate you lifting up the, the structural role. I think that, uh, you know, just as those of us, uh, concerned with equity have begun to really focus more and more on structural racism, structural sexism, structural ableism, all the different isms, structural ageism is alive and well. But I don't think that that's the way it has to be. I think that there really are opportunities to shift the way that we, um, collectively are thinking about, uh, the aging process that we're all going through, and, uh, looking for those solutions which are out there, that our community-based partners and innovative leaders and, and forward-thinking policymakers have so much momentum behind them that I think if we can all collectively kind of lean into that sentimentality, um, uh, and the practicalities that are coming out of it will really all be creating a better world for, for all of us as we age, which is certainly what I want. Well, Robert, is there anything else in closing that you'd like to highlight? I've loved getting to chat with you.

Robert Espinoza, PHI & American Society on Aging (23:18):

Yeah, likewise. Um, I, you know, I would highlight two additional points. One is that I mentioned the role of the workforce, but there's also the role of framing strategies and the role of communications in really bringing to life the great guidance that has been offered by groups like The Reframe, the National Center to Reframe Aging and by the Frameworks Institute, right? Certainly we need stronger communicators and organizations that are really working with journalists and with entertainment industry, and with so much more to craft a new, more positive narrative on aging, and to more bring the less visible populations of older adults into the forefront so that we can understand their lives. Um, the other point that I'll make is that I really appreciate organizations that are asking us to think about aging in broader ways. Mm-hmm. <affirmative> from Lifespan and longevity, like how long do, should we live?

(24:17):

And what does it mean to be healthy and connected to community, right. Um, to organizations that are thinking about issues like climate change or solo ages, or the sexual lives of older people, right? These kind of smaller topics that, that are less discussed within the sector, but are actually quite profound for all of us. Um, I think the more that we unpack aging and presents a a wide range of topics and ideas that explain what it means to grow older in this country, the more we'll challenge ageism because the more we'll see ourselves. So I appreciate organizations that are doing that.

Mary O'Donnell, RRF Foundation for Aging (24:55):

Terrific. Terrific. Yes. You mentioned that we have a couple times the, uh, National Center Reframe Aging, which can, you know if people are interested in learning more about this topic? Certainly. Uh, their website is reframeaging.org. Uh, we mentioned your, the organization that you're currently with, which does such tremendous work. Uh, PHI and their website is phinational.org. And, uh, of course, American Society on Aging, another group that is really a leader in this space, uh, as aging.org, um, just to name a few. There's, there's really a wonderful caravan to, to hop on board for any of those who would like to learn more. I am going to, uh, close by saying thank you. Uh, thank you so much by sharing actionable steps that we can really take to reframe the way we talk and think about aging, which we know will inform the actions and behaviors and collective efforts that, uh, all of us can put into action in our communities, in our families, in our workplaces, in our healthcare institutions, all these settings. Um, this is, you know, a really important discussion and, and for me, uh, who works in this space, I myself have had a couple aha and light bulb moments. So thank you for providing such great insights for our listeners. Robert. Um, I'd also like to thank MATTER. Uh, your partnership with our RRF Foundation for Aging is something that we value so much and we truly, uh, appreciate MATTER hosting this conversation. So thank you.

Steven Collens, CEO of MATTER (26:34):

Thank you, Mary, and thank you, Robert, for joining us to discuss the effects of ageism, why we need to reframe the way we think about aging and steps we can collectively take to get closer to achieving health equity for older adults. Thanks everyone for tuning into Advancing Health Equity. Join us next time to learn how inequitable wealth and economic opportunities across races creates and exacerbates health disparities.