As the state prepares to care for the largest generation of elders ever, many wonder whether Alaska can use the wisdom of all those years to help families provide and pay for the services needed.
"I think (Alaska) is going to be about as ready as anybody else, and that isn't ready," said Kathy Kloster, administrator for Wildflower Court, a nursing and assisted-living home near Bartlett Regional Hospital. "Nobody's going to be ready. I just think we don't realize the impact of what's going to happen."
Agencies caring for the elderly already have trouble finding enough workers. Nursing and assisted-living homes have waiting lists and medical care for Alaska's elderly costs the state more than $30 million a year.
Juneau has 116 beds at the state-run Juneau Pioneers' Home, the nonprofit Wildflower Court and a few private assisted-living homes. They almost always are occupied.
"We have a waiting list that's a couple of years long," said Pioneers' Home Administrator Rosemary Gute-Gruening.
Most of the people entering the home now first applied two or three years ago, Gute-Gruening said. Wildflower Court has about 15 people waiting to get in, Kloster said.
While they wait, they stay at home or are sent to care centers in Anchorage or Washington state, putting stress on seniors and their families, said Julie DeLong, a social worker at Wildflower Court.
"There's a great support and strength from family members," DeLong said. "Residents will often do much better, mentally and physically, if they have family members around and family involvement."
Looking for alternatives
Rather than expanding the nursing homes or building more, the state is trying to encourage the development of smaller, home-like care facilities called assisted-living homes, as well as services that help people stay longer in their own homes. That's what most seniors, such as Aurelia Thibodeau, want anyway.
"As long as we can live in our own homes, take care of our own place, we don't want assisted living," said Thibodeau. "As long as we're able I don't want to give up the house."
About 84 percent of people 65 or older are able to take care of themselves without help, according to the federal Administration on Aging. Sometimes all they need is someone to stop by regularly to help with chores. The most common difficulties are bathing, getting around inside and getting in and out of a bed or chair.
Cornerstone Home Health, a private business, and the Center for Community, a nonprofit agency, send personal-care attendants and other workers into private homes in Juneau to help with tasks from washing dishes to bathing.
The problem is finding workers willing to care for the elderly, and the money to pay them. The current shortage of health-care workers is likely to worsen as the baby boomers retire, leaving a smaller generation of workers behind.
Looking for alternatives outside senior homes
The day Jim Costa came home to find his 84-year-old father-in-law in the kitchen with a butcher's knife, swinging precariously on his crutches as he tried to slice cheese, they knew it couldn't go on.
Pat Costa's father, Gene Specht, was having a difficult time staying at her home anyway. He couldn't go up and down the stairs, so he'd been sleeping on a bed in the living room. He had to be helped to the bathroom.
"There just was no dignity," Pat Costa said.
For his safety and their sanity, Dad would have to go somewhere else, but where?
The Costas called the state-run Juneau Pioneers' Home and were told it would be four years before Specht could get in. The cost of a private nursing home seemed too high, and Pat Costa said she couldn't bear to put her father in an institution anyway.
After six weeks Costa found a place for her father at Shattuck Manor, an assisted-living home in Juneau. Other families have had to send their parents to nursing homes in Anchorage or Washington while they wait for a bed in Juneau.
"I know a lot of people whose parents live in their home," Costa said.
The dilemma they face will be more common in the next 20 years as the population of senior citizens grows. The state is looking for ways to provide more care, but Juneau's nursing homes aren't likely to add beds.
David Pierce, who issues state nursing-home permits, said Alaska needs more alternatives, not more nursing homes. Alaska currently has 15 nursing homes with 744 beds, Pierce said. When the nursing homes were surveyed in July, they were 87 percent full. He aims to keep them between 90 to 95 percent full, since even empty beds cost the state money.
"This state is at the forefront of something many other states are trying to do and that is provide alternatives to nursing-home care," Pierce said. "Alternatives are less expensive, they're less restrictive, and people would like to stay in more of a home environment."
The alternatives are smaller assisted-living homes or ways to keep people in their own homes.
"The longer they can stay in the community, the longer they can stay in their own home, that's the ideal," said Rosemary Gute-Gruening, director of the Juneau Pioneers' Home. "It's not nice to move to an institution and no matter how you try to make it like a home, you still move to an institution. ... The individuality and the care and attention is always more pleasant in a smaller setting."
She's noticed more people on the Pioneers' Home's active waiting list are turning down the beds that come open, which she attributes to an increase in alternatives in Juneau.
One of the alternatives is Shattuck Manor, where Costa brought her father. One Saturday this fall, Specht lounged on a plush brocade chair watching TV, his legs propped up on a matching footrest.
"It's just wonderful to find a place like this," Specht said. "It's nice to know you've got a place that you can rest and nobody bothers you."
The living room, like the rest of the house, is wallpapered and decorated with historic Alaska photos. The house often smells like bread or cookies baking and in the evenings one of the residents sometimes plays the old upright piano.
"There's no place like home," said Delores Reina, who runs Shattuck Manor. "So what we are trying to give them is something really similar to home."
Alaska has 121 assisted-living homes licensed to care for the elderly with 826 beds, including 24 beds in Juneau.
Bob Polson, a nurse for Hospice and Home Care of Juneau, a nonprofit group providing end-of-life care, said more are needed.
"More often than not we end up with people who shouldn't be in the home and their relatives are exhausted, but there's nowhere for them to go," he said.
"It's a crisis that people have been talking about and that we are on the edge of," said Glen Ray, who coordinated a government task force on the lack of in-home caregivers.
Tara Smith, a Cornerstone supervisor, recently said she had 15 attendants on staff and needed more.
"It's never enough, there's very high demand for these types of service," Smith said. "The only way I've been able to keep anybody is by teaching our own PCA (personal-care attendant) class."
The pay is based on what Medicaid will reimburse. Cornerstone employees start at $10.50 an hour. Most in-home caregivers in Juneau could earn as much working at a large retail outlet or seasonally in tourism, Ray said. And many do switch in the summer, making it even harder to find workers. On top of the low pay, the hours are irregular and the work can be unpleasant.
"You're doing anything from showering the person to assisting them in and out of their wheelchair," Smith said.
Recruiting people to work in nursing and assisted-living homes is also difficult.
"There's not enough people out there that are willing to do this kind of work," said Kloster of Wildflower Court.
Wildflower Court, Bartlett Regional Hospital and other care-giving agencies have begun addressing the shortage of staff by working with the University of Alaska Southeast to train more certified nurses' aides.
"It has helped. ... Whether they can keep up with it is another story," said Gute-Gruening of the Pioneers' Home. "The community just absorbs them."
The cost of care
Whether care is hard or easy to find, it comes at a price.
The public and private cost of caring for an older person in developed countries such as the United States is roughly two and a half times more than caring for a child, according to a United Nations report on population.
Medical bills and nursing care frequently use up whatever savings seniors have, and they end up turning to Medicaid, a government health-care funding program for the poor, elderly and disabled. Eighty-five percent of nursing-home residents are Medicaid recipients, said David Pierce, who issues state nursing-home permits.
"People who have not been eligible before, when they need long-term care they will spend down their assets and qualify for Medicaid, sometimes very quickly given the high cost of long-term care in Alaska," said Jon Sherwood, manager of beneficiary eligibility policy for Medicaid in Alaska.
In 2000, about 15 percent of the seniors in the Alaska were on Medicaid. They accounted for only a small portion of the Medicaid beneficiaries, but their care cost proportionally more than other groups because of the high cost of hospitalization and long-term care. Medicaid spent almost $75 million on the elderly in Alaska that year.
The federal government picks up 59.8 percent of the Medicaid tab, but that still left the state paying $30.15 million from the general fund and various other money pots. As the elderly population grows, that amount will increase, Sherwood said.
If seniors continued to need Medicaid at the same rate, in 2020 there would be 13,800 elderly Alaskans using Medicaid to pay $193 million in medical bills, not taking into account rising medical costs. The federal government decides, and can change, the portion it pays, but if the percentage stayed the same the state's share would be $77 million.
It's hard to predict how much the need for Medicaid will grow, Sherwood said. He said the new population of elders is better off financially than the previous generation and may be less likely to need Medicaid.
Tax exemptions cost city
On a local scale, aging Juneau residents increase the city tax burden on younger residents.
Juneau exempts senior citizens from city sales tax and from tax on the first $150,000 of value of a private home. Last year, the sales tax exemption cost the city $927,000, said city Sales Tax Administrator Joan Roomsburg. The property tax exemption, claimed by about 900 Juneau seniors, cost the city about $1.4 million, said city Finance Director Craig Duncan.
The exemptions' total cost, about $2.3 million, came close to equaling about one mill of property tax revenue the city had to find elsewhere, said Duncan.
"What the seniors do not pay the city has to make up either by not providing a service or by getting the taxes from everyone else," Duncan said.
Taxpayers under 65 now pay about $200 more per household to the city to cover the senior exemptions. With the expected growth in the senior population, the cost to younger families will be $540 a year by 2018, Roomsburg said.
"The issue is, at what point does this senior tax exemption get to be so costly it becomes unfair?" Duncan said.
At the same time, seniors benefit the community and economy, spending their retirement and Medicare money here, creating jobs and providing a core of volunteers. The state, and the nation, have 10 years to come up with better, cheaper, less labor-intensive ways of providing services to aging Americans.
"We have a growing elderly population that needs services and we have a shrinking younger population able to give services," Wildflower Court director Kloster said. "Not only do we have to think of a smorgasbord of ways to provide services, but we need to think of the most efficient ways to take care of people."
Average basic costs for different types of senior-care in Alaska:
- In-home care: $50/day.
- Private assisted-living home care: $166/day.
- Nursing home care: $255/day.
Basic costs for senior-care facilities in Juneau:*
- Pioneers' Home coordinated care: $65/day.
- Pioneers' Home basic assisted-living care: $111/day.
- Pioneers' Home comprehensive care: $183/day.
- Wildflower Court assisted-living care: $161/day.
- Wildflower Court skilled nursing care: $450/day.
- Bridge Adult Day Program care: $108/day.
*Discounts or subsidies are sometimes available.
Source: State agencies and businesses listed.
Kristan Hutchison can be reached at firstname.lastname@example.org.