Looking back to move forward – About aging in rural Minnesota (published in 2019)

Minnesota is approaching a landmark shift in demographics: In just a few years, we will have more residents over 65 than kids in grades K-12. This aging population will mean special issues that will require some shifts in thinking as well as in policy.

By LaRhae Grindal Knatterud, MN Department of Human Services

One of the most critical issues facing the new Governor of Minnesota in January 2019 will be the dramatic aging of our state’s population over the next 30 years. In 2020, Minnesota will reach an important milestone—we will have more individuals over 65 than we have K-12 kids. Between 2010 and 2030, we will double the number of older adults 65+, and between 2030 and 2050 we will triple the number of older adults 85+. By 2050 we will have made a dramatic permanent shift in the age of our population.

Rural Minnesota is already older than the state as a whole and older than the Twin Cities metro area. This trend will only continue into the future. In 2030, about 22.6% of Greater Minnesota’s population will be 65+ compared to 20.6% for the state as a whole and 19% for the Metro Area.

So, what does it mean to have this type of once-in-a-lifetime change in our demographic reality? And what does a governor need to know and what actions should he consider taking to address the opportunities and challenges that arise from this change, especially in the state’s rural areas?

I have worked for my whole career in aging and within Minnesota’s state agencies. Much of that time I have worked on projects that will prepare the state for the coming age wave of older adults. So, having thought a lot about this question and having worked on a variety of responses, here is my list of issues that our new Governor will need to address.[1]

Encourage older adults to continue working in paid or nonpaid roles

• A number of demographic, economic and social trends are converging to redefine work and retirement. The percentage of boomers who are not retiring but continuing to work is on the rise. Retirement is being redefined as a time to explore new interests, engage in volunteer activities and meet family needs such as caring for grandchildren and/or older relatives.
• The Governor can underscore the enormous resource that our growing aging population represents and can encourage older adults to continue to use their skills and talents within the labor force. Older adults, especially in rural areas, are remaining in the labor force longer than those in urban areas because of labor shortages.
  • The size of the baby boomer population together with the inclination of boomers to want to stay connected will provide a “demographic dividend” until the large boomer generation is much older. To take advantage of this demographic window, the Governor can encourage employers to retain and retrain their older workers so they can keep their skills current in an ever-changing marketplace. At the same time employers should be strengthening their knowledge transfer strategies for the day when these older workers decide to retire. The best way to retain these workers longer is to ask them what types of benefits or accommodations would keep them in the labor force.
• The Governor can also publicly recognize the enormous resource that the state’s older volunteers represent. Minnesota has an enviable record with higher rates of volunteerism than the rest of the country across all ages. Within the 65+ group, 50% volunteer to help individuals and 57% volunteer with an organization such as their church or a nonprofit agency. Volunteers have lower mortality rates, fewer disabilities and lower rates of depression later in life. They also provide enormous in-kind benefits to their communities. Without this volunteer engagement by older adults in rural communities, the rural areas would be much less livable for all ages, especially for older adults.

Ensure that older adults have a strong safety net for their economic security

• Minnesota, through the governor and others, can advocate for keeping federal Social Security, Medicare and Medicaid strong. These are foundational programs for the economic security of older adults. In 2014, 22% of Minnesotans 65+ relied on Social Security for 90% of family income and received an average monthly benefit of $1,351.[2] Rural elderly are more dependent than urban elderly on Social Security and public health and long-term care programs. When older adults do not have enough retirement income to pay for their housing and health care, they turn to the public sector for assistance and quickly become eligible for a variety of state-funded programs. It is in the interest of the state to keep these safety net programs viable and solvent, so that the state does not need to replace federal dollars with state monies.

Support family caregivers caring for older relatives by making all workplaces “eldercare-friendly” and redesigning services to wrap around family care

• Over 90% of the care that older Minnesotans receive is provided by family caregivers and other informal sources such as friends and neighbors. This percentage is even higher in the rural areas in part because of the severe shortage of professional caregivers.
• Many of the changes under way in families directly affect the family’s ability to care for older relatives. Smaller families, continued high labor force participation rates by women, and the decline in “caregiver ratios” (the number of females age 45—64 in a community compared to the number of individuals over age 85) mean greater challenges to the family’s continued care of older relatives. For example, the caregiver ratio in 2010 was 6.9. By 2050 it will have declined to 2.7, with the lowest ratio found in the older counties in the state.[3]
• The issue of staff shortages is a critical one for the state. The enormous amount of unpaid help provided to older adults by families is worth over $8 billion per year, using the average hourly wage paid to caregivers in the state. If family care begins to decline, older adults who must find and pay caregivers will quickly spend down their resources and become dependent on the state’s Medical Assistance (MA) program.
  • The Governor has the broadest view of the public policy issues that collide on this extremely critical issue. He needs to encourage and applaud the unpaid family care but also enlist the state’s employers, eager to keep their productive workers on the job, to make all workplaces “eldercare friendly” through such supports as flexible schedules and more flexible support services that wrap around family care and make the services more person/family-centered. The state can help make it easier for workers to be both attentive family caregivers and productive workers.

Foster communities for a lifetime as good places to grow up and grow old by offering key community elements to residents

• According to surveys, older adults want to remain in their own homes and communities as long as possible and age in place there. They are more likely to be able to do so if they live in “communities for a lifetime.”
• The key elements of communities for a lifetime include:
  • A variety of types of housing options that are affordable and accessible and not just what we traditionally call “senior housing.”
• Transportation and mobility systems that connect locally and to other parts of the community and the rest of the state.
• Social connections that help older adults develop new friendships and roles between generations and other groups.
• An array of products and services that are sensitive to the special needs of older adults in the community.
• Minnesota could be considered the national poster child for “communities for a lifetime” because of our tradition of organizing and providing services at the grass roots level, giving residents more control over what and how services are organized to meet their needs locally. Many communities in Minnesota are working to become livable for all ages. This work can be encouraged and expanded through the Governor’s bully pulpit and more coordination of related efforts across state agencies, e.g., grant programs that can help improve communities.
• As a recent survey found,[4] rural Americans value many aspects of their life in their communities. The most important reason they choose to live in their community is because their family lives there. They also feel very attached to their local community, mentioning the closeness of their community, liking life in a small town and being around good people in their community.

Transform Minnesota’s health care system, improve chronic care and intensify long-term care reform

• One of the greatest challenges of the future will be the increased need for health and long-term care by an aging population. In the last 20 years, death from heart disease has declined, but the incidence of diabetes, arthritis and Alzheimer’s has continued to climb. Unfortunately, we can expect to see large increases in the number of older adults with chronic conditions who will require care and treatment.
• This trend will be more apparent in the rural areas, where older adults have higher mortality rates. In addition, the cost of health care is a critical problem in rural Minnesota. According to the NPR survey done earlier this year, 50% of rural residents say that the cost of their family’s health care in recent years has caused serious problems for their family’s overall financial situation. Medicare coverage probably shields older adults in rural Minnesota from some of the cost issues, but other issues such as access to providers clearly can negatively affect rural health care.
• The state’s health care community needs to identify and invest in care models that effectively treat older adults with chronic conditions and educate older adults about what they can do to self-manage their own chronic conditions.
• One of the biggest risks that older adults face is the potential need for long-term care. Experts predict that 70% of those over 65 will need some long-term care, defined as help with personal care and household tasks that many older adults need as they age and become frail. Minnesota has been working on comprehensive long-term care reform for a decade or more. We have closed 11,500 nursing home beds and added over 60,000 units of assisted living/housing with services in the past 20 years, transforming our system from institutional-based to more residential and home-based.
• The overwhelming care preference of older adults is to stay at home or move to a residential (rather than a medical) setting. Assisted living facilities have become the place where most elderly are cared for when they can no longer live safely in their own home. The recent horrific reports of abuse and neglect of elderly in these lightly regulated settings clearly show the need for much stronger regulatory oversight by the state and a more effective system of reporting problems to the state, together with vigorous and speedy follow-up. This is a blemish on Minnesota’s long record of high-quality care for older adults. Developing and implementing an appropriate level of oversight for care of frail elderly in these settings and a strong protective services system in general needs to be a high priority of the Governor.
• Another critical issue in long-term care is the way we pay for this care. Long-term care is growing as a percentage of the state’s Medical Assistance (MA) program. If we do nothing to change this, these MA payments could overwhelm the state budget as the population of frail elderly escalates. Through an initiative started by the previous administration called Own Your Future, the state has been working to educate individuals on their need to plan for their long-term care, including how to pay for it. The effort has also developed more affordable private financing options for middle-income households, which would reduce or delay the number of Minnesotans needing to turn to the MA program to pay for long-term care expenses. Thus far, two product concepts have been developed, and work continues to identify additional options. The new Governor should continue this work to bring more private dollars into long-term care.
• The mental and chemical health needs of the older population, including opioid abuse, are also becoming front-and-center issues. The Governor needs to address the tragic consequences of opioid use by finding ways to prevent the addictions that lead to so many problems for people of all ages in the state.

Use technology to maximize the opportunities that accompany Minnesota’s permanent age shift

• Today’s older population has lived through more technology change than any previous generation in history. They accept much of today’s technology as a normal part of their lives and are grateful for the changes made available through technology.
• The continued development of new devices and related items to simplify and improve health care will increase our ability to achieve good health outcomes and reduce disability levels for those who have chronic conditions. But they will only work for rural areas with increased broadband coverage. Therefore, it is important for the Governor to finish covering the state with broadband so that older people and the agencies that serve them in all parts of the state—especially in rural areas—can benefit from high-speed, high-quality Internet connections.

Conclusion

• As the top elected official during this aging demographic shift, the Governor will have the opportunity to reframe aging for the citizens of Minnesota. Reframing refers to changing the public view of aging from one based on the myths about aging to a more realistic view of aging—that growing old is normal and lifelong and is distinct from disease and decline.
• We need to underscore the fact that older adults are a very heterogeneous group with a wide continuum of traits related to income, health, gender, race/ethnicity, and education, to name just a few. We need to stress the fact that older adults have a huge positive economic and social impact on our state. They have an impact on the economy as the keeper of much of the country’s wealth. They also contribute mightily to the state’s social and economic productivity by caring for older relatives, children and grandchildren, providing economic support for children and grandchildren, and engaging in and supporting their communities.
• Minnesota is blessed with many individuals and public, nonprofit and private groups that have made our system of services for older adults the best in the country twice in a row.[5] All those individuals and organizations are at the ready to assist the new Governor in reframing aging and continuing the work to improve our award-winning system of services for older Minnesotans focusing on those parts that need upgrading and continued advocacy.
• As the new Governor thinks about his platform for rural Minnesota, it is important to remember that residents of rural areas say they will need government help to address the issues that affect their regions. In fact, they want government help because they believe it will be necessary to overcome the forces causing problems in their communities, like opioid availability and use. In NPR’s survey of rural areas, a full 30% thought the state government would have to play a significant role in that assistance. This provides an opportunity for the Governor and his administration to work with the communities and residents in the rural portions of Minnesota on the issues described here and others uppermost in their minds.
• The new Governor will have the ear of the Minnesota Board on Aging, a Governor-appointed board that is both federally and state designated to be an advocate for aging. It is now working on an initiative called MN2030, looking at the system changes required to address the demographic shifts. The Board is especially qualified to follow up on the issues laid out in this memo.

This Governor has a unique opportunity to articulate and lead the reframing of aging in Minnesota. He can help transform our view of aging from one that is deficit-based to one that celebrates the growing numbers of connected and vital Minnesotans—who just happen to be old.

LaRhae Knatterud is the director of aging transformation at the Minnesota Department of Human Services. She has spent her entire career working on aging issues for the state of Minnesota in a variety of positions and agencies.

[1] I work for the State of Minnesota, Minnesota Department of Human Services, but the thoughts expressed here are my own and do not necessarily represent state policy.

[2] Social Security Bulletin.

[3] AARP Public Policy Institute. The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers. 2013.

[4] Life in Rural America. Survey conducted by National Public Radio, the RWJ Foundation and the Harvard School of Public Health. June 6 – August 4, 2018.

[5] AARP Public Policy Institute. The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers. 2013.