Tag Archives for Maureen Maigret

Senior Agenda Coalition of RI unveils legislative agenda to packed house of seniors

Published in RINewsToday on April 1, 2024

Last Wednesday, the main ballroom at the Crowne Plaza in Warwick was filled, to capacity. Hundreds came to the Senior Agenda Coalition of RI’s (SACRI)  2024 Legislative Leaders Forum to learn about the advocacy group’s issue priorities. House and Senate leadership, along with members of both caucuses came to listen, learn and to respond to SACRI’s four priority issues for 2024.

We’re back, and we are stronger than ever,” announced Maureen Maigret, SACRI’s Policy Advisor, to 275 attendees who came to this year’s annual legislative forum held on March 27, 2024.  Before she unveiled SACRI’s ambitious legislative priorities she painted a demographic picture of older Rhode Islanders.

The graying of Rhode Island’s population

“We know that 200,000 Rhode Islanders are age 65 and over, and this number is growing,” noted Maigret. According to the former state legislator and Director of the Department of Elderly Affairs, in just six years, 1 in 5 persons will be age 65 and over. Today, 20% of the population in 18 Rhode Island communities are in their mid-sixties and over.

Many seniors still work. They pay taxes, provide care to loved ones, volunteer to contribute to their communities, and religiously vote,” stated Maigret, who noted that they contribute over $3.28 billion to Rhode Island’s economy through Social Security benefits. 

Maigret pointed out that as the older population ages, the percentage of woman increases over men.  At age 65 and over , 56% of this age distribution are woman, 44% are men.  At age 85 and over, the percentage of women rapidly increase to 69% compared to 31% for men. And in nursing homes, 68% of residents are woman while 32% are men. 

According to the U.S. Census Bureau, many older Rhode Islanders have limited incomes. Twenty-seven percent of age 65+ households earn less than $25,000 a year, while 50% earn less than $50,000 a year.

With women leaving their jobs over the years to raise their family, it is no surprise to Maigret that women’s incomes are less than men, this ultimately resulting in a smaller Social Security benefit. The average Social Security benefits of women aged 65 and over ($20,333) is $5,000 less than their male counterparts ($25,204), she says.

Unveiling SACRI’s Legislative Agenda

“Keeping seniors strong” is the theme of this year’s legislative forum, Maigret told the hundreds of seniors and aging advocates in attendance before announcing the SACRI priorities. SACRI is pushing for legislative issues in the areas of:

·       Economic Security

·       Supports at Home

·       Community Connections

·       Housing Options

She called on the House Speaker K. Joseph Shekarchi (D-Dist. 23, Warwick), and Senate Majority Whip, Valarie Lawson (D-Dist. 14, East Providence), in attendance, to support House and Senate legislation, and state budget proposals to address these issues.

SACRI’s top legislative priority is to addressEconomic Security issues. Polls show that healthcare affordability is a major concern, and this impacts many seniors.  Maigret pointed out that Medicare premiums  and co-payment gaps have a major impact on low-income Rhode Islanders who struggle to pay for healthcare, food, rent and basic needs.”

According to Maigret, legislative proposals (S. 2399/H. 7333) would be a legislative fix to reduce high out-of-pocket costs for persons on Medicare. The bills would expand income eligibility for the Medicare Savings Program (MSP), helping an estimated 17,000 low-income seniors and disabled residents pay their $175/month Medicare Part B premium and covering co-pays and deductibles for those with very low-income.

Thousands of low-income seniors and persons with disabilities on Medicare, but not eligible to participate in the state’s Medicaid program, struggle each month to pay their Medicare Part B premiums and co-pay costs for services and prescription drugs causing many to forgo needed health care as they cannot afford to pay the co-payments.

And eligibility to join MSP qualifies those on Medicare to enroll in the federal Extra Help program that provides significant additional financial assistance to pay for

SACRI also calls on the state lawmakers to provide necessary funding in the 2025 Fiscal Year Budget to enhance programs to assist seniors to age in place in their communities. “It’s a very important legislative issue for seniors,” notes Maigret, stressing that most seniors want to stay at home when they need care.   

In large part due to the existing home care staffing shortage, 75% of those referred for state-subsidized home care wait two months or more for these services. A state study recommended home care rate increases to improve access to home health care services which would help to address the worker shortage and provide livable wages for home care workers.  Maigret urged Shekarchi and Lawson to put funding in this year’s budget to implement the study’s recommendations.

Meanwhile, SACRI supports increased funding for local Senior Centers to enable them to continue to provide “community connections” to seniors. “They do amazing work by offering meal programs, technology assistance and training and all kinds of social, health and recreations programs, says Maigret.

Seniors benefit from, and enjoy going to Senior Centers, adds Maigret, reflecting on a comment told to her by a senior attending Warwick’s Pilgrim Senior Center. “It’s my home away from home,” she says.

Governor Dan McKee’s Fiscal Year 2025 Budget would distribute $1.4 million (about $7 per person aged 65 and over in each community) to the local communities for Senior Centers and programs. SACRI calls on the General Assembly to increase this budget allocation by about $660,000 (making the funding tied to $10 per person aged 65 and over. “It’s a small funding request,” says Maigret.

Finally, SACRI urges the General Assembly to continue to address the lack of options and affordability of housing for seniors. Maigret notes that this problem is the result of the state’s growing older population with fixed incomes, combined with low housing production, skyrocketing rent increases, and high property taxes, 

There are many legislative remedies to address the state’s housing crisis, says SACRI, calling on the General Assembly to use a portion of the proposed Housing Bonds to support affordable housing options for older Rhode Islanders. She also suggested that lawmaker’s continue funding the Home Modification Program, expanding the Property Tax Relief Program and finally promoting  accessibility features in new housing developments.

Like previous years, SACRI worked hard to drive home the point of putting a spotlight to its legislative agenda by having “storytellers” translated the priorities into personal stories.  

House Speaker talks turkey at Legislative Forum

Aging is a very important and personal issue to House Speaker Shekarchi, who is taking care of his 98-year-old father, who remains at home. “That is where he wants to be, he says. “I know that not everyone is fortunate – not everyone has the same support system,” says Shekarchi. “But it’s important that seniors have options so they can choose what’s best for them,” he says

“We need to provide support for seniors to age in place and to remain in their homes, living independently,” states Shekarchi. A great option – which is also the top legislative priority for AARP Rhode Island this year – is creating Accessory Dwelling Units (ADUs). They enable seniors – even young college graduates – to live independently while remaining near family and others, he adds.

“As for seniors who live in assisted living facilities and nursing homes, we need to ensure those facilities are adequately staffed, and that caregivers are paid a sustainable wage,” says Shekarchi. 

“We expect this to be a very challenging budget year, with many worthwhile, but competing, priorities,” says Shekarchi.

“I know the Senior Agenda has legislative priorities in 2024 that I promise we will consider very carefully. And I have a request for all of you. Please stay involved, make your voices heard at the State House,” Shekarchi suggests, “give us feedback. You can testify in person at the State House, or in writing by letter or email.

Valarie Lawson, Senate Majority Whip, took the opportunity to discuss the Rhode Island HEALTH Initiative… a Senate legislative package designed to address affordability and accessibility of health care in the state.

According to Lawson, the HEALTH Initiative seeks to ensure the strength of the state’s community hospitals, attract, and retain primary care doctors and makes sure Rhode Islanders can access quality, affordable care. The legislation includes a bill by Sen. Alana DiMario to create a drug affordability commission in Rhode Island … which is a critical step to make the state’s prescription drug system less complicated and less costly. And Sen. V. Susan Sosnowski’s legislation to transform and mandate a continuous Medicaid reimbursement rate review process by the Office of the Health Insurance Commission.

Lawson noted the Senate was working on the SACRI MSP priority legislation and that she is a co-sponsor of the bill. She said that the Senate shares the Senior Agenda’s  priority of making Rhode Island a place where residents can age with comfort and security. “At the State House… we rely on your voices to help guide us,” she said.

Call to Action

Diane Santos, SACRI Board Chair, ended the forum with a Call to Action for attendees to let their voices be heard by contacting their local legislators to express their concerns and to support programs to help keep seniors strong.

SACRI Legislative Leaders Forum organizational partners included: Cranston Enrichment Center, Edward King House, Leon Mathieu Senior Center, Meals on Wheels RI, Pilgrim Senior Center, Ocean State Center for Independent Living, St. Martin de Porres Center, The RI Organizing Project and The Village Common of RI.

To watch the 2024 Senior Agenda Coalition Leaders Forum Conference, go to: https://capitoltvri.cablecast.tv/show/9023

Medicare Savings Program bill will be a win for low income seniors, and Rhode Island

Published in RINewsToday on March 25, 2024

A few weeks ago, advocates for seniors gathered on Smith Hill, attending a Senate Committee on Health & Human Services hearing to push for passage of S. 2399.  The legislation would expand income eligibility for the Medicare Savings Program (MSP), helping many lower income seniors and disabled residents pay their $175/month Medicare Part B premium and covering co-pays and deductibles for those with very low-income.

Thousands of low-income seniors and persons with disabilities on Medicare, but not eligible to participate in the state’s Medicaid program, struggle to pay their Medicare Part B premiums and co-pay costs for services and prescription drugs causing many to forgo needed health care as they cannot afford to pay the co-payments.

S. 2399, introduced by Pawtucket Sen. Sandra Cano (D-Dist. 8, Pawtucket), would expand eligibility for the Medicare Savings Program (MSP) by increasing the income limit to 186% of the federal poverty line and eliminating the strict asset limit.  It also increases from 100% to 138% of the federal poverty line a part of the program that covers deductibles and co-payment.

S. 2399 was heard on March 12, 2024 and held for further study.  At press time, H. 7333, introduced by Pawtucket Rep. Karen Alzate (D-Dist. 60, Pawtucket, Central Falls), has been referred to the House Finance Committee for consideration. No hearing date has been scheduled.

“With health care costs rising at an alarming rate, it is imperative that we make sure that no one goes without the care they need due to unaffordability.  This bill adapts to the significant changes in our society and economy while also ensuring that our most vulnerable senior and disabled residents are able to access the care and medicine that is essential to their daily lives,” said Cano, who champions S. 2399 and in previous legislative sessions introduced legislation to expand the MSP.

“Too many of our low-income seniors and disabled residents are falling through the cracks and foregoing crucial health care services due to rising co-pays and out of pocket costs.  This is unacceptable, but thankfully, we can do something about it.  By passing this legislation, thousands or more Rhode Islanders will be able to receive the care that they desperately need while also keeping more money in their pockets that’s needed for daily living expenses,” said Alzate, who sponsored the House companion measure.

“We understand this is very important legislation. We had a very informative, thorough hearing on this bill, and I look forward to reviewing all the information we collected.” says Senate Health and Human Services Committee Chairman Joshua Miller (D-Dist. 28, Cranston, Providence).

The Policy Problem and its Solution  

Currently, the income limit of $20,331 leaves thousands of older Rhode Islanders and disabled low-income persons on Medicare with significant gaps in coverage and hefty out of pocket costs.

If the MSP income limit is increased to $28,012, as required by the legislation, an estimated 17,000 persons would be newly eligible to have their Medicare Part B covered by being enrolled in MSP. Anyone enrolled in the MSP receives automatic enrollment in Part D “Extra Help,” a federal program which significantly lowers out-of-pocket Medicare prescription costs at no cost to the State. The federal government establishes the minimum income and asset thresholds for the MSP, and states are permitted to increase these limits and many have done so. 

Advocates of Cano’s MSP legislative proposal say it also particularly helps Rhode Island’s older woman and minorities. “Since women and people of color and persons with disabilities are disproportionately represented in low-income populations, increasing access to the MSP promotes equity,” finds an advocacy partnership’s analysis of the legislative proposals. “Poverty rates among older adult Hispanic women are two and one-half times that of older Hispanic men and persons age 18 and over with disabilities are twice as likely to live below 150% of the poverty level, said the analysis.

The advocacy partnership’s analysis also noted that significant numbers of older adults and those with disabilities enrolled in Medicare face financial challenges meeting basic needs. The number of older adults living below or near poverty has increased, housing costs have climbed dramatically, food cost have increased and many more rely on food pantries.

Covering the $175/month Medicare Part B premium for 17,000+ Rhode Islanders (at no cost to the State) and additionally covering co-pays and deductibles for thousands of very low-income adults and persons with disabilities on Medicare will give them much needed financial relief.  And enrollment in the Extra Help program to reduce drug-related costs provides significant additional financial assistance and improves access to critical medication.

Testimony At the Senate Committee Hearing

Nine organizations either testified at this hearing or submitted written testimony to urge passage of S. 2399.  AARP Rhode Island did not testify at the hearing but signed up in support in the committee room.  There was no opposition to Cano’s legislative proposal.

“I first became aware of the need to expand the income eligibility for MSP quite a few years ago when an older man in my neighborhood contacted me to tell me he lost out on the program because he was just a few dollars over the income limit. As a result, the Senior Agenda Coalition of RI (SACRI) has advocated for several years to increase the income cap,” says Maureen Maigret, SACRI’s policy Advisor.

It’s a win-win for both older Rhode Islanders  and for the Rhode Island General Assembly, says Maigret. “S. 2399 would help Medicare beneficiaries to access care along with putting money back in their pockets to pay for food, rent and their basic needs.  By increasing the Medicaid income to $28,012, the federal  government will pay the full cost of the newly eligible Medicare beneficiaries,” she told the lawmakers.  

Strongly supporting S2399, Karen Malcolm, of Protect Our Healthcare Coalition, noted that the legislative proposal is modeled on the MSP changes enacted in New York last year and approved by the Centers for Medicare and Medicaid Services. “Rhode Island should take advantage of the opportunity to expand access to affordable coverage for seniors and people with disabilities and bring new [federal] revenue to our state.”

H. Phillip West, Jr. lobbyist for the Village Common of Rhode Island, states MSP already makes an enormous difference for many beneficiaries. But, “Rhode Island’s low threshold for eligibility and low allowable assets leaves thousands of our needy neighbors out. The good news is that Senator Cano’s legislation address these defects,” he said.

In submitted written testimony, Heather Smith, MD, president of the Rhode Island Medical Society stated “From our perspective as physicians, we witness firsthand the adverse effects of financial barriers on patient health outcomes. Too often, individuals are forced to forgo or ration medications, delay necessary treatments, or skip preventative care due to concerns of affordability. These delays can exacerbate health conditions, lead to complications, and ultimately result in higher healthcare costs down the road.”

Alex Moore, political director of SEIU 1199NE, stressed the many benefits of passing S. 2399, specifically enhancing access to care, providing needed financial  relief, leveraging federal funds, and strengthening the health care workforce. By supporting the legislative proposal, “we demonstrate our commitment to health and well-being of our state’s most vulnerable populations,” he stated in written testimony.

Even with the strong support of the aging community, the state’s Office of Healthy Aging has not yet taken an official position on S. 2399.  “As with any other bills at this stage of the session, we are reviewing the impact of H 7333 and S 2399 on Rhode Islanders. We will continue to follow these bills as they make their way through the legislative process,” says  Director Maria Cimini.

Samuel Salganik, JD, executive director of RIPIN, which offered testimony in support for S.2399, said, “This is one of the best investments available right now for our state government.  At a cost of just over $5 million, the State can draw down more than $40 million in federal support to assist low-income seniors in Rhode Island,” says Salganik. “It’s a great deal for the state. I think that’s a deal that most of us would happily take,” adds Salganik.

Gov. Dan McKee’s recently released FY 2024 Budget does not include funding for to expand the state’s MSP.  Now the ball is in House Speaker Joseph Shekarchi’s (D-Dist. 23, Warwick) court as his chamber collaborates with the Senate to hammer out budget resolution to be approved by the Rhode Island General Assembly to be sent for the Governor’s signature. Hopefully, Shekarchi will see the expansion of the state’s MPM as a win-win for lower-income and disabled persons on Medicare and the state.  As supporters of  S 2399 and H 7333 say, “it’s a no brainer.”

The Advocacy Partners for MSP Expansion was established to push for the passage of S 2399 and H 7333 during this legislative session. They are: the Senior Agenda Coalition of Rhode Island, Rhode Island Organizing Project, RIPIN, the Economic Progress Institute, the Protect Our Healthcare Coalition and the Ocean State Center for Independent Living.

To access the bills under consideration: http://webserver.rilegislature.gov/BillText/BillText24/SenateText24/S2399.pdf – http://webserver.rilegislature.gov/BillText/BillText24/HouseText24/H7333.pdf

Expanding the income eligibility for the Medicare Savings Program (MSP) is one of the legislative priorities of the Senior Agenda Coalition of Rhode Island. These policy issues will be discussed at its upcoming  Legislative Leaders Forum scheduled on Wednesday, March 27, 2024, from 10:00 a.m. to 11:00 a.m., at the Crowne Plaza Hotel, 601 Greenwich Ave,, Warwick, RI. 

The Senior Agenda Coalition of RI’s Annual Legislative Leaders Forum is this week:

Report says nation not prepared to tackle senior housing crisis

Published in RINewsToday on March 11, 2024

With the graying of America, the nation is unprepared to provide needed housing and care for millions of seniors, warns a recently released 40-page report by the Cambridge-based Harvard Joint Center for Housing Studies.  The US population age 65 and over has skyrocketed 34% in the last decade, from 43 million in 2012 to 58 million in 2022. This growth is widespread, with urban, suburban, and rural communities across the country reporting increases in older residents, notes the report released on Nov. 30, 2023.

The report’s authors noted that over the same period, the share of households headed by older adults increased from 22 to 27% of all U.S. Households. The number of households headed by a person aged 80 and over will more than double between 2021 and 2040 to reach nearly 17 million households.  

Key takeaways of Harvard’s Housing Report

According to the report, “Housing America’s Older Adults 2023,” as the nation’s population of older adults swells, so, too, does demand for housing that is both affordable and able to accommodate older adults’ changing [health care] needs.   

Accessible housing is also in short supply, say the authors, noting that fewer than 4% of US homes offered the three key features of accessible housing—single-floor living, no-step entries, and wide hallways and doorways—at last measure.

As the US population ages, more older adults will struggle to afford either the home of their choice or the care they need, warns the report. “With subsidies for housing and LTC services scarce, many older adults will have to forgo needed care or rely on family and friends for assistance,” says Jennifer Molinsky, Project Director of the Housing on Aging Society Program at the Center. More funding would be a start, but there is tremendous need for creative alternatives to existing models of care and housing to better support the country’s rapidly aging population,” suggests the report. 

The report noted that seniors, whose incomes are often fixed or declining, increasingly face the “twin challenges” of finding affordable housing and the health care services they need to remain independent and at home. In 2021, an all-time high of nearly 11.2 million older adults were cost burdened, meaning they spent more than 30 percent of their income on housing. Cost burdens are particularly high for renters, homeowners with mortgages, and households aged 80 and over, the report emphasized.  

Costly long-term care (LTC) is out of reach for most seniors, the authors noting the cost of  LTC averaging over $100 per day, nationwide.  They say that most seniors who require these services, having very low incomes, have the fewest resources to pay for them. When LTC services are combined with housing costs, only 14% of single people 75 and over can afford a daily visit from a paid caregiver, and just 13% can afford to move to assisted living.    

The researchers say that government-funded rental assistance can provide crucial support to older adults with very low incomes, but demand dramatically outstrips supply. With homelessness on the rise among the older population, assistance is more important than ever, they add.  Even those with slightly higher incomes also struggle to qualify for government assistance; 29% of people living alone, aged 75+, have incomes above 50% of area median income, but cannot afford the cost of assisted living. Just 8% of this group could afford a daily visit from a home health aide, the report found.

Equity in housing as we age

The report also found that renters and homeowners of color face steeper burdens, too, in paying for housing.  While some older adults have home equity that can be tapped to pay for care or services, many do not. “This is not only because of the increasing number of older adults, but because of widening wealth and income inequality,” says Jennifer Molinsky, Project Director of the Housing an Aging Society Program at the Center, in a statement released on Nov. 30, 2023.  She served as the report’s lead author.

Older renters have only 2% of the net wealth of older homeowners and there are steep inequalities among owners as well; older Black homeowners have the lowest housing equity at $123,000, compared to $251,000 for older white homeowners, $200,000 for older Hispanic owners, and $270,000 for older owners who are Asian, multiracial, or another race, say the authors.

The report’s findings indicated that mortgage debt among older adults is rising, noting that between 1989 and 2022, the share of homeowners 65 to 79 with a mortgage increased from 24 to 41%, and the median mortgage debt shot up over 400%, from $21,000 in 1989 to $110,000.  Over 30% of homeowners age 80 and over are also carrying mortgages, up from just 3% three decades ago.

“Borrowing is often a way for older homeowners to access cash for basic needs or care,” says Chris Herbert, Managing Director of the Center. “Given the importance of housing equity later in life there is a real need for safe and affordable mortgage products that work for older owners with limited incomes,” says Herbert.

The report’s authors suggested that financing incentives could provide better opportunities for those who wish to remain in their communities, but in more suitable homes; this would be particularly welcome in rural and other low-density areas where the choices are especially limited.

Climate change impacts housing

Finally, the growing threat of climate change is impacting older homeowners. The report’s authors noted that some states long favored by older adults because of their warmer weather are increasingly experiencing extreme heat and harsh storms. In addition to health risks, property damage is a rising concern, particularly for the increasing number of older people without insurance. “Severe storms in Florida caused $228 billion in property damage from February 2020 through April 2023, a state that is home to 8.3% of the nation’s older population,” says the report.

Tackling the senior housing crisis in Rhode Island

“Accessibility and affordability of housing has reached a crisis level, impacting all age groups. This excellent report from the Joint Center for Housing Studies at Harvard University confirms that the impact on older Americans is particularly acute. That is why my focus on housing issues is at the top of my agenda, and why I am fighting so hard to pass legislation encouraging the development of accessory dwelling units (ADUs), the number one priority of AARP.  The Harvard study makes it very clear that the need for housing and housing-based care for older adults is growing at an alarming rate, and in Rhode Island, I am dedicated to increasing the availability of suitable housing opportunities for our older residents,” says House Speaker K. Joseph Shekarchi (D-Dist. 23, Warwick).

“The housing report provides comprehensive information on the significant challenges related to the housing needs of older adults. The challenges in Rhode Island are amplified by an old housing stock usually lacking accessibility features and our low rate of housing production,” says Maureen Maigret, policy advisor for the Senior Agenda Coalition of RI.

Maigret, a former Director of the former Department of Elderly Affairs, identifies one particularly relevant section of Harvard’s Housing Report that discusses dual problems faced by older adults with both housing and support needs and how few have the financial means to pay for both housing and even a small amount of home care. This is important for Rhode Island with its high costs for long term care and a growing older population.

The Senior Agenda Coalition of RI (SACRI) applauds House Speaker Shekarchi and so many members of the legislature, specifically for their intense efforts to address the state’s housing needs, says Maigret. “We support the Governor’s budget proposal for a $100 Million Affordable Housing Bond issue but recommend the amount be increased along with an increase in the suggested amount of funds for priority projects for vulnerable populations including economically struggling seniors from just $7.5 Million of the bond dollars,” she says.

SACRI also supports legislation to ease development of ADUs, proposals that include accessibility features in new housing production, continuing the state Home Modification grant program and increasing the income cap for the state Property Tax Relief program, a program that helps both older homeowners and renters) to $50,000,” she says. 

ADUs and the Ocean State

Last week, Senator Victoria Gu (D-Dist. 38, Westerly, Charlestown, South Kingstown) introduced S. 2630, that would allow homeowners to develop an accessory dwelling units (ADU) within the existing footprint of their structures by right, or build an attached or detached ADU if the lot is large enough. This is the companion bill to the one introduced in the House.

ADUs, sometimes referred to as in-law apartments, backyard cottages or “granny flats”, are accessories to existing housing, created as a conversion of part of a house (such as a walkout basement), an attachment to a house, a garage conversion, or a smaller, detached dwelling. They have become increasingly popular around the country in recent years as states and municipalities balance the need to create more housing with preserving the character of residential neighborhoods.

Seniors, especially, have taken to ADUs as a way to downsize while continuing to stay independent in the community. Now the Senate is poised to pass legislation to boost ADU development.

S. 2630 is similar to H 7062, sponsored by Rep. June S. Speakman (D-Dist. 68, Warren, Bristol) which passed the House on Feb. 14, but it differs primarily in how it allows municipalities to apply several code regulations.

If the Senate passes an ADU bill this year, lawmakers will have an opportunity to reconcile the two bills, either passing the house or senate version, or reconciling them somewhere in the middle, or making changes that aren’t in either. Lawmakers must now compromise, on behalf of their older constituents to hammer out legislation for Gov. Dan McKee to sign into law. This would be a first step in tackling the Senior housing crisis in Rhode Island.  It’s a no brainer – and passing it this year is critical to addressing the crisis in housing.

For a copy of Harvard’s Housing report, go to https://www.jchs.harvard.edu/housing-americas-older-adults-2023.