The COVID-19 pandemic is a public health crisis of proportions and complexity not seen in over a century. The highly contagious and dangerous virus has caused millions of deaths in the U.S. and worldwide. It created dual crises in health and economic security and continues to profoundly affect many aspects of Americans’ lives.
The COVID-19 Health Crisis
The COVID-19 pandemic disproportionately impacted older adults. Between March and October 2020, around 95 percent of COVID-19-related deaths in the U.S. were among those aged 50 and older. And about 80 percent of such deaths were of people age 65 or older. The pandemic has underscored the vulnerabilities, needs, and rights of older people. It also exposed the inability of the federal government and health systems to sufficiently protect them. There are a range of complex challenges that must be addressed.
Long-term care (LTC) settings: COVID-19-related mortality has been especially high among those living in the nation’s LTC facilities. Data show that 2.1 million Americans, or 0.62 percent of the U.S. population, reside in nursing homes and assisted living facilities. Nevertheless, those residents have accounted for nearly 40 percent of all U.S. deaths due to COVID-19.
LTC facilities have responsibility for any failures to ensure the health, safety, and quality of life of residents (see also Quality, Consumer Rights, and Emergency Preparedness in all Long-Term Services and Supports Settings and Immunity). These facilities require measures to minimize disease transmission through the use of personal protective equipment, physical distancing requirements, and regular testing of residents, staff, and visitors. Families need greater transparency about COVID-19 cases within the facility and about treatment and discharge decisions. And care facilities must be held accountable when residents are harmed, neglected, or abused.
Social isolation and loneliness contribute to worse health outcomes for older adults under normal circumstances (see also Social Isolation). The pandemic has exacerbated these challenges. During periods of required physical distancing and stay-at-home orders brought on by COVID-19, social isolation and loneliness became new or worsening problems among many older adults. It perhaps was worse for those living in nursing homes, which in many cases were completely closed to outsiders. Experts believe that extensive social isolation in locked-down nursing facilities has contributed to worsening dementia, overall declining health, and increased deaths. This has made planning how and when to reopen facilities to visitors particularly difficult. Facilities must balance different types of risk. They need to combat social isolation while maintaining the safety of the facility.
Some LTC facilities are attempting to combine best practices for infection control with the vigorous support of virtual visitation options like video visits and telehealth options (see also Long-term Services and Supports). This requires staff who know how to use and clean tablets and other tools and are trained to facilitate engagement between residents and would-be visitors. In the community, older adults who are isolating or keeping physical distance from others can also use virtual visits. However, they must have the knowledge, ability, tools, and infrastructure to do so.
Health care utilization: COVID-19 has had enormous impacts on the U.S. health system as a whole. Providers have had to focus on treating those with the virus and, increasingly, those experiencing long COVID. Further, some people have forgone medical care to avoid the risk of exposure to the virus. The resulting decrease in utilization and supply of health services has caused worsening health outcomes for those with chronic or other conditions. This means an overall weakening of the health system, lack of trust in the quality of services available, and increases in all causes of mortality, not just limited to COVID-19.
Telehealth services: Digital access to health care via telehealth became increasingly important and popular during the pandemic (see also Telehealth). High-speed internet access enables connection to telehealth services. It allows people to interact with their health care team safely from home, improving accessibility and potentially quality of care. It can also enable individuals to remain safely in the community (see also High-Speed Internet Services). As access to telehealth is expanded, it is important to collect data on its use, cost, and quality. It is also important to recognize and address that some people do not have the internet access necessary to engage in telehealth. Congress enacted legislation to improve the affordability of high-speed internet service during the pandemic. But some households, particularly those in rural areas, do not have the infrastructure necessary to get broadband service. Others may not have the required technology (e.g., a tablet, smartphone, or computer) or sufficient ability and comfort in using the technology. Even if they have the necessary technology, they may require assistance to use it.
Vaccine distribution challenges: The weakening of the overall health system also has impacted the access to and distribution of COVID-19 vaccines (see also Vaccine policy). The system faces many challenges in ensuring authorized COVID-19 vaccinations are distributed quickly and equitably. The federal government oversees vaccine allocation to the states and assists in the distribution. States are responsible for funding and organizing the distribution of vaccine doses to providers and creating public service messaging about the vaccine and how to obtain it. All parts of the process have faced challenges, slowing initial vaccine access.
Crisis standards of care: In 2020, the COVID-19 pandemic caused critical shortages of medical supplies and care. Under circumstances like these, doctors and hospitals are forced to decide who gets potentially lifesaving treatment and who does not.
The COVID-19 pandemic revealed the critical role and responsibility policymakers have to plan and implement strategies to do everything possible to avoid the emergence of shortages when there are severe outbreaks of highly contagious diseases such as COVID-19.
Some organizations, states, and federal agencies have developed resources and guides for hospitals and systems to address these challenges. Federal health agencies, including the Department of Veterans Affairs and Department of Health and Human Services, have also published guidance that includes approaches for allocating scarce resources during a pandemic.
These guidelines typically employ a utilitarian approach. They seek to maximize overall health by directing care toward those most likely to receive the greatest benefit from it. If a hospital had only one ventilator, for example, it would go to the patient more likely to survive. It would not go to whichever patient was first admitted, and it would not be assigned via a lottery system. The guidelines also often prioritize the health of front-line health care workers to maximize the number of lives saved.
Developing guidelines for these profoundly difficult decisions requires a thorough ethical, clinical, and legal analysis. The process should be transparent and include genuine public outreach, education, and engagement in order to establish public trust. It is equally critical that the guidelines build in protections for groups that often face discrimination. This includes older persons, persons with disabilities, those with lower incomes, the uninsured, and other groups that are discriminated against. There are already documented racial, ethnic, and socioeconomic disparities in care. Therefore, these protections are essential in ensuring no group is disproportionately harmed by these policies and guidelines. Transparency is essential in the logic, reasoning, and analysis behind the guidelines. Finally, the guidelines should be updated and revised in line with advances in clinical knowledge and changes in societal norms. Feedback from clinicians and the public is also essential.
The Office for Civil Rights at the Department of Health and Human Services, which enforces several antidiscrimination laws in health care facilities that receive federal funding, issued a bulletin emphasizing the need for protection against discrimination for certain groups. This included older adults and those with disabilities. Specifically, it said medical care should not be denied based on stereotypes, assessments of quality of life, or judgments about a person’s relative “worth” due to age or the presence or absence of disabilities.
The COVID-19 Economic Crisis
In addition to the profound loss of human life, COVID-19 has led to an economic disruption that continues to affect some parts of the U.S. economy.
Public health measures required to slow the spread of COVID-19 (physical distancing, stay-at-home orders, and the like) led to a surge in unemployment in April 2020. Since that time, job growth has been largely steady, and many industries have reached pre-pandemic employment levels. Recent increases in inflation reflect rising prices and have led to higher interest rates. This creates financial difficulty for many families and is likely to impede the ability to save money for emergencies, retirement, and other purposes (see also Employment).
Unemployment insurance and other benefits: Currently, only about one-third of people out of a job receive unemployment insurance. Benefit calculation formulas leave many with only a fraction of their previous earnings. At the beginning of the pandemic, Congress established enhanced unemployment benefits. These measures substantially increased the benefits for displaced workers. They also extended unemployment benefits to workers who previously did not qualify for unemployment. However, these programs have now ended. Paid sick leave, family leave, and flexible work arrangements have become more critical than ever (see also Job-Protected Leave). With the economic downturn, food insecurity has increased, especially among Black and Hispanic/Latino older adults (see also Food and Nutrition Assistance Programs). Widespread job loss is likely one of the largest reasons for this increase. Strengthening the nutrition safety net is critical to meeting the rising need.
Worker safety: The pandemic has also called attention to worker safety (see also Protections for Workers). Only about 45 percent of older workers have jobs that allow remote work. The rest face possible exposure to the virus in the work environment. Or they may deplete financial resources as they wait for the environment to get safer before returning to work. There are currently no solid guidelines or requirements for employers to provide access to personal protective equipment, implement sanitation strategies to prevent disease spread, facilitate physical distancing, or accommodate remote work where possible.
Housing: Housing stability during major emergencies or crises, such as pandemics or other public health emergencies, natural disasters, and severe economic downturns, is critical (see also Home Mortgage Lending). Many people, especially older adults, find themselves in need of financial assistance for housing costs. It is necessary to protect against eviction and foreclosure during and following the crisis. And once the crisis has ended, they will likely need a reasonable repayment period (see also Home Mortgage Lending and Housing in Declared Emergencies).
Student loans: Most federal student loan borrowers have not had to make loan payments during the pandemic. Congress and the U.S. Department of Education provided a repayment pause for borrowers of student loans owned by the federal government (see also Student Loans). Relief included automatically deferring payments, waiving interest accrual, and suspending collections. But borrowers who have privately held student loans have not enjoyed the same relief.
Credit scores: Throughout the pandemic, many people have been able to defer payments on mortgages and student loans without damaging their credit rating. As these deferments come to an end, people may face difficulty restarting payments and, thus, maintaining good credit scores. During the pandemic, negative credit reporting was suspended (see also Consumer Credit).
Price-gouging and product-hoarding: At the start of the COVID-19 pandemic, some sellers attempted to profit from the scarcity of essential services and products such as masks and hand sanitizer. This has happened in other declared emergencies, such as natural disasters (see Price-Gouging and Product-Hoarding).
Other Impacts of The COVID-19 Pandemic
Along with impacts on health and the larger economy, COVID-19 has also severely impacted the everyday rights and protections that older adults benefit from daily.
Civic rights and voting: The COVID-19 pandemic affected both the 2020 presidential election and the 2022 midterm election. Many states expanded the early and absentee voting programs (see also Voting). Voting access and safety issues during the COVID-19 pandemic were especially important for older adults, particularly from communities of color who were disproportionately affected by the virus. About 46 percent of voters used methods that did not require them to appear in person to cast their ballots for the 2020 general election. Many cited the COVID-19 pandemic as the reason.1 These elections highlighted the vital importance of helping all Americans exercise their right to vote, including during public health crises, natural disasters, and other emergencies.
Assistance during emergencies: Government challenges in responding to the COVID-19 pandemic also underscored the importance of disaster planning at every level of government. Disaster planning is critical when pandemics and other emergencies disproportionately affect certain populations, such as older adults and people with disabilities. It is important that plans address the needs of these populations and their caregivers. For example, older adults and others who have trouble navigating systems are often left behind in emergencies. Clear directions to the public about where to access services and assistance are critical during such times.
Travel: The safety and reliability of public transportation systems during public health crises are a concern (see also Community Transportation). Many people rely on public transportation to get to work. These can include essential workers, those who cannot work from home, or others who have no other means of transport. They need to feel safe traveling on public transportation at all times. For many older adults, travel is also an important way to encounter new experiences, visit with friends and family, and obtain necessary medical care or other services (see also Travel Protections). Additionally, many travel plans were canceled due to the pandemic. This highlights the need for consumer protections regarding refunds or vouchers for missed or canceled plans.
PUBLIC HEALTH and COVID-19: Policy
PUBLIC HEALTH and COVID-19: Policy
Crisis standards of care
Policymakers and health care administrators must conduct adequate emergency preparedness planning. It is crucial to avoid scarcity of medical equipment, supplies, and personnel that can result in care being rationed.
They should also develop guidelines for the allocation of scarce resources. The process should be transparent and include broad input and genuine public outreach, education, and engagement in order to establish public trust.
If policymakers design guidelines for the allocation of scarce health resources in times of emergency, the guidelines must be transparent.
Decisions concerning whether an individual is a candidate for treatment must not be based on age, race, disability, income, or other nonclinical factors but on an individualized clinical assessment of the patient and their circumstances using the best available objective medical evidence.
Coordinated emergency and crisis planning
Policymakers should collaborate to identify, develop, fund, and implement timely, effective response plans for national, state, and local public health crises. These plans should adequately protect the health and welfare of vulnerable populations such as older adults and people with disabilities during a public health crisis (see also Disasters and Extreme Weather).
Governments should develop strategies to meet the health care needs of people affected by declared emergencies. Such strategies should, at a minimum, finance health care for the uninsured for a reasonable period. They should ensure the availability and accessibility of needed services and equipment.
Policymakers should create and implement a national response plan for national public health emergencies. The plan should include acquiring and distributing necessary equipment and supplies. Federal and state governments should work cooperatively to address the emergency and avoid unnecessary competition for goods (see also Price-Gouging and Product-Hoarding).
Data collection in public health emergencies
Federal and state governments should ensure the collection and public reporting of comprehensive, accurate data during an epidemic or pandemic and other public health crises or natural disasters.
Federal and state governments should work together to establish uniform data collection requirements for assisted living facilities during epidemics or pandemics.
Data collection should include demographic information, including race, ethnicity, and other key factors.
Health care providers, businesses, schools, organizations, and individuals should be educated about behavioral risk factors for contracting and spreading serious communicable diseases. These include tuberculosis, hepatitis, HIV/AIDS, and COVID-19. Health providers should recognize the importance of taking sexual histories and discussing HIV/STD prevention with patients age 50 and older. Programs should teach all individuals who know or have reason to believe that they may be infected to protect others from infection. In addition, they should advise those they know to be at risk to seek testing. The outcome of such tests must be confidential, consistent with public health responsibilities, and subject to the requirements of confidentiality standards.
All levels of government should:
- direct sufficient financial and technological resources toward the timely development and manufacture of safe, effective, and affordable vaccines;
- during vaccine shortages, federal and state governments should develop transparent, nondiscriminatory, evidence-based guidelines for vaccine allocation that maximize overall public health and protect those at highest risk of harm;
- provide funding to ensure that key public- and private-sector health care personnel are adequately prepared to respond to public health crises relevant to their areas of practice;
- federal and state governments should adopt policies that ensure that vaccines have appropriate clinical evidence of safety and efficacy, are allocated equitably, and are widely available; and
- public officials and other stakeholders should employ targeted, evidence-based outreach strategies to build public trust and help individuals make informed decisions about FDA-approved vaccines.
During vaccine shortages, federal and state governments should not adopt policies that allocate vaccines solely based on age.