It’s annual enrollment season once again. Here’s a look at the pros and cons of the two approaches to health insurance.The sales pitches show up in your mailbox and inbox, in robocalls and texts. Ads target you on radio and television and social media. Touting Medicare Advantage plans, these campaigns promise low premiums and all kinds of extra benefits.And they work. The proportion of eligible Medicare beneficiaries enrolled in Medicare Advantage plans, funded with federal dollars but offered through private insurance companies, has hit 48 percent. By next year, a majority of beneficiaries will probably be Advantage plan enrollees.The annual enrollment period is once again underway. Beginning last month and until Dec. 7, beneficiaries can switch from traditional Medicare to Medicare Advantage or vice versa, or switch between Advantage plans. So it’s a good moment to look at the differences between these two approaches.“It’s a very consequential decision, and the most important thing is to be informed,” said Jeannie Fuglesten Biniek, senior policy analyst at the Kaiser Family Foundation and co-author of a recent literature review comparing Advantage and traditional Medicare.A key finding, Dr. Biniek said: “Both Medicare Advantage and traditional Medicare beneficiaries reported that they were satisfied with their care — a large majority in both groups.”Examining 62 published studies, the researchers found that Advantage plans performed better on a few measures. For instance, beneficiaries were more likely to use preventive services such as the annual wellness visit and flu and pneumonia vaccinations. Advantage beneficiaries were also more likely to say that they had a doctor, a “usual source of care.”Traditional Medicare beneficiaries, on the other hand, experienced fewer affordability problems if they had supplementary Medigap policies, but worse affordability problems if they didn’t. And they were more likely to use high-quality hospitals and nursing homes.None of these differences, however, have prompted widespread shopping or shifting between the programs in either direction. (Dozens of lawsuits accusing some Medicare Advantage insurers of fraudulently inflating their profits have apparently not made much difference to consumers, either.)A prime rationale for Advantage plans is that consumers can compare them to find the best individual coverage. But in 2020, only three in 10 Medicare beneficiaries compared their current plans with others, a Kaiser Family Foundation survey reported.Even fewer beneficiaries changed plans, which may reflect consumer satisfaction or the daunting task of trying to evaluate the pluses and minuses. This year, the average beneficiary can choose from 38 Advantage plans, the Commonwealth Fund reports.Yet Medicare Advantage and traditional Medicare, also known as original or fee-for-service Medicare, operate quite differently, and the health and financial consequences can be dramatic.Advantage plans offer simplicity. “It’s one-stop shopping,” Dr. Biniek said. “You get your drug plan included and you don’t need a separate supplemental policy,” the kind that traditional Medicare beneficiaries often buy.Medicare Advantage may appear cheaper because many plans charge low or no monthly premiums. Unlike traditional Medicare, Advantage plans also cap out-of-pocket expenses. Starting next year, beneficiaries will pay no more than $8,300 in in-network expenses, excluding drugs — or $12,450 with the kind of plan that also permits participants to use out-of-network providers at higher costs.Only about one-third of Advantage plans allow that choice, however. “Most plans operate like an H.M.O. — you can only go to contracted providers,” said David Lipschutz, associate director of the Center for Medicare Advocacy.Advantage enrollees may also be drawn in by benefits that traditional Medicare can’t offer. “Vision, dental and hearing are the most popular,” Mr. Lipschutz said, but plans may also include gym memberships or transportation.“We caution people to look at what the scope of the benefits actually are,” he added. “They can be limited or not available to everyone in the plan. Dental care might cover one cleaning and that’s it, or it may be broader.” Most Advantage enrollees who use these benefits still wind up paying most dental, vision or hearing costs out of pocket.As for traditional Medicare, “the big pro is that there are no networks,” Dr. Biniek said. “You can see any doctor that accepts Medicare, which is just about any doctor,” and use any hospital or clinic.Traditional Medicare beneficiaries also largely avoid the delays and frustrations of “prior authorization.” Advantage plans require this advance approval for many procedures, drugs or facilities.“Your doctor or the facility says that you need more care” — in a hospital or nursing home, say — “but the plan says, ‘No, five days, or a week, or two weeks, is fine,’” Mr. Lipschutz said. The patient must either forgo care or pay out of pocket.Advantage participants who are denied care can appeal; when they do, the plans reverse their denials 75 percent of the time, according to a 2018 report by the Department of Health and Human Services’ Office of Inspector General. But only about 1 percent of beneficiaries or providers file appeals, “which means there’s a lot of necessary care that enrollees are going without,” Mr. Lipschutz said.Another Office of Inspector General report this spring determined that 13 percent of services denied by Advantage plans met Medicare coverage rules and would have been approved under traditional Medicare.Although people can switch between Medicare Advantage plans fairly easily, switching from traditional Medicare to Advantage involves a major caveat.Because traditional Medicare sets no cap on out-of-pocket expenses, the 20 percent co-pay can add up quickly for hospitalizations or expensive tests and procedures. Most beneficiaries therefore rely on supplemental insurance, also called Medigap policies, to cover those costs; either they buy a policy or they have supplementary coverage through an employer or Medicaid.Beneficiaries who leave traditional Medicare for Medicare Advantage plans give up those Medigap policies. If they later grow dissatisfied and want to return to traditional Medicare, insurers may deny their Medigap applications or charge high prices based on factors like pre-existing conditions.“Many people think they can try out Medicare Advantage for a while, but it’s not a two-way street,” Mr. Lipschutz said. Except in four states that guarantee Medigap coverage at set prices — New York, Massachusetts, Connecticut and Maine — “it’s one type of insurance that can discriminate against you based on your health,” he said.David Meyers, a health services researcher at Brown University, and his colleagues have been tracking differences between original Medicare and Medicare Advantage for years, using data from millions of people.The team has found that Advantage beneficiaries are 10 percent less likely to enter the highest-quality hospitals, 4 to 8 percent less likely to be admitted to the highest-quality nursing homes and half as likely to use the highest-rated cancer centers for complex cancer surgeries, compared with similar patients in the same counties or ZIP codes.In general, patients with high needs — they were frail, were limited in their daily living activities or had chronic conditions — were more likely to switch to traditional Medicare than those without high needs.Why was that? “When you’re healthier, you may run into fewer of the limitations of networks and prior authorization,” Dr. Meyers hypothesized. “When you have more complex needs, you come up against those more frequently.”Trying to figure out which kind of Medicare, including a Part D drug plan, is actually to your advantage can be difficult even for knowledgeable consumers. Advantage plan networks change frequently; doctors and hospitals that are in-network this year may be out the next. Drug formularies change, too. A new Senate report documented deceptive marketing and advertising practices that added to the confusion, prompting Medicare to promise increased policing.The best allies, along with Medicare’s website and its toll-free 1-800-MEDICARE number, are the federally funded State Health Insurance Assistance Programs, whose trained volunteers can help people assess Medicare and drug plans.These state programs “are unbiased and don’t have a pecuniary interest in your decision making,” Mr. Lipschutz said. But their appointments tend to fill up fast at this time of year. Don’t delay.

Americans over 65 remain the demographic most likely to have received the original series of vaccinations. But fewer are getting the follow-up shots, surveys indicate.Linda Brantman, a retired membership salesperson at a health club in Chicago, was paying attention last month when the Centers for Disease Control and Prevention recommended the new bivalent booster that protects against two variants of Covid-19. She went online and reserved an appointment at a Walgreens near her home.Ms. Brantman, 65, who was already vaccinated and boosted twice, has grappled with asthma on and off for years; she keeps an inhaler handy, even for an ordinary cold. If she were sick with Covid, she said, “I would definitely have breathing problems.” Within two weeks of the C.D.C. announcement, she had received the latest booster — and public health officials hope all Americans over 5 will also roll up their sleeves again.But many older Americans have responded more like Alan Turner, 65, who lives in New Castle, Del. and recently retired from an industrial design firm. He received the initial two doses of the vaccine but stopped updating his immunity after the first recommended booster. “I’ve become such a hermit,” he said. “I have virtually no contact with people, so I haven’t gotten around to it. I don’t see any particular need. I’m biding my time.”Although Americans over 65 remain the demographic most likely to have received the original series of vaccinations, at 92 percent, their interest in keeping their vaccinations up-to-date is steadily declining, data from the C.D.C. shows. To date, about 71 percent have received the first recommended booster, but only about 44 percent have received the second.Younger people have also been less likely to receive boosters than the original vaccinations, and only about one-third of people of all ages have received any booster, The New York Times vaccine tracker indicates. But seniors, who constitute 16 percent of the population, are more vulnerable to the virus’s effects, accounting for three-quarters of the nation’s 1.1 million deaths.“From the beginning, older people have felt the virus was more of a threat to their safety and health and have been among the earliest adopters of the vaccine and the first round of boosters,” said Mollyann Brodie, the executive director of public opinion at Kaiser Family Foundation, which has been tracking vaccination rates and attitudes.Now Kaiser’s most recent vaccine monitor survey, published last month, has found that only 8 percent of seniors said they had received the updated bivalent booster, and 37 percent said they intended to “as soon as possible.” As a group, older adults were better informed than younger respondents, but almost 40 percent said they had heard little or nothing about the updated bivalent vaccine, and many were unsure whether the C.D.C. had recommended it for them.(Currently the C.D.C. recommends that individuals over age 5 receive the bivalent vaccine, which is effective against the original strain of Covid-19 and the Omicron variant, if two months have passed since their most recent vaccination or booster.)“The messaging on boosters has been very muddled,” said Anne N. Sosin, a public health researcher at the Rockefeller Center for Public Policy and the Social Sciences at Dartmouth College. Partly as a result, she added, “older people are entering the winter with less protection than at earlier points in the pandemic.”Ms. Sosin and other experts noted that older Americans have several reasons to be on guard. Their immunity from previous vaccinations and boosters may have waned; mitigation policies like mandatory masking and vaccination have largely disappeared; and public testing and vaccination sites have shut down.Read More on the Coronavirus PandemicUpdated Boosters for Kids: The Food and Drug Administration broadened access to updated Covid booster shots to include children as young as 5.Long Covid: A study of tens of thousands of people in Scotland found that one in 20 who had been sick with Covid reported not recovering at all, and another four in 10 said they had not fully recovered many months later.A Persistent Variant: Ten months have passed since Omicron’s debut. Since then it has displayed a remarkable capacity to evolve new tricks.‘Anti-Vax’ Capital No More: Vaccine skeptics once found a home in Marin County, Calif. Now, the pandemic has made them unwelcome, as Covid vaccine rates soar there.Early on, Ms. Sosin said, many older adults changed their behavior by staying at home or masking and testing when they went out. Now they face greater exposure because “they’ve resumed their prepandemic activities.”“Many are no longer concerned about Covid,” she said.Public opinion polls bear that out. Older adults may also reason that improved treatments for Covid infections make the virus less dangerous.Eileen Nagle, 81, receiving the new bivalent Omicron booster shot at the Hebrew Home at Riverdale nursing home, in Riverdale, N.Y., in September.Andrew Seng for The New York TimesYet deaths in this age group doubled from April to July, exceeding 11,000 in both July and August, largely because of the increased transmissibility of the Omicron variant. Deaths began dipping again last month.For older people, the danger of Covid is “reduced, but it’s not gone,” said William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center. “You can’t forget it. You can’t put it in the rearview mirror.”Two factors make older people more vulnerable to the virus. “Their immune systems become weaker with advancing age,” Dr. Schaffner said. “And they accumulate underlying conditions,” including heart and lung disease, smoking histories, diabetes and obesity, that increase their risks.“Should you become infected, you’re at risk for a more serious outcome,” he said. “All the more reason to protect yourself as best you can.”Studies have shown that vaccination and boosters protect against serious illness, hospitalization and death, although that immunity ebbs over time. “The data are rock-solid,” Dr. Schaffner said.The Department of Health and Human Services estimated this month that among seniors and other Medicare beneficiaries, vaccination and boosters resulted in 650,000 fewer hospitalizations for Covid and had saved 300,000 lives in 2021.But even in nursing homes, where the early months of the pandemic had a devastating toll, the booster uptake “has been very stagnant,” said Priya Chidambaram, a senior policy analyst at Kaiser Family Foundation and co-author of a survey published this month.As of September, an average of 74 percent of nursing home residents had received one or more boosters, but that figure ranged from 59 percent in Arizona to 92 percent in Vermont. Rates were far lower among nursing home staff; nationally, only about half had received a booster, and in Missouri, Alabama and Mississippi, only one-third had.A federal mandate requiring nursing home staff members to be vaccinated remains in place, but it does not include boosters. A federal on-site vaccination campaign for residents that relied on CVS and Walgreens bringing vaccines to nursing homes was effective but has not been repeated for boosters.“That push sort of died down,” Ms. Chidambaram said. “The federal government took its foot off the pedal.”Some older adults who do not live in nursing homes may be homebound or have difficulty traveling to pharmacies. But their sense of urgency also appears to have diminished. “Most older people were vaccinated,” Ms. Sosin said. “They weren’t hesitant or opposed.” But when it comes to boosters, she said, “they’re not very motivated and they haven’t been given a reason to be. There’s more a sense of, ‘Why bother?’”A number of public health experts are now urging a full-scale crusade — including mass-media campaigns; social media and digital communication; pop-up and drive-through sites; mobile vans; and home visits — to raise the vaccination rate among seniors, and everyone else, before a possible winter surge of the virus.“We have never seen an all-hands-on-deck approach to booster delivery,” Ms. Sosin said. “We should be flooding people with information, to the point where it gets irritating.”The Biden administration’s fall Covid plan, announced early last month, has incorporated many of these ideas. But Dr. Schaffner argued that it did not spell out details or take a sufficiently aggressive approach for nursing homes.Ms. Sosin was similarly skeptical. “I’m not seeing the elements in the plan materialize,” she said. “They’re not reflected in the numbers we’re seeing,” she said in reference to the number of people getting boosters.Individuals can play a role in this effort. Kaiser surveys have found that doctors and other health care professionals are trusted sources of information, and the older population is in frequent contact with them.“If more providers recognized that four in 10 older adults don’t realize there’s a new booster and they should get it, that’s a lot of opportunity to make an impact,” Dr. Brodie said.Family members, friends, co-workers and neighbors also influence health decisions and behavior, and Kaiser studies show that they can help increase vaccination rates.For those on the fence, Dr. Brodie said, “asking or reminding your parent or grandparent about the new booster can make quite a difference.”

Over-the-counter hearing aids are coming at long last. But lower prices and greater accessibility may take time to materialize.The world of hearing health will change on Oct. 17, when the Food and Drug Administration’s new regulations, announced in August, will make quality hearing aids an over-the-counter product.It just won’t transform as quickly or as dramatically, at least at first, as advocates, technology and consumer electronics companies and people with mild to moderate hearing loss have been hoping.“It finally, actually happened after all these years,” said Dr. Frank Lin, the director of the Johns Hopkins Cochlear Center for Hearing and Public Health and a longtime supporter of the regulations, which Congress authorized five years ago.“Ninety-plus percent of adults with hearing loss have needs that can be served by over-the-counter hearing aids,” he said. For decades, the sale of hearing aids was restricted to licensed audiologists and other professionals; that has kept prices high — prescription hearing aids can cost $4,000 to $5,000 — and access limited. In contrast, the regulations provide “a clear glide path for new companies to enter this field,” Dr. Lin said.But, he quickly added, “it may be the Wild West for the next few years.”Barbara Kelley, the executive director of the Hearing Loss Association of America, concurred: “It’s a new frontier, and it is confusing. We need time to see how the market settles out.”In an ideal scenario, a person would be able to walk into almost any pharmacy or big-box store and buy a sophisticated pair of hearing aids for a few hundred dollars, no prescription required. But the shift won’t materialize right away, experts say.In 2017, Congress granted the F.D.A. three years to develop standards for safe and effective over-the-counter hearing aids. The agency took five years instead, and the long delay and continued industry opposition made manufacturers skittish about investing, Dr. Lin said.Pandemic-related shortages and supply chain snafus have not helped.So far, manufacturers and retailers have said little about new products, prices and distribution. But some details have emerged.Best Buy, for instance, will open hearing centers in more than 300 stores by late October. Customers will be able to use an online hearing assessment tool and choose from nine over-the-counter brands with help from sales staff members, who will undergo specialized training. Prices will range from $200 to $3,000, the company said.Sony has announced a partnership with WS Audiology Denmark, one of the big five hearing aid manufacturers, but has not revealed specifics. Bose Corporation and Lexie Hearing will introduce a new self-fitted over-the-counter aid for about $900, well below traditional prices but “still a price point people will think twice about,” Ms. Kelley said.Prices are likely to fall over time, “like everything else in consumer electronics,” especially as competition increases, Dr. Lin said. For now, many of the available over-the-counter products have already been offered online, but companies are likely to unveil new devices in January at the Consumer Electronics Show in Las Vegas.The potential market is enormous. Self-perceived mild to moderate hearing loss, the condition that these devices are designed to address, affects about one-quarter of people in their 60s, half of those in their 70s and three-quarters of those over 80.People with mild to moderate hearing loss may experience problems understanding conversations when they are in groups, when there is background noise and when they are on the phone; they may have to ask others to speak louder or repeat themselves, and turn up the television volume.Untreated hearing loss can increase the risks of social isolation and depression and contribute to falls. The Lancet Commission on Dementia Prevention, Intervention and Care identified it as the single greatest potentially modifiable risk factor for dementia.Yet, a 2018 study of Americans over 70 found that although hearing aid use had increased over several years, only 18.5 percent owned and used them, with still lower rates among low-income and Black respondents.Price has been a major obstacle, although not the only one. Traditional Medicare does not cover hearing aids; Medicare Advantage plans usually include some hearing coverage, yet beneficiaries still wind up paying 79 percent of their costs out of pocket.Expanding traditional Medicare to include hearing, vision and dental benefits was part of the Biden administration’s Build Back Better Act, which was passed by the House of Representatives last year but scuttled in the Senate.So the eventual advent of an array of lower-cost hearing aids, available without gatekeepers, presents opportunities for millions of people. Some devices will require smartphones and Bluetooth technology to customize their functions; others will be simpler, with preset amplification options. Most will be rechargeable, largely eliminating the need to fumble with tiny batteries.“I’m very enthusiastic about this,” said Jan Blustein, a health policy professor at New York University and an author of a recent overview in The Journal of the American Geriatrics Society. “The barriers in the current system are too great. People need access to devices.”But in these early months, she and other advocates warned, consumers should maintain realistic expectations and proceed with caution. Contrary to the widely used analogy, acquiring hearing aids is not like buying eyeglasses.Most aging eyes have not suffered any damage; they simply no longer bend light as effectively. Corrective lenses solve the problem and, with the correct prescription, often provide near-perfect vision. But with hearing in older adults, “there’s been damage to the inner ear with age and noise exposure,” Dr. Lin said. “The cells that send sounds to the brain die off and can’t regenerate.”With the appropriate aids, “your hearing will improve,” Dr. Blustein said. “But don’t expect you’ll go back to the way it was before you developed hearing problems.”Moreover, finding the right device and adjusting it to the correct “acoustic fit” — boosting whichever frequencies a user needs amplified — may take several tries. “It’s not climbing Mount Everest, but it’s complicated,” said Dr. Blustein, who uses hearing aids. “You really have to persevere.”That makes return policies important. The F.D.A. disappointed consumer advocates by not mandating them, leaving it to states, manufacturers and retailers to set their own. But the agency did require that return policies be clearly specified on the package. Since a user’s brain can take several weeks to adapt to amplified sound, consumers should look for at least a 30-day return policy.It remains to be seen how audiologists will adapt. For many, hearing-aid sales have been their primary source of income. How readily will they alter their practices to mainly provide testing, education, counseling and support, while customers purchase devices over the counter?Some users will feel comfortable self-fitting their new aids using online tools, but others will want guidance on choosing, fitting and learning to live with their devices. They may need help as problems arise, such as ear wax blockage and device repair. And since hearing aids have a three- to five-year life span, Dr. Lin said, users will eventually need to go through the process again, perhaps several times.Some companies selling directly to consumers, like Eargo, provide extensive support services remotely, but will that satisfy most older buyers? Dr. Lin said he hoped that “a lot of audiologists will see patients, spend time testing and counseling and educating them, and not have to sell them a $4,000 device.”To help consumers navigate the new terrain, the Hearing Loss Association of America has published a tip sheet. Wirecutter has published a useful guide to over-the-counter hearing aids and updates it frequently. (Wirecutter is a product recommendation service owned by The New York Times Company.) Hearing Tracker, a website published by the audiologist Abram Bailey, will assess over-the-counter devices as well.Last month, the Johns Hopkins Bloomberg School of Public Health created HearingNumber.org to help people determine their level of hearing loss and learn about treatment options. For now, its assessment tool requires an Apple smartphone or tablet.But as with almost everything else involved with this expected transformation, that will change in the next few months, Dr. Lin said. Give it a little time.

In the blizzard of paperwork needed to get into a nursing home or assisted living, some residents unwittingly surrender the right to a day in court.What the Jinks family wanted was to sue the memory care facility where their father, Charles, was attacked by another resident.It happened in October 2020, after Hurricane Laura forced his hasty evacuation from a similar facility in Louisiana. His three children moved him, at 80 years old and diagnosed with dementia, into Brookdale Dowlen Oaks in Beaumont, Texas. They installed a Ring camera in his room so they could keep an eye on him.That camera showed another resident entering his room while he slept one night and battering Mr. Jinks with the heavy lid of a toilet tank, sending him to an emergency room with fractured facial bones and lacerations. It took 11 staples to close the biggest wound.After Mr. Jinks recuperated and the family recovered from its shock, they consulted a lawyer. “We wanted Brookdale to be accountable for this,” said his daughter Charlene Jinks Young, 61. “I wanted 12 people” — a jury — “to hear this story.”But before a court could hear their lawsuit accusing the company of gross negligence, the family had to get past an arbitration clause in Brookdale’s residency agreement. Ms. Young, using her father’s power of attorney, had signed it the day the family moved him in.It stipulated that in the event of disputes, residents must submit to binding arbitration. A lawyer, not a judge or jury, would rule on their claims, with the parties required to split the proceeding’s costs.Arbitration clauses appear frequently, often little noticed, in contracts with businesses of many kinds: banks and financial firms, cellular companies, online marketers. The clauses are also “widespread in long-term care facilities, in nursing homes, assisted living, board and care homes,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care.Brookdale Senior Living — the nation’s largest long-term care company, with 674 facilities in 41 states — would not comment on the Jinks case but said in email that arbitration “allows parties to resolve a dispute in a more expeditious and cost-efficient manner than litigating in court.”But advocates for residents, families and consumers have opposed mandatory arbitration for decades. Sometimes, parties trying to settle a dispute both agree to seek arbitration, but compulsory arbitration “binds the resident upfront,” Ms. Smetanka said. “Essentially, you’re saying, ‘No matter what happens, I waive my right to a court decision.’”Eric Carlson, directing attorney of the legal advocacy group Justice in Aging, said, “Arbitrators in general are less sympathetic to residents than a jury might be. The nursing home is probably doing business with these arbitrators over and over. They have an incentive to favor the nursing home.”A Stanford Business School study of arbitration in the securities industry, for instance, found that companies — which use arbitration far more often than individuals — learned which arbitrators would favor their positions and kept selecting them. (Some agreements specify an arbitration firm; others allow each party to veto a certain number of arbitrators from a common list.)Binding arbitration also avoids the public attention a lawsuit and trial could bring; some agreements require strict confidentiality. The Brookdale agreement Ms. Young signed, for example, said the parties agreed not to discuss any settlement, the parties’ names or the facility’s name and location.“It’s a private system with a gag rule, in effect,” Mr. Carlson said. “It’s in society’s interest that these cases not be secret. It’s important public knowledge if something horrific happens in an assisted living facility.”When residents or their representatives sign these agreements, which are part of admission packets that can include dozens of pages, they may not realize they’ve waived their court rights or understand what arbitration entails.From left, Clayton Jinks, Mr. Jinks’s son; Mr. Jinks; and Trudy Jinks-Young and Charlene Jinks-Young, Mr. Jinks’s daughters.Emily Kask for The New York TimesResidents and their families are dealing with paperwork at what is often a stressful time, after a hospitalization or health crisis, with limited opportunity to scrutinize documents or consult a lawyer.When Ms. Young signed her father’s agreement, her sister and brother-in-law were moving their father into his room. “It was very rushed,” she said. “I probably wasn’t in that office for 15 minutes.”Nobody explained the 13-page residency agreement in detail, she said. Cody Dishon, the lawyer whom the Jinks family later retained, had to explain that her signature could preclude a court date.“I can’t imagine any other constitutional right you can sign over without even knowing it’s happening,” Mr. Dishon said in an interview. “But courts are allowing consumers, without attorneys, to do this.”Since 2019, Medicare regulations have prevented nursing homes from requiring arbitration for admission or residence. Yet “they’re still being included in admissions packets, and family members or residents are still being told, ‘Sign the papers,’” Ms. Smetanka said.If they do sign, residents have 30 days in which to rescind their agreement to arbitration.But assisted living, including memory care, is not federally regulated, so those rules don’t apply.In July, when Mr. Dishon filed a gross negligence suit against Brookdale on behalf of the Jinks family, the company responded with a motion to compel arbitration.Mr. Dishon filed an objection, arguing that the arbitration provision was “unconscionable” and estimating that Mr. Jinks’s half of the expenses could reach $20,000 to $50,000.A district court judge, unpersuaded, ruled last month that the arbitration should proceed.He allowed a separate suit to go forward, however, based on Brookdale’s “involuntary transfer” of Mr. Jinks, whom the facility discharged shortly after the attack, claiming his behavior was problematic.His three children, who aren’t bound by the arbitration agreement, are also suing for “loss of consortium” — deprivation of the family relationship because of their father’s injuries.In challenging arbitration agreements, “sometimes residents win, and sometimes they lose,” said Mr. Carlson, who annually reviews such litigation. “It depends on the facts, and it depends on the court.”In 2016, a federal court in Kentucky ordered arbitration after a resident died in a nursing home and his wife sued for negligence and wrongful death.But in 2020, a California court refused to compel arbitration when a daughter sued a residential care facility for elder abuse and wrongful death after her father’s death. An appeals court affirmed the decision.Both the National Consumer Voice and Justice in Aging urge residents and their representatives to simply strike out arbitration clauses when signing the initial paperwork.In nursing homes, arbitration clauses are not required. Assisted living companies may require them but may not be willing to push the matter, Mr. Carlson said, especially if there are multiple competitors nearby.“You’re not negotiating with the general counsel,” he said. “You’re just talking with an administrative clerk doing his or her job, who needs your business. It’s a problem if you walk away.”In fact, asked if a resident could strike an arbitration clause, Brookdale responded in an email that “whether an individual strikes an arbitration clause is not a deciding factor in determining whether Brookdale can meet that individual’s needs.”The American Health Care Association and National Center for Assisted Living, an industry group, said that disputes requiring formal resolution arise for fewer than 1 percent of residents.“We support the right of residents and families to pursue legal remedies for poor and inadequate care, but we should not promote a system that attempts to bankrupt a critical aspect of our health care system,” the group said in an emailed statement.Mr. Dishon hopes public pressure will lead Congress to ban arbitration requirements for long-term care, as it did earlier this year in sexual harassment cases. “I believe the public has a right to know what happened to Mr. Jinks,” he said.Mr. Jinks now lives in a memory care center in Lake Charles, La. His children, who visit several times a week, are pleased with his care. But, Ms. Young said, “We still have a camera in his room.”

At first, Dana Guthrie thought she could help care for her parents, whose health had begun to decline, and still hold onto her job administering a busy dental practice in Plant City, Fla.“It was a great-paying job and I didn’t want to lose it,” Ms. Guthrie, 59, recalled recently. So she tried shifting to a four-day schedule, working evenings to keep up with the office demands, and she began spending a few nights a week at her parents’ home instead of her own nearby.Ultimately, though, her mother’s liver disease progressed and her father was diagnosed with dementia. The family learned that the cost of hiring home aides for two ailing 82-year-olds exceeded even a middle-class retirement income and savings. “They really needed me,” Ms. Guthrie said. In 2016, she left her job “and moved in full time.”An estimated 22 to 26 million American adults currently provide care for family members or friends, most of them older people, who need help with daily activities; more than half of those caregivers have jobs. “There’s no doubt that juggling the two can be very difficult,” said Douglas Wolf, a demographer and gerontologist at Syracuse University.Caregivers who are employed often reduce their work hours or leave the workplace altogether, research has shown. Several recent studies, however, reveal the impact of these decisions in more detail, not only on working caregivers but on employers and the general economy.Yulya Truskinovsky, an economist at Wayne State University, and her co-authors combined data from a Census Bureau survey with Social Security records to follow unusually long employment trajectories for nearly 13,000 people.Among those who became caregivers, employment dropped almost 8 percent compared to demographically similar non-caregivers, the authors found. “It happens right away, in the first year,” Dr. Truskinovsky said. “We see little evidence that they either reduce hours or switch to self-employment. They leave the labor force and remain out of it for quite a long time.”She added, “Younger caregivers are just as likely to leave the labor force as older ones.” Seven years later, the study found, those caregivers had not returned to the level of labor participation of demographically matched non-caregivers.Moreover, there were significant gender differences among those exiting the work force.Men started to reduce their workloads well before they became caregivers; then, “they leave the labor force and they don’t come back,” Dr. Truskinovsky said. The study could not provide an explanation; perhaps men take on caregiving when their work lives are already winding down.In contrast, women caregivers leave the work force more abruptly and are more likely to return — after just two years, on average — “but at lower wages or fewer hours,” Dr. Truskinovsky said.The pandemic amplified the conflict between employment and caregiving, Dr. Truskinovsky and colleagues found in another study. “Caregiving arrangements are very fragile,” she noted. While families often patch together paid and unpaid care, “it’s unstable, and if one thing falls through, your whole arrangement falls apart.”In a national sample of adults over 55, half the family caregivers reported that Covid-19 had disrupted their care schedules, forcing them to provide more care (because paid help became unavailable) or less (because of quarantines and fear of transmission). Before the pandemic, more than one-third had been employed.Caregivers facing disrupted arrangements were more likely to be furloughed or lose their jobs; they also showed far higher rates of depression, anxiety and loneliness than either non-caregivers or caregivers who did not experience disruptions.After Ms. Guthrie’s parents died, she relocated to Radcliff, Ky., where her sister lives. She is currently unemployed, and though she has been interviewing for jobs, she wonders whether she will ever be able to retire.Natosha Via for The New York TimesThe toll on working caregivers takes many forms. Susan Larson, 59, an education services specialist for the U.S. Army, has forgone promotions, even when her superiors urged her to apply. “I’m not geographically mobile,” she said.She cannot leave her home in St. Paul, Minn., where she and her husband built a handicapped-accessible addition for her mother, 83, who needs extensive assistance. The Army has been very supportive, Ms. Larson said. But she estimated that her salary would be nearly 25 percent higher if she had accepted promotions, in turn bolstering both her eventual pension and Social Security benefits.Shawn French, 51, a video game writer in Limerick, Me., and his wife welcomed her widowed father into their home three years ago. Because Mr. French works remotely, he can help his father-in-law with meals, medications and mobility; his wife handles doctors visits and other tasks.“I wouldn’t have it any other way,” Mr. French said. But the stress led him to relinquish weekend freelancing that had generated $200 to $300 a week. “We relied on it anytime things were a little tight,” he said. His wife reconfigured her work arrangement, too, which led to him being dropped from her health plan and becoming uninsured.Even when caregivers keep their jobs, another recent study indicates, almost one-quarter report either missed work (absenteeism) or reduced productivity (known as presenteeism).Presenteeism accounts for the most productivity loss, said senior author Jennifer Wolff, a gerontologist and health services researcher at Johns Hopkins University. “Absenteeism is visible, presenteeism is less so,” she said. “You show up, but you’re making doctor calls or managing insurance.”Among affected employees, work productivity dropped by one-third, on average. Based on 2015 data, the most recent available on adults 65 and older, that translates to a $49 billion loss annually.Paid family leave, although better configured for the more predictable needs of new parents, might help workers providing care for the elderly as well. When California adopted paid leave, which took effect in 2004, residency rates at nursing homes declined by about 11 percent, Dr. Wolf of Syracuse and his co-author Kanika Arora found.Although the study could not establish the reason, Dr. Wolf speculated that “the change in the law induced people to stay on the job, but they took enough time off to keep their parents out of a nursing home.” The authors’ more recent work shows that paid sick leave also helps increase family caregiving.President Biden campaigned on an ambitious caregiving plan that would have provided 12 weeks of paid family leave annually, plus tax credits to offset caregiving expenses and Social Security credits for time family caregivers spend out of the labor force. Republican opposition in the Senate has prevented its passage.Debate on how best to support family caregivers will continue, but there is little debate about their need for help. Although many workers can handle the more predictable needs of aging parents and spouses, some face intense pressures incompatible with contemporary workplaces.After Ms. Guthrie’s parents died, she relocated to Radcliff, Ky., where her sister lives. She found positions at dental practices there but has never matched the compatibility or the salary of the job she left in Florida.Currently unemployed, Ms. Guthrie has been interviewing for jobs and wondering whether she will ever be able to retire, although she doesn’t regret the sacrifices she made to care for her parents.“We were a close-knit family and I would do it again,” she said. “But I took a beating, emotionally and financially, and I haven’t really been able to recover.”

Rituals like graduations and weddings are few and far between for older adults. Some are finding ways to honor their momentous occasions.Harry Oxman’s bar mitzvah at the Society Hill Synagogue in Philadelphia looked much like the traditional Saturday morning event.He recited the customary prayers before and after the Torah reading. He discussed the meaning of the day’s Torah portion. He carried the sacred scrolls in a procession around the sanctuary. The rabbi offered a blessing; the congregation yelled a congratulatory “Mazel tov!” and tossed pieces of candy to symbolize the sweetness of the days ahead. Lunch followed, with toasts from family members.The difference was that the celebration, a tradition that normally marks Jewish adulthood for 13-year-olds, occurred in 2019, when Mr. Oxman was 83. Because the 90th Psalm says that age 70 represents a full life span, some congregations offer this rite of passage — often for the second time — to those turning 83.“It comes at a different transitional moment in life,” Rabbi Nathan Kamesar, who proposed the ritual to Mr. Oxman, said. “It’s the reflective moment, the opportunity to look back at the life you’ve led, and perhaps ahead to what the next chapter might be.”Younger people have many rituals that mark important passages — graduations, weddings, ceremonies for newborns, even milestones like acquiring drivers’ licenses or casting first votes — while older adults have few. Though birthday and anniversary parties may be great fun, they do not usually involve the same kind of life-cycle changes or the contemplation that rituals can bring later in life.That’s partly because ceremonies observed since antiquity don’t acknowledge the longevity of modern life, Jeanette Leardi, a social gerontologist and community educator in Portland, Ore., said. Americans born in 1900 didn’t expect to see age 50; why would they have planned rituals for later in life?But the lack of opportunities to celebrate, Ms. Leardi said, also reflects the ageist assumption that older adults have nothing much to look forward to, that they are incapable of change. Yet transitions lie at the heart of such rites of passage, she added: “As a culture, we don’t have an appreciation that this person has lived for decades and is ready to move into a new role, and that we should honor that.”Mr. Oxman is now 86 and still a practicing lawyer. Raised by secular Jewish parents, he did not have a bar mitzvah as a teen. Decades later, “it was important to me to have done it,” he said. Although he had served as president of the congregation, he said, the ceremony and the weeks of preparation were “extremely meaningful” and marked “the first time I felt like I really belonged.”Here and there, older adults are inventing or reinventing other rites of passage at important junctures in their lives.Katherine Spinner, a child care provider, spent many weekends commuting from her home in Seattle to classes at Evergreen State College in Olympia, Wash. Decades earlier, bouts of depression had interrupted her education. But later in life, she said, “I was not horribly depressed, and after a lot of work, I’d finished my degree.”In 2018, at age 60, she marked her graduation at the University Friends Meeting in Seattle, where she had long been a member. She organized a special meeting for worship in the unprogrammed Quaker tradition, where some participants were moved to speak.The gathering included a potluck dinner, an exhibit of her ceramic sculptures and lots of singing. “I felt I was offering something and also receiving appreciation from my community,” Ms. Spinner said.Mr. Oxman’s tallit. While most older adults will have, of course, the late-life ritual of a funeral or memorial, they do not hear the hymns or poems, remembrances or eulogies.Michelle Gustafson for The New York TimesAt Congregation Beth Elohim in Brooklyn, Senior Rabbi Rachel Timoner plans to add blessings for congregants entering retirement or becoming grandparents to sabbath services. She also intends to offer a ritual developed in the 1980s for older women called simchat chochmah, a celebration of aging and wisdom.“The second half of life includes so many moments that are worthy of attention and communal celebration,” Rabbi Timoner said.Other late-in-life rites take secular forms as well. Some proponents have devised rituals for common but fraught experiences such as handing over car keys and relinquishing driving, or leaving the family home for a senior living facility.Nancy Rhine, a gerontologist and marriage and family therapist in Mill Valley, Calif., has helped about 40 older adults prepare for and process late-life rituals involving hours of retrospection and introspection, art and music. “They’re looking at legacy, life review, taking stock,” she said. “It’s that searching, a contemplative practice.” Her oldest such client was 81.This spring, Kris Govaars was turning 70 and still mourning his wife, Vicki Govaars, who had died in 2019, just weeks after being diagnosed with pancreatic cancer. “I was a boat without a tether,” Mr. Govaars, a former architectural consultant in the Bay Area, said. “I was struggling, trying to figure out my next steps.”He came across the Center for Conscious Eldering, founded by Ron Pevny, author of “Conscious Living, Conscious Aging,” and decided to join its weeklong retreat at Ghost Ranch in Abiquiu, N.M. His group of 14, which included people in their 50s to their 80s, spent several days engaging in spiritual practices, exercises and discussions.For his culminating ritual, called a “solo journey,” Mr. Govaars selected a private spot on a riverbank. After passing through a portal formed by two trees (and having a close encounter with a bobcat), he fasted, maintained silence, read poetry, journaled and wrote “legacy letters” for his two children. “I just spent a lot of time in thinking and meditation,” he said, deeply moved by the experience.“The outcome is hopefully a greater sense of happiness and purpose,” he explained. “I feel calmer. I feel much more introspective. I listen with an open heart and mind. I may look the same, but I am different.”In addition to helping people see old age as a phase of life with purpose and rewards, along with the more commonly recognized challenges and deficits, rituals for older adults may affect others, Ms. Leardi pointed out.“They benefit the community,” she said. “You might have little kids there — young people, other elders — watching you go through this, hopefully aspiring to this. You cross the threshold and walk into your future.”Most older adults, of course, will have the late-life ritual of a funeral or memorial, a remembrance some may plan themselves. That, too, involves contemplation of their lives, their contributions and accomplishments. But while some older adults plan their own memorials, they do not hear the hymns or poems, remembrances or eulogies.But Mr. Oxman, however, did see his family and friends celebrate him and his role in his synagogue, his community and the world. He heard his rabbi bestow a blessing and tell the gathering that Mr. Oxman had spent his days wisely.“Your presence is felt,” Rabbi Kamesar said. “Your legacy is accounted for. You matter, in a significant way, and in some ways, that’s all we’re here to do in this world.”

Studies found that centers provided incomplete or unbalanced information, which could lead to unnecessary screenings and health complications in older adults.Say a postcard arrives in the mail, a reminder to make an appointment for a mammogram. Or a primary care doctor orders a PSA test to screen a man for prostate cancer, or tells him that because of his years of smoking, he should be screened for lung cancer.These patients, trying to be informed customers, may look online for a cancer center to learn more about screening, when it is recommended and for whom.It might not be the best move. Medical societies and the independent U.S. Preventive Services Task Force publish guidelines about who should be screened for lung, prostate and breast cancers and how frequently, among many other prevention recommendations. But websites for cancer centers often diverge from those recommendations, according to three studies published recently in JAMA Internal Medicine.Researchers found that some sites discussed the benefits of screening but said little about the harms and risks. Some offered recommendations about the age at which to start screening but glossed over when to stop — an important piece of information for older adults.“If we acknowledge that these websites are important sources of information, based on screening according to the guidelines we have room for improvement,” said Dr. Behfar Ehdaie, a urologist at Memorial Sloan Kettering Cancer Center in New York and an author of the study on prostate cancer screening recommendations.Screening refers to tests for patients with no symptoms or evidence of disease, including prostate-specific antigen tests, mammograms, colonoscopies and CT scans.The researchers analyzed more than 600 cancer center websites that provided recommendations for prostate screening, and found that more than one-quarter recommended that all men be screened. More than three-quarters did not specify an age at which to stop routine testing.Yet guidelines from both the Preventive Services Task Force and the American Urological Association state that men over 70 should not be routinely screened, because, according to the Task Force guidelines, “the potential benefits do not outweigh the expected harms.”For men aged 55 to 69, both groups urge individual decisions after a discussion with a clinician about benefits and harms. Neither group, though, recommends routine screening for younger men at average risk.Moreover, the study reported, 62 percent of cancer center websites did not include information on the potential harms of screening. Because prostate cancer grows slowly, it often causes no problems. But detection and treatment can lead to complications from surgery or radiation, including lower quality of life from incontinence and sexual dysfunction.New Developments in Cancer ResearchCard 1 of 7Progress in the field.

Research shows that debt has risen among older people, and those who owe are more likely to have multiple diagnosed illnesses.Denise Revel had a history of developing blood clots, so in 2011, when her leg grew painfully swollen and hot to the touch, she knew what to do. She headed for the emergency room.She recovered from the clot but could not pay the medical bill. Working as a fitness instructor, she had no health insurance. “I’ve always been financially challenged,” said Ms. Revel, 62, who lives with her daughter in Stockbridge, Ga. “I was a single parent raising two children.”Four years later, when she was working as a part-time cargo agent for Delta Air Lines, a workplace accident severely injured her leg, leading to extended hospitalization and rehab. Workers’ compensation picked up most, but not all, of the medical costs. In addition to her still-unpaid E.R. bill from years before, she acquired thousands in additional medical debt.With some older people finding themselves unable to dig out from debt, such dilemmas threaten any notion of a comfortable retirement and have generated alarm among economists and other researchers.“It’s like a dark cloud over your head,” Ms. Revel said. “You get people calling you, being demanding; some can be very rude. You don’t even want to answer your phone.” She worried constantly about her debts, including monthly installments on her 2014 Toyota Camry, and about being unable to access medical care if she needed it.Now, researchers at the Urban Institute, by analyzing broad national data over nearly 20 years, have reported that indebted older adults fare measurably worse on a range of health measures: fair or poor self-rated health, depression, inability to work, impaired ability to handle everyday activities like bathing and dressing.Those in debt were also more likely to ever have had two or more doctor-diagnosed illnesses like hypertension, diabetes, cancer, heart and lung disease, heart attacks and strokes.“There seems a clear causal link between certain types of debts, especially at higher amounts, and negative health outcomes, both physical and mental,” said Stipica Mudrazija, a senior research associate at the institute.“Debt is not a bad thing in and of itself,” he said. “If it’s used cautiously, it can build up wealth over time.”Older adults typically carry less debt than younger ones because people tend to shed debt as they approach and enter retirement. But in recent decades, each cohort of seniors has been more indebted than the previous one.“There’s a group of older people in financial distress,” said Annamaria Lusardi, an economist at the George Washington University. “They’re highly leveraged; they’re carrying high-cost debt. They’re being contacted by debt collectors. They’re not going to enjoy their golden years.”Dr. Mudrazija and his co-author, Barbara Butrica, a senior fellow at the institute, used data from the national Health and Retirement Study and calculated that in 1998, about 43 percent of Americans over age 55 had debt, a median of $40,145. By 2016, about 57 percent had debt and more of it: a median $62,784, adjusted for inflation.The proportion whose debt represented 30 percent of their total assets had risen to almost 45 percent, and the proportion whose debt-to-asset ratio had reached a worrisome 80 percent nearly doubled, to 15 percent.Although seniors with any debt were more likely to encounter health problems, the kind of debt mattered, according to the study, which was published by the Boston College Center for Retirement Research.Secured debt, like mortgages and other home loans, is backed by an asset: the dwelling. Such debt rose among older borrowers as real estate prices soared and interest rates remained low. “It’s increasingly less the norm for people to pay off their mortgages before they retire, the traditional model,” Dr. Mudrazija said.But secured debt appeared less detrimental to health than unsecured debt like credit card balances, student loans and overdue medical payments, which usually charge higher interest rates. About 24 percent of older adults’ debt was unsecured in 1998; by 2016, the proportion had climbed to 35 percent.Dr. Mudrazija and Dr. Butrica found, for example, that limitations in a person’s ability to perform activities of daily living was only slightly higher for people carrying secured debt than those without debt; the difference did not reach statistical significance. But those with unsecured debt were 28 percent more likely to need help with such activities.Moreover, as the level of unsecured debt rose, their risks climbed steeply. If what they owed amounted to 30 percent of their assets, they were 65 percent more likely to have trouble with daily activities compared with those with no debt and almost twice as likely if they owed 80 percent of their assets. Other health problems showed similar associations with unsecured debt.Why would unsecured debt have such impact? The mechanism through which debt affects health remains unclear, Dr. Mudrazija said. He added that the relationship can also work in the other direction: People with poorer health might need to borrow more, especially as increases in health care costs have outpaced inflation.But “secured debt is a planned debt,” he said. “I decide I’m going to buy a house. It’s an investment, and often a well thought-out decision.”“Unsecured debt often comes as a surprise,” he added. “You lose a job and have to live off a credit card. You get sick and face a huge hospital bill. The shock and stress might translate to deteriorating health.”In a 2020 study, also using Health and Retirement Study data, Dr. Lusardi and her co-authors found that even in a relatively high-income group of 51- to 61-year-olds, whose average household income was $103,000, almost one-quarter reported being contacted by bill collectors. “I was frankly shocked,” Dr. Lusardi said. “People close to retirement should be at the peak of their wealth accumulation.”The pressures are stronger still on older people with less income and education, and on women and nonwhite people.In a study using credit bureau data, Dr. Mudrazija and Dr. Butrica documented the disparity. “In ZIP codes where people are better off, older people carry mortgages, but they pay them off,” Dr. Mudrazija said. “Where people are poorer, they seem to carry debt indefinitely.” They are also more vulnerable to predatory payday lending.What could help seniors avoid these credit traps, apart from higher incomes and more comprehensive health insurance? (In 2020, one-fifth of Medicare beneficiaries over 65 paid $2,000 or more out of pocket, beyond the premiums themselves, according to a study by The Commonwealth Fund.)Dr. Lusardi advocates financial literacy training in workplaces, where employers are more apt to emphasize retirement savings than debt management. Some borrowers don’t grasp fundamentals such as the way interest compounds, she said.“We have made it very easy to borrow,” she said. “We also need to help people make good decisions.”But regulating credit, providing clearer consumer information and reining in predatory lending practices could also reduce high levels of unsecured debt, Dr. Mudrazija said.Last fall, Ms. Revel got a call out of the blue. The nonprofit RIP Medical Debt, which uses donated dollars to buy bundled medical debt, had acquired her long-outstanding emergency room debt of $2,728.50 and erased it. “I was so grateful,” she said.Unable to work, relying on disability payments, Ms. Revel is now ensured by Medicare and Medicaid, shielding her from most future medical debt. She is down to the last three months of car payments and “I’m counting the days.”But she still owes a local group of vascular specialists $5,000. At a negotiated $25 a month, she will be nearly 80 when she pays it off.

Millions of Americans take aspirin to prevent a first heart attack or stroke. Now, doctors are advising against it — especially for people over 70.Regina Griffith was 64 when she met her new primary care doctor for a routine checkup. He recommended a daily low-dose aspirin for heart health, she recalled.It’s hard to be more fit than Ms. Griffith, the owner and chief instructor at a fitness studio in Montclair, N.J. She had a slightly elevated blood pressure at the doctor’s office (but not at home, using her own cuff); other than that, she had no significant health problems.Still, a daily aspirin didn’t seem like a big deal, and the doctor did not mention any downsides, so she took his advice. “I thought, ‘OK, I’m at a certain age,’” Ms. Griffith said. “It didn’t sound scary to take aspirin.”Millions of older Americans do likewise, and not always because of a doctor’s recommendation. Alan Turner, 64, an industrial designer in New Castle, Del., began taking aspirin on his own about five years ago, after his mother had several strokes. “I saw what that did to her,” he said. He had heard of other people his age taking prophylactic aspirin, so he “just went with it,” he said. “How much damage can you do with a baby aspirin a day?”Good question. For three decades, the United States Preventive Services Task Force, an independent and influential panel of experts, has been reviewing the growing evidence of aspirin use for preventing first heart attacks and strokes.Last month, it issued its latest recommendations on aspirin use, the first in six years. The panel warned adults over 60 against starting an aspirin regimen for primary prevention.“It carries possible serious harms” — notably, an increased risk of internal bleeding, said Dr. John Wong, a task force member. “And those harms are higher than we thought in 2016.” Dr. Wong is a primary care doctor and interim chief scientific officer at Tufts Medical Center in Boston.“Primary prevention” refers to patients who have never had a heart attack or stroke and do not have heart disease. (High blood pressure, or hypertension, is not considered heart disease.) That group is the task force’s focus.People taking aspirin for secondary prevention — because they have already had a heart attack, stroke or intervention like stenting or bypass surgery — face higher risk of subsequent cardiovascular events, and aspirin might remain part of their treatment.For adults aged 40 to 59, the net benefit of taking aspirin daily would be small, the task force concluded. They may choose to start a daily aspirin regimen if, based on widely used health calculators, they face a 10 percent or higher risk for cardiovascular disease over the next decade, but that should be an individual decision.It will take time for these new cautions to trickle down to the public. About one-third of Americans over 40 already take aspirin, a 2019 study found. Among those over 70, more than 45 percent take aspirin for primary prevention, probably representing significant overuse.“Many people don’t even think of aspirin as medication, they think of it as more like a vitamin,” said Dr. Amit Khera, the director of preventive cardiology at the University of Texas Southwestern Medical Center. “But just because it’s over-the-counter, doesn’t mean it’s not a drug with benefits and risks.”In 2019, Dr. Khera helped develop similar guidelines for the American College of Cardiology and American Heart Association, which recommended against routine aspirin use for primary prevention in people over 70. The American Geriatrics Society’s Beers Criteria, a list of medications considered inappropriate for older patients, is also considering recommending that “most older adults” avoid starting aspirin for primary prevention.The U.S. Preventive Services Task Force’s position on aspirin use for prevention has seesawed over the decades, noted Dr. Allan Brett, an internist at the University of Colorado, in a JAMA editorial accompanying the new guidelines. The task force initially recommended in 1989 that patients consider aspirin, then backed off, calling the evidence insufficient. It encouraged preventive aspirin for many adults in 2009 but had grown more skeptical by 2016.What has changed this time around? Three large, rigorous clinical trials published in 2018, following more than 47,000 older patients, “really highlighted the risks,” Dr. Khera said.Dr. Wong added: “Two didn’t find any significant reductions in heart attack or stroke, but there was an increased risk of bleeding.” The third clinical trial, which was limited to people with diabetes, a higher-risk group, found a small reduction in cardiovascular events — but with a higher bleeding risk. “The harm canceled out the benefit,” Dr. Wong said.The bleeding in question usually occurs in the gastrointestinal tract but can also include brain bleeds and hemorrhagic strokes. Although the risks are low — major bleeding occurred in 1 percent or fewer of older people taking aspirin in the 2018 studies — they increase with age. “These are serious bleeds,” Dr. Brett said. “They can require transfusions. They can put people in the hospital.”With the advent of other effective advances in preventing heart attacks and strokes — better blood pressure drugs, statins for lowering cholesterol, a reduction in smoking — the role for aspirin has narrowed, experts said.For people over 60, per the task force guidelines, or 70, per the cardiologists’ recommendations, the risks of starting aspirin now outweigh the benefits. This is particularly true for people with a history of bleeding, say from ulcers or aneurysms, or those taking medications like blood thinners, steroids or anti-inflammatories such as ibuprofen or naproxen.The 2016 task force recommendation raised the possibility that aspirin might play a role in preventing colon cancer. But, Dr. Wong said, “we’re no longer confident aspirin provides benefit for colorectal cancer. We don’t have enough evidence. We’re calling for more research.”The task force had frustratingly little to say, however, about people over 60 stopping aspirin if they have already begun taking it for primary prevention. It mentioned that people should consider stopping at about age 75 because any benefit would diminish with age, but it also said patients should not discontinue aspirin without talking to a health care professional.“There’s no urgency,” Dr. Khera said. “Put this on the agenda of things to discuss” at an upcoming appointment. But, he added, “for people generally healthy, with few risk factors, it’s reasonable to just stop.” Dr. Brett said he had been cautioning patients against routine aspirin use since 2018.Ms. Griffith, now 65, recently saw a different doctor in her new primary care practice. The doctor looked at her chart, which showed no heart disease and more than a year of aspirin use.“He said, ‘I don’t think you need to do that,’” she said.Ms. Griffith had already begun to question the practice and had cut back to an aspirin every other day. Now, she’s going to stop.