Hace más o menos una década, Andrea Clay se conectó a internet para leer sobre las nuevas directrices revisadas sobre el chequeo del cáncer de cuello uterino.Ninguno de sus proveedores de atención sanitaria le había mencionado que las mujeres mayores de 65 años con un riesgo promedio de cáncer de cuello uterino podían dejar de hacerse la prueba de papanicoláu si hasta entonces se habían realizado las pruebas pertinentes.Pero eso es lo que recomendaba el Grupo de Trabajo de Servicios Preventivos de Estados Unidos, según supo Clay, junto con el Colegio Estadounidense de Obstetras y Ginecólogos y la Sociedad Estadounidense del Cáncer.Enfermera y técnica de urgencias médicas en Edison, Washington, Clay se alegró en silencio. A lo largo de décadas de pruebas, nunca había tenido un resultado anormal en la prueba de papanicoláu y no pertenecía a ningún grupo de alto riesgo.“Ya no quería estar en esos estribos”, dijo. “No creo que sea necesario”. Imprimió las directrices, lista para pelearse si una enfermera o doctor le insistía en que siguiera haciéndose la prueba. Pero nadie lo hizo.Ahora, de 74 años, ya no se ha hecho exámenes para cáncer cervical en años. “Ya acabé con eso”, expresó.En cambio, JB Lockhart, de 70 años, una oficinista jubilada de Lake Oswego, Oregón, sigue programando un papanicoláu anual.El año pasado, cambió de ginecóloga-obstetra. “Me dijo que ya no tenía que hacerme la prueba”, recuerda Lockhart. “Pensé: hasta cierta edad todavía se puede contraer cáncer cervical”.Le dijo a la médica: “Prefiero estar tranquila y prevenir”.A Lockhart no la disuade el hecho de que el grupo de trabajo y los grupos médicos recomienden que se realice el cribado para el cáncer cervicouterino solo cada tres o cinco años (dependiendo de las pruebas a las que se sometan las pacientes) ni la recomendación de que las mujeres con un número determinado de resultados normales pueden dejar de hacerse la prueba a los 65 años.La calificación “D” del grupo de trabajo para el cribado del cáncer cervicouterino en mujeres mayores, la cual significa “certeza moderada o alta de que el servicio no tiene ningún beneficio neto o de que los daños superan los beneficios”, tampoco la ha hecho desistir.Muchas otras mujeres mayores siguen haciéndose pruebas de detección de este tipo de cáncer, según un estudio reciente publicado en JAMA Internal Medicine.Usando datos de Medicare para analizar a 15 millones de mujeres durante 20 años, los investigadores encontraron que la proporción que recibió al menos una prueba de papanicoláu o VPH (virus del papiloma humano) disminuyó de casi el 19 por ciento en 1999 al 8,5 por ciento en 2019, una victoria potencial para aquellos preocupados por las pruebas excesivas y el tratamiento excesivo en adultos mayores.“Esperábamos la tendencia”, dijo la autora principal del estudio, Jin Qin, investigadora de salud pública en la División de Prevención y Control del Cáncer de los Centros para el Control y la Prevención de Enfermedades. “Pero a esta escala, a este nivel, es un poco sorprendente”.Las directrices especifican que las mujeres con un riesgo promedio pueden dejar de someterse al chequeo de cáncer cervical después de los 65 años si, en los últimos 10 años, han tenido tres pruebas de papanicoláu consecutivas negativas o dos pruebas de VPH consecutivas negativas (que pueden hacerse al mismo tiempo que una papanicoláu). Las pruebas negativas más recientes deben haberse realizado en los últimos cinco años.Las mujeres que se hayan sometido a una histerectomía y no tengan lesiones precancerosas previas también pueden dejar de hacerse exámenes.Cuando se les dice que pueden dejar de hacerlo, “muchas de mis pacientes se alegran”, afirma Hunter Holt, médico de familia de la Universidad de Illinois, Chicago, y coautor del estudio. No muchas estaban deseosas de tener que desvestirse y que les introdujeran un espéculo para que un profesional de la salud raspara células del cuello uterino para analizarlas.Las mujeres con un riesgo medio de cáncer de cuello uterino pueden dejar de someterse a las pruebas de cribado a partir de los 65 años si no han dado positivo recientemente. Pero muchas mujeres se sienten incómodas al hacerlo.Tony Dejak/Associated PressAun así, más de 1,3 millones de mujeres mayores de 65 años siguieron recibiendo cribados y servicios relacionados en 2019; el 10 por ciento tenía más de 80 años, un grupo de riesgo especialmente bajo. “Con millones de pacientes, se convierte fácilmente en un costo para todos”, dijo Qin. El estudio calculó que Medicare gastó aproximadamente 83,5 millones de dólares en 2019.Entonces, ¿se está examinando de más a quienes siguen haciéndose estas pruebas? No necesariamente.“No todas las mujeres deben dejar de hacerse las pruebas a los 65 años”, señaló Sarah Feldman, ginecóloga oncóloga del Brigham and Women’s Hospital de Boston y coautora de un editorial que acompaña al estudio de Qin.Algunas mujeres se consideran de alto riesgo debido a antecedentes de cáncer cervicouterino o lesiones precancerosas o porque tienen un sistema inmunitario debilitado. Según Feldman, estas mujeres deben seguir sometiéndose a las pruebas, a veces hasta 25 años después de un resultado positivo. Las mujeres que estuvieron expuestas en el útero al fármaco dietilestilbestrol, o DES, también se consideran de alto riesgo.Otras mujeres deben seguir haciéndose pruebas de detección porque no se han sometido a suficientes pruebas previas o no están seguras de cuántas se han hecho y cuándo. Es posible que algunas no se hayan sometido a un control adecuado porque no contaban con seguro médico antes de tener derecho a Medicare y no podían pagar las pruebas.Dado que los registros de Medicare no incluían historiales médicos anteriores a los 65 años, los investigadores no pudieron determinar cuántas pruebas eran innecesarias. Pero varios estudios han revelado que muchas mujeres no se someten a las pruebas recomendadas antes de los 65 años y, por tanto, no deberían dejar de hacérselas después.Alrededor del 20 por ciento de los casos de cáncer del cuello de útero en Estados Unidos se dan en mujeres mayores de 65 años, señaló Feldman. “Es una enfermedad prevenible si se realiza un examen de diagnóstico a las personas adecuadas y se trata”, afirmó.Sin embargo, todo examen conlleva daños y beneficios. En el caso de las pruebas de detección de cáncer cervical, dijo Holt, las desventajas pueden incluir incomodidad, especialmente porque los tejidos vaginales se adelgazan con la edad y angustia emocional para las víctimas de abuso sexual.Además, “cuando vemos algo en la prueba, tenemos que responder”, dijo. “Cualquier prueba de detección que dé positivo puede provocar ansiedad, estrés y estigma”.Un resultado positivo también conlleva otros procedimientos, normalmente una biopsia en la que se utiliza un colposcopio, un instrumento de visión que amplía el cuello uterino. En ocasiones, las biopsias pueden provocar hemorragias e infecciones, y los resultados suelen mostrar que la paciente no tiene cáncer ni precáncer (aunque estos pueden desarrollarse en el futuro).También puede haber falsos positivos. Aunque los datos sobre los resultados del chequeo en mujeres mayores de 65 años son escasos, Holt y varios coautores publicaron en 2020 un estudio en el que se estimaban las tasas de falsos positivos en mujeres más jóvenes. Según su modelo, las mujeres que se someten a pruebas de detección durante 15 años a partir de los 30 años deberían hacerse una colposcopia, quizá dos, dependiendo de qué pruebas se realicen y con qué frecuencia.Entre el 60 por ciento y el 75 por ciento de esos procedimientos no encontrarían lesiones precancerosas ni cáncer, lo que indicaría que los resultados de las pruebas iniciales eran falsos positivos.Tiene sentido que las mujeres hablen con sus proveedores de atención médica sobre cuándo deben dejar de hacerse las pruebas. Las personas mayores constituyen una población diversa: las mujeres mayores de 65 años pueden tener múltiples parejas sexuales, lo que aumenta su riesgo de cáncer, por ejemplo, o quizá padezcan enfermedades graves que muy probablemente acabarían con sus vidas mucho antes de que lo hiciera el cáncer de cuello uterino.Los investigadores han observado que los adultos mayores a menudo son reacios a renunciar a las pruebas de detección del cáncer, independientemente de lo que digan las directrices.Mara Schonberg, internista del Beth Israel Deaconess Medical Center de Boston, lleva años trabajando para ayudar a las mujeres mayores a reducir las mamografías innecesarias, que el Grupo de Trabajo de Servicios Preventivos no recomienda a las mayores de 75 años, con el argumento de que no hay pruebas suficientes de su beneficio.Schonberg elaboró un folleto para explicar los pros y los contras. Reunió una muestra de 546 mujeres mayores de 75 años y descubrió que la mitad de las que recibieron el folleto estaban más informadas y eran más propensas a hablar de la mamografía con sus médicos. Además, más de la mitad de las que lo leyeron se hicieron una mamografía de todos modos. Una “ayuda para la toma de decisiones” similar no consiguió disuadir a las personas mayores de someterse a una prueba de cáncer de colon.La Sociedad de Medicina Interna General desaconseja las pruebas de detección del cáncer a los pacientes con una esperanza de vida inferior a 10 años. Pero la esperanza de vida puede ser un concepto difícil de discutir con los pacientes.Una encuesta realizada a proveedores de California que realizaban pruebas de detección del cáncer cervical en mujeres de bajo riesgo mayores de 65 años, a pesar de conocer las directrices en contra, evidenció qué es lo que dificulta que estas se pongan en práctica. El 56 por ciento de los profesionales de la salud creía que si dejaban de realizar la prueba no detectarían un caso de cáncer, pero casi el mismo número reconocía que se tardaba menos tiempo en realizar la prueba que en explicar a las pacientes por qué era innecesaria. Y el 46 por ciento señaló que las pacientes los “presionaban” para que siguieran haciéndoles la prueba.Lockhart programó una cita en febrero para su próxima prueba de papanicoláu. La persona encargada le explicó que no necesitaba otra prueba, pero Lockhart dijo que seguiría haciéndosela de todos modos.

About a decade ago, Andrea Clay went online to read about newly revised guidelines on cervical cancer screening.None of her health care providers had mentioned that women over age 65 who were at average risk for cervical cancer could stop getting Pap tests if they had been adequately screened until then.But that’s what the United States Preventive Services Task Force recommended, Ms. Clay learned, along with the American College of Obstetricians and Gynecologists and the American Cancer Society.A nurse and emergency medical technician in Edison, Wash., Ms. Clay quietly cheered. Over decades of screening, she’d never had an abnormal Pap result and wasn’t in any high-risk group.“I didn’t want to be in those stirrups anymore,” she said. “I didn’t see the need for it.” She printed out the guidelines, ready for battle if a nurse practitioner or doctor insisted she continue screening. But nobody did.Now 74, she hasn’t undergone tests for cervical cancer in years. “I’m done,” she said.However, JB Lockhart, 70, a retired office worker in Lake Oswego, Ore., still schedules an annual Pap.Last year, she switched to a new obstetrician-gynecologist. “She told me I didn’t need to get tested any more,” Ms. Lockhart recalled. “I thought, you can still get cervical cancer over a certain age.”She told the doctor, “I’d rather set my mind at ease and be preventive.”Ms. Lockhart isn’t dissuaded by the fact that the task force and medical groups recommend cervical cancer screening only every three to five years (depending on which tests patients undergo), or by the recommendation that women with a specified number of normal results can stop at 65.The task force’s “D” rating for cervical cancer screening in older women, meaning “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits,” hasn’t discouraged her, either.A lot of other older women continue cervical cancer screening, a recent study in JAMA Internal Medicine reported.Using Medicare data to look at 15 million women over 20 years, the researchers found that the proportion who received at least one Pap or HPV (human papillomavirus) test dropped from almost 19 percent in 1999 to 8.5 percent in 2019 — a potential victory for those concerned about over-testing and overtreatment in older adults.“We expected the trend,” said the study’s lead author, Jin Qin, an epidemiologist at the Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control. “But at this magnitude, this level, it’s a little surprising.”The guidelines specify that women at average risk can stop cervical cancer screening after age 65 if, within the past 10 years, they have had three consecutive negative Pap tests or two consecutive negative HPV tests (which can be done at the same time as a Pap). The most recent negative tests must have been performed within five years.Women who’ve had hysterectomies and no previous precancerous lesions can also forgo screening.Told that they can stop, “a lot of my patients are overjoyed,” said Dr. Hunter Holt, a family medicine practitioner at the University of Illinois Chicago and a co-author of the study. Not many looked forward to undressing and having a speculum inserted so that a health care professional could scrape off cervical cells for testing.Women at average risk for cervical cancer can stop screenings after age 65 if they have not had recent positive tests. But many women are uncomfortable doing so. Tony Dejak/Associated PressYet more than 1.3 million women over age 65 still received screening and related services in 2019; 10 percent were over 80, an especially low-risk group. “With millions of patients, it adds up quickly to a cost for everyone,” Dr. Qin said. The study put the Medicare cost at $83.5 million in 2019.Are those who continue screening over-tested, then? Not necessarily.“Stopping at 65 is not OK for every woman,” said Sarah Feldman, a gynecologic oncologist at Brigham and Women’s Hospital in Boston and the co-author of an editorial accompanying Dr. Qin’s study.Some women are deemed high-risk because of a history of cervical cancer or precancerous lesions, or because of compromised immune systems. These women should continue screening, sometimes for as long as 25 years after a positive test result, Dr. Feldman said. Women who were exposed in utero to the drug diethylstilbestrol, or D.E.S., are also considered high risk.Other women should continue screening because they haven’t had enough previous tests or aren’t sure how many they’ve had and when. Some may have been inadequately screened because they were uninsured before becoming eligible for Medicare and couldn’t afford testing.Because the Medicare records didn’t include medical histories before age 65, the researchers couldn’t determine how many tests were unnecessary. But a number of studies have found that many women don’t receive the recommended screenings before age 65 and thus shouldn’t stop the tests after then.About 20 percent of cervical cancer in the United States occurs in women older than 65, Dr. Feldman pointed out. “It’s a preventable disease if you screen the right people and treat it,” she said.All screening involves harms as well as benefits, however. In the case of cervical cancer testing, Dr. Holt said, the downsides can include discomfort, especially since vaginal tissues thin with age, and emotional distress for victims of sexual abuse.Moreover, “when we see something in the test, we have to respond,” he said. “Any screening test that’s positive can lead to anxiety and stress and stigma.”A positive result also leads to further procedures, typically a biopsy involving a colposcope, a viewing instrument that magnifies the cervix. Biopsies can occasionally cause bleeding and infection, and the results often show that the patient has no cancer or precancer (though those may develop in the future).False positives may also occur. Though data on screening outcomes for women over 65 is scarce, Dr. Holt and several co-authors published a 2020 study estimating false positive rates for younger women. On average, according to their model, women screened for 15 years starting at age 30 would be expected to have one colposcopy, perhaps two, depending on which tests were done and how frequently.Sixty to 75 percent of those procedures would find no precancerous lesions or cancer, indicating that the initial test results were false positives.It makes sense for women to talk with their health care providers about when they should stop testing. Seniors are a diverse population: Women over 65 may have multiple sexual partners, increasing their cancer risk, for example, or they may have serious illnesses that could very likely end their lives well before cervical cancer could.Researchers have found that older adults can be reluctant to give up cancer screenings, whatever the guidelines say.Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston, has worked for years to help older women reduce unnecessary mammograms, which the Preventive Services Task Force doesn’t recommend for those over 75, citing insufficient evidence of benefit.Dr. Schonberg developed a brochure to explain the pros and cons. She assembled a sample of 546 women over 75 and found that the half who received the brochure were more knowledgeable and more likely to discuss mammography with their doctors. Then, more than half of those who read it had a mammogram anyway. A similar “decision aid” failed to deter seniors from colon cancer screening.The Society of General Internal Medicine recommends against cancer screenings for patients with life expectancies of less than 10 years. But life expectancy can be a tough concept to discuss with patients.A survey of California providers who performed cervical cancer screening in low-risk women over 65, despite knowing the guidelines to the contrary, showed what makes it difficult. Fifty-six percent of the providers believed they might miss a cancer diagnosis if they stopped testing, but about the same number also acknowledged that it took less time to do the test than to explain to patients why it was unnecessary. And 46 percent reported “pressure” from patients to continue.Ms. Lockhart has made a February appointment for her next Pap test. The office scheduler explained that she didn’t need another screening, but Ms. Lockhart said she would continue anyway.

Lynne Ingersoll and her cat, Jesse, spent a quiet Thanksgiving Day together in her small bungalow in Blue Island, Ill.A retired librarian, Ms. Ingersoll never married or had children. At 77, she has outlived her parents, three partners, her two closest friends, five dogs and eight cats.When her sister died three years ago, Ms. Ingersoll joined the ranks of older Americans considered “kinless”: without partners or spouses, children or siblings. Covid-19 has largely suspended her occasional get-togethers with friends, too. Now, she said, “my social life consists of doctors and store clerks — that’s a joke, but it’s pretty much true.”Like many older adults, Ms. Ingersoll copes with an array of health problems: kidney disease, asthma, heart disease requiring a pacemaker, arthritis that makes walking difficult even with a cane. She’s managing, but “I can see a time when that’s not going to be true,” she said. “I’m not sure what I’m going to do about it.”An estimated 6.6 percent of American adults aged 55 and older have no living spouse or biological children, according to a study published in 2017 in The Journals of Gerontology: Series B. (Researchers often use this definition of kinlessness because spouses and children are the relatives most apt to serve as family caregivers.)About 1 percent fit a narrower definition — lacking a spouse or partner, children and biological siblings. The figure rises to 3 percent among women over 75.Those aren’t high proportions, but they amount to a lot of kinless people: close to a million Americans without a spouse or partner, children or siblings in 2019, including about 370,000 women over 75.“We assume that everyone has at least some family, but that’s not the case anymore,” said Rachel Margolis, a sociologist at the University of Western Ontario and co-author of the study.Several demographic factors have fostered increased kinlessness. Baby boomers have lower marriage rates and higher divorce rates than their parents, and more have remained childless. The rise of so-called gray divorce, after age 50, also means fewer married seniors, and extended life spans can make for more years without surviving family.Books stacked in Ms. Ingersoll’s home. She has outlived her parents, three partners, her two closest friends, five dogs and eight cats. Jamie Kelter Davis for The New York Times“All the pathways to singlehood have grown,” said Dr. Deborah Carr, a sociologist and researcher at Boston University.Among older couples, cohabitation has increased as an alternative to marriage, but those seniors are less likely than married couples to receive care from their partners. Those in committed relationships who don’t live with their partners are less likely still.In addition, seniors who are Black, female and have lower levels of wealth have particularly high rates of kinlessness.The growing number of kinless seniors, who sometimes call themselves “elder orphans” or “solo agers,” worries researchers and advocates, because this group faces numerous disadvantages.A study of middle-aged and older adults in Canada found that those without partners or children (this study included no data on siblings) had lower levels of self-reported mental and physical health and higher levels of loneliness. They were less likely to participate in activities like sports, cultural or religious groups, or service clubs — a predictor of later cognitive impairment.Kinless Americans die earlier. Dr. Margolis and her co-authors, using data from the Health and Retirement Study, found that a decade after respondents’ initial interviews, more than 80 percent of seniors with partners and children had survived, compared with only about 60 percent of those without either.At the end of life, researchers at Mount Sinai in New York reported, people without partners and children had received fewer hours of caregiving each week and were more likely to have died in nursing homes.“Getting old is hard under the best of circumstances, and even harder if you’re going it alone or with weak social ties,” Dr. Carr said.On the other hand, meet Joan DelFattore, 76, a retired English professor at the University of Delaware. Like some solo agers, “I had a sense from an early age that I simply didn’t see myself as a wife and mother,” she said.Preferring to live alone, “I went about constructing a single life,” she said.Joan DelFattore, a retired English teacher, objects to the perception that older people without immediate family are somehow needy. Karsten Moran for The New York TimesDr. DelFattore, who is in good health, still writes and researches, and she teaches a graduate course every other fall. She stays in near-daily contact with a group of friends, walking several times a week with one of them, and remains close to cousins in New Jersey, with whom she spent Thanksgiving. She takes an active role in several local organizations.And she dislikes “the cultural perception that old people being without immediate family has to mean that you’re needy, you don’t have support.”Sociologists call that strategy “substitution” — turning to friends and neighbors for the connections and sustenance that families traditionally have provided.In Mount Lebanon, Pa., for instance, Celeste Seeman, who is divorced and childless and has lived alone for 25 years, has befriended neighbors in her apartment building. When one had surgery recently, Ms. Seeman, 65 and still working as an embroidery machine operator, walked the neighbor’s Chihuahuas, did her laundry and called her almost daily for weeks.“I hope that what goes around comes around,” Ms. Seeman said. Because she has outlived her family, after caring for her parents until their deaths, there’s no remaining relative to provide similar help if she needs it herself.“I’m frightened about it,” she acknowledged, then added, “You can’t dwell on stuff. It might not happen.”A study of sole family survivors, the last members of the families they grew up in, found that, for unclear reasons, they were also disproportionately likely to lack spouses or partners and children, and thus were doubly vulnerable.Of course, having family is no guarantee of help as people age. Estrangement, geographic distance and relatives’ own declining health can render them unwilling or unable to serve as caregivers.Still, “our system of caring for the aged has functioned, for better or worse, on the backs of spouses and, secondarily, adult children,” said Susan Brown, a sociologist at Bowling Green State University and an author of the study of sole family survivors.Ms. Ingersoll with her companion, Jesse.Jamie Kelter Davis for The New York TimesRelying on substitutes has limitations. About two-thirds of older Americans will eventually hit a rubber-meets-the-road moment and require help with the activities of daily living, such as bathing, dressing and using the toilet.“Friends and neighbors may help with meals or pick up a prescription, but they’re not going to help you in the shower,” Dr. Margolis said.Dr. DelFattore has prepared for that possibility by buying insurance for long-term care years ago, so that she can hire home care aides or afford assisted living. Few Americans have done that or can afford the costs, yet most will also be unable to pay for sufficient care out-of-pocket and don’t have incomes low enough to qualify for Medicaid.“Policies tend to lag behind reality,” Dr. Carr said. “There was the belief in past decades that older adults would be married and have children; that’s what the classic American family looked like. It no longer does.”In the absence of any broad public program, experts suggest a variety of smaller solutions to support kinless seniors.Shared housing and co-housing, providing safety and assistance in numbers and community, could grow, especially with public and philanthropic support. The village movement, which helps seniors age in place, might similarly expand.Revised family-leave policies and caregiver-support programs could include friends and neighbors, or more distant relatives like nieces and nephews.However governments, community organizations and health care systems begin to address the issue, there’s little time to waste. Projections indicate that kinlessness will increase greatly as the population cohorts behind the baby boom age.“Younger people are less likely to marry and have children, and they have fewer siblings” as family sizes shrink, Dr. Brown said. “How will they navigate health declines? We don’t have a good answer. I’m not sure people are paying attention.”

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.”