Health care researchers argue that hospice facilities could better serve some terminal patients, and ease the burden on exhausted loved ones.Where do people most want to be when they die? At home, they tell researchers — in familiar surroundings, in comfort, with the people they love.That wish has become more achievable. In 2017, according to an analysis in The New England Journal of Medicine, home surpassed the hospital as the most common place of death — 30.7 percent of deaths occurred at home, compared with 29.8 percent at the hospital.“It’s probably the first time that’s happened in the United States in modern times,” said Dr. Haider Warraich, a cardiologist at the Veterans Affairs Boston Healthcare System and an author of the study, published in 2019. Technically, the proportion was even higher, since some people who died in nursing facilities (20.8 percent) were long-term residents and the nursing home effectively was their home.Dr. Warraich credited the change to the rise of hospice care, for which Congress authorized Medicare coverage 40 years ago. By 2019, more than half of Medicare beneficiaries who died were enrolled in hospice. “There’s been a cultural shift,” he said. “People don’t want to die in hospitals, and hospice helps make that possible.”But not always.When Lee Zeiontz was dying of lung cancer, she wanted to remain in her apartment on the Lower East Side of Manhattan with her cat on her bed and her neighbors stopping by. Lynda Hollander, her niece, hired a round-the-clock aide to supplement the hospice staff.But Ms. Zeiontz’s pain eventually intensified and her older relatives were uneasy about administering morphine. “I think they were afraid of her dying at home,” said Ms. Hollander, a social worker in West Orange, N.J. They moved Ms. Zeiontz to an inpatient hospice unit at Mount Sinai Beth Israel Hospital, where she died a day and a half later, at 70.Similarly, Alan Mironer had vowed to care for his wife, Lynne, with hospice help in their home in Edina, Minn., as she died of breast cancer. “He felt it was his responsibility,” their son, Mark, said. But as she weakened and became unable to walk to the bathroom, he said, “suddenly, it was so much more work to take care of her.” The elder Mr. Mironer, then 81, became overwhelmed.Neighbors told them about a small hospice facility in Edina, with room for eight patients. Ms. Mironer spent her final week there, dying at 78.Such experiences prompted an article this month in The New England Journal of Medicine that pointedly asks, “Is There Really ‘No Place Like Home’?”The lead author, Dr. Melissa Wachterman, a palliative care specialist at Harvard Medical School, and her co-authors argue that alternative locations, including free-standing inpatient hospice facilities and hospice units within hospitals, could better care for some terminal patients with difficult symptoms and provide relief for exhausted families. They also contend that financial incentives play a role in where death occurs.“There’s a lot of cultural pressure: ‘If you really loved this person, you’d keep them at home,’” Dr. Wachterman said in an interview. “We need to acknowledge that there are people whose needs are so great that families cannot manage death at home.”Ninety-eight percent of hospice patients covered by Medicare receive what is called “routine home care.” The hospice organization sends nurses, aides, a social worker and a chaplain, in addition to drugs and equipment like a hospital bed, to the patient’s home. But it can’t provide 24-hour care; that falls to family or friends, or helpers paid out of pocket.Often, that’s sufficient. But death can follow unpredictable trajectories, and some terminal conditions appear better suited to home death than others. Cancer patients have the greatest odds of dying at home, Dr. Warraich’s analysis showed. Patients with dementia are most likely to die in a nursing home, and those with respiratory disease in a hospital.Some patients “may not need someone at the bedside 24 hours a day, but they need someone available 24 hours a day,” Dr. Wachterman said.A handful of hospice patients receive “continuous home care,” which means nurses and aides are provided eight to 24 hours a day; this accounts for 0.2 percent of hospice days, according to the Medicare Payment Advisory Commission, an independent agency that advises Congress on Medicare issues. Another handful receive inpatient services in a hospice facility, hospital or nursing home.But inpatient care is hard to secure, accounting for just 1.2 percent of all hospice days in 2019. To be covered under Medicare, the patient must be diagnosed with a symptom that cannot feasibly be managed in any other setting, and “that’s a pretty high bar,” Dr. Wachterman said.The authors also argue that although Medicare pays more for inpatient care — $1,000 a day, on average, compared with $200 for home care — profit margins are higher at home. More than 70 percent of hospices are now for-profit agencies.Rankings on the quality of hospital care like those published by U.S. News & World Report may also prompt hospitals, who want to keep their mortality statistics low, to discharge patients to home hospice.Edo Banach, president and chief executive of the National Hospice and Palliative Care Organization, disputed the article’s financial assertions. “It’s not true that margins are necessarily higher for routine home care versus inpatient,” he said, attributing profit differences to the length of a patient’s stay rather than the setting.Instead, Mr. Banach primarily blamed a fear of Medicare audits, which are not uncommon, for the infrequent use of inpatient hospice care. “Providers are very reluctant to use that benefit unless it’s also clear that they won’t be hurt by the government on the back end” and forced to return contested payments, he said.Still, he said there was nothing in the authors’ recommendations that he fundamentally disagreed with, including their calls for changes like financial support for family caregivers who assist dying patients.The authors also advocate expanded access to continuous home care and lower barriers to inpatient end-of-life care, in hospice facilities (the national organization estimates that about 30 percent of hospices have them) or hospice units within nursing homes and hospitals.Of the three times I have accompanied family members to their deaths, we achieved the good-death-at-home paradigm once: My mother died at 80, with uterine cancer and after a major stroke, in her own bed. My father and I cared for her, with a hospice team. He died at 90, when sepsis overwhelmed him in a hospital before I could arrange for hospice care at home.My sister’s death in 2015 showed the possibility of a middle ground. Disabled by late-onset Tay-Sachs disease, a neurological condition, she had been hospitalized with an uncertain prognosis. I was her health care proxy.As she declined, she developed such severe pain that, between sobs, she was calling for our long-dead parents. I immediately enrolled her in hospice and began planning to move her back to her assisted-living facility, so that she could die in her own apartment.It soon became clear that would be impossible. In the hospital, hospice nurses visited twice a day, constantly raising the dose of her morphine drip before switching to more potent medications. Having staff nurses always nearby allowed us to provide comfort, relying on a team we never could have duplicated on our own.To its credit, the hospital understood our needs. It arranged for a private room with 24-hour access for my cousin and me. We turned off the TV and the intercom, dimmed the lights, played soothing music, allowed family and friends to come and kept the vigil. It wasn’t homey, but it was peaceful. My sister, just 62, died after 24 days in the hospital and 14 in hospice care.Far more hospice patients and families could probably benefit from a similar option when home care proves too difficult.“For many patients, ‘home’ isn’t the physical place,” Dr. Warraich said. “It’s a metaphor for a place that’s not medicalized, that’s comfortable and full of love.”

The Program of All-Inclusive Care for the Elderly, funded by Medicare and Medicaid, has quietly succeeded in enabling some older Americans to age in place.Felicia Biteranta was struggling when, five years ago, she enrolled in a PACE program operated by Lutheran Senior Life in Jersey City, N.J.Having suffered a stroke, she found it hard to eat without choking. She fell frequently; her diabetes was out of control; she had pulmonary disease and asthma. She might miss a medical appointment if she could not arrange or afford a taxi. Her family lived far away.She was, in short, a candidate for a nursing home. But such a move is what PACE — the Program of All-Inclusive Care for the Elderly — was designed to prevent.“The main goal is to let people age in place,” said Maria Iavarone, executive director of the PACE program that Ms. Biteranta participates in. “Nobody wants to give up their home. It’s where you’re most comfortable. It’s where you should stay.”Ms. Biteranta now receives all of her health care through PACE, which monitors her, along with 120 other seniors, meticulously. PACE supplies much of her social life, too.“Here, they schedule you for appointments,” said Ms. Biteranta, 74, a retired nurse. “They send someone to take you and bring you home.”Carpal tunnel syndrome in her wrists and arms makes personal care and household chores difficult, so PACE sends an aide to her home 12 hours a week. “She cleans and does my laundry and the shopping,” Ms. Biteranta said. “She knows the food I like.”PACE provided the portable oxygen unit that freed her from dependence on the larger oxygen tanks she uses at home. It arranged cataract surgery and regularly ferries her to a podiatrist, a cardiologist, an endocrinologist and other specialists. It delivers a host of medications at no charge, including asthma inhalers and diabetes-testing supplies. A staff social worker helped her apply for and move into an apartment in a subsidized building for seniors.As a Medicaid beneficiary, she pays nothing for this care — no co-pays, deductibles or other out-of-pocket care expenses, and no caps on benefits. Should she require more home care hours or, eventually, a nursing home, PACE will cover those costs, too.“It’s worry-free,” said Ms. Biteranta, who was preparing to have lunch at the PACE Center as she spoke. “They worry for me.”Yet both the state and federal government also save money. PACE programs receive a set amount monthly from Medicare and Medicaid to provide nearly everything for people over 55 whose needs qualify them for a nursing home but who don’t want to enter one. This includes doctors’ visits, tests, procedures, physical, occupational and speech therapy, social workers, home care, transportation, medication, dentistry and hearing aids. Participants typically visit a PACE center like the one in Jersey City several times a week for meals and social activities as well as therapy and health monitoring.That monthly payment is 15 percent lower, on average, than Medicaid would ordinarily pay to care for what are primarily low-income seniors, the National PACE Association said.Research has shown that PACE programs reduce hospitalization, emergency room visits and nursing home stays. Participants survive longer than similar patients in less comprehensive programs. A study last year by the federal Department of Health and Human Services noted that the PACE program “stands out from our analysis as a consistently ‘high performer.’”Why, then, do so few PACE programs exist — and enroll so few older Americans? Almost three decades after Medicare and Medicaid began funding PACE programs — today, there are 144, operating 272 centers in 30 states — the endeavor collectively serves fewer than 60,000 people, the National PACE Association reports.The association estimates that 1.6 million Medicare beneficiaries might meet PACE eligibility requirements. As a list of current programs shows, however, 21 states have no PACE program, and 11 have just one.Ms. Biteranta and her aide, Ms. Garcia-Reyes, on the way to lunch. Brian Fraser for The New York TimesProfessionals in elder care tend to be fans. “Every geriatrician loves this model,” said Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine.Specialists like Dr. Lachs have complained for years that traditional Medicare will cover costly surgery to repair broken hips but won’t pay to install inexpensive grab bars that might prevent falls. With PACE’s fixed payments, “there might be less money, but you spend it the way you want to, without getting on the phone for insurance company approval,” Dr. Lachs said.At the ArchCare PACE program in New York City, for instance, “if a person’s air-conditioner breaks during a heat wave, we replace it,” said Walid Michelen, the program’s chief medical officer. “If there’s a snowstorm and they need food, we send it.”With coordinated care and close observation, “you head off a urinary tract infection before it becomes sepsis,” said Jay Luxenberg, the former chief medical officer of the On Lok PACE program in San Francisco. “Or pneumonia when it can still be treated by antibiotics, before you desperately need a hospital.”Yet growth has been slow. “We’ve had a lot of headwinds over the years,” said Shawn Bloom, the association’s chief executive.Persuading state legislators to expand PACE enrollment or authorize new programs has proved challenging; such moves represent new expenditures, even if they eventually reduce costs.For individuals, the enrollment process — which involves a state assessment to determine whether their medical conditions, cognitive status and functional limitations would warrant a nursing home — can take weeks. A family needing elder care immediately may be unable to wait.Moreover, agreeing to receive all health care from PACE often means relinquishing one’s individual doctor, and some patients balk at that demand. Programs can evade that barrier by allowing PACE programs to work with community physicians.But prospective patients may not know about PACE at all. “We’re trying to expand awareness, but we don’t have a ‘Got Milk?’ budget,” Mr. Bloom said.Still, the pandemic has intensified older Americans’ desire for alternative forms of long-term care. “If people didn’t want to be in nursing homes before Covid, they really don’t want to be there now,” Dr. Lachs said. According to the association, Covid deaths among PACE participants have been about one-third those of nursing home residents.So PACE’s growth is picking up, with 45 new programs expected to begin enrollment in the next two years, in part because of higher federal incentives. Moreover, for-profit companies are starting to establish or acquire PACE programs, although skeptics worry that for-profit status will lower quality.Several bills introduced in Congress would remove barriers to growth; one would build partnerships with Veterans Affairs hospitals to make PACE more accessible to veterans.Another intriguing possibility: Encouraging middle-class patients, for whom long-term care costs can also be ruinous, to enroll in PACE. Older adults who aren’t poor enough to qualify for Medicaid can already participate, but few do because their monthly premiums would be high — in many states, $4,000 to $5,000 a month.But that is still less than they would pay for nursing homes or assisted living in many locations. Policy analysts are looking into ways to reduce costs and expand PACE eligibility for the middle class.In Jersey City, Ms. Biteranta is doing well, although she misses concerts, Zumba classes, birthday parties and other events at the PACE center. Administrators curtailed such activities during the pandemic but hope to restore them as Covid rates decline.“Oh, my God, I’d be so depressed” without PACE, Ms. Biteranta said. “It gives me a life.”

Three recent developments — incremental and undramatic but encouraging — are likely to improve the lives and health of seniors.The Covid pandemic has presented older Americans with plenty of grim news, from staffing shortages in long-term care and hospices to the punishing effects of loneliness and isolation. But there have been encouraging developments too — the kind of incremental progress that can take years to achieve, as lawsuits wend their way through courts, bills die in state legislatures and rise again, and the pandemic complicates everything.The results are not always dramatic, but they can improve lives and health for older people, especially those with low income. Here are three.A New Right to Appeal Medicare DecisionsFirst, a federal appellate court recently ruled that if Medicare declines to pay for your rehabilitation in a nursing home after you’ve left the hospital, because you were “on observation,” you can appeal the decision.This issue has boggled patients and families for years. You were in a hospital bed, doctors and nurses provided care, you were examined and perhaps received medication, but you were not actually admitted. Or you were, and then the hospital changed your status to “on observation.” Technically you were an outpatient, not an inpatientBut Medicare requires three consecutive days as an inpatient for you to be eligible for nursing home coverage. So you are left either having to pay the tab yourself (the national average nursing home cost is $260 a day) or forgoing care. In fact, if you are among the 9 percent of Medicare beneficiaries who don’t have Part B, which covers outpatient care, you must pay the hospital bill, too.Hundreds of thousands of patients discharged from hospitals have probably faced this conundrum. “You can appeal just about every issue regarding your Medicare coverage, but not that one,” said Alice Bers, litigation director at the Center for Medicare Advocacy.To change this, the center — along with Justice in Aging and a private law firm — sued the federal Department of Health and Human Services in 2011.Last month, the U.S. Court of Appeals for the Second Circuit affirmed that Medicare beneficiaries have a constitutional right to appeal if hospitals reclassify them as observation patients. If patients win their appeals, traditional Medicare will pay for up to 100 days of nursing home care, and those who were previously forced to pay out-of-pocket could receive refunds. (Medicare Advantage plans don’t generally require the three-day stay.)The Center for Medicare Advocacy answers frequent questions here.One catch: The government could still ask the Supreme Court to take the case, or seek a rehearing by the Second Circuit court. And the Medicare appeals process is no picnic. “People have the best chance of winning if they persist and work their way up through the levels,” Ms. Bers said.Repealing the three-day requirement would take Congressional action. But at least with the right to appeal, you have a fighting chance.California Eases Medicaid QualificationsIn a second promising development, California is eliminating asset limits for older people who are trying to qualify for Medicaid, and other states are considering similar moves.Medicaid, the state and federal program that provides health care for the poor and for people with disabilities, and also pays for long-term care in nursing homes and at home, sets strict ceilings on recipients’ wealth. In most states, if you are older than 65, you can amass no more than $2,000 in assets, or $3,000 for a couple (usually with a home and a car exempted).“It makes people live in very deep poverty,” unable to save for emergencies or even modest expenditures, said Amber Christ, director of health care policy and advocacy for Justice in Aging. “If you go over the limit by a dollar, you lose eligibility.”California will abolish this ceiling in two steps. In July, the asset limit rises to $130,000 for an individual and another $65,000 for each family member. In July 2024, the state will discard asset limits altogether. If you are older or disabled, you will qualify for Medi-Cal (as California calls its Medicaid program) if your income does not exceed 138 percent of the federal poverty level. The state estimates that about 17,000 residents will become newly eligible.Gov. Kathy Hochul of New York has incorporated a similar measure in her proposed state budget, eliminating asset limits as of Jan. 1, 2023; the state legislature will tackle the budget in March. Arizona eliminated asset limits in 2001, although not for long-term care, and other states are looking into the approach, Ms. Christ said.One catch: This year, 138 percent of the federal poverty level amounts to an annual income of $17,774. Medi-Cal recipients must still be poor, but less poor than before, and will be better able to hold onto their health coverage.Social Security Offices to ReopenOffices closed since the beginning of the pandemic will reopen.Fred Prouser/ReutersIn a third piece of a good news, the Social Security Administration has finally announced that it will soon reopen its 1,200 local offices.Except for limited “dire need” appointments made at the discretion of managers, offices have remained closed since the pandemic hit in March of 2020. Now, said Mark Hinkle, a spokesman for the agency, “we anticipate that local field offices will restore increased in-person service to the public, without an appointment, in early April.”This matters. “There are things that have to be done in person for Social Security,” said Kate Lang, senior staff attorney at Justice in Aging. You can apply online for retirement benefits but not for survivors’ benefits or for Supplemental Security Income, or S.S.I., which helps support seniors with very low income.These in-person requirements have meant that hundreds of thousands of applicants who would normally walk into local Social Security offices, carrying the required original documents, have been out of luck for two years.Moreover, “people already on benefits have gotten notices saying their benefits are being reduced or discontinued, and they’re unable to get in touch with anyone at Social Security to find out what’s going on,” Ms. Lang said. “There’s no way to fix these problems.”Trying to reach Social Security by phone can be an exercise in frustration. A report from the agency’s inspector general found that monthly calls to field offices rose from 4.6 million before the pandemic to 7.5 million in April through September 2020, and to 12 million in March of 2021. If you called field offices or the national 1-800 number, you often encountered busy signals or long waits; many callers abandoned the effort.Even after the Social Security Administration agreed to reopen offices, protracted negotiations with its uneasy employees followed. But the agency and its unions have reached agreements, although they are still working out the logistics of reopening.One catch: Visitors to a field office will likely face occupancy limits, and the agency must cope with huge backlogs. In an email, Mr. Hinkle said that the agency encourages the public to use its online or phone services when possible and to schedule in-person appointments in advance.Ms. Lang noted: “It’s not like everything will be hunky dory on April 1.” In fact, Justice in Aging has brought a class-action suit against the Social Security Administration on behalf of S.S.I. recipients who were unable to provide information or challenge decisions while offices were shuttered.But, Mr. Hinkle said, offices will reopen this spring “dependent on the course of the pandemic” — indisputably a good thing.

Health experts are concerned that the pandemic, in upending daily routines, has reduced mobility and physical conditioning in older adults.In normal times, Cindy Myers, an executive at a nonprofit organization, is “not a real physical person,” she said. “I work at desk jobs. I’m not a big exerciser.”Still, before the pandemic, Dr. Myers, who is 64 and has a doctorate in organization development, commuted from her home in Petaluma, Calif., to an office in San Francisco. She met friends for lunch or coffee, and she went to restaurants, theaters and lectures with her wife. “There was so much more variety in my life, more locations, more people,” she said. “You’re not cognizant of all the moves you’re making.”Like many employees, Ms. Myers has now been working remotely for two years, curtailing social and cultural events and forgoing travel. That shift, perhaps exacerbated by a bout of depression in 2020, has taken a physical toll, she said. Her limbs feel weak, her balance rocky; she has fallen several times.“Basic kinds of movement you take for granted, like walking from one end of the house to the other, are exhausting,” she said. “I’m worried about it.”Many health experts are worried about worsening physical conditioning and mobility among older adults since Covid-19 upended the daily routine. Recent research indicates that many of those who had mild to moderate infections, even some who have managed to avoid the virus altogether, may be suffering functional declines.To date, much of the attention paid to the pandemic’s effects on the older population has focused on its frightful mortality rate: Nearly three-quarters of Americans who have died have been 65 or older.Researchers have also reported that, unsurprisingly, older adults whose Covid symptoms became serious enough to require hospitalization often contended with persistent physical and mental health problems.“When you’re hospitalized and you’re older, it takes a long time to get back on your feet,” said Marla Beauchamp, who researches mobility, aging and chronic disease at McMaster University in Hamilton, Ontario. “Covid is still impacting them in a significant way months and months later.”But less severe disease can also affect their physical ability. Dr. Beauchamp led a recent study of Canadians over 50 who had confirmed, probable or suspected Covid in 2020, when testing was not widely available. The study revealed worsened mobility among those with mild to moderate illness — 93 percent of whom were never hospitalized — compared with those without Covid.Nearly half of those 65 and older who had contracted Covid reported less ability to engage in physical activity like walking and exercising than before the pandemic — but so did about one-quarter of those who did not become infected. Smaller proportions of those uninfected said their ability to move around the house, and to do housework like dishwashing and dusting, had also declined.Although some of that decline might reflect normal aging, the study measured changes over only a nine-month period. In people who did not develop Covid, “the most plausible reason for the decline is public health restrictions during the pandemic,” Dr. Beauchamp said.Declines in physical function are showing up in older Americans, too. A University of Michigan team surveyed about 2,000 American adults aged 50 to 80 in early 2021, asking about their activity levels (but not about their Covid status).It found that almost 40 percent of those over 65 reported both reduced physical activity and less daily time spent on their feet since the start of the pandemic in March 2020. In this representative national sample, those factors were associated with worsened physical conditioning and mobility.“It’s a cascade of effects,” said Geoffrey Hoffman, a health-services researcher at the university’s School of Nursing and the lead author of the study. “You start with changes in activity levels. That results in worsened function. That in turn is associated with both falls and fear of falling.”Dr. Beauchamp added: “It’s really concerning to see this decrease in mobility. This is telling us that the pandemic alone has had a significant impact on older adults.”Neither of these observational studies, in Canada or in the United States, explored reasons for the self-reported increase in physical decline. But their authors suggested that pandemic-related restrictions could have caused deconditioning, even in people who were not ill.Not only did gyms, yoga studios, pools, adult day programs, community and senior centers all close for extended periods; many older people also undertook fewer ordinary chores and errands and may have skipped recreational pastimes.“If you’re limiting visits to the grocery store or having groceries delivered, or not going to visit or help with your grandchildren, if you’re not meeting friends at a coffee shop — those all take a certain level of physical activity,” Dr. Beauchamp said.Many older people did less traveling or in-person shopping; religious services, family gatherings and medical appointments moved online. “Picture how much activity we do without even thinking about it,” Dr. Hoffman said. When that changes substantially, “it adds up over six or nine months, then you have loss of balance or muscle strength, which leads to more trips and falls.”Disparities in health and income also appear to play a role, with reduced physical conditioning and mobility more commonly reported, in both countries, by respondents in low-income categories, in fair or poor health or with multiple chronic conditions.“Relatively healthy older adults have sufficient reserve if they reduce activity,” said Neil Alexander, a geriatrician at the University of Michigan and Ann Arbor Veterans Affairs who was not involved in the study. “High-risk people may be driving these numbers.”Dr. Alexander also pointed out that early in the pandemic, older patients had less access to rehabilitation and other services. “It was difficult to get people into the home for occupational therapy and physical therapy,” he said. “The support services to keep people mobile and functioning were disrupted.” Now, work force shortages may be having a similar effect, he noted.Physical function is key to living independently — the future that a great majority of older people envision for themselves. A loss of mobility and function across a considerable proportion of the senior population could mean increasing disability, a greater need for eventual long-term care, and higher Medicare and Medicaid costs.But that is not inevitable, Dr. Hoffman said: “You can reverse deconditioning. You can recover mobility.”Dr. Hoffman would like to see Medicare, which covers hip fracture surgery and rehabilitation after serious falls, underwrite extensive “pre-habilitation,” to rebuild the strength and balance of beneficiaries and prevent falls and fractures. He hoped that doctors conducting annual Medicare wellness visits would ask about fall risks and refer deconditioned patients to occupational and physical therapy.In the interim, individuals can resume walking, enroll in yoga or tai chi classes (outdoors, online, or seated in chairs, as needed), join fall-prevention programs, even practice getting in and out of chairs and lifting small weights on their own. (People should consult a doctor or physical therapist first if they have become severely deconditioned, however.)“You want to do everything you can to be as active and mobile as possible,” Dr. Beauchamp said.Dr. Myers, having found that “simply going about my daily routine isn’t enough to bring back my stamina and strength,” has a portable exercise bike set up in front of her television. She uses it, she said, but not often enough, a pattern she wants to change.“I need an intervention,” she said. “This isn’t the way I want to live.”

In a troubling picture, American women are looking at a rockier road to secure retirement than their male counterparts.Susan Hartt describes herself as an incorrigible optimist, drawn to change and challenge. After a long, successful career in marketing and public relations, she had reason to feel financially confident in her older years.But three years ago, a bank foreclosed on her modest house in Hamden, Conn. “I don’t think I’ve ever been as anxious in my life,” she recalled.Ms. Hartt, 79, had encountered a combination of adversities. After a late-life divorce she called “amicable and equitable,” she had no retirement plan; it had seemed unnecessary because her husband had a “substantial” 401(k). Successive jobs had grown less lucrative, and her freelance work dried up during the recession.Soon, temporarily living in an apartment owned by friends, she was selling off possessions — a collection of stained-glass lamps, first-edition books, her piano — partly to downsize, but also to raise money.A recent AARP survey found that almost 30 percent of women over age 65 reported feeling very or somewhat worried about their current financial situations (compared with 20 percent of men that age).Despite gains in education, employment and earnings in recent decades, American women still face a rockier road to secure retirement than men. Yet they live longer and are more apt to encounter illness, disability and the eventual need for expensive long-term care. It’s a troubling picture.“Women are considerably more likely to experience poverty in retirement than men,” said Richard Johnson, an economist at the Urban Institute in Washington, D.C.In 2020, according to Dr. Johnson’s analysis, 10 percent of women over 65 lived in poverty, compared with 8 percent of men, with far higher rates for women who were older, of color or unmarried. The poverty rate for unmarried Black women over 65, for instance, topped 20 percent.Even women who don’t sink below the federal poverty line — $12,413 last year for a one-person household — face economic precariousness. A quarter of working women over 55 are at risk of being among the working poor, defined as those who earn below two-thirds of the median hourly wage, or $15.29 an hour last year. Only 15 percent of men fell into that category, according to researchers at The New School in New York.Small wonder that a quarter of women over 65 consider an unexpected $1,000 expense “a major setback,” as the AARP survey showed.Anne Turley, 68, a veteran film and video editor, is getting by after some scary years of underemployment. She relies on about $1,200 in monthly Social Security benefits that she claimed early, at 62; a reverse mortgage on her house in Los Angeles; and the rent from a small studio in her backyard.But she recently needed a new hot-water heater and about $4,000 of dental work. “Every month is ‘How do I pay this?’ ‘How can I find money for that?’” she said.Economists attribute much of the retirement gender gap to “the motherhood penalty.” Women who raise children have fewer and lower-paid years in the work force than men or childless women, and “they never completely make up for the deficits,” said Matthew Rutledge, a research fellow at the Center for Retirement Research at Boston College.Social Security calculates benefits based on workers’ highest-earning years, he pointed out, and mothers are apt to have some zero-earning years that bring the average down, along with years of part-time work. Social Security offsets only part of the penalty.But much of the discrepancy in financial stability at older ages stems from a major demographic shift: Women now spend much less of their adulthoods in marriages.That is partly because women are increasingly marrying later, or not at all. But “gray divorces” — among people over 50 — doubled between 1990 and 2010, even as divorces declined in younger cohorts, said I-Fen Lin, a sociologist at Bowling Green State University in Ohio.Gray divorce now accounts for one in three U.S. divorces, Dr. Lin said. Although her research shows the rate holding steady, the number of divorced older people keeps growing as the population ages.Divorces in late middle age may improve women’s emotional well-being — they initiate them more often than men — but frequently devastate their financial health.Marriage combines incomes, reduces living costs and works “to smooth out the fluctuations, the job losses, the periods of disability, the years you took off to care for an elderly parent,” Dr. Rutledge said. “It’s almost like getting an insurance policy.”Losing that insurance takes a financial toll on women at any age, but after 50 “there’s less time to recoup,” Dr. Lin explained. “It’s hard to get back into the labor force, if you’re not working. And you don’t have as many years left to work and recover.” Moreover, older working women face both age and gender discrimination.Cynthia Palazzo, 61, spent most of her married years raising three sons in Akron, Ohio. When she and her husband started a manufacturing company, she was paid for her work there but never opened a retirement account, because “all our money was going back into the business.”When she divorced after nearly 30 years, Ms. Palazzo felt lucky to land a $17-an-hour job in medical billing and then, after being laid off in June, to quickly find another. With spousal support, “I’m OK now,” she said.But she bought a condo, and “it freaks me out that I’m going to have a mortgage until I’m 80,” she said. “I basically started life over at 54.”After gray divorce, women’s standard of living fell by 45 percent, Dr. Lin and her co-author found, while men’s decreased by just 21 percent. Repartnering, either through remarriage or cohabitation, helped divorced older women regain their financial footing, but only 22 percent of women repartnered, compared with 37 percent of men. (In Ms. Palazzo’s case: “Not going to happen.”)Changes in Social Security eligibility and benefits could reduce some of this inequity. The benefit for a divorced spouse, for instance, is half what a widowed spouse can claim. Caregiver credits could partially compensate for years spent in child rearing or elder care.“The basic rules were written in the 1930s,” Dr. Rutledge said. “They don’t recognize women’s increased employment. They don’t recognize that people don’t stay married for good.” Mandated retirement savings programs (Australia has one) would also help workers whose employers don’t offer them.It’s possible to see progress in these patterns. “It’s good news that women are working and living independently, emerging as independent economic actors,” said Teresa Ghilarducci, an economist at The New School, noting that younger women were narrowing the gender gap in earnings and savings.But many women currently approaching retirement may struggle, especially if they’re single like Ms. Hartt. She now lives frugally on a $2,500 monthly Social Security benefit. She drives a leaky 2001 Nissan she will be unable to replace when it dies. “Because I have no family and no savings, what worries me is if I were to become disabled, physically or mentally,” she said.One piece of luck: In September 2020, she moved into a cheerful apartment in a Section 8 subsidized housing complex in New Haven, for seniors and people with disabilities. The rent comes to $670 a month, including utilities.“I feel safe,” she said. “I’m at a kind of peace.” And because she hasn’t fully squelched her optimism, she buys a few lottery tickets each week.

Medicare has extended coverage of remote health care. While telehealth removed barriers to care for many during the pandemic, some say there is more to be done.Ben Forsyth had doubts about telehealth.When the coronavirus pandemic hit New York, he was wary of trekking by subway from Brooklyn to see his palliative care doctor at Mount Sinai Hospital in Manhattan. The prospect of entering a hospital and sitting in a waiting room troubled him, too.But when his doctor, Helen Fernandez, suggested a video visit to monitor his chronic kidney disease and other conditions, “I wasn’t sure how it would work,” said Dr. Forsyth, 87, a retired internist and university administrator. “Would I feel listened to? Would she be able to elicit information to help with my care?”Still, he logged on through Mount Sinai’s patient portal (“I wouldn’t say it was completely user-friendly”) on his laptop — and quickly became a convert.He’s had four video appointments with Dr. Fernandez since, along with two in-person visits once he was fully vaccinated. He consulted her remotely when he wintered in Florida; he has also seen his cardiologist and his sleep specialist through telehealth.Telehealth, also called telemedicine, refers to providing care remotely using technology such as video and phone calls, monitoring devices and patient portals.“It should be part of the options that people have,” said Dr. Forsyth.For now, it will be. In March 2020, Medicare greatly expanded coverage for telehealth, giving older Americans and others access to more health care options during the pandemic. Telehealth use promptly soared to nearly 52.7 million Medicare visits last year from 840,000 in 2019, according to a new federal report.Last month, Medicare announced that it would extend most telehealth coverage through 2023, to allow time to “evaluate whether the services should be permanently added” to its coverage. It had already made certain telehealth services permanent.This represents enormous change for telehealth. Before Covid, Medicare coverage for telehealth “simply wasn’t very available,” said Tricia Neuman, the executive director of the Program on Medicare Policy at Kaiser Family Foundation. Traditional Medicare permitted telehealth only in rural areas, for a narrow range of services. (Medicare Advantage plans had more flexibility.) Even then, patients had to travel to a clinic or hospital to do video calls if, for instance, they needed to consult with a specialist far away. They couldn’t receive telehealth at home, nor could they receive care over the phone.Doctors or physician assistants could provide telehealth and get reimbursed, but not physical therapists or nurse practitioners, and they had to have previously seen the patient in person.Then “the floodgates really opened at the beginning of the pandemic,” said Gretchen Jacobson, the vice president for Medicare at The Commonwealth Fund, which supports research to improve Medicare.Medicare removed the geographic barriers, so that patients across the country could receive telehealth in their homes.Jay Berger, left, a physical therapist, saw a patient from home in Frederick, Md.Dan Gross/The Frederick News-Post, via Associated PressOne hundred and forty additional remote services became eligible for coverage because of the move, as did more kinds of providers. Practitioners no longer needed a previous relationship with the patient and did not need to work in the same state as the person receiving care. If health care professionals lacked digital platforms that complied with federal privacy laws, Medicare allowed them to use widely available apps like FaceTime or Skype. It allowed coverage for audio-only phone visits, too.And it raised reimbursement amounts so that providers were not paid less for telehealth than for in-person visits, eliminating a critical disincentive.Now, it’s hard to imagine health care without the “tele-.” Nearly a quarter of U.S. adults over 65 have had a video visit during the pandemic, a Mount Sinai study found.“They’re most likely to need frequent medical care,” said Julia Frydman, the study’s lead author. Seniors also may face mobility problems that make office visits daunting, and with less effective immune systems, they’re at higher risk for Covid-19. Using telehealth, “they wouldn’t have to travel back and forth and be exposed to a deadly disease,” she said.Dr. Frydman discovered that another benefit of telehealth was learning more about her patients’ home environments. One older telehealth patient proudly told her about tending the greenery she noticed behind him. Then, over several months, she saw that his house plants were wilting and dying. “It prompted me to ask about his mood, his energy,” she said, and his answers revealed a previously unsuspected problem.In her palliative care practice at Mount Sinai, Dr. Frydman has found that of course, telehealth has limits. “You sometimes want to see patients walk into the room,” she said. “Has their gait changed? How do they get in and out of a chair?”That’s what soured Marcia Weiser, 83, on telehealth. “It’s better than nothing, but I don’t see that it’s optimal,” said Ms. Weiser, a retired calculus teacher on Manhattan’s Lower East Side. Many of her health issues, like joint pain and cholesterol monitoring, require “something hands-on, or a blood test or a urine test or an eye test,” she said. “I can’t get that on a computer.”While telehealth may not be for everyone, studies have shown that both patients and doctors broadly support it. After 2023, when the current Medicare extension ends, “the core question for policymakers will not be whether to allow telehealth, but how to make it efficient, effective and equitable, available to everyone,” said Dr. Jacobson.Researchers are still investigating whether patients using the virtual services fare as well as they do with in-person care, though one review of clinical trials using video teleconferencing found largely similar results.Analysts are also tracking whether video and phone visits replace in-person appointments or are additional, unnecessarily boosting Medicare spending. Whether telehealth is more prone to fraud than in-person care is unclear, too.Improving equity in telehealth poses another challenge, since access to digital devices and the internet varies significantly between different groups.JB Lockhart, 69, a self-described telehealth partisan in Lake Oswego, Ore., began video visits with her primary care doctor even before the pandemic. “I live on my computer,” she said.But a Kaiser Family Foundation survey in the fall of 2020 found that a quarter of Medicare beneficiaries over age 75 had no access to the internet. A little over half owned a computer or smartphone, a much lower proportion than among those 65 to 74.The Pew Research Center reported this year that over a third of adults over 65 never used video to talk to other people during the pandemic. Only 45 percent used a social media site. About a third lacked home broadband.Among the Medicare population last year, Black and rural beneficiaries used telehealth less often than whites and urban dwellers, the federal report showed. Dr. Frydman’s national study also noted geographic differences, and found that beneficiaries with lower education and those living alone also used telehealth less.“We need to be really careful that telemedicine doesn’t worsen health disparities,” said Dr. Frydman.Several recent federal initiatives will help make broadband more available. The largest appropriation, in the infrastructure bill President Biden signed last month, directs $65 billion to improve internet access in rural areas and tribal communities, and for low- income families.Along with improved internet access, older Americans may need coaching to use the technology, and web designers may need to make telehealth platforms simpler to use. An analysis of electronic health records at Mount Sinai, for instance, found that during New York City’s initial Covid surge, only 53 percent of patients in the geriatrics practice had activated their patient portal, which is necessary for telehealth via video.Health systems trying to reach older patients might heed Dr. Forsyth, who offered a marketing tip. “Telemedicine sounds so cold and technical,” he said. “If it were called an ‘electronic house call,’ people could feel more comfortable.”

The federal government recently lifted most visitation restrictions at nursing homes. But concerns linger that a full reopening could leave residents vulnerable to another coronavirus surge.For nearly 20 months, the roughly 1.3 million Americans living in nursing homes and their families grappled with strict visitation policies that, while designed to keep vulnerable residents safe from the coronavirus, caused distress for separated loved ones and had serious health consequences for many suddenly isolated seniors.Initially, visitors were barred entirely. Later, facilities enforced a variety of rules: Some prohibited visitors from residents’ rooms, allowed visitors only outdoors and during brief scheduled windows, or permitted only one at a time.Many of these restrictions were based on rules, known as “guidance,” mandated by the Centers for Medicare and Medicaid Services, the federal agency that closed facilities to visitors in March 2020. It has issued several revisions since.Now all that has changed. On Nov. 12, the federal agency removed virtually all such restrictions and advised the country’s nursing homes to allow visitation “for all residents at all times.” The agency noted that 86 percent of U.S. nursing home residents and 74 percent of employees were fully vaccinated, and that Covid-19 cases had fallen drastically.The update means no more limits on the frequency, time, duration, location or number of visitors. Access to residents’ rooms, unless a roommate is unvaccinated or immunocompromised, is allowed, and advance scheduling is not required.The federal policy still encouraged vaccination and emphasized infection control measures, including masks and distancing policies established by the Centers for Disease Control and Prevention.“It makes an important statement,” said Lori Smetanka, the executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group that had pushed for such change. Previously, “facilities were given a lot of discretion,” she said. “Whereas this is pretty clear: It puts rights back in residents’ hands.”While facilities can ask visitors about their vaccination status and encourage testing, they can’t require either vaccination or tests for entrance. Even during a Covid outbreak, under the new guidance nursing homes must allow visitors inside, albeit with masks. Visitors who decline to disclose whether they are vaccinated must also wear masks.The rules cover only nursing homes, which are federally regulated, but they may have a spillover effect. “I think many states will apply this to other settings, like assisted living,” Ms. Smetanka said. California, for instance, has already responded by loosening some assisted living rules.In nursing homes, with their frail and disabled residents, “there can be precautions, but cutting off residents from their families was unethical and it was bad care,” said David Grabowski, a health care researcher at Harvard Medical School. “These are not social visits.”With nursing homes short-staffed well before the pandemic, family visitors frequently helped feed, wash and dress their loved ones. They provided not only reassurance and stimulation, but also the ability to monitor the facility’s safety and quality. A study on which Dr. Grabowski was a co-author, for instance, showed that nursing home residents with dementia received better care at the end of life if a family member visited regularly.When the pandemic cut off such contact, for more than a year in many cases, families reported disturbing health declines. A study of Connecticut nursing home residents, for instance, found substantial increases in depression and unintended weight loss during the lockdown; incontinence increased and cognition declined.Gloria DeSoto, 92, met with family members through glass at the Hebrew Home last year.Seth Wenig/Associated PressTrish Huckin spent nearly a year battling administrators at her 96-year-old mother’s nursing home in Pinckney, Mich., before she was allowed inside to make so-called compassionate care visits. Even then, “the restrictions were ridiculous,” she said. The facility allowed her three one-hour visits a week in a public area, only by appointment. If she couldn’t make one of the prearranged times, she could not reschedule.When the facility finally eased restrictions, Ms. Huckin — with her wife, a hospital nurse — was finally able to see her mother, who has dementia, in her room. They discovered that in addition to losing weight and becoming depressed, her mother had developed a bedsore and early pneumonia.Claudia Hutchinson has also seen her sister, who resides at a facility outside Philadelphia, grow depressed and lose weight and mobility since her visits were restricted to an hour or less outdoors. “If we’d been allowed inside, she wouldn’t have had this downward spiral,” she said. “She wouldn’t be on hospice care.”Some doctors and families now worry that the pendulum has swung too far, that fully reopening will leave an already vulnerable population prey to another surge. Covid infections are rising in nursing homes; flu cases are up nationally as well.The day the new federal guidance was announced, a Connecticut nursing home reported the deaths of eight residents with serious underlying health issues from a late September outbreak.“To have people tromping in and out during an outbreak, we know that’s not a good idea,” said Dr. Karl Steinberg, a California geriatrician and the president of the Society for Post-Acute and Long-Term Care Medicine, which represents health care workers in long-term care.As a medical director or attending physician at three nursing homes, he saw the pandemic’s early toll: “It was a blood bath.” He wished the latest federal guidance had left administrators more flexibility. Medicare might also have waited until after the holidays, he noted, and until booster shots were more widely distributed.Despite the removal of federal restrictions, some administrators think state and local health regulations may supersede the new federal guidance, potentially blunting its impact.“The standard rule is that a facility has to follow the most restrictive rule,” said Dr. Noah Marco, the chief medical officer at the large Los Angeles Jewish Home. He is cautiously optimistic that in a few weeks the state and county will loosen their policies, too. But for now, the facility continues to require advance scheduling, limit visit length and permit each resident only one visitor at a time indoors.Since the new federal policy was announced, “our staff has constantly been on the phone,” Dr. Marco said. “We’ve had family members who’ve heard about this and are saying, ‘Yippee!’ We’ve had to say, ‘We’re so sorry, but not so fast.’”A representative for the Centers for Medicare and Medicaid Services said that state or local health departments might need to reinstate restrictions “due to severe safety reasons,” but only in “isolated situations.” The representative added, “local governments should generally not seek to add rules and regulations which limit a nursing home resident’s right to receive visitors.”The new federal policy — bolstered by the Biden administration’s mandate that all nursing home staff members be fully vaccinated by Jan. 4 — is likely to loosen more extreme local and state policies.Alison Hirschel, the managing attorney at the Michigan Elder Justice Initiative, has been advising a woman whose relative, in her 70s, suffered a brain injury after an accident and entered a nursing home a few months ago.“She was very distressed,” Ms. Hirschel said of the advisee, who lives out of state. “She had to drive seven hours for a visit, and the visit was limited to 15 minutes — and only on weekdays during business hours.”Then, a day after the liberalized federal policy was announced, Michigan issued new guidance that allowed visits at all times, with no limits on the length of the visit or the number of visitors. “This really is a complete game changer,” Ms. Hirschel said.

Complex restrictions are preventing patients from accessing medical aid in dying, even in states where it is allowed. New legal and legislative efforts are pushing to change that.Five years ago, Dr. Nicholas Gideonse spoke with an older man who had received a terminal cancer diagnosis and was hoping to use Oregon’s medical aid-in-dying law.Oregon’s Death With Dignity Act, in effect since 1997, permits doctors, after a complex process of requests and waiting periods, to prescribe lethal medication for dying patients to self-ingest.The nonprofit group End of Life Choices Oregon had referred the man to Dr. Gideonse, a primary care doctor at Oregon Health & Science University and a hospice medical director, who had already helped many patients use the law.But this time he could not. “I’m really sorry,” he told the man on the phone. “I’m not going to be able to help you with this.” Oregon’s law — and all the laws that permit medical aid in dying in 10 states and in Washington, D.C. — has residency requirements. This man would have qualified — except for that fact he lived in nearby Washington State.The patient’s response, Dr. Gideonse recalled, was “stunned silence, deep disappointment.” A number of Dr. Gideonse’s primary care patients drive 20 to 30 minutes across the Washington border to his office in Portland. There, he can offer them any medical service he is qualified to provide — except that one — without proof of residency. And although Washington has its own aid-in-dying law, its southwestern region has few providers who can help patients use it.Last month Dr. Gideonse, backed by pro bono lawyers and Compassion & Choices, an advocacy group for expanding end-of-life options, filed a federal lawsuit claiming that the residency requirement for Oregon’s aid-in-dying law is unconstitutional. “I realized how important this could be for patients seeking access,” he said.The lawsuit is one of several legal and legislative efforts around the country to reduce the requirements that patients must contend with in order to receive aid in dying. In some states, lawmakers have already broadened the types of health care providers that can participate, or have shortened waiting periods or allowed waivers.“I think of it as MAID 2.0,” said Thaddeus Pope, an end-of-life bioethicist at Mitchell Hamline School of Law who tracks such actions, referring to the acronym for medical aid in dying. “We found out there’s an access problem.” He added, “We set all these safeguards and eligibility requirements and they locked a lot of people out.”Oregon led the shift in easing access, amending its law in 2019. The state previously required patients to make two verbal requests for life-ending medication, at least 15 days apart, to ensure that they had not changed their minds. Now, if the patient is unlikely to survive that long, their doctor can waive the 15-day waiting period.“Fifteen days is everything when you are suffering,” said Kim Callinan, the president and chief executive of Compassion & Choices, which supported the change. “People who are eligible for the law are hitting roadblocks and barriers.”In 2016, for example, Youssef Cohen, a political scientist at New York University, took the extraordinary step of moving across the country to use the Oregon law as he was dying of mesothelioma at 68. “He wanted the option to determine the end of his life,” said his wife, Lindsay Wright, who is an associate dean at the university.To establish residency, the couple had to hurriedly sign an apartment lease, obtain an ID from the state motor vehicle agency, transfer medical records and arrange an immediate appointment with a Portland doctor to qualify for medical aid in dying. Dr. Cohen then faced the 15-day waiting period.“He didn’t make it,” Dr. Wright said. “He died six days after we arrived. And he suffered.”A 2018 study from the Kaiser Permanente health system in Southern California showed that about one-third of qualifying patients died before they could complete the process.New Mexico, which in June became the most recent state to legalize medical aid in dying, has adopted a markedly less restrictive approach than other states. The largely rural state is the first to allow not only doctors but advanced practice registered nurses and physician assistants to help determine eligibility and write prescriptions for lethal medication. “In some communities, they’re the only providers,” said Representative Deborah Armstrong, a Democrat and the bill’s primary sponsor.Although a doctor must also affirm that a patient is terminally ill, New Mexico patients can skip that step if they have already enrolled in hospice, as most do. The patient need only make one written request, rather than two or more requests, as other states require. A 48-hour waiting period between when the prescription is written and when it is filled can be waived. “People walk up and tell me how thankful they are to have this option if they need it,” Ms. Armstrong said.California has simplified its 2016 law as well. In October, Gov. Gavin Newsom signed legislation that, starting in January, reduces the 15-day wait between verbal requests to 48 hours and eliminates the requirement for a third written “attestation.”Similar bills died during the most recent legislative sessions in Hawaii, Washington and Vermont, but will be reintroduced, Ms. Callinan said. And in many states — including Delaware, Indiana, North Carolina, Virginia, Pennsylvania and Arizona — new aid-in-dying bills, if passed, will ease requirements for patients or expand the kinds of providers who may participate.On the legal front, the Oregon lawsuit filed by Dr. Gideonse argues that residency requirements for aid in dying violate two sections of the U.S. Constitution, one barring state laws that limit the ability of a nonresident to access medical care and one prohibiting state laws that burden interstate commerce. The state must respond by Dec. 27.“This is the only medical procedure we can think of that is limited by someone’s ZIP code,” said Kevin Diaz, the chief legal advocacy officer at Compassion & Choices.A separate federal class action suit claims that California’s law, which like the others requires patients to self-administer the drugs that end their lives, discriminates against patients dying of neurodegenerative diseases that make it physically impossible to take medication without assistance.The plaintiffs, charging violation of the Americans With Disabilities Act and California law, include patients with multiple sclerosis and A.L.S., also known as Lou Gehrig’s disease, and their doctors. (In denying a request for a preliminary injunction, a judge ruled in September that the plaintiffs were asking California “to cross the line to euthanasia.”)Catholic organizations, anti-abortion advocates and some disability groups continue to oppose aid in dying. The California Catholic Conference, the church’s public policy organization, for example, argued in June that liberalizing the state’s law “puts patients at risk of abuse and the early and unwillful termination of life.”But polls regularly report broad public support. Last year, Gallup found that 74 percent of respondents agreed that doctors should be allowed to end patients’ lives “by some painless means” if they and their families request it.Liberalizing the laws will likely increase participation, the bioethicist Dr. Pope predicts. “We know from evidence around the world that if you reduce the waiting period, or allow waivers in certain cases, it materially expands access,” he said.Experts do not expect a major surge, however. Even in states where the practice has been legal for years, aid in dying accounts for very few deaths, a fraction of one percent. Of those who successfully navigate the process, moreover, about one-third do not use the drugs and instead die of their diseases.Still, should Dr. Gideonse prevail in his lawsuit and a likely appeal, residency requirements in other regions might also start to fall. That could allow New York or Pennsylvania patients to use New Jersey’s aid-in-dying law, for instance, or Maryland and Virginia residents to seek providers in Washington, D.C.It is an outcome that would please Dr. Gideonse. “This is an action in support of a needed and very important service,” he said. “I’m optimistic.”

Most Medicare beneficiaries don’t compare plans during open enrollment season, and may be paying more, or accepting more restrictions, than they should.One morning last month, Eunice Korsah, a retired nurse in Burke, Va., spent about half an hour on the phone being guided through the complexities of various plans for Medicare Part D, which covers prescription drugs.Her current drug plan was being discontinued and the insurer wanted to move her into one with sharply higher premiums. “I decided, ‘No way,’” she said. But what to replace it with? She looked at the Medicare website for Part D plans available in Fairfax County and found 23, with monthly premiums ranging from $7.10 to $97.30. “There are so many choices, so I wanted someone to clarify them for me,” she said.Jack Hoadley, a health policy researcher at Georgetown University, was on the other end of the call with Ms. Korsah. He has for two years volunteered with the State Health Insurance Assistance Program, or SHIP, the federally funded, free counseling service that helps Medicare beneficiaries find the coverage that’s best for them.“Some very smart people just don’t know how Medicare works and get confused,” Dr. Hoadley said. For example, “it can make a $1,000-a-year difference if you’re willing to try several different pharmacies.”Ms. Korsah, 74, and her son had already compiled a list of her eight medications — for blood pressure, cholesterol, acid reflux and glaucoma — and their doses. Using the online Medicare Plan Finder, Dr. Hoadley narrowed the field to three suitable selections.With the cheapest plan, from Wellcare, Ms. Korsah’s estimated total yearly drug and premium costs (“the magic number,” he said) would be $301 a year if she used a CVS or Giant pharmacy — but $1,125 if she took the same prescriptions to a Walmart. Conversely, a Humana plan would cost $525 a year through a Walmart pharmacy, but more than twice that at CVS. With a Cigna plan, the best deal involved a mail-order pharmacy.In theory, all beneficiaries who have traditional Medicare with Part D coverage, or who are interested in or enrolled in Medicare Advantage programs (an “all-in-one” alternative offered through private insurers), should be making similar calculations during this annual open enrollment period, from Oct. 15 until Dec. 7. It’s the reason that insurers’ pitches for plans are showing up in their mailboxes and inboxes, and on TV ads featuring Joe Namath and Jimmie “Dyn-o-mite” Walker.“The idea is that consumers can re-evaluate what coverage is best for them,” said Tricia Neuman, the executive director of the Program on Medicare Policy at the Kaiser Family Foundation. Since each year brings changes to Part D and Medicare Advantage — in premiums, benefits, co-payments and provider networks — shopping around makes sense.But that’s not what happens.For 2019, 71 percent of beneficiaries said they didn’t compare plans during the open enrollment period, according to a Kaiser study published last month. The rate was even higher among Black and Hispanic beneficiaries, people over 85 and those with lower income and fewer years of education — precisely the groups most likely to require more medical services and drugs, and least able to pay high costs.Roughly half of respondents had never visited the official Medicare website, used its 1-800-MEDICARE help line or read the “Medicare & You” handbook that annually arrives by mail.Accordingly, “there’s not a lot of switching,” Dr. Neuman said. Kaiser found that in 2019, only eight to 10 percent of beneficiaries voluntarily changed their Medicare Advantage or stand-alone Part D plans.Ms. Korsah’s medications. Because she ended up signing up with the low-cost Medicare Wellcare Part D plan, she will probably pay less for drugs than she did last year.Kenny Holston for The New York TimesSome of that inertia may reflect people’s satisfaction with their coverage; it might also indicate an overwhelming amount of choice. For 2022, beneficiaries face an average of 33 Medicare Advantage plans to select from (but 56 in Philadelphia and 63 in Cincinnati) and 30 stand-alone Part D plans.“It is hopelessly, needlessly complicated and it continues to get more complicated,” said David Lipschutz, associate director of the Center for Medicare Advocacy. “The entire system relies on savvy actors maximizing their choices, and that just does not happen.”Even those who are motivated to comparison shop can have trouble finding reliable information. Most overtures and ads come from brokers or agents with financial incentives, though the offers may mimic official Medicare communications.Moreover, “brokers typically only market a portion of plans,” sometimes excluding the most advantageous, a fact they’re not required to disclose, said Gretchen Jacobson, a vice president of Medicare at the Commonwealth Fund, a foundation which supports health research.The Center for Medicare Advocacy, a nonprofit group, has charged that Medicare itself has shown bias toward private Medicare Advantage plans in its promotional materials, starting in 2017. “They started overplaying some of the benefits and downplaying some of the negatives,” said Mr. Lipschutz. “I think they wanted private health insurers to thrive.”Medicare has since resumed a more neutral stance, but “they still have a way to go,” Mr. Lipschutz said.As for the star ratings that Medicare awards, critics have begun to invoke “the Lake Woebegon” effect (after the radio personality Garrison Keillor’s fictional town where “the children are all above average”). Medicare gave four stars or higher to 68 percent of 2022 Medicare Advantage plans with drug coverage, making the rankings less than useful for comparisons.How much does all this matter? With Part D, choosing the most cost-effective plan goes beyond a financial issue, because skipping unaffordable medications can have health consequences. And choosing between traditional Medicare and Medicare Advantage involves substantial differences in the health care experience.Medicare Advantage plans, so increasingly popular that 42 percent of Medicare beneficiaries are now enrolled in one, offer one-stop shopping. They include a Part D benefit, and don’t require a supplemental Medigap policy to cover co-payments and deductibles.They put a cap on out-of-pocket expenses ($7,550 for in-network coverage in 2021). They also promote “extra benefits” like dental, hearing and vision coverage, and transportation — though “they may not be very generous,” Dr. Jacobson said. However, some services aren’t available to everyone in the plan, and beneficiaries can’t learn if they’ll qualify until after they’ve enrolled.Medicare Advantage also restricts full coverage only to doctors, hospitals and pharmacies within their networks; if patients go outside the network, they face higher costs or may have to pay entirely out of pocket. In-network providers change frequently, and it can be challenging to ascertain which ones a plan includes.Except for emergency or urgent care, Medicare Advantage coverage may not extend outside beneficiaries’ county or state. “If you’re in Albany, you may not be able to get care in New York City,” Dr. Jacobson said. Advantage plans also often require preauthorization from the insurer for services and drugs.With traditional Medicare, “you can see any provider you want to at any time, without getting prior approval,” Dr. Jacobson said. It’s accepted nationally. But factoring in a private Medigap policy and a separate Part D plan sometimes pushes overall costs higher.Still, a recent Commonwealth Fund analysis found that traditional Medicare and Advantage plans (excluding special needs plans) now attract similar populations in terms of demographics and health, with high rates of satisfaction in both groups (though both reported waiting more than a month for a doctor’s appointment).Advantage beneficiaries are more likely to receive some care management services, such as a review of their medications, the study found. But when it comes to patients’ health, “it doesn’t seem to change the outcomes much,” Dr. Jacobson said, because hospitalization and emergency room use were roughly the same for both groups.That raises the question of whether the federal government should continue paying Advantage plans 4 percent more per beneficiary than it pays for those in traditional Medicare. Everyone who pays a Part B premium, which is almost every beneficiary, winds up subsidizing that higher cost.But for now, it’s open enrollment season. SHIP programs in every state, with 12,500 trained team members, represent the best source of unbiased information and work with more than 2.5 million people each year.Ms. Korsah, who opted for traditional Medicare because she wants to be able to choose her doctors, signed up with the low-cost Wellcare Part D plan and will probably pay less for drugs than she did last year.So she appreciated Dr. Hoadley’s counsel. “He was a great help,” she said.

Anne Cotton had enjoyed her years at an assisted living facility in Corvallis, Ore. But at 89, her health problems began to mount: heart failure, weakness from post-polio syndrome, a 30-pound weight loss in a year.“I’m in a wheelchair,” she said. “I’m getting weaker. I’m having trouble breathing.” On Sept. 30, Dr. Helen Kao, her palliative care doctor and a medical director at Lumina Hospice & Palliative Care, determined that she qualified for hospice services — in which a team of nurses, aides, social workers, a doctor and a chaplain help patients through their final weeks and months, usually at home.Ms. Cotton, a retired accountant and real estate broker, embraced the idea. “I’ve lived a very full life,” she said. “I’m hoping I’m near the end. I need the help hospice gives.” Her sister died in Lumina’s care; she wants the same support. For older patients, Medicare pays the cost.But Lumina and other hospices that serve Benton County, Ore., are grappling with pandemic-fueled staff shortages, which have forced them at times to turn away new patients or delay their enrollment — as it did with Ms. Cotton. “It’s devastating,” Dr. Kao said.Another of her palliative care patients, Ruth Ann McCracken, 91, has declined physically and cognitively since suffering two strokes last year. Last month, her family made an appointment for hospice enrollment.The day before the appointment, Dr. Kao made a difficult call to Ms. McCracken’s daughter, explaining that Lumina had lost several nurses and could not safely admit new patients, perhaps for several weeks.Distressed and fearful of delay, the family followed her advice and made an appointment for enrollment with another local hospice, Samaritan Evergreen — only to have that meeting postponed, too, because of a nursing shortage.Ms. Cotton and Dr. Kao. “I’ve lived a very full life,” said Ms. Cotton, whose sister died Lumina’s care. “I’m hoping I’m near the end. I need the help hospice gives.” Alisha Jucevic for The New York TimesAn imitation rose sat on top of Ms. Cotton’s meal schedule at Regency Park Place.Alisha Jucevic for The New York TimesHospice staff shortages have developed across the country, and while closing to new patients is not a common response, “it’s getting worse,” said Edo Banach, the president and chief executive of the National Hospice and Palliative Care Organization. “If this goes on much longer, it’s going to happen more.”In a stressed health care system, some routine procedures or elective surgeries can be deferred without much harm. But more than half of the 2.3 million Medicare beneficiaries who die annually rely on hospice care, Medicare reported. To qualify for hospice, patients are deemed to be within six months of death, which cannot be postponed.Because many put off enrolling — American patients spend only a median of 18 days in hospice — even short waits can mean the loss of valuable care, from pain relief to help with household tasks.“It causes huge distress to tell a family, ‘We can’t serve you,’” said Barbara Hansen, who directs Oregon’s and Washington’s state hospice and palliative care organizations.The Center for Hospice Care in northern Indiana, which serves about 2,000 patients annually, has not had to turn away patients. But the smaller of its two inpatient units, a seven-bed hospice in Elkhart, has remained closed since July because of inadequate staff.The Center had planned to reopen it on Oct. 1, but a newly hired nurse left, so the unit remains unavailable. “I keep thinking it’s going to get better,” said Mark Murray, the Center’s president and chief executive.In New York State, “it’s a day-to-day jigsaw puzzle that puts a strain on the organization,” said Jeanne Chirico, the president and chief executive of the state’s Hospice and Palliative Care Association. Some hospices, which often pride themselves on enrolling new patients within a day, may take an additional day or two, since admissions are a labor-intensive process. They may send home aides for fewer hours.Many hospices are trying to recruit staff with signing bonuses; on the high end, EvergreenHealth Hospice Care in Seattle is offering $15,000 for registered nurses and $5,000 for licensed practical nurses. It has not lost much staff, said Brent Korte, the agency’s chief home care officer, “but we may go from our average care load of 12 patients per nurse to 15, temporarily.”The shortage, hospice administrators say, stems partly from an exhausted staff who visited patients’ homes through the worst of the pandemic, wearing full protective gear (once they could acquire it).Now Willamette Valley Hospice and Palliative Care, which also serves Corvallis, has lost 25 percent of its registered nurses since the pandemic began and has closed to new patients several times. “The fatigue, the disappointment is hitting us,” said Iria Nishimura, its executive director.Staff shortages also reflect economic pressures. Hospice nurses typically earn less than those employed by hospitals or traveling nurse agencies, which have raised their wages and bonuses as they also face a pandemic-related lack of nurses.In Oregon and Washington, for instance, a registered nurse working for a hospice might make $40 to $60 an hour, Ms. Hansen said. Agencies in those states are advertising up to $130 an hour for traveling nurses, she said, and one in Seattle is said to be dangling $275. “No hospice can match that,” she said.Dr. Kao has had to turn away patients or delay their enrollment in hospice, and it takes its toll on families, patients and caregivers alike. “It’s devastating,” she said.Alisha Jucevic for The New York TimesMs. Cotton rubbed her hands during a check-up with Dr. Kao.Alisha Jucevic for The New York TimesAt Lumina, where staff turnover has run 80 percent higher than usual, “we’ve had job postings for months without any applicants at all,” Dr. Kao said. It has begun offering $2,000 bonuses for registered nurses.Hospice aides, who are usually certified nursing assistants, are being lured away, too, sometimes leaving health care entirely. “When they’re getting paid in the low double digits and Amazon pays twice that, it’s hard to compete,” Mr. Banach said.Vaccination resistance is also shrinking hospice staffs in states — roughly 20, according to Leading Age, which represents nonprofit senior care providers — that mandate shots for health care workers.Hospice organizations have supported such mandates, and report that most workers have complied. But losing even a few resistant hospice staff — perhaps five percent in New York State so far, Ms. Chirico estimated — could bring temporary closures, wait lists or higher caseloads for the remaining staff. (Rules for the Biden administration’s federal mandate, governing all health care providers that receive Medicare and Medicaid funding, including hospices, are expected soon.)Hospice organizations received aid through several rounds of federal pandemic relief, but they need more to rebuild their staffs, Mr. Banach said. They could also benefit from changes in immigration law to help bolster the work force.Those kinds of changes take time, however. Hospice workers require specialized training. Even if scrambling hospices could hire nurses tomorrow, it would take several months for most to be fully ready to work with dying patients.“It’s going to be a tough six months,” Ms. Hansen predicted; other administrators interviewed found her statement optimistic.In Oregon, Samaritan Evergreen Hospice began receiving overflows from other local hospices and, for two weeks in September, was forced to practice triage. “We were taking the most ill, actively dying patients first,” said Karen Daley, the hospice director. Those who weren’t struggling with symptoms and had good support at home waited for several days.Evergreen’s staff has stabilized for now, and triage is no longer necessary, although it could resume at any time. Ms. McCracken, to her family’s relief, was enrolled on Oct. 8.Ms. Cotton prefers to use Lumina, so she is still waiting. “I don’t know how many people are ahead of me,” she said. “Basically, I have to wait for people to die, and that’s not a pleasant thought.”Dr. Kao and Ms. Cotton at Regency Park Place.Alisha Jucevic for The New York Times