Three Wishes

6 min read

You know that old trees just grow stronger/ And old rivers grow wilder every day
Old people just grow lonesome/ Waiting for someone to say, “Hello in there, hello”
– John Prine, 1971

Loneliness kills.

Elderly loneliness leads to depression, obesity, high blood pressure, and cognitive impairment. Together these lead to declining health and mobility, which result in more falls, more emergency room visits, more hospitalizations, and more early deaths. It boosts early-mortality expectation twice as much as obesity, and two-thirds as much as poverty. If loneliness were cancer, it would be in line for billions in annual grant funding – and unlike cancer, it’s easily curable, today, at low cost.

The antidote is community. Study after study confirms what anyone with a relative knows: feeling connected to others improves one’s mood, which improves one’s well-being, which extends, both, one’s lifespan and one’s healthspan.

Despite this intersection between science and common sense, in elderly affordable housing properties today, three current rules (made decades ago with different facts and circumstances in mind) obstruct the creation of truly human communities in our elderly housing, and in so doing, foster loneliness. We can change this, and revolutionize elderly housing, if a genie grants us three wishes:

Problem 1: No funding for elderly services. With declining mobility and increasing fragility, our ability to be physically independent declines, and the radius of journeys, both physical and psychological, that we are willing to make gradually shrinks. What once we happily did for ourselves, now we need others to help us with. Whether these are Activities of Daily Life (ADLs), outings, guest speakers or entertainers, wellness checkups, low-impact exercises, helping us fill the pill boxes, or just making each day a little different from the day before, there are people who make a living providing these services. But elderly service is a business, whose entities and people need to be paid – and the property’s affordable and regulated rents cannot sustain a line item to do so.

The logical funding source – Medicaid – is almost always barred to us. The tantalizing Section 1115 Medicaid waiver whereby states can grant broad authority for “providing services not typically covered by Medicaid or using innovative service delivery systems that can improve care, increase efficiency, and reduce costs” is guarded by the dragon CMS (the Center for Medicare and Medicaid Services) lurking deep in the HHS lair. Many have ventured in; few have returned successful.

Wish 1: Broad national demonstration program with bulk Section 1115 waivers on a per-capita basis by state.

Problem 2: No financing to retrofit structures to accommodate aging-in-place. Beyond the direct service provision, many of today’s aging elderly live in structures long since physically obsolete for them:

  • In-apartment modifications. A score of things suitable for ambulatory adults become silent barriers for the elderly. Grab bars, handles not knobs, bath shower stalls and bath chairs, non-slip flooring, storage relocated from reaching height to sitting height are all easily and cheaply fixed, but they add up and they take an apartment redesign.
  • Barriers to movement. Narrow doors, narrow and long corridors, dim lights, even a handful of intra-building steps pose barriers to sociability. Even wayfinding guidance and pause points, cheap though both are, make a big difference.
  • Missed networking opportunities. All public spaces can be socialization venues. Corridors can have pause points. Public spaces become activity and computer centers. Outdoor space can be colonized by gardeners and walkers. Wi-fi throughout the building brings the world in safely. Bright young people set up Skype and its headset, then load addresses of friends, relatives, children and grandchildren, remove the barrier of technophobia.

The package of retrofits faces a threefold challenge:

A. Rousing the slumbering grandfather. The provisions that exempt many older properties from today’s accessibility requirements are nullified on major renovation, so we tiptoe around the edges, not doing what the building truly needs because the accessibility compliance surcharge ruins the economics.

B. Diverting the stream. Even with a Section 1115
Medicaid waiver, any funds flowing into the property are trapped in housing’s regulatory agreement vortex. Instead, we need the incoming fee stream to run ‘outside’ the operating budget, and that complicates not only the service provision (previous point) but also the forms of service contract.

C. Cutting in front of the lienholders. When the property was financed originally, each additional loan (including soft loans) claimed the added ‘security’ of a mortgage. Now, with changing economic imperatives, what perfectly suited us long ago is a financial straitjacket –any asset that is physically attached into the buildings is considered part of the real estate, and hence is ‘additional collateral’ for each lienholder in the queue.

Wish 2: New form of ‘collateral assignment lien,’ covering service-oriented retrofits, that is declared to be outside the original mortgage(s) collateral and instead can be independently pledged as security for the payment of the service-oriented funding stream.

Problem 3: No ability to sprinkle young families in with the elderly. For the elderly, the most bracing youthfulness tonic of all is friendly contact with the younger generation: the sons and daughters they never had or seldom see, the grandchildren whose delight in the world is matched only by the grandparent’s delight in revealing it. Still, the elderly like to sip their youth tonic in Paracelsian small doses at measured intervals, so the ideal living configuration would be majority (say, two-thirds) elderly, minority family, with the families chosen to include adults who are in the service professions that the elderly need, so the newcomers have jobs in the property they live in.

This paradigm exists in your town, possibly in your extended family: you call it the live-in companion or home health aide. In some places (e.g. Vermont) it’s the home-sharing model. It makes perfect sense for affordable housing, but there’s just one flaw: Under the Fair Housing laws and regulations, no one may live separately from families with children, except genuine seniors living in an elderly-disabled property. Sprinkle in even a few families and the Fair Housing exemption is destroyed. That long arm of the Federal government explains why the home-sharing model is arising bottom-up, from people to families to neighbors, and why in our world it’s rare.

Wish 3: Broad Fair Housing waiver to enable piloting of multi-generational housing anchored by the elderly.

Three obstructions, three wishes. Who then can be our genie? A glance at them shows the answer: The two-headed genie of HHS and HUD. On the ground of public health the two-headed genie can do just about anything (say, seeking to ban smoking in public housing). If loneliness were smoking or Alzheimer’s, it would be their top priority.

Genies never grant what you do not ask. Though death by loneliness in today’s elderly affordable housing may be the fault of no one, if we as affordable housing experts do nothing, the fault of inaction will be ours.

It is up to us to ask.

So if you’re walking down the street sometime/ And spot some hollow ancient eyes
Please don’t just pass ‘em by and stare/ As if you didn’t care. Say, “Hello in there, hello”

David A. Smith is founder and CEO of the Affordable Housing Institute, a Boston-based global nonprofit consultancy that works around the world (60 countries so far) accelerating affordable housing impact via program design, entity development and financial product innovations. Write him at