“Listen. Ninety-three, eighty-six, seventy-nine….”
This is how my father greeted me from his chair on the porch when I pulled into the driveway of my parents’ longtime home, in an Ontario village, three years ago.
“Uh, hi Dad,” I said.
“Shh!” he shot back. “Seventy-nine, seventy-two, sixty-five….”
I knew what the performance was about. One part of the Mini-Mental State Examination that doctors use to assess a person’s cognitive health asks patients to count backwards from 100 by sevens. My father thought that if he passed the “Serial Sevens” test during his next appointment with the gerontologist, she’d give him back the driver’s license his family doctor had revoked. He was desperate to show me how much progress he had made since I last practiced with him on the phone from New York.
Indeed, his flow was steady and flawless and I cheered when he landed at “two.” But I already recognized that not even a perfect score would have won him the right to drive again. Not with his Alzheimer’s diagnosis and the early effects it was having on his brain.
What I didn’t fully recognize in that moment was that the first domino had fallen. Without transportation, my parents would start missing doctor appointments, become isolated, and show signs of depression, despite the heroic efforts of one supremely kind neighbor. Within a year—and predictably, I now understand—a crisis involving hallucinations would send my father to the hospital, and my sister and I would begin scrambling to find them both a new place to live. He was not to be discharged, the hospital officials told us, without a plan for 24-hour care in place.
So, like millions of other adult children of aging parents, we were thrown into the massive private senior housing industry, valued at an estimated $409 billion in the US alone, and we had to get up to speed fast.
Thus we entered a disorienting, parallel universe of brick buildings with taupe, white or faintly peach trimmings, which had emerged seemingly out of nowhere. They were assisted-living centers, and they had been built over the past few years near my sister’s house in the suburbs of Toronto, but remained irrelevant and invisible to me until the moment I needed them. They were almost all about five or six stories tall and built with covered entryways that led to piano lounge-like foyers.
Tortured by guilt and grief, panicked about finances, we began touring these assisted-living homes and meeting with sunshiney sales and marketing reps who were all too familiar with our predicament.
I’m here to tell you that it wasn’t all that bad. In fact, many seniors homes, even those not part of the “luxury” market, are nice places to visit and—dare I say—live.
We found tastefully decorated residences that housed small screening rooms for movie nights, spas and salons to keep your nails polished and hair coiffed (for an extra cost), and dining rooms illuminated with natural light. Rather than identical boxes, the living quarters themselves were available in various layouts and sizes. The new assisted living is nothing like the dreary, cookie-cutter nursing homes that were most people’s only choice 30 years ago.
There’s also reason to believe that the options are going to keep getting better—at least for those who have the means.
Already, one company in Switzerland, The Embassies, is launching a global seniors co-living model based on the Soho House club structure. And in California, the San Francisco Zen Center, in partnership with a not-for-profit senior housing company, is opening “Enzo Village,” a “Zen-inspired” seniors’ continuum care retirement community (CCRC) for those who seek morning zazen sessions or simply want “to be more present and relaxed, surrounded by a community of people like you facing the aging process with joy, curiosity and equanimity,” according to its website. At Arizona State University, a glass tower of assisted-living residences, anchored by an aquatic center and theater, will open next year. The Mirabelle@ASU, part of a boomlet of university-based retirement communities under development, is almost sold out.
But the seniors’ housing industrial complex, as such, also has its dark side. Surprisingly high rents (which average $4,000 to $5,000 a month, and reach well beyond that in big cities) mean that it’s mainly wealthy, white seniors who are residents in these communities. You’ll find more diversity among the caregivers, who often are women of color; despite the extreme labor shortage in their profession, their employers are routinely called out for underpaying staff. And the industry runs with spotty oversight in countries like the US, with its confusing array of state regulations.
Many assisted living homes also stand accused of accepting residents who are too frail to be cared for properly in an understaffed facility, or one where caregivers are not well-trained. The tragic and often horrific lawsuits documenting senior neglect and abuse point to a need for reforms.
Nevertheless, for some families, an ethically managed assisted-living home with a compassionate and skilled staff may indeed be within reach, and a very sensible answer at that. I just have a word of warning: Don’t wait until it’s an emergency. Get to know this world now.
By the digits | Profit or not-for-profit: Is that the question? | How we got here | Wait, how does anyone pay for this? | The dark side of assisted living | The biggest players | The American Model is exported abroad | Final thoughts: Zen and the art of “next gen” senior housing
22%: The proportion of the world’s population that will be over age 60 by 2050.
400 million: Number of people who will be over age 60 in China alone, by 2050.
10,000: Number of US baby boomers turning 65 every day.
2030: The year by which the US Census Bureau projects there will be more residents aged 65 and older than people under age 18 in the country.
6 million: Number of US seniors expected to transition into senior housing in the next decade.
768,000: Number of US jobs supported by senior housing businesses.
13.3%: Annualized one-year returns on senior housing property investments, according to industry stats.
$4,051: National average monthly cost of renting an assisted living suite (prices can rise considerably in some regions)
$11,000 to $33,500: Per-person price range, per month, to reside in Sunrise Living’s new luxury senior housing development, “Sunrise at East 56th” in Manhattan, according to a sales manager.
$90,000: Out-of-pocket cost per year to live in a US nursing home, if you don’t have Medicaid coverage.
$16,743: Average monthly cost of in-home 24-hour personal care by a home health aide in Cleveland, according to the GenWorth Cost of Care Survey 2019 calculator.
50/50: Chances you’ll need paid long-term care, as of age 65, which currently costs an average $140,000 in total.
Most hospitals in the US are run as nonprofits. But in senior housing, the opposite is true: the profit motive drives operations in about 70% of properties, excluding CCRCs, according to the nonprofit National Investment Center for Seniors Housing & Care, or NIC.
On the surface, this sounds like a case of inherently incompatible interests. Some elder-care advocates would like to see the for-profit model pushed out of senior care entirely, citing the grave risks created when care and staffing levels are compromised in the name of higher investor returns. And, indeed, some studies show that seniors have better outcomes in not-for-profits, on average.
However, Chris Mulrooney, who heads the for-profit Villas at Killearn Lakes in Tallahassee, Florida, says that he has worked “on both sides of the aisles, so to speak,” and that quality comes down to senior leadership. “People who are motivated by wanting to make a positive change can be people who work in both not-for-profit and for-profit settings,” he says, and you’ll find people who care solely about hitting a metric answering to shareholders or not-for-profit boards of directors.
Other experts who spoke to Quartz relayed a similar message: It’s most important to understand the culture of an individual facility. There are several checklists of questions to ask when shopping for a seniors home available online. To these, Mulrooney suggests adding a question about the goals of senior leadership. Are they committed to empowering elders, especially those without a voice, he asks? Are they part of a culture change that embraces supporting and valuing caregivers as care “partners”?
Keren Brown Wilson, an industry pioneer and adjunct professor at Portland State University, likewise advises getting to know the “person who runs the building,” i.e., the executive director or general manager. “They are the ones that answer up and manage down,” she says. “If that person is not a good administrator, you’ll know.
She tells shoppers to visit on a Sunday morning or a Saturday afternoon “and see how it feels, see how it looks.”
“You can talk to the residents, nobody can keep you from talking to people,” she adds. “Don’t just listen to the person who’s the marketing person. Go and have lunch and sit around and just watch, because you will learn an awful lot by investing a little bit of time.”
The birth of the modern assisted-living industry in the US was fueled by two young entrepreneurs, working independently of each other on opposite coasts.
One was Brown Wilson, known as the architect of the Oregon model of assisted living—that is, a care facility that houses residents in private apartments, but is nevertheless largely funded by Medicaid. She wrote a history of the sector, published in The Gerontologist in 2007, that traces the genesis of the first licensed assisted-living house in the US, which she opened in 1989 in Oregon.
Now an adjunct professor at the Portland State University Institute on Aging and still an adviser to one of the three senior housing companies she founded, Concepts in Community Living, Brown Wilson was inspired to build the model after witnessing her mother’s dissatisfaction when, after a stroke at age 55, she was moved into a traditional nursing home. Brown Wilson was a college student at the time. One day, she told her mother that she planned to become a gerontologist, to which her mother said, “Why don’t you do something to help people like me?” That is, people who couldn’t afford other options but a highly regulated public bed, and were thus forced to eat hospital cafeteria food and live without privacy, deprived of their personal belongings, including pets and, in her mother’s case, cigarettes. “It really exposed me to a great disparity, in terms of what the goals were of her, as a person, and they, as an institution,” says Brown Wilson.
She would go on to complete a PhD in urban studies and dedicate her career to helping low-income seniors age with dignity. She subscribed to the philosophy of an American aging researcher named M. Powell Lawton, “who said people function best when they had sufficient support in their environment to help them be as independent as they could be. If they were in an environment that was not supportive, they would not do well, and if they were in an environment that was too too helpful, then they would not flourish either,” Brown Wilson says. “My goal was to find the point at which people could be as independent as they could be without exposing them to undue risk.”
As part of her efforts to lobby the state for backing, she put together a Medicaid demonstration project—a project she says is the reason why there are now more people in Oregon served in assisted living than in nursing homes.
In the east, meanwhile, a style of senior residence that would come to be recognized as “the hospitality model” was developed by Paul and Terry Klaassen, co-founders of Sunrise Senior Living, one of the largest senior-housing providers in the country.
In 1981, the Klaassens opened a small communal home for seniors near Fairfax, Virginia, fashioned after the cozy verzorgingstehuizens, or Dutch nursing homes, Paul Klaassen had come to know through trips to the Netherlands with his immigrant parents. “I started Sunrise when I was 23 years old and that’s important because I didn’t have any real biases other than my Dutch experience,” he says.
Back then, he says, “you had an incredible over-reliance in the United States on the nursing home model, meaning the institutional, fluorescent lit, very hospital-like model.” Senior apartments offered an alternative, but they lacked services. In the Netherlands, he says, long-term care “looked different. It was more residential, but it also provided high quality of life, most importantly also high quality at the end of life.”
The Dutch approach, akin to what also could be found in parts of Scandinavia, was pragmatic: Why would you want to move somebody “when they’re frail, at end of the life, to a fluorescent lit hospital room like Americans did—or do?” says Klaassen. The idea with Sunrise was to be an alternative to a nursing home, not a pitstop on the way to one, as some people now see it. (In some cases, state laws prevent seniors from remaining in private assisted living facilities when, say, they require two people to lift them out of bed or help them use a bathroom, or when they lose the ability to swallow food. Others allow all kinds of care, including hospice services, in the private-pay setting.) “Our model was going to be much more residential in appearance, more like a big mansion, it had beautiful finishes, like you’d find in a five-star hotel, because there’s nothing about long-term care that requires fluorescent lighting,” he says. “In 400 communities we built, we never installed a fluorescent tube.”
That first home they converted became a showpiece meant to raise awareness of what was possible. “We wanted to create a movement, not a company,” says Klaassen. “Our first prototype, we were very, very clear that we wanted to be copied. We purposely had it toured hundreds and hundreds of times a year.” He invited hotel operators and led tours to the Netherlands through the Assisted Living Federation of America (ALFA), a professional group he founded. (Though you’ll still hear the association referred to as “ALFA”, it has officially rebranded as Argentum.)
In 1987, the Klassens opened the first Victorian mansion-style community that has come to symbolize the couple’s brand, with hundreds of replications. Like Brown Wilson, a friend and longtime industry ally, Paul Klaassen says he wanted to give freedom of choice back to elders in residential care, “which means you can get your bathing assistance at whatever time of day you want, not when the staff tells you. You get your choice of when you want to dine and you have dining options,” he says. In his opinion, too much emphasis on safety and efficient schedules suck the joy out of life, and if you’ve ever been to an old-school, publicly funded nursing home, you know that it’s hard not to be sympathetic to this view.
The Klaassens’ vision solved a pain point for millions of Americans, particularly women, who were and still are the ones volunteering for eldercare duty more often than men, and dealing with the professional and physical setbacks that follow. Privately run assisted-living homes made it possible for women to stay in their jobs without condemning a beloved parent to a barely disguised hospital. As Brown Wilson writes, early assisted living models also attracted controversy. Detractors of her Oregon model cited wide-ranging concerns, she writes, “e.g., could the carpet be kept free of urine odors, would people be safe behind closed doors, might not pets be dangerous, would staff know what to do if a resident’s condition changed?”
By the 1990s, assisted living was exploding in popularity, especially at the high end of the market. Several new companies came online and found Wall Street backing. “We were building 20, 25 communities, even 30 communities per year,” Klaassen says of his own firm in that era. Many companies, including Sunrise, went public in that time. (After surviving an accounting scandal that hung over the company’s stock in 2006 and 2007, Sunrise was acquired in 2013 by Health Care REIT for $845 million.)
The 2008 financial crisis delivered a big punch to the industry, Sunrise included. Occupancy rates plummeted, and developers discovered they had built too many new multimillion-dollar projects.
Now, in response to our rapidly aging population, there’s a second boom developing, insiders say, but its full force won’t be felt until the 2030s and 2040s, when the largest cohort of baby boomers enter their late 70s and 80s. The typical age at which seniors move into assisted living homes is 83, if they go that route at all.
Today, although senior housing oversupply has again become a problem in some markets, the demand for services has caught the eye of Silicon Valley types like Alexis Ohanian, co-creator of the internet giant Reddit (and spouse to tennis pro Serena Williams). Seeing the opportunity in the demographic shift that’s about to radically transform the country, he’s directing some of his Initialized Capital venture capital fund toward #eldertech startups, like Voyage, an autonomous taxi company that’s testing its vehicles in a senior living community. The rumbling promise of the so-called “silver tsunami” is also on the radar of large firms like Phillips, Ikea, Best Buy, and Amazon.
In December, CNBC reported that SoftBank’s massive Vision Fund 2 was in talks to invest $150 million in the home health care brand Honor, an online platform linking professional home aid caregivers to consumers. The deal has not been finalized, but it is one of the few known potential investments for the tech fund since SoftBank and the first Vision Fund together wrote down more than $8 billion in losses for the truly troubled co-working company WeWork last year. Senior Housing News editor-in-chief Tim Mullaney says he wouldn’t be surprised to see similar disruption in private senior housing facilities as early as this year.
When I first began investigating assisted-living homes for my parents, I didn’t understand where the industry found its consumers. My mother had worked in Canada as a primary school teacher, so we had a solid public pension to work with as a base income, plus government pensions. We had options beyond government-subsidized nursing homes, which had waitlists of three to five years anyway. This was fortunate, though, and not entirely common. How did everyone else manage the cost of assisted living?
“We’re business people. We know you have to price it in a way that makes sense,” says Andrew Carle, executive director at The Virginian, a seniors residence in Fairfax, Virginia, and adjunct lecturer in the Senior Living Administration Concentration at Georgetown University in Washington. “We’ve done the math and we priced it out so that basically if you’ve owned a home, you can afford senior living, and obviously a significant number of retirees own a home. It also means that you will have some money left over, typically. You may spend it all, but you know, you still have your social security, you still have your pension.”
The housing you’re getting, he adds, is just a better fit for most older folks: “We’ve gotten rid of all of your bills, your electric bills, utility bills, your home maintenance, your groceries. Everything that you were paying for in your house is included in one lump sum in an assisted living community. You can very quickly do the math and realize, ‘My gosh, if I sold my home, I could live there for as long as I wanted and still have plenty left.’”
This is certainly true for the lucky Americans who bought homes for less than $20,000 in the 1960s and can now sell them in an urban market for $800,000 to $1 million (or more, in turbo-powered real estate markets), an example he cites. In rural areas, Carle says, housing prices are lower, but so is the cost of moving into a facility. Plus, in many instances, working adult children top up their parents’ income. If several siblings can pitch in, the cost quickly becomes even more manageable.
And what, I ask, about those two-thirds of affluent Americans who say they’re counting on an inheritance for their own retirement, and all of the young adults, still saddled with student loans, who assume they will one day benefit from the sale of their parents’ home? Even if seniors do have the money, spending it has repercussions for their families’ financial futures.
The problematic truth about the assisted living business model is that, by relying on savings and home sales, it perpetuates the same class- and race-based structural inequality that has led to higher rates of home ownership among white, middle-class citizens.
This is not at all what Klaassen and Brown Wilson say they had in mind when they started down this path. Brown Wilson, Klaassen says, tried harder than he did to get a decent Medicaid program passed, and she succeeded. Still, in the states that offer some medicaid coverage for long-term care, reimbursement for assisted living is often far less generous than for nursing homes, according to Klaassen. They’re like, ‘We’ll pay for $200 a day at a nursing home, or $35 a day if [mom] gets her long-term care anywhere else,” he says.
The current structure is most unforgiving for those seniors who don’t qualify for Medicaid coverage nor have the retirement income or assets to pay for private care. Democratic presidential candidate Pete Buttigieg, former mayor of South Bend, Indiana, discovered that his family fell into this gap when his father was gravely ill and his mother looked into nursing homes last year. A social worker suggested his mother spend her savings to qualify for Medicaid.
“While I heard about these kinds of stories in the past, I understood in a different way,” Buttigieg told Time magazine.
That wake-up call is why Buttigieg is proposing an expansion of coverage for long-term care as part of his campaign platform. It also exemplifies why Howard Gleckman, a senior fellow at the Tax Policy Center, told Washington Monthly that the long-term care issue does not fall along ideological lines for politicians, but according to who has had personal encounters with the system and who hasn’t.
Klaassen would like to see the US adopt a system similar to that of the Netherlands, where families have the option of applying for care vouchers, that are means-tested and needs-based. “The Dutch will give it to the family and say, ‘We calculated it’s going to cost $100 a day care and you can use it by hiring your granddaughter, or you can go to the apartment and try to bring in services, [or] you can go to the assisted living setting. They are site-neutral.”
For her part, Brown Wilson believes that an affordable housing model for seniors is possible, and necessary—between rising inequality and the hard hit younger boomers took to their income and savings in the Great Recession, future seniors will likely have less wealth than today’s. Brown Wilson predicts that we’re going to have to look to ideas like modular building, and no-frills living. We will have to give up “all of the doodads that we’ve added to attract the children of the people who need housing,” she says. “We don’t need grand staircases, we don’t need pianos, we don’t need a lot of those things.”
“What we do need is accessibility, we do need safety features,” she adds. “We do need to build in as much technology as possible to facilitate independent living within that space, and I do think that will be coming.” She’s had conversations with people who want to start experimenting, she says, adding, “I think that there’ll be a few pilots, and then people will not be afraid to try it.”
Should you find yourself surveying senior care options for a loved one, you’ll quickly discover that a few large chains play an outsized role in the industry, and most of their names have an upbeat vibe: In the US, there’s Sunrise Senior Living, Life Care Services, Holiday, and Atria. In Canada, there’s Amica, ReVera, and Verve.
Among the American giants, there is one absolute behemoth: Brookdale, a public company that trades under the ticker BKD on the New York Stock Exchange and is valued at $1.3 billion. Nearly 80,000 seniors live under a Brookdale roof, across 45 US states. Its 800 properties include the former Emeritus residences that were the target of a damning (and haunting) ProPublica and Frontline investigation in 2013. It uncovered several instances of abuse leading to untimely death of residents, including one man with dementia who died from drinking industrial strength dishwashing fluid he discovered one night in an unlocked facility cupboard. (Brookdale bought the Emeritus properties in 2014.)
Here’s a look at the top 10 providers in 2019, according to the industry group Argentum.
Those who operate seniors housing are often not the owners of the properties. Instead, the real estate belongs to large institutional investors, like hedge funds and private equity groups, and publicly traded REITs.
Some REITs, as the NIC explains, may act as landlords, but others may be exposed to the operator’s performance, meaning a REIT may apply pressure when financial returns are not meeting the demands of shareholders.
“Most of the companies in the States now are owned by REITs, are owned by pension funds, are owned by people who, potentially for them, it doesn’t matter if it’s a warehouse, an industrial site, or a senior residence, it’s an asset,” cautions Elroy Jespersen, founder of the Village Langley, a new dementia village in Langley, B.C. “Absolutely in inside each of those companies and organizations, there are people wanting to do the right things,” he adds, but you have to look at where pressures are coming from, because “those assets have to perform.”
These are the eight largest REITS in senior housing:
Several entrepreneurs in the US are reimagining senior housing for elder care (see Final Thoughts, below). Meanwhile, the current model is being exported abroad.
“The US model is by far the most popular senior living model in the world,” boasts Andrew Carle, executive director at The Virginian, a private-pay seniors residence in Fairfax, Virginia, and adjunct lecturer in the senior living administration concentration at Georgetown University. The potential for growth overseas is huge, he adds. We may talk about a demographic time bomb in North America, but it isn’t near the top of list ranking regions and countries with the most aging population.
US senior housing companies, particularly Sunrise, have already set up shop in the UK and Europe. But the greater opportunities appear to exist in developing economies. In a 2016 column for Forbes, Benjamin Shobert, a former analyst at the National Bureau of Asian Research (NBR), a US-based think tank, wrote: “The same BRIC economies that created much of the economic growth over the last thirty years are now coming to terms with their own aging population. What this means is that healthcare and senior care operators from more developed western economies have the same type of opportunity to export their commercial and care models as their industrial counterparts have taken advantage of since the 1980s.”
Indeed, it isn’t only a business that the US is exporting, but a solution to a lifestyle that was originated in industrialized nations. The result is “a substantial weakening and breakdown of the extended family as a provider of care for older people living in their homes,” says Stephen Golant, a gerontologist and geographer, and professor emeritus at the University of Florida. The pressure to find a solution to elder care is especially urgent in China, where a one-child policy has contributed to an aging population, and the birth rate is falling. In that country, the number of people over age 60 reached 250 million last year. That figure is expected to surpass 400 million by 2050. Or, as Carle notes, “there will be more people over age 60 than there are all Americans,” by then. Meanwhile, young adults who have moved into urban areas find their lives too consumed with work for eldercare to be a priority.
The Chinese government, Carle adds, is “about to hit a tsunami of elderly citizens in their country that they’re going to be responsible for. As many of them as [leaders] can move off the government system and into private pay, nice, high-end senior living communities, the better.” The political leadership, he says, is “eager to have companies come over there and build beautiful, in some cases, very large—holding thousands and thousands of residents, many times larger than anything we’ve done here—retirement communities that will be private pay.”
But not all of the corporate interests venturing into China and other countries are American. In India, domestic companies like Ashiana Housing and Antara Senior Living have opened private elder care properties, often serving families whose adult children live abroad.
Last summer, The Financial Times reported that Lendlease, an Australian property group, announced plans to spend $A400 (then $281 million) on a senior community in Shanghai, in what the company expects to be the first of four properties it will build in the country by 2025. In total, the demand for senior services in China was thought to be worth a potential US $72 billion, the FT also reported, but supply fell short.
Argentum, the US industry group, reported in 2018 that Seattle-based Merrill Gardens had opened four projects in China, while another Seattle-based company, Leisure Care ran two properties in India. Japan’s Panasonic has announced plans to build health tech-enabled senior housing in China in collaboration with a Chinese health conglomerate. Those units should be on the market by 2021, according to the Japan Times.
China opened the eldercare sector to private investment, including wholly-owned by foreign investors, in 2014. But a report that year from Deloitte suggested that the challenges are as daunting as the opportunity is tremendous. Its research found issues with government policy gaps and inconsistent implementation, and alarmingly, “Unified standards or norms are not in place to safeguard the development and regulation of the industry.”
“Live now. Live here.”
The marketing slogan for the aforementioned Enzo Village, a project by the San Francisco Zen Center that will one day offer assisted living and memory care homes for seniors who can buy into the CCRC, sounds like a quote from the late spiritual leader Ram Dass.
It’s ironic, really, considering that in 2009, gerontologist Bill Thomas refers to Dass’s classic book Be Here Now in his TED Talk about ageism and the problems with elder-care culture. Thomas is known for founding the Green House Project, a model that is changing nursing homes (and now expanding to private-pay seniors housing) by designing them as small households and emphasizing personalized care. His thesis in the TED Talk is that because the hulking boomer generation bends the culture to its will, it made the values of youth the only morals that mattered when they were teenagers in the 1960s and early ’70s. Bestselling books of the era included Dass’s landmark study of mindfulness and Abbie Hoffman’s Steal This Book, he notes.
Then, when the boomers were at the height of adulthood, they encouraged us all to live in denial of the next phase of life, elder-hood. But now that the boomers are reaching that stage, they will repeat the same trick. Their preferences about elder care—what it looks like, what it offers, what it costs—will reshape the zeitgeist, and influence how the rest of us will live for decades to come.