Executive Brief

Executive Brief IntroductionKey FindingsSocial and Economic Factors Physical Environment Clinical Care Behaviors Health OutcomesState Summaries
Alabama
US SummaryAppendixMeasures Table Data Source Descriptions The Team
2021 Senior Report – Executive Brief 2021 Senior Report 2021 Senior Report – State Summaries 2021 Senior Report – County-Level Maps for Risk of Social Isolation 2021 Senior Report – Report Data (All States)
Overview
According to the U.S. Census Bureau, more than 54 million adults ages 65 and older live in the United States today – accounting for about 16.5% of the nation’s population.[1] This past year has illuminated the growing health concerns they face amid the COVID-19 pandemic, which has claimed the lives of nearly 450,000 seniors across the country as of May 5, 2021 — accounting for around 80% of all U.S. COVID-19 related deaths — and affected countless others.
According to the Centers for Disease Control and Prevention (CDC), adults ages 65 and older are at increased risk of hospitalization or death from COVID-19. Further, the pandemic has disproportionately affected certain racial and ethnic groups, reflecting some of the longstanding disparities that persist in many of the measures included in the Senior Report.
The number of older adults living in the U.S. is large and growing; by 2050, the total number of adults ages 65 and older is projected to rise to an estimated 85.7 million — roughly 20% of the overall U.S. population. Thus, it is essential that policymakers, community leaders and public health officials consider how to best safeguard and improve the health of older Americans.
The America’s Health Rankings Senior Report, now in its ninth year, provides a portrait of the health and well-being of older adults in the U.S., capturing key trends, successes and challenges in order to spark meaningful dialogue and action to improve senior health. Using an updated model that emphasizes the impact that social, economic and environmental factors have on overall health, this year’s Senior Report highlights 49 measures of population health from 22 unique data sources to provide a comprehensive look at the health of seniors across the nation and on a state-by-state basis.
This year’s report was developed in partnership with the Gerontological Advanced Practice Nurses Association (GAPNA). The United Health Foundation is pleased to partner with GAPNA because of the valuable role that advanced practice nurses continue to play in promoting the health and well-being of America’s seniors, including during the COVID-19 pandemic. As front-line clinicians, advanced practice nurses are active across the continuum of care, working in primary, acute, post-acute care, home care and long-term care to improve the health of seniors every day. The mission of the United Health Foundation — to enhance the well-being of our communities — closely aligns with GAPNA’s goal of advocating for quality care for older adults.  
Prior to the COVID-19 pandemic, seniors across the country were experiencing both improvements and challenges. Outcomes of the pandemic have not been fully realized.
Prior to the COVID-19 pandemic, seniors across the country experienced some improvements when it comes to clinical care measures of access to quality health care and preventive services, reflected in an increase in flu vaccination rates. Additionally, the number of geriatric providers increased between 2018 and 2020. Leading up to the pandemic, seniors also experienced a number of worsening behavioral health outcomes, including increases in drug deaths, suicides and frequent mental distress. The pandemic has highlighted the social impact challenges seniors face from increased isolation, underscoring the impact it has on overall health. Despite recent successes in clinical care measures, health improvements for older adults were not experienced equally across the country, with populations in rural states and certain racial and ethnic populations facing greater challenges. 
While the Senior Report uses the most recent publicly available data for each measure, the majority of the measures in the report leverage data from 2019 and thus serve as a baseline for the health of older Americans prior to the COVID-19 pandemic. The preliminary impact of the pandemic across numerous health measures will likely be reflected in the America’s Health Rankings’ 2022 Senior Report as more data are made available.
Although only limited data capturing the health impact of COVID-19 at the state level are currently available, America’s Health Rankings is working to frequently update the platform to better equip public health leaders with the data they need to inform responses to and navigate the pandemic. The America’s Health Rankings website contains state-by-state and national data for six COVID-19 measures, including Medicare claims case and hospitalization rates and COVID-19 vaccination rates among adults ages 65 and older.
Out of the shared understanding that the country is facing significant and unprecedented health challenges due to COVID-19, America’s Health Rankings has chosen not to include overall state rankings in this year’s Senior Report. Instead, we aim to equip health leaders with data and insights that can inform their priorities as they manage public health needs during this unprecedented time.
The United Health Foundation and GAPNA are pleased to present highlights from the report. Readers are also encouraged to visit www.AmericasHealthRankings.org, where they can browse the full report and access the entire suite of data and resources, including a set of curated measures from across the platform that are classified as COVID-19 risk factors, as well as other national and state-level COVID-19 data.
Key Findings 


Measured Improvements in Clinical Care
Prior to the COVID-19 pandemic, seniors across the country experienced some improvements related to clinical care measures of access to quality health care and preventive services, reflected in an increase in flu vaccination rates. Additionally, the number of geriatric providers increased between 2018 and 2020.
The number of geriatric providers — including nurse practitioners — per 100,000 adults ages 65 and older increased 13% between 2018 and 2020, from 26.7 to 30.1. This was a positive development for the health of older adults. Compared with standard care, seniors receiving care in specialized geriatric units have better function at the time of discharge, and rehabilitative services involving geriatricians result in lower nursing home admissions and improved function at follow-up.
Between 2017 and 2019, flu vaccinations among seniors improved as well — increasing 6% to 63.8% of adults ages 65 and older in 2019, up from 60.4% in 2017. During the same time (2017 to 2019), flu vaccination rates significantly increased in 17 states, led by Wisconsin (52.7% to 63.9%) and Massachusetts (57.5% to 67.6%).
The flu vaccination rate for older adults is approaching the U.S. Department of Health and Human Services’ Healthy People 2030 target of 70% vaccination rate among all Americans ages 6 months and older. Notably, flu vaccination rates for adults ages 65 and older reached the 70% target in North Carolina and Connecticut, though neither state has reached the target rate among the overall population.

Seniors Faced Increasing Challenges in Behavioral Health Outcomes Prior to COVID-19
Leading up to the pandemic, seniors faced a number of worsening behavioral health outcomes, including increases in drug deaths, suicides and frequent mental distress. As Americans entered a nationwide shutdown that increased isolation, these outcomes were potentially exacerbated.
During 2017-19, the number of deaths due to drug injury (including unintentional deaths, suicide, homicide or undetermined) per 100,000 adults ages 65-74 was 10.3 — a rate increase of 39%, or 3,282 additional deaths, since 2014-16. In 2017-19, this corresponded to an estimated 9,417 drug deaths among adults ages 65-74.
Drug death rates varied widely across states: the rate among adults ages 65-74 was 4.5 times higher in Nevada (19.9 deaths per 100,000) than in Nebraska (4.4) and 14.6 times higher when considering the District of Columbia (64.4) in 2017-19. Alarmingly, between 2014-16 and 201719, the drug death rate increased in 15 states, led by New Jersey (4.7 to 10.5 deaths per 100,000), Maryland (8.7 to 18.7) and Louisiana (5.6 to 10.8). 
In 2017-19, the national suicide rate among adults ages 65 and older increased 3% to 17.1 deaths per 100,000, an estimated 26,843 deaths by suicide, compared to 16.6 deaths per 100,000 in 2014-16 — an increase of over 3,000 additional deaths. Suicide rates in two states significantly increased among older adults between 2014-16 and 2017-19: Nebraska (9.7 to 15.2 deaths per 100,000) and Maine (17.4 to 24.4). The suicide rate was:  
3.4 times higher in Nevada (31.1 deaths per 100,000) than in New York (9.2).
6.1 times higher among males (31.9 deaths per 100,000) than among females (5.2). 
In 2019, 4.2 million (8.1%) adults ages 65 and older reported frequent mental distress, meaning they reported their mental health was not good 14 or more days in the past month — an increase of 11% since 2016 (7.3%). Frequent mental distress was:
2.4 times higher in West Virginia (10.9%) than in South Dakota (4.5%).
2.8 times higher among those with an annual household income less than $25,000 (12.7%) than among those with an income of $75,000 or more (4.5%).  
Risk of Social Isolation Continues  to Impact Senior Health 

The pandemic has underscored the challenges seniors face from the social impacts of increased isolation. Social isolation, defined as an absence of meaningful social relationships, continues to play a role in understanding overall senior health — especially in the context of the COVID-19 pandemic.
This year’s report found that before the pandemic, the risk of social isolation — based on risk factor measures such as disability, marital status, difficulty living independently, living alone and poverty status — for seniors in a given state was correlated with higher rates of frequent mental distress (r=0.64), early death (r=0.63), food insecurity (r=0.66) and preventable hospitalizations (r=0.63).
Additionally, in 2019, 78.0% of households with adults ages 65 and older had a broadband internet subscription and a computer, smartphone or tablet — an increase of 10% since 2016 (71.1%) and 2% since 2018 (76.1%). By giving older adults greater ability to use the internet, work remotely, use video chatting software and meet virtually with health professionals, seniors’ increased internet access held potential to offset some of the negative effects of the pandemic. Before the COVID-19 pandemic began, states with higher rates of high-speed internet among senior households tended to have lower rates of risk of social isolation (r=-0.59).
Disparities by Geography, Race and Ethnicity and Other Factors Persist
Despite measured improvements in some areas of senior health, large and longstanding disparities continued to impact older adults based on their location, race and ethnicity, income, education and gender. In particular, improvements in clinical care measures and high-speed internet were not equally shared across the population of older Americans.
Geographic Disparities
  In 2019, an estimated 18.7% of the U.S. population was estimated to live in a rural area. The estimate varied from 5.0% in California to 60.9% in Maine. Vermont and West Virginia also had an estimated rural population above 50%. This year’s report found states with a higher rural population faced challenges in access to care compared with states with a lower rural population. For example, a state’s level of rurality was associated with fewer geriatric providers (r=-0.47). Although the number of geriatric providers increased nationally in 2020, disparities existed by geography. In 2020, the number of geriatric providers per 100,000 adults ages 65 and older was 5.3 times higher in Rhode Island (57.7) than in North Dakota (10.8). In general, rural areas are often under-resourced compared with more urban areas, which correlates with a higher rate of morbidity and mortality in those ages 65 and older.
Disparities also persist when it comes to social and economic indicators that affect the health of older adults. For example, in 2018, food insecurity among adults ages 60 and older was 2.9 times higher in Nevada (20.9%) than in Minnesota (7.3%). As the COVID-19 pandemic disrupted food access and increased food insecurity for Americans of all ages, older adults in particular have experienced increased challenges related to food access.
Disparities by Race and Ethnicity, Education and Income in Flu Vaccination
Disparities also existed in flu vaccination rates across race and ethnicity, education and income. In 2019, flu vaccination rates were:
1.2 times higher among white (65.8%) than among multiracial (54.4%) adults.
1.2 times higher among college graduates (70.6%) than among those with less than a high school education (56.9%), with the prevalence of flu vaccination growing with each increase in education level.
1.2 times higher among those with an annual household income above $75,000 (70.0%) than among those with an income less than $25,000 (57.7%), with the prevalence of flu vaccination growing with each increase in income level. 
Building Healthier Communities for America’s Seniors
This year’s Senior Report shows meaningful progress made on key measures of senior health in the period immediately preceding the COVID-19 pandemic, including significant improvements in clinical care. Yet, the pandemic has underscored the challenges and disparities that impair healthy living for older adults around the country, further highlighting the need for greater attention to senior health. The data in this report provide timely insights to better understand the underlying health of a population at greater risk of more severe illness from COVID-19.
Readers are encouraged to further explore the report’s findings elsewhere on this website, where they can access the platform’s full suite of data and resources including state-by-state and national data for six COVID-19 measures, including Medicare claims case and hospitalization rates and COVID-19 vaccination rates among adults ages 65 and older.
The United Health Foundation remains committed to building healthier communities for all Americans. As the realities of the COVID-19 pandemic have underscored the need for greater attention to senior health, the United Health Foundation encourages policymakers, public health officials and community leaders to use this report, new web tools and the entire suite of America’s Health Rankings data to better understand and improve the health of older Americans.
About the Gerontological Advanced Practice Nurses Association (GAPNA)
GAPNA is the premier professional organization that represents the interests of advanced practice nurses who care for older adults. Advanced practice nurses are active in a variety of settings across the health care continuum including primary, acute, post- acute care, home care and long-term care. GAPNA provides opportunities for education, leadership, research, advocacy, networking and advancement of evidence-based care for older adults. To learn more, visit our website here.