Early Socioeconomic Disparity Affects Women’s Health in Later Life

The economic disparities seen between older men and older women begin much earlier in life. Socioeconomic status, particularly during working years, plays a significant role. Women often face challenges like lower wages ⁸ and career interruptions due to childcare responsibilities. ⁹ This translates to lower lifetime earnings and smaller retirement savings compared to men. ¹⁰ Because this economic disadvantage persists into their older years, many women are left more vulnerable due to financial insecurity and with less access to quality health care and support for activities of daily living.¹¹

This socioeconomic disparity is evident in Central Indiana, as well.¹² While men might experience a sharp income decline only after the age of 85, women are more likely to enter retirement with considerably less and need to stretch those resources further due to their longer lifespans. This creates a situation where some women face financial strain throughout their older years, a burden not shared equally by their male counterparts.

Comparing personal income numbers for older adults with the Asset Limited, Income Constrained, Employed (ALICE) survival budget for Central Indiana further emphasizes the economic vulnerability of older adult women. County-level ALICE survival budgets are based on ten different categories of monthly costs. ¹³ The total annual survival budget for one senior living alone is $32,232 in Central Indiana. For two older adults living together in Central Indiana, the total annual survival budget is $50,544.

For all older adult age groups, women’s median personal income on average is below the ALICE survival threshold. The personal income of men, on average, does not fall below the ALICE threshold until they are age 85 or older. In Central Indiana, almost 13,000 older adult women live in poverty compared to almost 8,300 older men.

In focusing on just the female older adult population, we see that Black and Hispanic older women start out retirement with significantly less income than their white counterparts.

Many older adults prefer to live independently.¹⁴ However, older adults who live alone are approximately 2 time more likely to experience poverty, regardless of sex. Women who live alone are 20 percent more likely to be housing cost burdened than men living alone (49.4 percent versus 41.3 percent for men). In Central Indiana, older women are on average are 70 percent more likely to live alone, with 34.4 percent of older women versus 20.3 percent of older men living alone. Black older women are over 20 percent more likely than white women to live alone (41.6 percent vs 33.7 percent) and almost 90 percent more likely to live alone than Hispanic women (41.6 percent vs. 22.1 percent).

The impact of lower socioeconomic status goes beyond finances. Studies have shown a correlation between lower income and higher rates of depression in older women.¹⁵ The financial strain, coupled with potential social isolation and lack of resources, can lead to mental health struggles. Additionally, the gender gap in life expectancy¹⁶ means older women often outlive their spouses, potentially facing increased loneliness and a decline in social support networks, further impacting their well-being.¹⁷

The next section will explore how these socioeconomic disparities may translate into health outcomes for older women.

Socioeconomic Disparity and the Chronic Disease Burden in Older Adults

Chronic and mental health conditions consume 90 percent of the US’s annual healthcare spending.¹⁸

Research has established that gender is an important social determinant of health and that men and women age differently. Disparities such as higher rates of living alone, lower incomes, and higher rates of functional disabilities in older women impact their ability to age well. In turn, men are more likely to be challenged when they lose a spouse, need to act as caregivers, or have to relocate.^{19 20}

In Central Indiana, the average prevalence rates are over 20 percent for diabetes and obesity in both older men and women. When examining male/female disparities, we observe that older men in Central Indiana show a higher prevalence of physical ailments like diabetes (29.5 percent versus 23.5 percent for women) and some cancers, with rates increasing steadily with age.²

On the other hand, older women face a significantly heavier burden of depression than older men. Central Indiana data show consistently higher rates of depression for older women, mirroring a national trend documented for several years now.¹⁵ Higher rates of depression among older women could be influenced by women being more likely to seek mental health care. Research has suggested that only access to healthcare and social limitations predict whether women seek help for self-reported mental health issues, whereas there are numerous sociodemographic and psychological factors that predict whether men seek care.²¹ However, on average adult women also self-report experiencing more unhealthy mental days than men.

Due to their longer lifespans, women also face an increased risk of developing Alzheimer’s Disease as they age,^{22 23} which increases their need for long-term care.

In Central Indiana, as of 2022, we have an estimated 95,000 disabled older adults over the age of 65. While having similar rates of overall disability (approximately 34 percent for both sexes), when examining self-care disability rates in particular, we see a pattern emerge that highlights the vulnerabilities of older women as they age. Self-care disability is defined as “a person with a physical, mental, or emotional condition lasting six months or more, who has difficulty in doing any of the activities such as dressing, bathing, or getting around inside the home”.²⁴ In sheer numbers, there are more older women in Central Indiana with self-care disabilities (16,443) compared to older men (7,671).

Self-care disability rates for both men and women increase substantially as they age, with rates for older women rising even more sharply. In Central Indiana, the self-care disability rate for older women increases almost six-fold in post-retirement years (from 5.2 percent in the age 65-74 age range to 29.5 percent in the 85+ age range), compared to older men for whom the rate quadruples (from 4.3 percent in the age 65-74 age range to 17 percent in the 85+ age range).

There are evident racial disparities in self-care disability among older women, with Black women almost two times more likely than white women to be self-care disabled (13.1 percent vs 7.3 percent for white women) and almost one and a half times more likely than Hispanic women to be self-care disabled (13.1 percent vs 8.9 percent for Hispanic women).

Social Isolation and the Fragile Health of Older Women

Social isolation is another threat to the well-being of older adults, particularly women. In the United States, with one in four adults experiencing some form of disability,²⁵ social connections become even more critical for health. While disability rates, discussed above, may be comparable between the sexes, data from Central Indiana paints a concerning picture for older women. Since women live longer and are therefore more likely to live alone once their spouses pass away, they are more likely to face poverty, and struggle with housing costs, especially as they reach their most vulnerable eighties. These factors contribute significantly to social isolation and loneliness, which studies have linked to an increased risk of cardiovascular disease in older women.²⁶

The Need for Improved Access to Long-Term Care

The confluence of social and economic disadvantages creates a complex web of challenges for older women. The increasing longevity of women, particularly those who serve as caregivers for their spouses, coupled with age-related challenges, is contributing to an increased demand for care solutions for older adults. Their need for care intensifies as they age which makes them more likely to rely on institutionalization in nursing homes by their late seventies. This underscores the growing need for health care resources for older adults, particularly women.

While many social determinants of health have been validated as indicators that can explain disparities in health outcomes,²⁷ there is an ongoing need to develop a better understanding of factors that influence the accessibility of services and support needed by vulnerable older adults.

Women are more likely to require Medicaid assistance as they grow older and need nursing home level of care. For the 85+ age group, 20 percent of women are enrolled in Medicaid. Data from the Centers for Medicare & Medicaid Services reveal an uneven distribution of care facilities and service organizations across Central Indiana. Marion County, with its larger population, boasts the highest number of nursing homes and home health agencies. However, quality can vary significantly with only a little over 33 percent of facilities having high quality (four or above) ratings.

Adding to the challenge is the significant cost of long-term care.²⁸ In 2023, the median monthly cost in Indianapolis was $6,000- $7,000 for in-home care, over $6,000 for adult day care, and almost $4,000 for assisted living.²⁹ These costs can leave little room for other essential expenses and potentially push some older adults further into poverty. For patients with moderate dementia and Alzheimer’s, this cost can increase about 20-30 percent.³⁰ Such financial barriers can limit  the ability of some older women to access the care they need and impact their overall well-being.

Conclusion

The rising number of financially insecure older women who will need long-term care is a growing challenge in Central Indiana and beyond. Solutions are needed to provide older women with the level of care they need while allowing them to maintain some level of social connection and independence, potentially mitigating the negative health effects of social isolation.

Indiana is attempting to create an improved long-term care system for low-income older Hoosiers by increasing access to community-based and home-based care options.³¹ In addition to providing affordable and quality options for long-term care, there is also a need to promote increased socioeconomic wellbeing among all older women and equitable access to quality care. The findings in this report raise questions such as:

• As a community, how can we promote equitable access to long-term care and support for our older adult population?
• As individuals, what can women do to improve the likelihood of their being well-cared for in old age?