BRISTOL, R.I. — At age 82, Roberta Rabinovitz realized she had no place to go. A widow, she had lost both her daughters to cancer, after living with one and then the other, nursing them until their deaths. Then she moved in with her brother in Florida, until he also died.
And so last fall, while recovering from lung cancer, Rabinovitz ended up at her grandson's home in Burrillville, Rhode Island, where she slept on the couch and struggled to navigate the steep staircase to the shower. That wasn't sustainable, and with apartment rents out of reach, Rabinovitz joined the growing population of older Americans unsure of where to lay their heads at night.
But Rabinovitz was fortunate. She found a place to live, through what might seem like an unlikely source — a health care nonprofit, the PACE Organization of Rhode Island. Around the country, arranging for housing is a relatively new and growing challenge for such PACE groups, which are funded through Medicaid and Medicare. PACE stands for Program of All-Inclusive Care for the Elderly, and the organizations aim to keep frail older people in their homes. But a patient can't stay at home if they don't have one.
More people 55 and over without homes
As housing costs rise, organizations responsible for people's medical care are realizing that to ensure their clients have a place to live, they must venture outside their lanes. Even hospitals — in Denver, New Orleans, New York City, and elsewhere — have started investing in housing, recognizing that good health isn't possible without it.
And among older adults, the need is especially growing. In the U.S., 1 in 5 people who were homeless in 2024 were 55 or older, with the total older homeless population up 6% from the previous year. Dennis Culhane, a University of Pennsylvania professor who specializes in homelessness and housing policy, calculated that the number of men older than 60 living in shelters almost tripled from 2010 to 2020.
"It's a national scandal, really, that the richest country in the world would have destitute elderly and disabled people," Culhane said.
Over decades of research, Culhane has documented the plight of people born between 1955 and 1965 who came of age during recessions and never got an economic foothold. Many in this group endured intermittent homelessness throughout their lives, and now their troubles are compounded by aging.
But other homeless older adults are new to the experience. Many teeter on the edge of poverty, said Sandy Markwood, CEO of USAging, a national association representing what are known as area agencies on aging. A single incident can tip them into homelessness — the death of a spouse, job loss, a rent increase, an injury or illness. If cognitive decline starts, an older person may forget to pay their mortgage. Even those with paid-off houses often can't afford rising property taxes and upkeep.
"No one imagines anybody living on the street at 75 or 80," Markwood said. "But they are."
President Donald Trump's recent budget law, which makes substantial federal cuts to Medicaid, the public insurance program for those with low incomes or disabilities, will make matters worse for older people with limited incomes, said Yolanda Stevens, program and policy analyst with the National Alliance to End Homelessness. If people lose their health coverage or their local hospital closes, it will be harder for them to maintain their health and pay the rent.
"It's a perfect storm," Stevens said. "It's an unfortunate, devastating storm for our older Americans."
Adding to the challenges, the Labor Department recently halted a job training program intended to keep low-income older people in the workforce.
New partners for PACE
Those circumstances have sent PACE health plans throughout the country into uncharted waters, prompting them to set up shop within senior housing projects, partner with housing providers, or even join forces with nonprofit developers to build their own.
A 1997 federal law recognized PACE organizations as a provider type for Medicare and Medicaid. Today, some 185 operate in the U.S., each serving a defined geographic area, with a total of more than 83,000 participants.
They enroll people 55 and older who are sick enough for nursing home care, and then provide everything their patients need to stay home despite their frailty. They also run centers that function as medical clinics and adult day centers and provide transportation.
These organizations primarily serve impoverished people with complex medical conditions who are eligible for both Medicaid and Medicare. They pool money from both programs and operate within a set budget for each participant.
PACE officials worry that, as federal funding for Medicaid programs shrinks, states will curtail support. But the PACE concept has always had bipartisan support, said Robert Greenwood, a senior vice president at the National PACE Association, because its services are significantly less expensive than nursing home care.
The financing structure gives PACE the flexibility to do what it takes to keep participants living on their own, even if it means buying an air conditioner or taking a patient's dog to the vet. Taking on the housing crisis is another step toward the same goal.
In the Detroit area, PACE Southeast Michigan, which serves 2,200 participants, partners with the owners of housing designated for senior citizens The landlords agree to keep the rent affordable, and PACE provides services to their tenants who are members. Housing providers "like to be full, they like their seniors cared for, and we do all of that," said Mary Naber, president and CEO of PACE Southeast Michigan.
For participants who become too infirm to live on their own, the Michigan organization has leased a wing in an independent living center, where it provides round-the-clock supportive care. The organization also is partnering with a nonprofit developer to create a cluster of 21 shipping containers converted into little houses in Eastpointe, just outside Detroit. Still in the planning stages, Naber said, the refurbished containers will probably rent for about $1,000 to $1,100 a month.
In San Diego, the PACE program at St. Paul's Senior Services cares for chronically homeless people as they move into housing, offering not just health services but the backup needed to keep tenants in their homes, such as guidance on paying bills on time and keeping their apartments clean.
St. Paul's PACE program also helps those already in housing but clinging to precarious living arrangements, said Carol Castillon, vice president of its PACE operations. The program connects them with community resources, helping fill out forms for housing assistance, and providing meals and household items to lower expenses, she said.
At PACE Rhode Island, which serves nearly 500 people, about 10 to 15 participants each month become homeless or at risk of homelessness, which was a rare situation five or six years ago, CEO Joan Kwiatkowski said.
The organization contracts with assisted living facilities, but its participants are sometimes rejected because of prior criminal records, substance use, or health care needs that the facility operators feel they can't handle. And public housing providers often have no openings.
So PACE Rhode Island is planning to buy its own housing, Kwiatkowski said. PACE also has reserved four apartments at an assisted living facility in Bristol for its participants, paying rent when they're unoccupied. Rabinovitz moved into one recently.
Housing and medical care
Rabinovitz had worked as a senior credit analyst for a health care company, but now her only income is her Social Security check. She keeps $120 from that check for personal supplies, and the rest goes to rent, which includes meals.
Once a week or so, Rabinovitz rides a PACE van to the organization's center, where she gets medical care, including dental work, physical therapy, and medication — always, she said, from "incredibly loving people." When she's not feeling well enough to make the trek, PACE sends someone to her. Recently, a technician with a portable X-ray machine scanned her sore hip as she lay in her own bed in her new studio apartment.
"It's tiny, but I love it," she said of the apartment, which she's decorated in purple, her favorite color.
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