'Elder Nation' in need of legislative choices.

We know that the elderly population of the United States is increasing dramatically. This aging population is aware that it will need long-term care, either at home or in SNFs and assisted living facilities. We also know that our healthcare infrastructure and healthcare financing systems are not prepared for this growing demand and that many "reforms" enacted by Congress and state legislatures during the 1990s have made the situation worse.

The older Americans most affected by this crisis generally are not a silent constituency. Older citizens are more likely than their children and grandchildren to register to vote and to actually cast ballots. They also tend to be more attentive to current events and more willing to join organizations with political agendas, such as AARP. The potential for current and future long-term care residents to be a political force was one of the reasons AHCA supported the organization of the Family Alliance for Compassionate Elder-Care in 2002.

Given the reality of the elderly as constituents, long-term care administrators may wonder why legislators appear reluctant to address the problems of SNFs and home healthcare. It's true that Congress and state legislatures rarely defeat proposals that could help meet older voters' needs for care for chronic conditions. Instead, potentially useful legislation typically is introduced and then allowed to die in committee, without debate or decision. This annual exercise in frustration seems to make no sense in a government that is designed to respond to constituent interests.

One important part of the explanation for this state of affairs can be found in the literal center of the country: Smith County, Kansas, birthplace of the song "Home on the Range" (the log cabin of the Kansas pioneer who wrote its lyrics still stands in Smith County today). Smith County's 4,500 residents are typical of America's Midwestern rural heartland. Although about half live on the county's more than 500 farms, approximately 2,000 live in the quiet town of Smith Center. Few of them are wealthy, but few have incomes low enough to qualify for Medicaid. Most importantly, a surprisingly high percentage of the county's residents are elderly. In fact, more than one-third of Smith County's registered voters were born before 1940.

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Smith County is part of what some demographers call the "Elder Nation": a large and growing sprawl of rural counties in the Northern and Midwestern United States in which at least 25% of the adult population is more than 65 years old. That description fits 43 of the 105 counties of Kansas, 32 of the 99 counties of lowa, and 28 of the 66 counties of South Dakota. In some of these areas, the elderly represent as many as 40% of the registered voters; by contrast, only two relatively small counties on Florida's southwest coast are so heavily dominated by older voters.

Despite their high percentages of elderly citizens, the "Elder Nation" counties in Kansas do not have a wealth of long-term care resources. A total of 88 Medicare-certified long-term care beds are available in Smith County--roughly one for every 25 residents more than 65 years old. These beds belong to the Infinia skilled nursing facilities at Smith Center and Kensington, which both filed for bankruptcy last December. The Parkview Care Center, a 72-bed facility located 40 miles away in Osborne, Kansas, is the only new SNF to open in the area during the past decade.

The congressman who represents Smith Center, Rep. Jerry Moran, is a Republican who has earned a reputation as a strong advocate for rural healthcare, but his interests do not extend to skilled nursing facilities. According to Darrel Miller, editor and publisher of Smith Center's only newspaper, the weekly Smith County Pioneer, Congressman Moran "seems to be worried mostly about hospitals." Moran's Washington office adds that the congressman is a strong advocate for veterans' healthcare. His voting record indicates that he has supported the Republican party line in most of the votes affecting long-term care.

Moran represents most of the "Elder Nation" counties in Kansas. Since 1996, he has been the incumbent of the state's First Congressional District. Also known as the "Big First," Moran's district includes 69 counties and stretches hundreds of miles, from the Colorado state line to the suburbs of Wichita and Topeka. Roughly one in four voters in the district is at least 65 years old. And in 2004, none of these elderly voters will be able to indicate whether they believe that Moran is fairly representing their interests.

The problem in the Big First, as in most of the U.S. "Elder Nation," is that the area is written off as politically noncompetitive. Moran is running for reelection without a Democratic opponent. U.S. Senator Pat Roberts of Kansas ran for reelection in 2002 without a Democratic opponent, and U.S. Senator Sam Brownback of Kansas, who has just completed his first full term, will be reelected in 2004 with no Democratic opponent. In fact, no voter in the Big First has been offered a choice for Congress or the Senate since 1998.

Even in the state legislature, most Kansas residents of the "Elder Nation" lack effective choices. In the last election, Smith County voters could either cast ballots for GOP state legislator Clay Aurand or write in another name. Aurand was the sole candidate in neighboring Jewell and Republic counties; incumbent Republican Dan Johnson was the only choice in nearby Osborne and Rooks counties, while Joann Lee Freeborn faced no Democratic opponent in her bid to represent nearby Lincoln County. In all of these Kansas counties whose residents have roughly the same electoral choices as the inhabitants of Baghdad, at least 30% of the registered voters are more than 65 years old.

The tragedy is that the members of the white, aging electorate of Middle America's "Elder Nation" are not guaranteed to be Republican voters. When Democrats make a serious bid for office in Kansas's Big First, they prove to be competitive. Two years ago in Smith County, for example, Democratic gubernatorial candidate Kathleen Sebelius outpolled Republican Tim Shallenburger, winning a large margin in the town of Smith Center; Sebelius is now serving her first term as governor of Kansas.

Smith County newspaper publisher Darrel Miller isn't certain why so many legislative races in his part of Kansas are not competitive. "Few people want to run; there aren't many who want to expose themselves to that kind of publicity," he says. He also suggests that it is becoming very difficult to reach the voters of the rural Midwest except through costly mass media, and there are few opportunities to raise the funds needed for a credible race. The sole would-be Democratic opponent of Sen. Brownback cited the cost of campaigning in rural areas as her reason for dropping out of the contest.

The political dynamics of Smith County, Kansas, are repeated in literally hundreds of rural counties in the United States. In most jurisdictions where the elderly comprise a substantial percentage of voters, they are not offered an effective choice of candidates. They can express neither their support for their legislators' actions on long-term care nor their disappointment with their legislators' inaction.

As we look around the world for places to restore democracy, perhaps we could start with our own "Elder Nation."

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