“She is doing remarkably well — for her age.”

As a physical therapist who treats older adults, I have heard versions of this statement many times. It is usually intended as praise. But I pause at those final three words.

Would we consider the same level of strength, mobility or dependence acceptable for a younger patient with comparable medical conditions? Have we objectively evaluated what this person can achieve, or quietly lowered the standard because of the year printed on their birth certificate?

Age can affect physiological reserve, recovery time and chronic illness. But it should inform clinical reasoning — not replace it. Otherwise, an older patient may encounter an invisible ceiling before rehabilitation has been given a fair chance.

That concern will become increasingly important in California. According to the state’s Master Plan for Aging, nearly 10 million Californians will be older adults by 2030, representing approximately a quarter of the state’s population.

Age bias is not always hostile or deliberate. In geriatric care, it can appear as caution, protection or a recommendation that seems reasonable.

Imagine an 89-year-old admitted to rehabilitation after hospitalization. Before completing a comprehensive assessment, someone says that independent walking is probably unrealistic at her age. The speaker may sincerely believe this. But if the same conclusion would not be reached about a younger patient with comparable strength, cognition, medical stability and prior function, age may be receiving more weight than the evidence supports.

The assumption can shape everything that follows. Walking is practiced less. Goals become less ambitious. Discharge planning focuses on permanent assistance instead of testing whether greater independence is possible. Eventually, the outcome appears to validate the original prediction.

Implicit bias is harder to recognize. A clinician may prescribe exercise below an older patient’s safe capacity, attribute declining balance to “normal aging” before investigating reversible causes, or redirect an ambitious goal toward something the team considers more appropriate.

These decisions are rarely intended to cause harm. Yet lower expectations create fewer opportunities, and fewer opportunities can produce less improvement.

We may believe we are predicting an older patient’s potential when, in some cases, we are helping determine it.

Medicare policy offers an important reminder. The 2013 Jimmo v. Sebelius settlement addressed the mistaken use of an “improvement standard.” The Centers for Medicare & Medicaid Services explain that skilled nursing and therapy coverage does not depend on whether a beneficiary is expected to improve. Skilled care may be medically necessary to improve or maintain function, or prevent or slow deterioration.

Yet remnants of the old improvement mindset can survive in clinical culture and insurance decisions.

A June 2026 report from the U.S. Department of Health and Human Services Office of Inspector General found that 19 Medicare Advantage organizations denied 12 percent of skilled nursing facility admission requests reviewed from June 2024.

Only 18 percent of those denials were appealed. But when patients or providers did appeal, the plans overturned 95 percent of the denials in favor of the enrollee.

The report did not attribute these denials to age bias. But it shows how consequential an initial rehabilitation decision can be. An older adult recovering from hospitalization may not understand the appeal process or have someone available to advocate.

The federal office recommended that CMS address breakdowns in initial reviews and investigate large variations in denial rates. Those recommendations deserve urgent attention. But improving access also requires examining what happens after an older patient enters the treatment room.

Clinicians should establish prior function and personal goals before deciding what is realistic, use objective measures of strength and mobility, and provide adequately dosed treatment. Caution should not automatically mean low-intensity rehabilitation. Goals and restrictions should be based on individual findings and reassessed as the person’s condition changes.

Goals should also be established with the patient, not merely for the patient. Walking to the bathroom, attending worship or entering a grandchild’s home may carry more meaning than improving a number on a standardized test.

The Age Discrimination Act of 1975 and Section 1557 of the Affordable Care Act prohibit covered health programs from excluding, denying or limiting services based on age, subject to legally recognized exceptions. But formal nondiscrimination does not automatically create equal clinical opportunity.

California health systems and Medicare Advantage plans should incorporate age-bias education into clinical competency and quality-improvement programs. CMS should act on the federal recommendations and require greater transparency around initial post-acute care denials. Decisions to deny or limit rehabilitation should be tied to the individual’s documented condition and needs — not generalized expectations associated with age.

Clinicians can begin with personal reflection. Harvard University’s Project Implicit offers a free Age Implicit Association Test that explores automatic associations involving age. It is not a diagnosis or a verdict on anyone’s character. It can, however, prompt us to ask whether we would recommend the same goals and treatment intensity for a younger patient with comparable findings.

Age and weakness are not interchangeable. Neither are age and incapacity, dependence or futility.

Equal care does not mean identical care. It means that every person receives an individualized opportunity based on clinical findings, personal goals, preferences and response to treatment.

Growing older may change the path of recovery. It should not determine where that path is allowed to end.

Pradeepika Samagh is a physical therapist and director of rehabilitation at Auburn Oaks Care Center in Auburn.

Arjun Dutt is a physical therapist and director of rehabilitation at Rock Creek Care Center in Auburn.