The Right to a Different Story

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Glenda Jimmo of Bristol, Vermont was blind and had lost her right leg to complications from diabetes. She used a wheelchair. She received multiple home health services each week for her complex medical condition. And then Medicare denied coverage for those services — on the grounds that she was unlikely to improve.

She was being denied care because Medicare contractors were applying an unlawful “improvement standard” — a rule of thumb that treated recovery, rather than the need for skilled care, as the touchstone for coverage. No trajectory of recovery, no entitlement to skilled care. The logic was simple, brutal, and — as it turned out — wrong in law, wrong in science, and wrong in its most fundamental assumption about what aging is.

What followed from Glenda Jimmo’s case did not end with a 2013 settlement; implementation and enforcement would continue for more than a decade. What Dr. Becca R. Levy and Martin D. Slade’s research has now confirmed, in a landmark 2026 study, is that the assumption behind that denial — that older adults cannot maintain function or improve, that later life moves in only one direction — was never true to begin with.

The Lawsuit That Changed the Standard

The Center for Medicare Advocacy and Vermont Legal Aid filed Jimmo v. Sebelius, a class action on behalf of Medicare beneficiaries who were being denied coverage for skilled care because they were not improving or were not expected to improve. Filed in 2011, the case named Kathleen Sebelius, then Secretary of Health and Human Services, and challenged what plaintiffs alleged had become a widespread and unlawful practice in Medicare coverage determinations.

The Center for Medicare Advocacy — a national nonprofit legal advocacy organization established in 1986, headquartered in Connecticut and Washington, D.C. — had been documenting this problem for years. Beneficiaries across the country were being told that Medicare would not cover their skilled nursing or therapy services because they had plateaued, because their conditions were chronic, because recovery or even maintenance was not possible. 

The Improvement Standard, as it came to be called, was not written into Medicare law — and it never had been. It was not enacted by Congress, not adopted by regulation, and not authorized by official CMS policy. It grew from clinical habit and administrative assumption, applied so consistently by providers, contractors, and adjudicators over so many years that it acquired the force of law without ever having been law. As the Centers for Medicare & Medicaid Services would later acknowledge in its own Fact Sheet issued following the settlement: “Medicare has never supported the imposition of an ‘Improvement Standard’ rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient's condition.” By the time the Center for Medicare Advocacy filed suit in 2011, the standard had calcified so completely that most of those applying it had stopped questioning whether it had any legal basis at all. It did not.

In 2013, the federal district court approved a settlement agreement that clarified that Medicare coverage should be determined by a beneficiary’s need for skilled care, not the individual’s potential for improvement. Medicare covers skilled care to maintain an individual’s condition or slow further decline, provided the other coverage criteria are met. The settlement applied nationwide to home health care, skilled nursing facility services, and outpatient therapies. The Medicare statute and regulations had never supported the imposition of an Improvement Standard rule of thumb in determining whether skilled care was required. The settlement did not change the law. It clarified what the law had long required.

The Center for Medicare Advocacy did not stop there. Three years after the Jimmo settlement, the Center was still hearing daily about providers who had never heard of the case and patients who could not get necessary care based on an Improvement Standard. In 2016, plaintiffs’ counsel returned to court to seek enforcement. The struggle to implement what the law had long required did not end with the settlement.

The Improvement Standard was not merely an unlawful administrative practice. It reflected a deeply embedded assumption that older adults, especially those with chronic conditions or disabilities, were on an inevitable downward trajectory and that skilled care counted only if it produced improvement. Care aimed not at recovery but at preservation was too often denied entirely: care to maintain, care to slow decline, care to preserve function and dignity. Those aims, the law had always recognized — even when practice did not — were more than sufficient.

Jimmo rejected that premise as a matter of Medicare law. And now Dr. Levy and Slade’s research has added scientific force to that broader point.

The Theory That Helped Naturalize the Bias

To understand how deeply the Improvement Standard was embedded — not just in Medicare policy but in clinical culture, professional training, and public expectation — it helps to understand where the assumption of inevitable decline came from.

In 1961, Elaine Cumming and William Henry published Growing Old, introducing disengagement theory, often described as the first distinct social theory of aging. The theory posited that aging involved an inevitable, mutual withdrawal between the individual and society — framed not as loss but as functional necessity, even as social benefit. The theory helped rationalize a mid-century culture of age segregation and exclusion: employers pushed older workers out, institutions segregated by age, and the cultural script for later life was written as a story of managed exit. The assumption that aging meant decline — cognitive, physical, social — was not merely popular. It was scientific. Or so it was said.

The rebuttal came quickly, and from the same data. In the early 1960s, Activity Theory, associated with Robert Havighurst and colleagues, argued that older adults who remained active and socially engaged tended to report greater life satisfaction. What disengagement theory treated as natural withdrawal, later critics increasingly saw as shaped at least in part by social conditions and lost opportunities, rather than any internal drive toward disengagement. The science was contested from the start. But the cultural power of the decline narrative was not so easily reversed.

Sixty years later, that narrative continues to cause harm that is real, recurring, and largely invisible — in clinical practice, in Medicare coverage determinations, and in the courtrooms where guardianship proceedings convert an unexamined assumption of decline into binding legal judgments. Jimmo challenged it in law. Levy and Slade has now challenged it in science.

The Study That Redefined Aging

Published in March 2026 in the journal Geriatrics, Becca R. Levy and Martin D. Slade’s longitudinal study — Aging Redefined: Cognitive and Physical Improvement with Positive Age Beliefs — draws on the Health and Retirement Study and follows nationally representative cohorts of older Americans for up to twelve years, with 11,314 participants in the cognitive analyses and 4,638 in the walking-speed analyses. Its central finding is both simple and arresting.

Nearly half of adults sixty-five and older — 45.15 percent — showed measurable improvement in cognitive function, physical function, or both over the course of the study. Not stability. Not managed decline. Improvement.

In the cognitive analyses, 31.88 percent improved. In the walking-speed analyses, 28.00 percent improved their speed, a widely used indicator of physical functioning. And when those who remained stable were counted alongside those who improved, the numbers rose to 51.06 percent for cognition and 37.56 percent for walking speed. On the study’s cognitive measure, in other words, a majority were either stable or improving rather than declining.

As Levy observed in a Yale press release, 

“What we found is that improvement in later life is not rare,  it’s common, and it should be included in our understanding of the aging process.”

The study’s methodological contribution is as significant as its findings. Levy and Slade write that the World Health Organization's recommended approach for assessing later-life cognitive and physical capacities classifies those capacities in terms of decline or no decline. It does not allow for the possibility of improvement as an expected outcome. This is not a neutral design choice. It is a structural assumption embedded in the methodology itself — the same assumption behind the Improvement Standard that the Jimmo Settlement dismantled. That matters. It suggests that some of the most influential ways of measuring aging have been built to detect loss more readily than gain.

Levy and Slade place their findings against a broader culture of expectation. They cite the World Alzheimer Report 2024, which found that 65 percent of health and care professionals and 80 percent of the general public incorrectly believe dementia is a normal part of aging. They also cite an AARP survey reporting that 77 percent of adults age forty and older expect cognitive decline in later life. These are not isolated misunderstandings. They are signs of how thoroughly the decline narrative has saturated both professional judgment and public imagination.

So the importance of Levy and Slade’s study is not only that it reports improvement. It is that it asks aging a different question. Instead of treating decline as the default and everything else as anomaly, it measures whether later life may also include recovery, resilience, and gain. And when that possibility is finally counted, improvement turns out not to be rare at all. 

What We Believe About Aging Changes How We Age

The most consequential finding in Levy and Slade’s study is not the 45.15 percent figure, striking as it is. It is the finding that positive age beliefs — attitudes toward aging absorbed from culture, language, and social expectation across the life course — predicted improvement in both cognitive and physical function, independently of age, sex, education, chronic disease, depression, and length of follow-up.

This is what Levy calls stereotype embodiment theory: individuals internalize both positive and negative age beliefs from the culture around them. In later life, when these beliefs become self-relevant, they can influence functioning and health. Negative age beliefs do not merely describe decline; Levy’s work suggests they can help drive worse outcomes. Positive age beliefs, conversely, are associated with better outcomes and, in the 2026 study, with measurable improvement.

Levy’s landmark 2002 study had already established this in dramatic terms: people who held more positive self-perceptions of aging lived an average of 7.5 years longer than those who held negative ones — a survival advantage that exceeded the benefits of low blood pressure, low cholesterol, not smoking, maintaining a healthy weight, and regular exercise, each measured separately. The 2026 study extends that line of research. The beliefs we hold about aging — absorbed from culture, reinforced by institutions, and carried in the language we use — do not merely color experience. They can help shape health trajectories in later life. 

The policy implication is direct. Age beliefs are not fixed. They are formed by culture, reinforced by institutions, and transmitted through language. As Cristina Bicchieri argues in Norms in the Wild, abandoning a social norm requires more than private disagreement. It requires a coordinated shift in social expectations — people must come to believe not only that change is justified, but that others are changing too. To undo a norm, in Bicchieri’s account, empirical expectations must shift first; only then do normative expectations begin to change.

That is one way to understand the durability of the decline narrative in aging: it is not merely a misconception lodged in individual minds, but a social norm reproduced across institutions, professions, and everyday interactions. That means it can also be changed — through education, through the reframing of public narratives, and through measurement systems that make room for improvement instead of presuming decline.

Levy and Slade end with a recommendation that is as much civic as scientific: 

“It would be accurate and beneficial to expand the prevailing definition of aging so that it includes the possibility of health improvement. Insofar as we found that positive age beliefs contributed to this outcome, it is imperative that researchers and policymakers seek and deploy ways to amplify them.”

From the Clinic to the Courtroom

Jimmo established that improvement is not required for Medicare coverage. Levy and Slade have shown that improvement in later life is not rare, and that positive age beliefs predicted better cognitive and physical outcomes over time.

The implications reach beyond Medicare directly into the guardianship proceedings that remove the rights of older adults every day in probate courts across the United States. Guardianship often unfolds against a story about aging. That story holds that cognitive and physical decline is the expected trajectory of later life, that capacity once lost is unlikely to return, and that the appropriate response to vulnerability is the permanent transfer of legal authority to a surrogate. It is a story of irreversibility.

Levy’s research does not decide guardianship law. But it does challenge the decline narrative that can make sweeping interventions seem natural or inevitable. If nearly half of older adults show measurable improvement in cognitive function, physical function, or both over time, then assumption of one-way decline are not a sound scientific starting point for systems that allocate care, assess capacity, or remove rights.

The clinical bias that Levy and Slade document may help illuminate rushed capacity assessments, inadequate representation in guardianship proceedings, and the default toward plenary orders when limited or supported alternatives would serve. When a clinician signs a capacity assessment on the assumption that the person before them is on an inevitable downward trajectory, the assessment risks reflecting age-based assumptions rather than individualized, evidence-based judgment — with legal consequences that may prove permanent.

Jimmo corrected an unlawful administrative practice that treated maintenance care as unworthy of coverage. Levy and Slade challenge a broader cultural and scientific habit of treating later life as synonymous with decline. Taken together, they point toward a common conclusion: the systems we have built around older adults — in Medicare policy, in clinical practice, in guardianship law — have been organized around a story of inevitable decline that was never accurate, that has caused serious and largely invisible harm, and that we now have both the legal precedent and the scientific evidence to dismantle. Those systems should not presume that lack of improvement is the norm. Still less should they presume that decline alone justifies the sweeping loss of autonomy that plenary guardianship imposes.

Improvement is not a requirement for Medicare coverage. Decline is not the whole story of aging. And the loss of rights should never be the default response to vulnerability, particularly when the science now shows that later life can include stability, resilience, and improvement as well as loss.

From the Lab to the Public Square: Science in the Service of Justice

Levy and Slade's research belongs far beyond the pages of Geriatrics. It belongs in hospital discharge meetings, in Medicare appeals, in state aging plans, in guardianship courtrooms, and in the intimate family conversations that begin when a parent, spouse, or neighbor starts to need help. It belongs wherever decisions are made on the assumption that later life means inevitable decline — and wherever that assumption still passes for common sense.

Getting it there will take more than publication. It will take translation — the sustained, deliberate work of carrying scientific findings into the places where they can change practice, policy, and public understanding. That work is never automatic. Jimmo v. Sebelius was settled in 2013, but three years later the Center for Medicare Advocacy was still fighting for implementation because providers were still ignoring a standard the federal government had already agreed to. Levy and Slade's science now faces the same danger. A finding that 45.15 percent of older adults improved in cognitive function, physical function, or both over a decade could remain little more than a footnote in the literature while clinicians continue ordering capacity assessments on the assumption of irreversible decline and probate courts continue issuing plenary guardianship orders on that same premise.

That is precisely the problem the Gerontological Society of America has named — and begun to address — through its scientist-citizen initiative. At a moment when science is being challenged on many fronts, GSA has called on its members — scholars, researchers, clinicians, and educators — to bring their expertise beyond the lab, clinic, and classroom into everyday conversations with families, neighbors, community groups, elected leaders, and the press. GSA CEO James Appleby has publicly urged members to take up that charge and has backed it with institutional support, including training, advocacy tools, and Capitol Hill programming — recognizing that the integrity of aging science depends not only on what is discovered, but on whether those discoveries reach the people and systems that need them most.

There is precedent for exactly this kind of public-facing engagement in the history of gerontology itself. In 1969, Robert N. Butler coined the term “ageism” not only in peer-reviewed publication, in The Gerontologist, but also in public discourse, where Carl Bernstein quoted him in The Washington Post on housing opposition in Chevy Chase. From the outset, in other words, the work of naming the harm moved on two tracks at once: scholarly definition and public communication. As aging journalist Paul Kleyman has recalled, Butler also modeled that ethic in practice, urging aging professionals to make time for reporters and treating journalism as part of the work of public education. 

Levy and Slade’s research is exactly the kind of finding the Gerontological Society of America’s scientist-citizen initiative is designed to carry beyond the journal page. Positive age beliefs are shaped by culture, reinforced by institutions, and transmitted through language — which means they can also be reinforced, reframed, and amplified by people who understand the science and are willing to take it into the public square. Every aging researcher who tells a family that improvement is common, not exceptional; every clinician who approaches a capacity assessment knowing that many older adults improve over time; every policymaker who comes to understand that some widely used approaches to measuring aging have made improvement harder to see — is doing the work the scientist-citizen initiative calls for.

Paul Kleyman has been doing that work for more than fifty years. His 1974 book, Senior Power: Growing Old Rebelliously, was already arguing, before the science had caught up, that the story being told about aging was wrong and that the cost of telling it would be measured in human lives and human dignity. His two decades as editor of Aging Today, his nine years at New America Media, and his co-founding of the Journalists Network on Generations in 1993 place Paul Kleyman at the center of a lifetime’s effort to carry aging science into public understanding. He continues that work as JNG’s National Coordinator and as editor of its e-newsletter, GBONews.org. As head of JNG, he has also partnered with the Gerontological Society of America since 2009 and serves as senior advisor to the two organizations’ Journalists in Aging Fellows Program. His March 2026 piece on Levy and Slade's research in Aging in America News is one more act in that effort — bringing a peer-reviewed finding into clearer public view and making it more urgent and usable for broader audiences.

Paul describes his aim at this stage of his career as exploring how the words of wiser people he has met and interviewed over the decades may help enlighten our anti-aging culture. That aim and Levy and Slade’s science are closely aligned. So is the scientist-citizen initiative that GSA has launched. So is the work of the Center for Medicare Advocacy, which has spent more than a decade fighting to make a legal standard real in the daily lives of the people it was designed to protect.

These are not separate efforts. They are the same effort — carried forward in different registers, by people with different tools and different platforms, toward the same destination: a world in which the story we tell about aging is accurate, and in which the systems built around aging are organized around that more accurate story rather than around a cultural assumption of decline that the science has now powerfully challenged.

Improvement is not a requirement for Medicare coverage. Decline is not the whole story of aging. And the loss of rights should never be the default response to a person whose story is not yet finished.

The work of making that truth count — in policy, in clinical practice, in law, and in public understanding — is the work that connects all of us who have chosen to take it seriously.

The Paradigm Will Not Break Itself 

Thomas Kuhn taught us that scientific revolutions do not happen when a new finding is published. They happen when the assumptions, methods, and questions that define a field are fundamentally reorganized — when the old framework can no longer adequately account for its anomalies, and a new one takes its place. Levy and Slade’s research has supplied one such anomaly. A finding that 45.15 percent of older adults improved in cognitive function, physical function, or both over time does not sit easily inside a framework built on inevitable decline. In Kuhn’s terms, it is the kind of result that puts real pressure on a paradigm organized around one-way loss.

But paradigms do not change only in journals or laboratories. They change in the places where assumptions are taught, applied, and repeated — in clinical training, in policy manuals, in Medicare coverage determinations, in guardianship courtrooms, and in the conversations families have when someone they love begins to need help. That is precisely the insight behind the Gerontological Society of America’s scientist-citizen initiative, which calls on scholars, researchers, clinicians, and educators to extend their expertise beyond the lab and clinic into those very places. As GSA frames it, scientist-citizens are committed to proactive public engagement that improves understanding of science and the policies that shape how we age.

The scientist-citizen does not merely publish new knowledge. The scientist-citizen helps carry it into the world where it can change practice, policy, and public understanding. Levy and Slade's research gives that effort something essential to carry: not another cautionary tale about decline, but a documented, evidence-based, peer-reviewed finding that improvement in later life is common, that positive age beliefs predicted better outcomes, and that some of the field’s dominant assumptions — and some of the tools built around them — now require rethinking. 

Paul Kleyman's reporting in Aging in America News on Becca Levy's 2026 study was the catalyst for this essay — and for the connections it attempts to draw.

Disclosure: The author serves on the Advisory Board of the Center for Medicare Advocacy, a national nonprofit organization whose litigation and advocacy work is discussed in this essay.

Sources and Authorities

Alzheimer's Disease International, World Alzheimer Report 2024: Global changes in attitudes to dementia.

https://www.alzint.org/resource/world-alzheimer-report-2024/

Bicchieri, C. (2017). Norms in the wild: How to diagnose, measure, and change social norms. Oxford University Press.

https://academic.oup.com/book/6479 

Center for Medicare Advocacy. (n.d.). Improvement Standard and Jimmo Resources.    

https://medicareadvocacy.org/medicare-info/improvement-standard/ 

Cumming, E., & Henry, W. E. (1961). Growing old: The process of disengagement. Basic Books

https://search.worldcat.org/title/260696 

Gerontological Society of America. (n.d.). Scientist-citizen. 

https://www.geron.org/scientistcitizen 

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Havighurst, R. J. (1966). How does it feel to grow old? The Gerontologist, 6(3, Part 1), 130–135.

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Kleyman, P. (2026, March 23). Yale study debunks myth. Aging in America News.

https://aginginamerica.news/2026/03/23/yale-study-debunks-myth/ 

Kleyman, P. (1974). Senior power: Growing old rebelliously. 

https://search.worldcat.org/title/918361601 

Levy, B. (2022). Breaking the age code: How your beliefs about aging determine how long and well you live.

https://becca-levy.com/the-book/ 

Levy, B. R., & Slade, M. D. (2026). Aging redefined: Cognitive and physical improvement with positive age beliefs. Geriatrics, 11(2), Article 28.

https://doi.org/10.3390/geriatrics11020028 

Jimmo v. Sebelius, No. 5:11-cv-17 (D. Vt. filed Jan. 18, 2011).

https://law.justia.com/cases/federal/district-courts/vermont/vtdce/5:2011cv00017/19913/56/   

Mehegan, L. (2025, August). Brain healthy behaviors and worry about cognitive decline: Adults 40 and older. AARP Research, available as “What Adults Think and Do About Brain Health.”

https://doi.org/10.26419/res.00985.001 

U.S. Centers for Medicare & Medicaid Services. (2014). Jimmo v. Sebelius settlement agreement program manual clarifications fact sheet.

https://www.cms.gov/medicare/medicare-fee-for-service-payment/snfpps/downloads/jimmo-factsheet.pdf