Older people in the US say their health declined between 2021 and 2022, according to the Centers for Disease Control and Prevention.

Americans 65 and older in 34 states reported higher rates of “fair” or “poor” health when surveyed as part of the CDC. Survey of the Behavioral Risk Factor Surveillance Systemso Northwell Health partnership with Forklift to see which states saw the biggest declines.

The population of adults over 65 in the US has experienced tremendous growth. They are more diverse, work longer and are better educated than previous generations. However, they also face serious challenges beyond the one caused by the COVID-19 pandemic, which reduced life expectancy by about 2.5 years between 2019 and 2021.

The rising cost of living, the opioid crisis, the shortage of affordable housing and access to care are affecting the health of older adults.

More than 11 million elderly people they spent more than 30% of their income on housing, utilities, taxes and insurance in 2021, according to a Harvard Joint Center for Housing Studies report. That qualifies them as cost-burdened, a distinction the Department of Housing and Urban Development uses to assess whether housing is affordable. This number is up significantly from the 9.6 million who fell into this category in 2016.

Rising housing costs mean that instead of seniors using money for prescription drugs and health care, it goes toward rent. Without these medicines, the conditions a person is dealing with may not be properly treated. Older adults taking diabetes medication who don’t buy the drugs they need to maintain their insulin levels can face serious problems, such as blindness, amputation, and death.

Opioid deaths in the elderly population have increased also four times between 2002 and 2021, reported researchers from Stanford University School of Medicine and the David Geffen School of Medicine at the University of California, Los Angeles. The Drugs and Aging Journal found that one of the health hazards of opioid abuse led to an increase in fallswhich could affect the ability to walk and move freely.

“Older adults who lose mobility are less likely to remain at home; they have higher rates of disease, disability, hospitalization and death and have a poorer quality of life,” according to the study. National Institute on Aging.

Older people usually have at least a chronic health conditionsuch as heart disease, diabetes or cancer, reports the Department of Health and Human Services. However, older adults may face difficulties in accessing health care, whether they live in a rural area, cannot drive themselves, or because of high out-of-pocket costs.

But the way older people feel about their health is not universal.

Decline factors in most states

It’s hard to say why older people in certain states rated their health worse in 2022 compared to the previous year. New Jersey, for example, saw demographics report better health, which follows with a US News & World Report ranking the state’s health care system 8th in the nation. However, this list ranks Hawaii No. 1 for health care, while older people there have reported a decline in their health.

Nationally, states are grappling with how to help this population, which the Census Bureau projects a 47% increase by 2050. In Maine, a new pilot program aims to use $2.5 million in federal funds to help connect senior residents with the resources they need to stay in their homes. Tennessee created the Apprenticeship Program for Direct Support Professionals, which increase pay for on-the-job training for workers in fields such as long-term care. And Vermont created the Old Vermonters Act, a broad measure to make a living in the state more friendly for older adults.

Story editing by Ashleigh Graf and Kelly Glass. Copy editing by Paris Close.

This story originally appeared on Northwell Health and was produced and distributed in partnership with Stacker Studio.