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Seniors, Accessibility and CMS

The Centers for Medicare & Medicaid Services (CMS) serve a population that is aging and increasingly online. CivicActions, along with our partners Fearless, led CMS.gov’s development efforts with an understanding that aging Americans are more likely to experience disability. In doing so, we incorporated accessibility features into the user experience to ensure that all users can access CMS content and services, including Medicare.gov and several open data sites. 

Certain disabilities disproportionately impact older internet users; as we age, our sight, hearing, mobility, and cognition tend to deteriorate. According to the Nielsen Norman Group (pioneers in usability who’ve worked extensively with seniors), the decline in these abilities starts much earlier. 

“In testing middle-aged users, we’ve found that between the ages of 25 and 60, people’s ability to use websites declines by 0.8% per year.” – Jakob Nielsen

This is important because we know that as people age, it is more difficult for them to use the digital interfaces we are building for them. Perceptions about how and when seniors use technology should also account for those who have used computers for a significant portion of their adult lives. 

In this project, it was important to prioritize the accessibility of CMS.gov and Medicare.gov by implementing features in line with Web Content Accessibility Guidelines (WCAG), the standard for web accessibility adopted worldwide. The aim is to create website experiences that benefit CMS’s primary audience and ultimately all visitors to CMS sites who at some point in their lives will suffer from situational, temporary, or permanent disability. 

Accessibility Concerns for Older Users

Below are factors we take into account when considering older users and accessibility.


When it comes to navigating the web, visual impairment can make it harder to:

  • Recognize the meaning of unlabeled symbols & icons, especially small ones
  • Do quick visual searches (spotting the target item amid distractors)
  • Read moving text or track a screen-pointer
  • Near-focus without reading glasses
  • See clearly without sufficient contrast
  • Read when there is glare and adapt to lighting changes
  • Recognize color differences, especially in blue-green wavelengths

To address these concerns, CivicActions updated CMS.gov sites to include features that accommodate low vision or blindness, such as ensuring that pages and text can be resized (or magnified using the “zoom” control) to increase readability, implementing a high-contrast color palette, and including text alternatives for users who navigate with a screen reader.


Audible website content, like video soundtracks, can be difficult to discern as hearing declines. It’s important to provide ways for users to access text transcripts and closed captions, filter out background or other distracting noise, and understand speech or sounds that provide meaningful context. Being able to adjust the volume will help some, but not, all users. Some users will need a high-quality recording. 

CivicActions’ work often doesn’t include audio or video content because we always recommend providing inclusive solutions. We have addressed some concerns related to audio by including transcripts for audio/video materials, such as with CMS.gov’s Open Door Forum Podcast.  

Mobility and Dexterity

Users with disabilities that impact hand grip, joint mobility, or movement control can find using a computer mouse more challenging and prone to mistakes. As we grow older, it may be harder to:

  • Grasp/manipulate small objects
  • Control continuous movements
  • Execute coordinated gestures
  • Reliably control movements
  • Avoid unintentional actions

We can address these issues in part by ensuring that our sites are keyboard accessible and responsive (usable on a range of devices and viewport orientations, from handheld to desktop). 

A computer keyboard provides a static “hit” area for hands or pointer devices, can be used reliably by those who don’t have fine motor control, and even can be customized for common keystrokes. For this user group in particular, it’s important — and according to WCAG, always necessary — to make all content and clickable elements keyboard accessible

At CivicActions, we’re also committed to addressing accessibility early and often in our development. Often referred to as shifting left, we consider accessibility concerns like keyboard control by reviewing interface elements during the design process and before implementation details are hammered out. Keyboard usage in particular needs to be considered early in an agile cycle to ensure that keyboard-supporting elements are present, like an explicit button to confirm an action and adequate visual feedback for the focused state. 

Considering accessibility in the design phase also means leveraging the CMS design system to avoid many common problems. We built the patterns to allow for a range of mobility when using both mobile and desktop browsers to engage with CMS sites. 


Despite common perceptions that overall cognition declines as we age, people actually retain the ability to develop new skills, increase vocabulary, and learn new technology. Cognitive issues generally are limited to reduced memory recall, attention, and multitasking

The content and interactive experiences we create for CMS.gov should accommodate all the ways our cognition evolves with age, with a focus on ensuring that content and ideas are communicated with fewer distractions, less repetition, and consistent guideposts throughout, including:

  • Clear and consistent navigation
  • Alternate ways to find content, such as breadcrumbs, a site map and dynamic search functionality
  • Standard implementation of interaction patterns (i.e., leveraging the CMS design system)

To that end, our colleagues at Fearless compiled a ROT analysis during a recent redesign of CMS.gov to weed out content and design patterns that may present barriers to those with cognitive disabilities. They identified several areas for improvement, where content was duplicated or infrequently updated, or where navigation redundancy led to unnecessary clicks.


According to Pew Research, rates of smartphone and tablet ownership have grown consistently across all age groups. While those over 65 may not participate in social media as frequently as younger people, they are keeping pace with the technology and overall Internet usage. 

Despite similar rates of technology adoption, one study of older users’ perceptions of new technology found that “most of our participants were eager to adopt new technology and willing to learn using a tablet. However, they voiced apprehension about lack of, or lack of clarity in, instructions and support.

Therefore, it is important that we consider older users’ mindset when using the web, including:

  • How comfortable they are with new technology
  • Concerns about “breaking something” or making a “wrong” move when interacting with a website
  • A tendency to read everything on screen before acting
  • Frustration with redundant or unclear content
  • Hesitation to share personal information online

In our work, we strive to ensure that people are confident they are on a reliable site. Especially when dealing with vaccinations, it has been important to provide factual information in an easily understandable manner. Conscious of our visitors’ top tasks, we work to see that users are able to find the information they need.

General Guidance and Conclusions  

Ultimately, everyone benefits when website designs: 

  • Use sufficient contrast 
  • Avoid patterned backgrounds, gradients and animations that distract users
  • Are consistent and have discoverable content
  • Think about linked content by using large, underlined text more than two-words long to ensure better readability and making next-page prompts more prominent 
  • Allow people to pause, mute, or stop website movement and sound to avoid distractions 
  • Write in Plain Language and avoid jargon

When addressing temporary and situational disabilities, all users can benefit from teams doing the hard work of making a simple interface. We increasingly face juggling priorities and concerns, and we should be writing to ensure that it is easy for everyone to understand. The tools and implementations that aid users — such as people benefiting from CMS — ultimately help not just those senior beneficiaries, but all site users. 


Mike Gifford is a Senior Strategist at CivicActions and a thought leader on digital accessibility in the public sector. Previously, he was the Founder and President of OpenConcept Consulting Inc., a web development agency specializing in building open source solutions for the open web. OpenConcept was an impact driven company and Certified B Corporation. Like CivicActions, OpenConcept worked extensively with the Drupal CMS. Mike was also part of the Government of Canada’s Open Source Advisory Board. Mike spearheaded accessibility improvements in Drupal since 2008, and officially became a Drupal Core Accessibility Maintainer in 2012.

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