Peter Kemper

Lifetime Use of Nursing Home Care

BACKGROUND AND METHODS Despite the growth in the number of Americans in nursing homes, there are only limited data on the total amount of time that people spend in such facilities. We estimate the amount of time the average person spends in nursing homes over his or her lifetime (lifetime nursing home use), using data from the National Mortality Followback Survey of the next of kin of a sample of persons 25 years of age or older who died in 1986. On the basis of these data, we estimated the likelihood that Americans will use nursing home care during the course of their lifetimes and the total duration of such care. Current data on life expectancy were then used to reweight the sample to project lifetime nursing home use for those who became 65 years old in 1990. RESULTS Of those who died in 1986 at 25 years of age or older, 29 percent had at some time been residents in a nursing home, and almost half of those who entered a nursing home spent a cumulative total of at least one year there. The probability of nursing home use increased sharply with age at death: 17 percent for age 65 to 74, 36 percent for age 75 to 84, and 60 percent for age 85 to 94. For persons who turned 65 in 1990, we project that 43 percent will enter a nursing home at some time before they die. Of those who enter nursing homes, 55 percent will have total lifetime use of at least one year, and 21 percent will have total lifetime use of five years or more. We also project that more women than men will enter nursing homes (52 percent vs. 33 percent), and among them, more women than men will have total lifetime nursing home use of five years or more (25 percent vs. 13 percent). CONCLUSIONS Our projections indicate that over a lifetime, the risk of entering a nursing home and spending a long time there is substantial. With the elderly population growing, this has important implications for both medical practice and the financing of long-term care.

Does Publicly Provided Home Care Substitute for Family Care?: Experimental Evidence with Endogenous Living Arrangements

This paper analyzes the extent to which publicly provided formal (paid) home care substitutes for unpaid care provided informally by family and friends. Unlike most previous research, we recognize that the choice among alternative combinations of formal and informal care depends on the type of living arrangement chosen, and that these living arrangement choices in turn are influenced by the public provision of formal home care. Using data from a social experiment, we find that a generous public home care program significantly increases the probability that unmarried persons will live independently and reduces the probability of living in shared households or in nursing or personal care homes. However, any substitution effects-either direct effects on provision of informal care given living arrangement or indirect effects due to living arrangement changes-appear to be small.

The risk of nursing home use in later life.

Data from the 1982-1984 National Long-Term Care Survey were used in this paper to estimate the risk of nursing home use. The data revealed that 37% of a nationally representative sample of individuals dying between 1982 and 1984 used a nursing home sometime after turning 65. This proportion increased with longevity and was higher among females and whites and in the North Central and Western regions of the country. Because individuals now turning 65 have a longer life expectancy than the persons studied, they face an even higher remaining lifetime risk of nursing home use (43%). Assuming that past utilization patterns will continue, over half of the women and almost one-third of the men turning 65 in 1990 can be expected to use a nursing home sometime before they die.

Long-Term Care Over an Uncertain Future: What Can Current Retirees Expect?

The leading edge of the baby boom generation is nearing retirement and facing uncertainty about its need for long-term care (LTC). Using a microsimulation model, this analysis projected that people currently turning age 65 will need LTC for three years on average. An important share of needed care will be covered by public programs and some private insurance, but much of the care will be an uninsured private responsibility of individuals and their families—a responsibility that will be distributed unequally. While over a third of those now turning 65 are projected to never receive family care, three out of 10 will rely on family care for more than two years. Similarly, half of people turning 65 will have no private out-of-pocket expenditures for LTC, while more than one in 20 are projected to spend

The amount, distribution, and timing of lifetime nursing home use.

100,000 or more of their own money (in present discounted value). Policy debate that focuses only on income security and acute care—and the corresponding Social Security and Medicare programs—misses the third, largely private, risk that retirees face: that of needing LTC.

Spouses and children of disabled elders: how large a constituency for long-term care reform?

OBJECTIVES Information on lifetime nursing home use is needed to design and evaluate long-term care financing reforms. Whereas a number of studies have estimated mean lifetime use or its distribution, very little is known about variation in use among subgroups of the population, the timing of use, the number of distinct episodes of care experienced by nursing home users, and the risk and expected use at ages other than age 65. The purpose of the study was to fill these gaps in knowledge. METHODS The study used a data base constructed to represent decedents who used nursing homes. The sample was derived from the sample of discharges collected as part of the 1985 National Nursing Home Survey. Weights were constructed for the purpose of making projections of remaining lifetime nursing home use at selected ages in 1995. RESULTS There was considerable variation in lifetime use among demographic groups. Overall, estimates of the amount of use remaining at selected ages tended to be relatively constant at approximately 1 year. Mean years until nursing home admission, however, decreased sharply from almost 40 years at age 45 to approximately 5 years at age 85. CONCLUSIONS The distribution of lifetime use was highly skewed, providing support for efforts to spread risk through public or private insurance. With roughly one quarter of all use occurring after 5 years of nursing home residence, however, a substantial share of use would exceed benefit maximums that are part of many proposals for public financing of long-term care as well as private insurance policies.

The density gradient for manufacturing industry

Over 13 million adults in the United States have disabled elderly parents or spouses and are potential providers of long-term care, financial assistance, or emotional support. Articles in the popular press notwithstanding, data from the 1984 National Long-term Care Survey indicate that a relatively small number of adult children and spouses assume the multiple responsibilities of elder care and child care or employment. These individuals form a subset of a much larger group of 4.2 million persons, however, who care for disabled parents or spouses. Current and future availability of spouses and children need to be considered in estimating the demand for formal long-term care and the costs of public programs.

LIFETIME PATTERNS OF PAYMENT FOR NURSING HOME CARE

Abstract This study employs a rich set of disaggregated manufacturing industry data to estimate density gradients for five metropolitan areas over the time span 1967–1971. The results are consistent with both expectations and with a number of other studies of industry location. More importantly, however, this study examines many of the methodological problems associated with the density gradient. It is concluded that the density gradient has reached the point of diminishing returns as a tool of the urban economist.

Public and private responsibility for financing nursing-home care: the effect of Medicaid asset spend-down.

Although much is known about who pays the annual aggregate nursing home bill, relatively little is known about payment-source patterns of individuals during their lifetimes. In this article, lifetime payment-source patterns are analyzed for elderly nursing home users, particularly the extent to which they spend down assets to become eligible for Medicaid. During their lifetimes, 44% of persons who use nursing homes after 65 years of age start and end as private payers, 27% start and end as recipients of Medicaid benefits, and 14% spend down assets to become eligible for Medicaid benefits. Although still a relatively small proportion, the asset spend-down estimate based on lifetime data is 2.5 times previous national estimates based on data for single nursing home stays. The projected risk of spending down assets in nursing homes for all persons who turn 65 years of age in 1995, including users and nonusers of nursing homes, is slightly more than 6%. Equally or more important for policy is that 17% of all persons who turn 65 years of age can expect to end up using a nursing home and receiving Medicaid reimbursement. Of those, more than 3 in 5 will have entered the nursing home already eligible for Medicaid benefits.

Meeting the need for personal care among the elderly: does Medicaid home care spending matter?

Data from a nationally representative sample of nursing-home residents at the beginning of 1987 are used to assess the interaction of Medicaid asset spend-down, the distribution of nursing-home days by payment source, and the effect of proposed changes in public financing of nursing-home care. Three out of five nursing-home residents were covered by Medicaid in January 1987; nearly all of the remainder were private-pay. Most Medicaid recipients were covered by Medicaid when they entered the care facility at the start of an episode, but 18 percent had spent down and were originally admitted as private-pay. A universal nursing-home benefit that insured the first six months of each nursing-home episode would cover 16 percent of the people in nursing homes on a given day, disproportionately those who are private-pay. A universal benefit with a 24-month waiting period would cover 56 percent of nursing-home residents on a given day, and would tend to favor those financed by Medicaid.