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Objectives: To examine changes in active life expectancy in the United States over 30 years for older men and women (aged ≥ 65 years)., Methods: We used the 1982 and 2004 National Long Term Care Survey and the 2011 National Health and Aging Trends Study to estimate age-specific mortality and disability rates, the overall chances of survival and of surviving without disability, and years of active life for men and women., Results: For older men, longevity has increased, disability has been postponed to older ages, disability prevalence has fallen, and the percentage of remaining life spent active has increased. However, for older women, small longevity increases have been accompanied by even smaller postponements in disability, a reversal of a downward trend in moderate disability, and stagnation of active life as a percentage of life expectancy. As a consequence, older women no longer live more active years than men, despite their longer lives., Conclusions: Neither a compression nor expansion of late-life disability is inevitable. Public health measures directed at older women to postpone disability may be needed to offset impending long-term care pressures related to population aging.

Context: The cost of late-life dependency is projected to grow rapidly as the number of older adults in the United States increases in the coming decades. To provide a context for framing relevant policy discussions, we investigated activity limitations and assistance, care resources, and unmet need for a national sample of older adults., Methods: We analyzed the 2011 National Health and Aging Trends Study, a new national panel study of more than 8,000 Medicare enrollees., Findings: Nearly one-half of older adults, or 18 million people, had difficulty or received help in the last month with daily activities. Altogether, 1 in 4 older adults receiving help lived in either a supportive care (15%) or a nursing home (10%) setting. Nearly 3 million received assistance with 3 or more self-care or mobility activities in settings other than nursing homes, and a disproportionate share of persons at this level had low incomes. Nearly all older adults in settings other than nursing homes had at least 1 potential informal care network member (family or household member or close friend), and the average number of network members was 4. Levels of informal assistance, primarily from family caregivers, were substantial for older adults receiving help in the community (164 hours/month) and living in supportive care settings (50 hours/month). Nearly all of those getting help received informal care, and about 3 in 10 received paid care. Of those who had difficulty or received help in settings other than nursing homes, 32% had an adverse consequence in the last month related to an unmet need; for community residents with a paid caregiver, the figure was nearly 60%., Conclusions: The older population-especially those with few economic resources-has substantial late-life care needs. Policies to improve long-term services and supports and reduce unmet need could benefit both older adults and those who care for them., (© 2014 Milbank Memorial Fund.)

Objectives: To inform public health efforts to promote independent functioning among older adults, we have provided new national estimates of late-life disability that explicitly recognize behavioral adaptations., Methods: We analyzed the 2011 National Health and Aging Trends Study, a study of Medicare enrollees aged 65 years and older (n = 8077). For 7 mobility and self-care activities we identified 5 hierarchical stages--fully able, successful accommodation with devices, activity reduction, difficulty despite accommodations, and receipt of help--and explored disparities and associations with quality of life measures., Results: Among older adults, 31% were fully able to complete self-care and mobility activities. The remaining groups successfully accommodated with devices (25%), reduced their activities (6%), reported difficulty despite accommodations (18%), or received help (21%). With successive stages, physical and cognitive capacity decreased and symptoms and multimorbidity increased. Successful accommodation was associated with maintaining participation in valued activities and high well-being, but substantial disparities by race, ethnicity, and income existed., Conclusions: Increased public health attention to behavioral adaptations to functional change can promote independence for older adults and may enhance quality of life.

This article updates trends from five national U.S. surveys to determine whether the prevalence of activity limitations among the older population continued to decline in the first decade of the twenty-first century. Findings across studies suggest that personal care and domestic activity limitations may have continued to decline for those ages 85 and older from 2000 to 2008, but generally were flat since 2000 for those ages 65-84. Modest increases were observed for the 55- to 64-year-old group approaching late life, although prevalence remained low for this age group. Inclusion of the institutional population is important for assessing trends among those ages 85 and older in particular.

Objectives: We estimated national and state-level potential medical care cost savings achievable through modest reductions in the prevalence of several diseases associated with the same lifestyle-related risk factors., Methods: Using Medical Expenditure Panel Survey Household Component data (2003-2005), we estimated the effects on medical spending over time of reductions in the prevalence of diabetes, hypertension, and related conditions amenable to primary prevention by comparing simulated counterfactual morbidity and medical care expenditures to actual disease and expenditure patterns. We produced state-level estimates of spending by using multivariate reweighting techniques., Results: Nationally, we estimated that reducing diabetes and hypertension prevalence by 5% would save approximately $9 billion annually in the near term. With resulting reductions in comorbidities and selected related conditions, savings could rise to approximately $24.7 billion annually in the medium term. Returns were greatest in absolute terms for private payers, but greatest in percentage terms for public payers. State savings varied with demographic makeup and prevailing morbidity., Conclusions: Well-designed interventions that achieve improvements in lifestyle-related risk factors could result in sufficient savings in the short and medium term to substantially offset intervention costs.

This study estimates how informal care, paid formal care, and caregiver stress or burden relate to nursing home placement. Data came from the 1999 National Long Term Care Survey and were merged with administrative data. Results show that stress is a strong predictor of entry over follow-up periods of up to two years, and physical strain and financial hardship are important predictors of high levels of caregiver stress. The estimates indicate that reducing these stress factors would significantly reduce caregiver stress and, as a result, nursing home entry. We conclude that initiatives to reduce caregiver stress hold promise as a strategy to avoid or defer nursing home entry.

Although the prevalence of late-life disability has been declining, how best to promote further reductions remains unclear. This article develops and then demonstrates an approach for comparing the effects of interventions on the prevalence of late-life disability. We review evidence for three potentially high-impact strategies: physical activity, depression screening and treatment, and fall prevention. Because of the large population at risk for falling, the demonstrated efficacy of multi-component interventions in preventing falls, and the strong links between falls and disability, we conclude that, in the short run, multi-component fall-prevention efforts would likely have a higher impact than either physical activity or depression screening and treatment. However, longer-term comparisons cannot be made based on the current literature and may differ from short-run conclusions, since increases in longevity may temper the influences of these interventions on prevalence. Additional research is needed to evaluate longer-term outcomes of interventions, including effects on length and quality of life.

In September 2002, a technical working group met to resolve previously published inconsistencies across national surveys in trends in activity limitations among the older population. The 12-person panel prepared estimates from five national data sets and investigated methodological sources of the inconsistencies among the population aged 70 and older from the early 1980s to 2001. Although the evidence was mixed for the 1980s and it is difficult to pinpoint when in the 1990s the decline began, during the mid- and late 1990s, the panel found consistent declines on the order of 1%-2.5% per year for two commonly used measures in the disability literature: difficulty with daily activities and help with daily activities. Mixed evidence was found for a third measure: the use of help or equipment with daily activities. The panel also found agreement across surveys that the proportion of older persons who receive help with bathing has declined at the same time as the proportion who use only equipment (but not personal care) to bathe has increased. In comparing findings across surveys, the panel found that the period, definition of disability, treatment of the institutionalized population, and age standardizing of results were important to consider. The implications of the findings for policy, national survey efforts, and further research are discussed.

Recent research indicates declining age-adjusted chronic disability among older Americans, which might moderate health care costs in the coming decades. This study examines the trend's underlying components using data from the 1984-1999 National Long-Term Care Surveys to better understand the reasons for the declines and potential implications for acute and long-term care. The reductions occurred primarily for activities like financial management and shopping. Assistance with personal care activities associated with greater frailty fell less, and independence with assistive devices rose. Institutional residence was stable. More needs to be known about the extent to which these declines reflect environmental improvements allowing greater independence at any level of health, rather than improvements in health, before concluding that the declines will mean lower costs.

Objectives: The elderly population at risk for costly nursing home care is increasing. It is important to understand patterns of lifetime nursing home use and their implications for public and private payers. We provide new lifetime nursing home use estimates, project future use, and discuss cost implications., Methods: Data are next-of-kin reports of nursing home use for representative samples of decedents from the 1986 and 1993 National Mortality Followback Surveys. Future use is based on projected mortality from the Social Security Administration., Results: The proportion of elderly decedents who ever used a nursing home rose modestly between 1986 and 1993, with increased use before the last year of life. Rising longevity after age 65 and older the next 20 years will increase the risk for a 65 year old ever entering a nursing home to 46%. With increased survival to age 65, the number of 65 year olds ultimately using nursing homes will double by 2020., Conclusions: Disability declines and changes in Medicare policy between 1986 and 1993 had little impact on overall patterns of nursing home use. Barring dramatic changes in health status or other factors, population aging will make nursing home costs a growing share of national health spending. More needs to be known about relationships between nursing home use and alternative care settings and the cost and quality implications of shifts from one setting to the other. A key issue is how constraints on Medicare SNF and home health benefits will affect use and the distribution of costs.

Informal family care giving has been a traditional mainstay of care for the frail elderly. As the Baby Boomers approach retirement and old age, it is not clear that society can continue to rely on informal arrangements. The 1984 and 1994 National Long Term Care Surveys were used as sources for examining changes over a decade in the population of chronically disabled elderly, their sources of care, and the characteristics of family caregivers. The results showed that although the total number of active family caregivers declined, a constant number of primary caregivers was looking after recipients who were more severely disabled. Members of the "sandwich generation" and full-time workers maintained or even increased their participation as primary caregivers. The competing demands confronting these caregivers and the higher disability levels among care recipients probably contributed to the growing pattern of reliance on formal care, a situation that is likely to continue.

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.

Private insurance is one strategy for financing the large and growing cost of long-term care. Little is known, however, about the extent to which medical underwriting may limit the potential of private insurance to cover nursing home care, or whether the underwriting criteria used in this relatively new market successfully identify high-cost groups. This paper uses data from the National Mortality Followback Survey to address these two questions. We estimate that between 12% and 23% of the population would be rejected for private long-term care insurance because of their health if everyone applied at age 65. These figures rise to between 20% and 31% at age 75. Our simulation results suggest that long-term care insurance underwriting criteria identify individuals who vary substantially in the financial risk they pose to insurers. In most cases, whether a criterion identifies a high-cost group is sensitive to the policy individuals are assumed to buy.

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.

Recent proposals to increase access to health insurance suggest the need to know what the magnitude of responses would be if the one in five nonelderly persons uninsured for all or part of the year were to become insured. This paper finds that an additional commitment of resources to hospital and ambulatory care on the order of $26 billion (in 1989 dollars), or about 4% of total national health care spending, would be required if those now uninsured were to use these services on a par with the privately insured. The primary inputs to this result are new estimates of the impact of being uninsured which indicate a substantial potential response to insurance, particularly by adults.

In this paper data from the National Mortality Followback Survey and the National Nursing Home Survey are used to estimate the lifetime cost of nursing home care. The expected discounted cost for persons turning 65 in 1990 is $27,600. However, variation around this average is high. The 9% of persons expected to use at least 5 years of nursing home care will account for 64% of aggregate cost for the cohort; the 68% using less than 3 months of care will account for only about 1% of cost. The percentage of costs covered under alternative financing strategies also varies widely. An entitlement covering the first 3 months of care subject to 30% coinsurance would cover 5% of aggregate cost; an entitlement with a 2-year deductible and the same coinsurance would cover 41% of cost.