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When private resources are defined broadly to include informal care as well as private expenditures, 73 percent of the elderly long term care population rely entirely on private resources for their care. The emphasis of current programs on institutional care directs public resources toward those with more serious disability and less family to care for them. Among those with four or five disabilities in ADLS, 35 percent of those without a spouse or children currently receive no public support, compared with nearly 80 percent of those with both a spouse and children. Thus, even if restricted to seriously disabled persons, a new program expanding public long term care financing would increase eligibility for public benefits disproportionately among those with greater informal care resources. [ABSTRACT FROM AUTHOR]

Objective: Despite cross-sectional evidence that persons living with dementia receive disproportionate hours of care, studies of how care intensity progresses over time and differs for those living with and without dementia have been lacking., Method: We used the 2011-2018 National Health and Aging Trends Study to estimate growth mixture models to identify incident care hour trajectories ("classes") among older adults (N = 1,780)., Results: We identified 4 incident care hour classes: "Low, stable," "High, increasing," "24/7 then high, stable," and "Low then resolved." The high-intensity classes had the highest proportions of care recipients with dementia and accounted for nearly half of that group. Older adults with dementia were 3-4 times as likely as other older adults to experience one of the 2 high-intensity trajectories. A substantial proportion of the 4 in 10 older adults with dementia who were predicted to be in the "Low, stable" class lived in residential care settings., Discussion: Information on how family caregiving is likely to evolve over time in terms of care hours may help older adults with and without dementia, the family members, friends, and paid individuals who care for them, as well as their health care providers assess and plan for future care needs., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: We provide national estimates of caregiving networks for older adults with and without dementia and examine how these networks develop over time. Most prior research has focused on primary caregivers and rarely on change over time., Method: We identify a cohort of older adults continuously followed in the National Health and Aging Trends Study between 2011 and 2015 and receiving help from family members or unpaid caregivers in 2015 (n = 1,288). We examine differences by dementia status in network size, types of assistance and task sharing, and composition-differentiating between "specialist" and "generalist" caregivers helping in one versus multiple activity domains. Multinomial regression is used to estimate change over time in network task sharing and composition., Results: In 2015, older adults with dementia had larger caregiving networks involving more task sharing than those without dementia and more often relied on generalist caregivers, especially the subset assisting with medical, household, and mobility or self-care activities. Uniformly greater reliance over time on these more intensely engaged generalist caregivers chiefly accounts for larger dementia networks., Discussion: Findings lend support to the need for caregiver training on managing multiple task domains and-for dementia caregivers in particular-task-sharing skills. More generally, the design of new approaches to better support older adults and their caregivers should consider the complexity, heterogeneity, and change over time in caregiving networks., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Studies have reported decreasing dementia prevalence in recent decades in the United States. We explore with a new national data source whether declines have occurred since 2011, whether trends are attributable to shifts in dementia incidence or mortality, and whether trends are related to shifts in population composition or subgroup prevalence., Methods: We use the 2011-2015 National Health and Aging Trends Study (N = 27,547) to examine prevalence of probable dementia among the 70 and older population. To minimize the influence of potential learning effects on prevalence rates, we require individuals to meet probable dementia criteria at two consecutive rounds., Results: Prevalence of probable dementia declines over this period by 1.4% to 2.6% per year. Declines are concentrated among women, non-Hispanic white and black groups, and those with no vascular conditions or risk factors. The latter group also has experienced declines in dementia incidence. Declines in prevalence are largely attributable to age- and education-related shifts in population composition., Discussion: Given the role of age and educational composition in short-term declines, the United States is likely to continue to experience short-term declines in dementia prevalence. However, persistently high rates among minority groups, especially of Hispanic origin, are concerning, and, barring new treatments, long-run trends may reverse course.

Purpose: The United States is facing an unprecedented opioid epidemic. The Affordable Care Act (ACA) included several provisions designed to increase care coordination in state Medicaid programs and improve outcomes for those with chronic conditions, including substance use disorders. Three states-Maryland, Rhode Island, and Vermont - adopted the ACA's optional Medicaid health home model for individuals with opioid use disorder. The model coordinates opioid use disorder treatment that features opioid agonist therapy provided at opioid treatment programs (OTPs) and Office-based Opioid Treatment (OBOT) with medical and behavioral health care and other services, including those addressing social determinants of health. This study examines state approaches to opioid health homes (OHH) and uses a retrospective analysis to identify facilitators and barriers to the program's implementation from the perspectives of multiple stakeholders., Methods: We conducted 28 semi-structured discussions with 70 discussants across the three states, including representatives from state agencies, OHH providers (OTPs and OBOTs), Medicaid health plans, and provider associations. Discussions were recorded, transcribed, and analyzed using NVivo. In addition, we reviewed state health home applications, policies, regulatory guidance, reporting, and other available OHH materials. We adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) model as a guiding framework to examine the collected data, helping us to identify key factors affecting each stage of the OHH implementation., Results: Overall, discussants reported that the OHH model was implemented successfully and was responsible for substantial improvements in patient care. Contextual factors at both the state level (e.g., legislation, funding, state leadership, program design) and provider level (OHH provider characteristics, leadership, adaptability) affected each stage of implementation of the OHH model. States took a variety of approaches in designing and implementing the model, with facilitators related to gathering stakeholder input, receiving guidance and technical assistance, and tailoring program design to build on the state's existing care coordination initiatives and provider infrastructure. The OHH model constituted a substantial change for almost all OHH providers in the study, who reported that facilitators to implementation included having goals and workplace culture that were compatible with the OHH model, and having technical support from the state or non-governmental organizations. Some of the main barriers to implementation reported by OHH providers include shortages of primary care providers, dentists, and other providers willing to accept referrals of patients with opioid use disorder; limited community resources to address social determinants of health; challenges related to state-specific program design, such as staffing requirements and reimbursement methodology; care coordination limitations due to confidentiality restrictions and technological barriers; and internal capacity of providers to adopt the new model of care., Conclusions: The OHH model appears to have the potential to effectively address the complex needs of individuals with opioid use disorder by providing whole-person care that integrates medical care, behavioral health, and social services and supports. The experiences of Maryland, Rhode Island, and Vermont can guide development and implementation of similar OHH initiatives in other states., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: To provide a profile of older adults who successfully accommodate declines in capacity by using assistive devices., Method: Using the National Health and Aging Trends Study, we provide national estimates of prevalent, incident, and persistent successful accommodation of mobility and self-care activity limitations. For incident and persistent accommodation groups, we describe their subjective wellbeing and participation restrictions, health and functioning, demographic and socioeconomic characteristics, and acquisition of assistive devices and environmental features. We estimate regression models predicting incident and persistent successful accommodation and the extent of wellbeing and participation restrictions for incident and persistent groups (vs. those who are fully able)., Results: Nearly one-quarter of older adults have put in place accommodations that allow them to carry out daily activities with no assistance or difficulty. In adjusted models, incident and persistent successful accommodation is more common for those ages 80-89, those with more children, and those living in homes with environmental features already installed; wellbeing levels for these groups are similar and participation restrictions only slightly below those who are fully able., Discussion: A focus on facilitating successful accommodation among those who experience declines in capacity may be an effective means of promoting participation and wellbeing in later life., (© The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Understanding long-range trends in longevity and disability is useful for projecting the likely impact of the baby-boom generation on long-term care utilization and spending. We examine changes in active life expectancy in the United States from 1982 to 2011 for white and black adults ages sixty-five and older. For whites, longevity increased, disability was postponed to older ages, the locus of care shifted from nursing facilities to community settings, and the proportion of life at older ages spent without disability increased. In contrast, for blacks, longevity increases were accompanied by smaller postponements in disability, and the percentage of remaining life spent active remained stable and well below that of whites. Older black women were especially disadvantaged in 2011 in terms of the proportion of years expected to be lived without disability. Public health measures directed at older black adults-particularly women-are needed to offset impending pressures on the long-term care delivery system as the result of population aging., (Project HOPE—The People-to-People Health Foundation, Inc.)

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.

Importance: Family and unpaid caregivers commonly help older adults who are at high risk for poorly coordinated care., Objective: To examine how caregivers' involvement in older adults' health care activities relates to caregiving responsibilities, supportive services use, and caregiving-related effects., Design, Setting, and Participants: A total of 1739 family and unpaid caregivers of 1171 community-dwelling older adults with disabilities who participated in the 2011 National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC)., Main Outcomes and Measures: Caregiving-related effects, including emotional, physical, and financial difficulty; participation restrictions in valued activities; and work productivity loss., Exposures: Caregivers assisting older adults who provide substantial, some, or no help with health care, defined by coordinating care and managing medications (help with both, either, or neither activity, respectively)., Results: Based on NHATS and NSOC responses from 1739 family and unpaid caregivers of 1171 older adults with disabilities, weighted estimates were produced that accounted for the sampling designs of each survey. From these weighted estimates, 14.7 million caregivers assisting 7.7 million older adults, 6.5 million (44.1%) provided substantial help, 4.4 million (29.8%) provided some help, and 3.8 million (26.1%) provided no help with health care. Almost half (45.5%) of the caregivers providing substantial help with health care assisted an older adult with dementia. Caregivers providing substantial help with health care provided more hours of assistance per week than caregivers providing some or no help (28.1 vs 15.1 and 8.3 hours, P < .001 for both). The use of supportive services was low but was greater among caregivers providing substantial vs some or no help (26.7% vs 15.5% and 7.6%, P < .001 for both). In multivariable regression models adjusting for older adults' function and caregivers' sociodemographic and health characteristics, caregivers providing substantial help with health care were significantly more likely to experience emotional difficulty (adjusted odds ratio [aOR], 1.79; 95% CI, 1.20-2.66), physical difficulty (aOR, 2.03; 95% CI, 1.39-2.97), and financial difficulty (aOR, 2.21; 95% CI, 1.52-3.22) than caregivers providing no help. Compared with caregivers providing no help with health care activities, caregivers providing substantial help with health care activities were more than 5 times as likely to experience participation restrictions in valued activities (aOR, 5.32; 95% CI, 3.31-8.59) and more than 3 times as likely to experience work productivity loss (aOR, 3.14; 95% CI, 1.40-7.02)., Conclusions and Relevance: Family caregivers providing substantial assistance with health care experience significant emotional difficulty and role-related effects, yet only one-quarter use supportive services.

The number of US adults ages sixty-five and older who are living with dementia is substantial and expected to grow, raising concerns about the demands that will be placed on family members and other unpaid caregivers. We used data from the 2011 National Health and Aging Trends Study and its companion study, the National Study of Caregiving, to investigate the role of dementia in caregiving. We found that among family and unpaid caregivers to older noninstitutionalized adults, one-third of caregivers, and 41 percent of the hours of help they provide, help people with dementia, who account for about 10 percent of older noninstitutionalized adults. Among older adults who receive help, the vast majority in both community and residential care settings other than nursing homes rely on family or unpaid caregivers (more than 90 percent and more than 80 percent, respectively), regardless of their dementia status. Caregiving is most intense, however, to older adults with dementia in community settings and from caregivers who are spouses or daughters or who live with the care recipient., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objectives: Studies of late-life disablement typically address the role of advancing age as a factor in developing disability, and in some cases have pointed out the importance of time to death (TTD) in understanding changes in functioning. However, few studies have addressed both factors simultaneously, and none have dealt satisfactorily with the problem of missing data on TTD in panel studies., Methods: We fit latent-class trajectory models of disablement using data from the Health and Retirement Study. Among survivors (~20% of the sample), TTD is unknown, producing a missing-data problem. We use an auxiliary regression equation to impute TTD and employ multiple imputation techniques to obtain final parameter estimates and standard errors., Results: Our best-fitting model has 3 latent classes. In all 3 classes, the probability of having a disability increases with nearness to death; however, in only 2 of the 3 classes is age associated with disability. We find gender, race, and educational differences in class-membership probabilities., Discussion: The model reveals a complex pattern of age- and time-dependent heterogeneity in late-life disablement. The techniques developed here could be applied to other phenomena known to depend on TTD, such as cognitive change, weight loss, and health care spending., (© The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose of the Study: Comprehensive measures of disability accommodations have been lacking in national health and aging studies. This article introduces measures of accommodations developed for the National Health and Aging Trends Study, evaluates their reliability, and explores the validity and reliability of hierarchical classification schemes derived from these measures., Design and Methods: We examined test-retest reliability for questions about assistive device use, doing activities less often, and getting help from another person with both percentage agreement and kappa (N = 111). Summary measures across activities and several hierarchical classification schemes (e.g., no accommodation, devices/activity reductions only, help) were developed. For the latter, we also evaluated validity by examining correlations with measures of capacity and demographic characteristics (N = 326)., Results: Items about assistive device use and help in the last month were robust (most kappas 0.7-0.9). Activity reduction measures were moderately reliable (around 0.5) but still showed reasonable agreement. Reliabilities for summary measures were good for device use (0.78-0.89) and help (0.62-0.67) but lower, albeit acceptable, for activity reduction (0.53). Hierarchical classifications had acceptable reliability and levels demonstrated hierarchical properties., Implications: National Health and Aging Trends Study's self-care and mobility accommodation measures offer ample reliability to study adaptation to limitations and can be used to construct a reliable and valid hierarchy., (© The Author 2013. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Older adults with care needs live in a variety of settings-from traditional community housing to nursing homes. This analysis provides new estimates of the size and characteristics of the older population across settings and examines unmet needs for assistance., Method: Data are from the 2011 National Health and Aging Trends Study (N = 8,077). Multinomial logistic regressions focus on people in settings other than nursing homes who are at risk for unmet needs, defined as receiving help or having difficulty with household, self-care, or mobility activities (N = 4,023)., Results: Of 38.1 million Medicare beneficiaries ages 65 and older, 5.5 million (15%) live in settings other than traditional housing: 2.5 million in retirement or senior housing communities, nearly 1 million in independent- and 1 million in assisted-living settings, and 1.1 million in nursing homes. The prevalence of assistance is higher and physical and cognitive capacity lower in each successive setting. Unmet needs are common in traditional community housing (31%), but most prevalent in retirement or senior housing (37%) and assisted living settings (42%). After controlling for differences in resident characteristics across settings, those in retirement or senior housing communities have a higher likelihood of unmet needs than those in traditional community housing, while those in independent or assisted living settings have a lower relative likelihood., Discussion: Substantial numbers of older adults, many with care needs, live in a continuum of settings other than traditional community housing. Unmet needs are prevalent among older adults with limitations across all settings and warrant further investigation and monitoring., (© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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.

Background: Measurement gaps continue to hamper fuller understanding of late-life disability trends and dynamics. This article reports findings that validate the self-reported components of the disability protocol to be used in the new National Health and Aging Trends Study. The protocol was designed to redress existing measures by attending to environmental aspects of disability, capturing a broader range of capacity to perform tasks and including participation restriction items., Methods: We undertook an in-person validation study to determine the reliability, validity, and initial measurement properties of the National Health and Aging Trends Study self-reported disability protocol (n = 326). A random subset (n = 111) was readministered the protocol within 2-4 weeks. The interview and reinterview included new self-reported measures of physical capacity, activity limitations, and participation restrictions, as well as established performance and cognitive tests. We calculated percent agreement and kappa between interviews for all self-reported items and summary measures. We also assessed the construct validity of summary measures through correlations with demographic characteristics, frailty, memory, and performance-based mobility and confirmed whether activity limitations and participation restrictions were distinct domains., Results: New items and derived summary measures demonstrate robustness over a short time period, with kappas for retained/recommended items in the .60-.80 range. The summary measures correlate as expected with age, sex, residential status, and established performance-based constructs. Two factors, representing activity limitations and participation restrictions, were confirmed., Conclusions: The National Health and Aging Trends Study protocol preserves the ability to examine more traditional measures of functioning while offering new insights into how activities are performed and preserving key conceptual distinctions.

Objective: To estimate risk and duration of chronic conditions and disability for all older Americans and demographic subgroups., Method: Analysis of National Mortality Followback Survey data for survivors to age 65 to project lifetime risk and duration of selected conditions and examine their relationship with life expectancy and disability., Results: For women, Blacks, and non-Blacks, arthritis is most common and has the longest average duration, followed by diabetes and COPD. Among men, diabetes duration is longest, followed by COPD. Disability risk is elevated for all conditions studied, except heart attack. Those very overweight most of life and persons with dementia have the greatest disability risk and relatively long disability durations. Among women, those very overweight most of life can expect to die 3.1 years sooner and have above average disability duration., Discussion: Findings provide new information about the relative burden of common chronic diseases among all older Americans and major subgroups.

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.

The authors consider an integrated income and disability annuity as an alternative framework for long-term care financing, show that pooling disability and mortality risks can reduce the need for medical underwriting, and discuss private and public implications. Data from the National Mortality Followback Survey of 1986 were used to simulate current underwriting and minimal underwriting, excluding only those already eligible for benefits. Remaining disability, life expectancy, and premiums are compared under both underwriting assumptions. Under minimal underwriting, 98% of persons age 65 would be eligible to purchase disability protection through an integrated annuity, versus 77% under current underwriting. Premiums for both the income and disability components were lower with minimal underwriting. Combining income and disability protection may be able to expand private markets for long-term care financing beyond what appears possible in the long-term care insurance market. Public policy should avoid the distortion of choices created by focusing exclusively on an insurance model.

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.

Background: The proportion of the population made up of elderly persons in the United States is projected to increase from 13 percent of the population in 2000 to 20 percent by 2030. The implications for health care expenditures may be profound, because elderly persons use health care services at a greater rate than younger persons. We estimated total expenditures for acute and long-term care from the age of 65 years until death and in the last two years of life., Methods: We combined data from Medicare, the National Mortality Followback Survey, and the National Medical Expenditure Survey to estimate total national expenditures for health care according to the age at death. We also simulated expenditures with the use of projected demographic characteristics of two cohorts: people turning 65 in 2000 and those turning 65 in 2015., Results: Total expenditures (in 1996 dollars) from the age of 65 years until death increase substantially with longevity, from $31,181 for persons who die at the age of 65 years to more than $200,000 for those who die at the age of 90, in part because of steep increases in nursing home expenditures for very old persons. Spending in the last two years of life also increases with longevity, but a reduction in Medicare expenditures ($37,000 for persons who die at the age of 75 years and $21,000 for those who die at the age of 95) moderates the effect of the increase in nursing home expenditures ($6,000 for those who die at the age of 75 years and $32,000 for those who die at the age of 95). Health care spending for women is consistently higher than that for men, after adjustment for the increased longevity of women. Simulations show that increased longevity after the age of 65 years has a relatively small effect on the anticipated increase in spending, especially for services covered by Medicare, from 2000 to 2015. The effects of the larger number of people born in 1950 than in 1935 and the larger number of people surviving to the age of 65 years are much more important., Conclusions: In the United States, the effect of longevity on expenditures for acute care differs from its effect on expenditures for long-term care. Acute care expenditures, principally for hospital care and physicians' services, increase at a reduced rate as the age at death increases, whereas expenditures for long-term care increase at an accelerated rate. Increases in longevity after the age of 65 years may result in greater spending for long-term care, but the increase in the number of elderly persons has a more important effect on total spending.

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.

When private resources are defined broadly to include informal care as well as private expenditures, 73 percent of the elderly long term care population rely entirely on private resources for their care. The emphasis of current programs on institutional care directs public resources toward those with more serious disability and less family to care for them. Among those with four or five disabilities in ADLS, 35 percent of those without a spouse or children currently receive no public support, compared with nearly 80 percent of those with both a spouse and children. Thus, even if restricted to seriously disabled persons, a new program expanding public long term care financing would increase eligibility for public benefits disproportionately among those with greater informal care resources.

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.