Long-Term Care for the Disabled Elderly: Current Policy, Emerging Trends and Implications for the 21st Century
By Robyn I. Stone, DrPH
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THE FUTURE SUPPLY OF LONG-TERM CARE SERVICES
While projections of the future demand for long-term care must be examined with caution, it is even more difficult, if not impossible, to predict the nature, size and scope of the supply side in the 21st century. The future landscape of services depends not only on the demand for care, but also how these services are financed and what we are willing to pay for. The design of delivery systems is in flux, including the extent to which managed care will change the way in which chronically disabled elders receive their acute, post-acute and long-term care. Some have argued that financing responsibility will continue to shift from the federal government to the states, individuals, and their families (Cohen, 1998). As consumers rely less and less on the government to pay for long-term care, they are also likely to demand greater flexibility in how and where they access services.
The Future Supply of Alternative Settings
One of the major unknowns is the extent to which nursing homes will remain the dominant setting for long-term care in the future. Much depends on the public and private incentives (financial and regulatory) to develop more home and community-based alternatives, including assisted living. Currently, there is not much substitution between nursing homes and assisted living facilities. Much of the institutional care is supported by Medicaid where people are either poor or have become poor in order to qualify for coverage. In contrast, the assisted living market has been primarily a wealthy, private pay consumer base, with little attempts to reach the modest or low-income market. Industry analysts estimate that the assisted living market is worth $13 billion to $15 billion, with the value expected to rise to $20 billion by 2020. But it is not clear whether these facilities will be primarily a senior living alternative for the rich, or a long-term care option offering the range of services required to meet the needs of disabled elderly with varying economic situations.
The Assisted Living Federation of America and the American Association of Homes and Services for the Aging, the two trade associations representing the majority of assisted living and housing facilities, have identified affordable housing with services as a major priority for the decade. Recent federal legislation requires the U.S. Department of Health and Human Services and the Department of Housing and Urban Development to collaborate on initiatives that will expand the opportunity to provide Medicaid-funded home care services in low-income housing. Such measures augur well for the development of new demonstrations that will test the feasibility of creating an affordable assisted living market for modest and low-income elders. At the same time, these efforts will be futile unless the private sector developers and investors are also at the table to help support these efforts.
The degree to which other options such as adult day care will proliferate throughout the country is unknown. Furthermore, if universal design concepts become more pervasive in the development of new communities, the potential for people to "age in place" in homes that are designed to adapt to the changing needs of individuals as they become more disabled will be enhanced. As telemedicine becomes more sophisticated and available, long distance caregiving may become more of a reality for both formal and informal caregivers, particularly in rural areas. The downside of such developments, however, include the potential to erode the "caring" aspects of long-term care that come from the hands-on, personal touch of a family member or home care worker.
The Future of the Long-Term Care Workforce
According to a study supported by the Alliance for Aging Research in 1996, the United States has a shortage of more than 13,000 doctors specially trained to treat older patients. The report estimated that this country currently needs 20,000 geriatricians and a total of 36,858 by the year 2030 to care for graying baby boomers. About 2,100 faculty members in geriatrics, or more than four times the current number, are needed.
The future demand and supply of frontline, paraprofessional long-term care workers should be of major concern to policymakers, providers and potential consumers. Paraprofessional workers provide 80 percent of the direct care in nursing homes and over 90 percent of the formal direct services in home care (Atchley, 1996). Factors influencing an increasing demand for home care aides include: 1) the aging of the population, 2) increased reliance of people of all ages on home care as an alternative to hospitalization and nursing home placement, 3) the expansion of home care coverage through the Medicare and Medicaid programs, and 4) the overwhelming preference of most disabled and their families for home care options (BLS, 1999a; Burbridge, 1993). Increasing financial pressures on hospitals, the development of post-acute care in skilled nursing facilities, and the trend toward integrated health and long-term care systems will contribute to a continued demand for nursing home aides. The high turnover rates in both the nursing home and home care industries underscore the replacement needs for more workers in the future.
According to the Bureau of Labor Statistics (1998b), the service occupation industries are expected to experience a growth rate of 18.1 percent between 1996 and 2006, compared with 14 percent for all occupations. Personal and home care aides are the fourth fasted growing occupation with an expected 84.7 percent growth rate in that same decade. Home health aides are the sixth fastest growing occupation, expected to increase 76.4 percent between 1996 and 2006. While not as dramatic, the nursing home aide industry is expected to increase 25.4 percent over the 10-year period.
There is, however, concern about the availability of these frontline workers in the future. By 2010, as baby boomers reach old age and begin to require assistance, the pool of middle-aged women available to provide low-skilled basic services will be substantially smaller than today (Feldman, 1997). In addition, the educational attainment of minority women-those most likely to enter the paraprofessional workforce-is improving dramatically. In 1980, 70.1 percent of white women aged 25 or over had completed at least high school; 14 percent had completed four or more years of college. The comparable figures for black women were 51.3 percent and 8.1 percent respectively. The educational status of women of both races has improved by 1998, but the increase is most dramatic for black women, where 76.7 percent have at least completed high school and 15.4 percent have completed four or more years of college (U.S. Bureau of the Census, 1998b). These more highly educated cohorts of minority women may be less willing to work in the same low wage, low benefit jobs as those who preceded them (Burbridge, 1993).
The availability of paraprofessionals is very much dependent on the local economy (Atchley, 1996). During the economic boom of the late 1990s with very low unemployment rates, providers experienced great difficulty in hiring and retaining aides, particularly in the home care industry. This service sector is very sensitive to the availability of competing low-wage jobs, and , has been oft-cited, individuals tend to be paid more for "flipping burgers" than providing essential personal care to disabled elders.
The future availability of paraprofessional workers may also be partially dependent on the immigration policy in the United States in the 21st century. This is particularly true in certain states like California, New York, Texas, Florida, and New Jersey, which in the aggregate reflected almost two-thirds of the geographic concentration of immigrants to the United States in 1996 (Bureau of International Labor Affairs, 1997). While available data do not differentiate paraprofessionals by immigrant status, a large proportion of these workers are nonwhite minorities, many of whom are probably immigrants.
Immigration accounts for 40 percent of the labor force growth in the United States today ("Employment, inequality," 1997). Forty percent of immigrants are in two occupational groups-operator/laborer/fabricator and service workers; recent immigrants and women are more likely to be in these two occupational groups (Fix & Passel, 1994). Almost two-thirds of immigrants come to the United States for family reunification, and are not seeking high-skilled employment opportunities. They comprise a current and future labor pool for low-skilled markets, including the paraprofessional long-term care workforce. Consequently, policies to control the entry of low-skilled immigrants, particularly by limiting family-based immigration (Camarota, 1998), may contribute to a smaller labor pool of nursing aide and home care workers in the future.
Some long-term care providers are so concerned about the current worker shortage that they have suggested liberalizing the immigration laws to allow importation of foreign workers for aide positions. Other countries that are far "grayer" than the United States have already adopted this practice; Italy recruits workers from Peru and Japan has begun to import women from the Philippines for these low-skilled jobs. While this may be one option for expanding the labor pool, the ethical and fiscal implications of such a strategy, including potential exploitation of these workers and the costs that will accrue to the nation, need to be seriously considered.
Outline | I. Introduction | II. Defining Long-Term Health Care | III. The Three Legged Stool of Long-Term Care Policy
| IV. Trends in Long-Term Health Care Delivery | V. Workforce Issues | VI. The Future of Long-Term Care Demand | VII. The Future Supply of Long-Term Health Care Services
| VIII. Sinking or Swimming Into the Future? | IX. Conclusion | X. References | XI. Author