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Abstract:
Like the rest of the world, the US is an ageing society (CITE SOMETHING). Between 2000 and 2050, the number of older people is projected to increase by 135% (CITE SOMETHING). Moreover, the population aged 85 and over, which is the group most likely to need health and long-term care services, is projected to increase by 350% (CITE SOMETHING). Over this time period, the proportion of the population that is over the age of 65 will increase from 12.7% in 2000 to 20.3% in 2050; the proportion of the population that is age 85 and older will increase from 1.6% in 2000 to 4.8% in 2050 (CITE SOMETHING). (WRITE 3-4 MORE SENTENCES DESCRIBING THE PAPER)
Introduction:
There are two points that are noteworthy about this demographic change. First, while a significant proportion of the US is elderly, much of Europe already has a higher proportion of its population that is over the age of 65 (CITE SOMETHING). For example, in 2000, 16.0% of the population in the UK and 16.4% of the population of Germany was over the age of 65. Thus, other countries already have to cope with the impact of an ageing society to a greater extent than the US (CITE SOMETHING). Largely as a result of higher fertility rates and immigration, America’s population, while ageing, is nonetheless likely to remain distinctly younger than other developed countries (CITE SOMETHING).
Second, the future strains of population ageing in the US derive not so much from the growth in the elderly population or the 85 and over population, but rather from the slow projected growth in the non-elderly, working age population (CITE SOMETHING). Between 2000 and 2050, the population age 16–64 is projected to grow by only 33%. The ratio of people ages 16–64 to those age 65 and over (the aged dependency ratio) is projected to decline from 5.1 in 2000 to 2.9 in 2050, a 43% decline (CITE SOMETHING). The slow growth in the working age population will mean that there will be relatively fewer people to pay the taxes necessary to support public programs for the older population and fewer people to provide the services that older people need (CITE SOMETHING). For this reason, America’s health care system will need to make drastic adjustments to keep up with the increasing elderly population.
Implications for organization and delivery of health care
The ageing of the population will have a major impact on the organization and delivery of health care. Of particular importance will be the shift from acute to chronic illnesses and the likely growing shortage of health care workers, especially nurses and paraprofessionals (CITE SOMETHING).
Shift from acute to chronic illnesses
The ageing population will require focusing on chronic diseases, such as Alzheimer ’s disease, heart disease, and osteoporosis, rather than acute illnesses (CITE SOMETHING). First, the style of medicine will need to change from one-time interventions that correct a single problem to the ongoing management of multiple diseases and disabilities; doctors and patients will have to have an ongoing relationship designed to help patients cope with illnesses rather than curing them (CITE SOMETHING). Second, with chronic illness often comes disability, meaning that long-term care services, such as nursing homes, home health, personal care, adult day care, and congregate housing, will become much more important sources of care (CITE SOMETHING). Third, new ways will need to be found to integrate medical and long-term care services, a feat that will be difficult in the US because of the fragmentation of the financing and delivery systems (CITE SOMETHING).
Health and long-term care workforce issues
There has been increasing concern about the current and future supply of acute and long-term care workers, especially nurses and paraprofessional staff, such as certified nurse assistants, home health aides, and personal care attendants (CITE SOMETHING). Unskilled paraprofessionals, who provide the bulk of long-term care services, are overwhelmingly women and disproportionately drawn from racial and ethnic minorities (CITE SOMETHING). Low wages and benefits, hard working conditions, heavy workloads and a job that has been stigmatized by society make worker recruitment and retention difficult (CITE SOMETHING).
While a short-term recession could temporarily relieve the worker shortage, the gap between the large projected increase in demand for acute and long-term care services and the slow projected growth in the labor force signals a dramatic long-run imbalance (CITE SOMETHING). Because of the ageing registered nurse workforce, by the year 2020, the registered nurse workforce is forecast to be roughly the same size as it is today, declining nearly 20% below projected workforce requirements (CITE SOMETHING). To attract additional workers in the future may require higher wages (CITE SOMETHING).
Acute care financing
Acute care services for older people, such as hospital and physician care, are financed through a mix of public and private sources (CITE SOMETHING). Medicare is a publicly financed and administered, social insurance program, with near universal eligibility. In addition to older people, the program also covers younger people with disabilities who have a significant work history. The program operates as an open-ended entitlement to individuals (CITE SOMETHING).
Financing for hospital and some other services (‘Part A‘) is through a payroll tax of 2.90% (split evenly between workers and employers) with no cap on the earnings subject to taxation; financing for physician and some other services (‘Part B‘) is through premiums paid by beneficiaries and general revenues (CITE SOMETHING). While enrollment in Part B is technically voluntary, virtually all older people enroll. Medicare expenditures in 2000 totaled $224 billion, slightly more than 2.2% of gross domestic product (GDP).
While Medicare covers a fairly broad range of services, it does not cover prescription drugs outside of institutions, dental services, or eyeglasses, and has extensive cost-sharing requirements (CITE SOMETHING). The program covers a limited amount of skilled nursing home and home health care. Proposals to provide coverage for outpatient prescription drugs for older people was seriously considered in 2000 and 2001 (CITE SOMETHING). The declining economic situation and the shift of priorities for spending to anti-terrorism activities in the wake of the tragedies of 11 September 2001, make enactment of additional benefits unlikely (CITE SOMETHING). In the absence of action at the national level, some states are developing pharmaceutical assistance programs for the low-income elderly and disabled populations who are not eligible for Medicaid, the federal-State health program for low-income people or people with high medical expenses (CITE SOMETHING).
Because of gaps in Medicare coverage, important additional sources of financing for acute care services for older people include private supplemental insurance provided by employers or purchased by individuals, health maintenance organizations, Medicaid, and out-of-pocket payments. In 1997, only 10% of Medicare beneficiaries did not have some sort of other third-party coverage (CITE SOMETHING).
Medicare beneficiaries have complete freedom-of-choice of providers, who are overwhelmingly private, non-governmental organizations or suppliers. An important recent trend has been the increase and then leveling off during the 1990s of enrolment in health maintenance organizations, which limit the choice of providers (CITE SOMETHING). As of 2000, 16% of Medicare beneficiaries were enrolled in Medicare health maintenance organizations (CITE SOMETHING).
Long-term care financing
Financing for long-term care services, such as nursing home care and home and community-based services, is through a combination of Medicaid, Medicare, state-funded programs, out-of-pocket payments and private insurance. By far the dominant source of long-term care funding is Medicaid (CITE SOMETHING). Approximately two-thirds of nursing home residents have their care paid by Medicaid. Financial eligibility standards are strict, with Medicaid nursing home residents having to contribute all of their income towards the cost of care, except for a small personal needs allowance of about $30 a month (CITE SOMETHING). Individuals may keep only $2000 in financial assets, although the home is generally an exempt asset. With some exceptions, the Medicaid program operates as an open-ended entitlement to individuals (CITE SOMETHING). Federal and state Medicaid long-term care expenditures for older people with disabilities were about $43 billion in 2000, about 0.4% of GDP. Many states also operate their own programs for home care, although most are fairly small (CITE SOMETHING).
Medicare covers skilled, relatively short-term care provided by home health agencies and nursing homes, not traditional long-term care. Private long-term care insurance has been growing steadily since the mid-1980s, but finances