Elder boomers and the future of long term care

Nursing homes are definitely not a growth industry. In 1973, there were 15,700 nursing homes in the United States; in 1999 the number peaked at 18,000. In 2009, the number was down to 15,700 again. This number includes hospital-based subacute units, which are certified and regulated as nursing homes, so the real number today may actually be less. The nursing home “industry” never fully recovered from the prospective payment system puncturing its lucrative rehabilitation bubble of the 1990s, and the resulting closures and bankruptcies.

On the other hand, the number of nursing home residents has been trending upward over the past thirty-plus years, indicating an expansion of existing facilities, or a fuller utilization of existing beds, or a greater patient turnover. There were 1,075,800 nursing home residents in 1973, and 1,401,718 in 2009.

Meanwhile, our elder population has been steadily increasing:

1980: 65 and over, 25,500,000; 85 and over, 2,200,000

1990: 65 and over, 31,200,000; 85 and over, 3,100,000

2000: 65 and over, 35,000,000; 85 and over, 4,200,000

2010: 65 and over, 40,200,000; 85 and over, 6,100,000

It will be further increasing, according to census projections, because of our increased life expectancy (thanks to modern medicine, nutrition, sanitation, pollution control, and healthier life styles), but especially because the “baby boomers,” born during the era of high birth rate (1946-1964) after World War II, are becoming “elder boomers”:

2020: 65 and over, 54,600,000; 85 and over, 7,300,000

2030: 65 and over, 71,500,000; 85 and over, 9,600,000

2040: 65 and over, 80,000,000; 85 and over, 15,400,000

2050: 65 and over, 86,700,000; 85 and over, 20,900,000

When the United States becomes one big Palm Beach County, will the nursing home industry keep up with demography, with twice as many nursing home beds by 2030, or three times as many by 2040? Probably not. In fact, we will probably have less. Regulation, litigation, uncertain reimbursement, and limited profitability have effectively suppressed expansion in the nursing home sector of long term care. It is unlikely that any of these factors will change. If anything, they will get worse.

As the demand for care increases, and the supply of long term beds fails to keep pace, nursing homes will become fully populated by “total care” patients who need full-time nursing. There will be no room for the well aged, for those with chronic but stable diseases, or those with terminal malignancies who have families which can care for them at home with hospice assistance. Some will call this rationing of care, which has acquired a negative connotation; others will rationalize the rationing and call it prioritizing, or triage.

Any expansion of long term care will take place in other sectors: home health care (including home hospice), adult day care, assisted living, and continued care retirement communities. All of these are significantly less expensive than nursing home care. Nursing homes will become a last-resort alternative. The convenience factor—putting a parent in a nursing home by a family that is able but unwilling to care—will disappear.

These changes will occur gradually. They will impact an aging generation which lived through a period of unprecedented material well-being, and will accept nothing less in their later years. None of the “baby boomers” knew the hardships of immigration, a Great Depression, or a World War. They had a better life than any previous generation, and are accustomed to demanding their perceived rights as consumers, taxpayers, patients, or clients. Many of them now have parents or other relatives in long term care, and they know what life in a nursing home is like. Unless totally incapacitated physically and/or mentally, they are unlikely to accept being put in a nursing home by their offspring. Even those who were the most permissive parents and devoted disciples of Dr. Benjamin Spock, will not allow their grown children the privilege of “enhoming” them.

As the number of elderly increases, so will their political clout. More federal and state funding for long term care will miraculously become available, at the expense of other programs.

The decline of the nursing home, as we now know it, may not be all that calamitous. Solutions still unimagined may emerge. Even today’s available alternatives offer a better quality of life at a lesser cost.

Assume that neither increased funding nor innovative solutions actually happen. Nursing home care will still be available for those who really need it. The rest will either be in the other forms of long term care, at less than half the cost, or living with a daughter or son, as was the tradition in our societal past, and is still the way in other societies. It may not be that bad, after all.

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