the CBO on elderly demographics and long-term care

June 27, 2013 3:45 PM

Rising Demand for Long-Term Services and Supports for Elderly People (pdf, 574 kb) - "By 2050, one-fifth of the total U.S. population will be elderly (that is, 65 or older), up from 12 percent in 2000 and 8 percent in 1950. The number of people age 85 or older will grow the fastest over the next few decades, constituting 4 percent of the population by 2050, or 10 times its share in 1950. That growth in the elderly population will bring a corresponding surge in the number of elderly people with functional and cognitive limitations."
posted by kliuless (18 comments total)

uncertainty about the stability of premiums in the future and the ability of insurance carriers to pay for care that might not be needed for several more decades

I've been thinking about what I'm going to do when I'm my mother's age (77, went into a retirement home last year) and these questions are very much on my mind. Also the question of whether I fundamentally trust a for-profit institution to pay out given my experiences with the US health insurance system.
posted by immlass at 4:26 PM on June 27, 2013

Also the question of whether I fundamentally trust a for-profit institution to pay out given my experiences with the US health insurance system.

I sure as hell wouldn't trust them. I'm not elderly (yet) and my insurer is already dicking with coverages, copays, and out-of-pocket definitions to avoid paying for the coverage I was buying. But, I do have experience with today's cluster-fuck of elder care, Medicare, Medicaid, and private insurance coverage, from dealing with my mother and my father-in-law.

Unless something changes soon for the drastically better, I think I'll be better off with a single bullet and a long walk off into the woods. The quagmire that is the elder care industry for anyone who isn't fabulously wealthy and/or impossibly healthy is disgraceful. God help you if you need rehab, physical care, memory care, etc.
posted by Thorzdad at 4:48 PM on June 27, 2013 [1 favorite]

I'll just say my experience with my father's long-term care insurance was paperwork-heavy, but relatively painless and transparent -- at least in comparison with health insurance and care providers and the basic fiction that is a US medical bill these days (it's $this! unless you're x in which case it's $that! unless you're y in which case it's $the other thing!). That said, my father's nursing home began adding activities of daily living charges over and above the insurance cap and now we have a job at home taking care of him (he needs 24/7 supervision). Right now we're working out how much home care is covered.

That is to say, I think a typical LTC policy is likely to pay out, but is also highly likely to not cover all your needs.
posted by dhartung at 4:53 PM on June 27, 2013

"Immigrants are more fertile."

This is why we need comprehensive immigration reform. We need young people that want to come into this country and have children to take care of my ass when I get old.

I've long made the joke that the problem with Social Security and whatnot isn't that there is a lack of money, it's that there's too many old people. In many ways this isn't a joke. We pay incredible amounts of money to prolong, by only a few months, the lives of cancer patients (often without consulting their wishes). We make decisions that bankrupt families all because no one wants to let grandma make an informed end of life decision. We can't have a rational discussion about physician assisted suicide or euthanasia without someone screaming about death panels. We're doing this wrong.

The vast majority of your medical expenses will occur in the last six months of your life. Would you rather live that six months (often with a shitty quality of life) and leave your family destitute or would you rather go out with dignity and leave a legacy? Fuck, I don't know the answer, but I do know I'd like to be the one making that decision for myself.

tl;dr? Single bullet, long walk, woods.
posted by cjorgensen at 5:12 PM on June 27, 2013 [2 favorites]

This is a massive, looming problem - and, of course, we don't hear anything from our policy makers about it; they're too busy lying their way through to the next election cycle.

Another looming problem is a shrinking job base in the future, owing to automation (and not just factory automation). So, there is going to be an under-supply of jobs, relative to the excess supply of ready and willing labor. Seems like the oversupply of old people (relative to current resources available to maintain them, might find a way to leverage the large masses of unemployed and idle people? That's one solution.

Another idea is to start having older people think about living in cooperative communities that are relatively self sufficient. Those communities can be as small as 3-4 people, on up to as many as desired depending on how it's set up.

One of the things I DON'T want to see is the importation of yet more immigrants to take care of old people, or infirm people.

And, we don't need more immigrants to do this work! That's absurd. There are many Americans who need jobs, and those Americans would gladly enter the health care field at a relatively low level if they were given proper training. Instead, our policy makers and greed-ball health care companies look for the fastest, cheapest ways to fill demand.
posted by Vibrissae at 6:03 PM on June 27, 2013 [1 favorite]

This is a massive, looming problem - and, of course, we don't hear anything from our policy makers about it; they're too busy lying their way through to the next election cycle.

Oh, they are talking about it. That's why people want to get rid of "entitlements", because they know it's going to cost a lot. So if they can convince the current 65+ crowd to vote to fuck their children and grandchildren, the problem is solved. Kinda.

One of the things I DON'T want to see is the importation of yet more immigrants to take care of old people, or infirm people.

I agree, but probably for different reasons. We don't really have a lack of people to do the work as much as we have a lack of young people to work for cheap. But the reason we don't want immigration is because it just moves the problems elsewhere. It does us no good to import all the talent out of Mexico and Central America if it leaves those areas as cesspools of poverty, corruption and crime. We want a world where everywhere is just as prosperous, because it is and will increasingly be, a global marketplace. We need to make sure the rest of the world improves its living conditions, not make them worse.
posted by gjc at 6:29 PM on June 27, 2013 [2 favorites]

And, we don't need more immigrants to do this work! That's absurd.

No shit. That wasn't my point. What we need is an influx of young healthy workers willing to have babies to balance the equation. We don't need these people as people to wipe the noses and asses of the elderly. We need them to succeed as Americans and become a part of a robust tax base that will better enable us to afford the burgeoning health care costs to come.

Either this or we need to start figuring out a way to humanely put down people who are too burdensome on the rest of society. Yes, this is absurd as well. The point is neither choice is appealing, but by not cultivating any other choices eventually this will be decided for us.

I would prefer to have the conversation.
posted by cjorgensen at 6:44 PM on June 27, 2013

Seriously, as someone without kids and a partner I plan to kill myself.

If my father was on his own right now without 3 adults to care for him his life would be horrid. He has dementia, it's likely to be genetic.
posted by sien at 7:30 PM on June 27, 2013

robot nurses.
posted by Golden Eternity at 7:39 PM on June 27, 2013 [1 favorite]

I'm not really looking forward to being at my most vulnerable and most dependent on the rest of society at exactly the point in history when many of the really crappy mismanagement decisions made by my generation and preceding ones have come home to roost, and half the land on the planet is desert or inundated-coast salt marshes, and we're the only ones around for the rest of humanity to be angry at.

As far as budgetary issues, though, I think we'd do well to remember how artificial a crisis this is and most other financial problems of scale are, being primarily due to the extreme concentration of society's wealth in the hands of a vanishingly small number of people who have arranged for the expenditures on taking care of the rest of us to be as tiny as possible. Even increasing the amount of money spent on "entitlements" tenfold would still be a fairly small slice of the extant wealth and ongoing GDP of society as a whole.

As noble as is the idea of culling oneself from the herd early for the sake of the children-who-are-the-future, we are extreeeeemely far away from any sort of situation that would demand euthanizing elderly people because of some kind of constraint imposed by the limitations of our wealth, and won't be much closer by 2050; any attempts to portray us as teetering on the brink of that are purely fearmongering. Don't off yourself early for the sake of one of Mitt Romney's kids or grandkids being able to afford an extra vacation home on the balmy coast of Antarctica.
posted by XMLicious at 7:41 PM on June 27, 2013 [8 favorites]

robot nurses.

Indeed! We are damn lucky it's robot-obsessed East Asian societies who are preceding us through these demographic gauntlets.
posted by XMLicious at 7:47 PM on June 27, 2013

Sorry, I should have written "put down people who have decide they are too burdensome to society." I'm talking allowing people to make informed and ethical end of life decisions. Not having them made for them.
posted by cjorgensen at 8:00 PM on June 27, 2013

Suicides by older men in particular are fairly common and there does not seem to be as much effort put into stopping that as in stopping younger people committing suicide. The rates by age are here.

There already are things like The Society for Old Age Rational Suicide.
posted by sien at 8:18 PM on June 27, 2013

One of the things I DON'T want to see is the importation of yet more immigrants to take care of old people, or infirm people.

Why not? It not only satisfies demand for labor, but also helps fund for elderly care. This already happens in large numbers. Around here, Filipino immigrants are practically synonymous with low and mid level health care workers. Thank FSM for 'em, I say.
posted by 2N2222 at 9:43 PM on June 27, 2013

As noble as is the idea of culling oneself from the herd early for the sake of the children-who-are-the-future, we are extreeeeemely far away from any sort of situation that would demand euthanizing elderly people because of some kind of constraint imposed by the limitations of our wealth, and won't be much closer by 2050;

Oh, I don't know. Opinions on the unthinkable can change real quick.

Look at Obama and gay marriage.
posted by IndigoJones at 5:23 AM on June 28, 2013

in other health-related news:

• A World of Rising Health Care Costs - "If it is not contained, government spending on health will rise to almost 12 percent of G.D.P. on average across the 34 O.E.C.D. nations, from 5.5 percent in the second half of the last decade. In the United States it will rise to 13.2 percent from 7.1 percent... Budgets will be easier to meet if health spending is tamed. Under the assumption that this happens, the O.E.C.D.’s public budget for health care eats up only some 8 percent of the economy by 2060. In the United States it takes up 9.3 percent."
• Test Driving The Obamacare Software - "Health-act proponents liken the signup software to Expedia or Travelocity, where travelers can book flights and hotels. It may be more like TurboTax, escorting you through requirements and choices much more complex than whether you want a flight in the afternoon or the morning."
• Walgreens and Johns Hopkins Partnering to Make Walgrees Even More Amazing - "the first Walgreens in Maryland with a clinic staffed by nurse practitioners, collaborating with Hopkins primary care physicians, who will be available for urgent, non-emergency care..."

posted by kliuless at 2:11 PM on June 28, 2013

"I'm not at all sure how best to start building social institutions to address these coming needs, but here are some thoughts."

1. It would of course be best if most people could make some provision for the costs of their own care. But many Americans don't have much in savings. And getting people to buy long-term care insurance is a tough sell, in part because it's unclear how this care will be provided several decades in the future and what it will cost, and in part because Medicaid eventually steps in and covers nursing home care for those whose assets are depleted--which gives people less incentive to buy private insurance. In fact, more than half of the current nursing home residents in the U.S. are having their bills paid by Medicaid. For more discussion, see this post on "Long-Term Care Insurance in the U.S."
2. Some other high-income countries have government programs to pay for long-term care. Not surprisingly, they spend a substantially greater share of GDP on long-term than does the U.S. In any event, the long-term U.S. budget picture is grim enough that adding another entitlement for the elderly isn't likely. For more discussion, see "Long-Term Care in International Perspective."
3. It's typically much less expensive if the elderly can continue to live in the community, whether in their own home or in some kind of community residence. CBO reports: "In 2011, the annual cost of care for a resident paying either out of pocket or with private insurance in a semiprivate room in a nursing home averaged nearly $80,000." Living in the community is also what most of the elderly prefer. Thus, the challenge is how to retrofit homes to be safe for the elderly, and to start planning and setting up a network of community-based residences near shopping, libraries, parks, public transit, and health care, and providing a network of services, but in a way that continues to encourage the provision of informal care and support by family and friends. It will be difficult to draw this balance.
4. Much depends on the health status of the elderly a few decades from now. If the elderly not only live longer but remain relatively active and healthy, then that should lead to one blueprint for long-term care. If the elderly start living much longer, and if their health becomes especially frail for many years, another blueprint for long-term care will be needed. Again, I don't have a clear blueprint in my own mind for how to address these issues. But it is virtually certain that the need for long-term care for the elderly is going to rise dramatically, and pushing most of them into Medicaid-funded nursing homes is unlikely to be the best answer.

posted by kliuless at 3:49 PM on July 9, 2013

-Move Over Nursing Homes — There's Something Different

One thing most people dread as they age is ending up in a nursing home, where they imagine they'll have to deal with sharing a room, rigid schedules and bad smells. But the Green House Project, an alternative to traditional nursing homes, is trying to change that. Its founder says he wants to "abolish" the old, often lonely model.

-Shrinking the Nursing Home Until It Feels Like a Home - "The Green House concept is the most comprehensive effort to reinvent the nursing home, including the way medical care is delivered."
posted by kliuless at 9:00 PM on July 24, 2013