One in four people age 45 and over are not at all prepared financially if they suddenly required long-term care for an indefinite period of time.
What is Long-Term Care?
Long-term care coverage is needed when a chronic condition, accident, or illness limits one's ability to take care of themselves. In industry speak, these tasks are called activities of daily living (ADLs), such as toileting, bathing, dressing or feeding). Also considered are instrumental activities of daily living (IADLs) such as household chores, meal preparation, or managing money). Long-term care often involves the most intimate aspects of people’s lives—what and when they eat, personal hygiene, getting dressed, using the bathroom. Other less severe long-term care needs may involve household tasks such as preparing meals or using the telephone.
Long-term care differs from other types of health care in that the goal of long-term care is not to cure an illness, but to allow an individual to attain and maintain an optimal level of functioning when illness or injury prevents it.
Long-term care encompasses a wide array of services needed by individuals who have lost some capacity for self-care because of a chronic illness or disabling condition.
Who Needs Long-Term Care?
Annually 8,357,100 people receive support from the 5 main long-term care service; home health agencies (4,742,500), nursing homes (1,383,700), hospices (1,244,500), residential care communities (713,300) and adult day service centers (273,200).1[Updated February 2015]
An estimated 12 million Americans needed long-term care in 2007.2 [Updated February 2015]
Most but not all persons in need of long-term care are elderly. Approximately 63% are persons aged 65 and older (6.3 million); the remaining 37% are 64 years of age and younger (3.7 million).
The lifetime probability of becoming disabled in at least two activities of daily living or of being cognitively impaired is 68% for people age 65 and older.
By 2050, the number of individuals using paid long-term care services in any setting (e.g., at home, residential care such as assisted living, or skilled nursing facilities) will likely double from the 13 million using services in 2000, to 27 million people. This estimate is influenced by growth in the population of older people in need of care.
Of the older population with long-term care needs in the community, about 30% (1.5 million persons) have substantial long-term care needs (three or more ADL limitations). Of these, about 25% are 85 and older and 70% report they are in fair to poor health.
Among the population aged 65+, 69% will develop disabilities before they die, and 35% will eventually enter a nursing home.
Nearly a fifth of older people will incur more than $25,000 in lifetime out-of-pocket long-term costs before they die.
The prevalence of cognitive impairment among the older population increased over the past decade, while the prevalence of physical impairment remains unchanged.
In 2002, the percentage of older persons with moderate or severe memory impairment ranged from about 5% among persons aged 65–69 to about 32% among persons aged 85 or older.
Individuals 85 years and older, the oldest old, are one of the fastest growing segments of the population. In 2012, there are an estimated 5.9 million people 85+ in the United States. This figure is expected to increase to 19.4 million by 2050. This means that there could be an increase from 1.6 million to 6.2 million people age 85 or over with severe or moderate memory impairment in 2050.
Where do People Receive Long-Term Care and from Whom?
Family and Informal Caregivers
Informal caregiver and family caregiver are terms used to refer to unpaid individuals such as family members, partners, friends and neighbors who provide care. These persons can be primary (i.e. the person who spends the most time helping) or secondary caregivers, full time or part time, and can live with the person being cared for or live separately. Formal caregivers are volunteers or paid care providers associated with a service system.
65.7 million informal and family caregivers provide care to someone who is ill, disabled or aged in the U.S.
52 million caregivers (or one out of every five households ) are involved in caregiving to persons aged 18 or over.
43.5 million caregivers provide care for someone aged 50+ and 14.9 million care for someone who has Alzheimer's or other Dementia.
27.3 million family caregivers provide personal assistance to adults (aged 15+) with a disability or chronic illness.
5.8 21 to 7 22 million people (family, friends and neighbors) provide care to a person (65+) who needs assistance with everyday activities.
8.9 million informal caregivers provide care to someone aged 50+ with dementia.
By the year 2007, the number of caregiving households in the U.S. for persons aged 50+ could reach 39 million.
Two out of three (66%) of older people with disabilities who receive LTSS at home get all their care exclusively from their family caregiver, mostly wives and daughters. Another quarter (26%) receives some combination of family care and paid help; only 9% receive paid help alone.
Even among the most severely disabled older persons living in the community, about two-thirds rely solely on family members and other informal help, often resulting in great strain for the family caregivers.
The use of informal care as the only type of assistance by older Americans aged 65 and over increased from 57% in 1994 to 66% in 1999. The growth in reliance upon informal care between 1994 and 1999 is accompanied by a decline in the use of a combination of informal and formal care from 36% in 1994 to 26% in 1999.
30% of persons caring for elderly long-term care users were themselves aged 65 or over; another 15% were between the age of 45–54.
Lost income and benefits over a caregiver's lifetime is estimated to range from a total of $283,716 for men to $324,044 for women, or an average of $303,880.
Home and Community-Based Care
The vast majority- 80%- of elderly people receiving assistance, including many with several functional limitations, live in private homes in the community, not in institutions.
Elderly people with limitations in three or more ADL's who live in the community receive an average of 9 hours of assistance per day (counting both formal and informal sources of care) and people age 85 or older with that degree of impairment typically receive about 11 hours of assistance per day.
The proportion of Americans aged 65 and over with disabilities who rely entirely on formal care for their personal assistance needs has increased to 9% in 1999 from 5% in 1984.34
Between 2000 and 2002, the number of licensed assisted living and board and care facilities increased from 32,886 to 36,399 nationally, reflecting the trend towards community-based care as opposed to nursing homes.35 Most assisted living facilities, however, are unlicensed.
Most assisted living facilities (ALFs) discharge residents whose cognitive impairments become moderate or severe or who need help with transfers (e.g. moving from a wheelchair to a bed.) This limits the ability of these populations to find appropriate services outside of nursing homes or other institutions.
Nursing Home Care
Institutionalization is much more common at older ages; in 2010, about one in eight people age 85 or older (13 percent) resided in institutions, compared with 1 percent of people ages 65 to 74.
In 2012, there were 1.4 million people in nursing homes nationally.
Between 2002 and 2012, private-pay prices for a private or semiprivate room in a nursing home grew by an average of 4.0 percent and 4.5 percent, respectively, per year.
Of the population aged 65 and over in 1999, 52% of the nursing home population was aged 85 or older compared to 35% aged 75–84, and 13% aged 65–74.
Between 1985 and 1999 the number of adults 65 and older living in nursing homes increased from 1.3 million to 1.5 million. In 1999, almost three-quarters (1.1 million) of these older residents were women.
Long-Term Care Expenditures
In 2012, total spending (public, out-of-pocket and other private spending) for long-term care was $219.9 billion, or 9.3% of all U.S. personal health care spending. This is projected to increase to $346 billion in 2040.
In 2010, approximately 45% of Medicaid long-term care funding was spent on HCBS. About 55% was directed toward institutional long-term care, which includes nursing homes and intermediate care facilities for people with developmental disabilities, and mental health facility services.
In 2002, 16.4 billion Medicaid dollars were spent for home and community-based services within long-term care. This figure has increased at a 25% rate annually since 1990.
Expenditures for skilled nursing facility (SNF) care are much greater than care provided in other settings. Average expenses per older adult in a skilled nursing facility can be four times greater than average expenditures for that individual receiving paid care in the community.
In 2003, Medicaid paid $83.8 billion dollars for long-term care services, roughly one-third of all Medicaid spending. 27.8 billion of these dollars were spent on community-based long-term care services. Home and community-based (HCBS) waivers accounted for roughly two-thirds of community-based long-term care expenditures.
In 2000, spending for older adults aged 65 or older accounted for 57% of Medicaid dollars, with the remaining 43% spent on those under age 65.
31.9% of the annual estimated home care expenditures were paid for by Medicare in 2003, a little over 18% were paid for out-of-pocket or by private insurance, and approximately 13% were covered by Medicaid.
Only 7% of residents receive Medicaid coverage for assisted living.
Over two-thirds of the current health care dollar goes to treating chronic illness; for older persons the proportion rises to almost 95%.56
The aging of the population, especially those 85+—the most in need of long-term care—is expected to result in a tripling of long-term care expenditures, projected to climb from $115 billion in 1997 to $346 billion (adjusted for inflation) annually in 2040.