The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 59:1213-1217 (2004)
© 2004 The Gerontological Society of America
Demographics and Payment Characteristics of Nursing Home Residents in the United States: A 23-Year Trend
Jose Ness1,
Ali Ahmed2 and
Wilbert S. Aronow3
1 Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Health Care, Iowa City.
2 Division of Gerontology and Geriatric Medicine, Department of Medicine, Schools of Medicine, and Department of Epidemiology and International Health, School of Public Health, Center for Aging, Center for Outcomes and Effectiveness Research and Education, and Geriatric Heart Failure Clinic, University of Alabama at Birmingham, Section of Geriatrics and Geriatric Heart Failure Clinic, Birmingham VA Medical Center, and Heart Failure Project, Alabama Quality Assurance Foundation, Birmingham.
3 Sections of Cardiology and Geriatrics, Department of Medicine, New York Medical College, Valhalla, and Mount Sinai School of Medicine, New York, New York.
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Abstract
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Background. With the aging of our population, an increased number of older Americans are expected to reside in nursing homes. Our objective is to determine the national trend in nursing home residence for older Americans.
Methods. Using the Beyond 20/20 software, we analyzed publicly available data from National Nursing Home Surveys 1977–1999 to determine the trend in the demographics, marital status, and source of payments for older Americans residing in nursing homes.
Results. The absolute number of persons aged 65 years and older residing in nursing homes increased from 1,126,000 to 1,469,500 during the 23-year study period, with those aged 85 years and older, women, and African Americans being at a higher risk for nursing home placement. The rate of residence per 1000 civilian population actually declined from 58 to 43. Decline was most notable for persons aged 85 years and older, female, and white residents. The proportion of widowed persons among residents declined during the study period as well. Overall, Medicaid and private sources were the most common sources of payment. In 1999, Medicaid use was particularly prevalent among residents who were aged 65–74 years old, women, and/or African Americans.
Conclusions. Older Americans at high risk for placement in nursing home facilities are aged 85 years and older, women, and African Americans, who are also more likely to rely on Medicaid as their primary source of payment. Preventive programs to keep older adults in the community should focus on this group of high-risk older adults.
NURSING homes play a pivotal role in caring for the frail population of older adults in the United States. An estimated 42% of the U.S. population aged 70 years and older will spend some time in a nursing home before they die (1). Since age is independently associated with residence in nursing homes, the number of older adults living in such sites of care is likely to increase dramatically over the next several decades (2). The United States Census Bureau has projected that the number of Americans aged 85 years and older will be approximately 19 million by 2050, representing approximately 5% of the country's population (3). Furthermore, the absolute number and relative proportion of women is expected to increase among older adults in the United States. Elderly women are more likely to be widowed, live alone, and have a lower income. They would be at higher risk for nursing home placement (4). The aging population is also likely to become more racially diversified, possibly leading to a more significant minority presence among nursing home residents (3). Finally, Medicaid and private payers have been the most traditional payment sources for nursing home care (5). The ongoing changes in the demographic make-up of America may also impact upon funding streams for this type of service. The purpose of this study was to analyze data from the National Nursing Home Surveys conducted from 1977 through 1999 to determine the national trends in the demographics and payment characteristics of older adults in the United States.
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METHODS
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Study Sample
The subjects of this study were persons aged 65 years and older, residing in a nursing home in the United States between 1977 and 1999.
Nursing Home Residents
A current nursing home resident was defined as a person on the roster of the nursing home as of the night before the surveys. Residents in personal care or domiciliary care homes were excluded from the surveys.
The National Nursing Home Surveys
The National Center for Health Statistics conducted the National Nursing Home Surveys in 1973–1974, 1977, 1985, 1995, 1997, and 1999. The surveys involved national samples of over 1000 nursing homes, their residents, and their staff, and provided basic demographic information about these settings. Nursing homes included in these surveys generally had at least 3 or more beds, and were either certified (by Medicare or Medicaid) or had a state license to operate as a nursing home. The facilities were selected by a stratified two-stage probability design. In the first stage, the facilities were selected, and, in the second stage, residents, discharges, and registered nurses were sampled from the selected nursing homes. Nursing home selection during the first stage involved classification into two strata based on Medicare and Medicaid certification. The nursing homes were then sorted by ownership, geographic region, metropolitan status, state, county, and Metropolitan Statistical Area and ZIP code. The selection was made randomly within each primary stratum. Residents, discharges, and registered nurses were then sampled by the interviewers during site visits in accordance with specific instructions given for each sample facility. From each nursing home, 5 or fewer residents were selected. The sample frame for discharges included all discharges, alive or dead, during the 12 months prior to the survey date. Residents who were discharged more than once during this 12-month period were included for each discharge. For each nursing home, a sample of six or fewer discharges was selected. The sampling of nursing staff consisted of all registered nurses who were employed by the nursing home on the day of the survey. For each nursing home, a maximum of 4 registered nurses were selected. The National Nursing Home Surveys collected data through personal interviews with administrators and staff and occasionally with self-administered questionnaires (6).
Statistic Analysis
For the purpose of this study, we used data on current residents at nursing homes derived from five National Nursing Home Surveys, 1977, 1985, 1995, 1997, and 1999. We used Beyond 20/20 software (Beyond 20/20, Inc., Alexandria, VA) (http://www.beyond2020.com), available at the National Center for Health Statistics (http://www.cdc.gov/nchs/about/otheract/aging/howto.htm) for data analysis. The Beyond 20/20 browser allows analysis of aggregate data to conduct descriptive analyses. At first, we described the prevalence (1977–1999) of nursing home residence among persons aged 65 years and older as number of residents in thousands and rates of residents per 1000 population. We then estimated the rates of nursing home residents per 1000 civilian population for the years 1977 to 1999, stratified by age (65–74 years, 75–84 years, and 85 years and older), sex, and race. The data stratified by race and sex are adjusted for age to the U.S. standard population in 2000. Age-adjusted resident rates (percents) are calculated using age-specific rates per 1000 resident civilian population for 3 age groups, 65–74, 75–84, and 85 years and older. The stratified rates of residence were calculated by dividing the number of nursing home residents in the age, sex, or race group by the midyear civilian population in their respective groups and expressed as number of residents per 1000 resident population. Because estimates based on small sample sizes are unstable, if the unweighted number of residents in the survey was less than 30, those numbers, percents, and rates were not shown.
We then estimated the percent distributions of nursing home residents aged 65 years and older between 1977 and 1999 in the United States by marital status, for all residents, and stratified by sex. Percent distribution by marital status by age groups (65–74, 75–84, and 85 years and older), and sex were calculated by dividing the weighted number of current residents in the demographic group of the particular marital status by the total weighted estimate of current nursing home residents in the demographic group. We finally estimated the percent distributions of nursing home residents aged 65 years and older between 1977 and 1999 in the United States by marital status, for all residents, and stratified by sex and race. Percent distributions by primary source of payment for age groups (65–74, 75–84, and 85 years and older), race, and sex were calculated by dividing the weighted number of current residents in the demographic group with the particular primary source of payment by the total weighted estimate of current nursing home residents in the demographic group. The percent distributions by sex and race were age-adjusted to the U.S. standard population in 2000. Estimates based on small sample sizes are unstable. Therefore, percents are not shown if the number of residents (unweighted) in the survey was less than 30.
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RESULTS
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Demographics
The absolute number of Americans over the age of 65 living in nursing homes increased considerably over the period of 23 years covered by the U.S. National Nursing Home Surveys. In 1977, 1,126,000 elderly people lived in nursing homes. That number had grown to 1,469,500 in 1999. This increase in absolute numbers affected both older men and women, although women continue to represent the largest segment of nursing home residents by a great margin (Table 1). The oldest-old, women, and African Americans are particularly susceptible to placement in these long-term care settings (Figures 1 and 2).
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Table 1. Civilian Resident Population in Thousands, Number of Nursing Home Residents in Thousands, and Age-Adjusted Rates of Nursing Home Residence Per 1000 Population, 65 Years of Age and Older in the United States, Between 1977 Through 1999, Data for All Persons and Stratified by Sex.
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Figure 1. Rates of nursing home residence per 1000 population aged 65 years and older between 1977 and 1999 in the United States by age category
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Figure 2. Rates of nursing home residence per 1000 population aged 65 years and older between 1977 and 1999 in the United States by age, race, and sex
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The rate of residence in nursing homes per 1000 resident civilian U.S. population actually declined from 58.3/1000 in 1977 to 43/1000 in 1999. This rate of decline was 27% for women (from 67.6/1000 to 49.3/1000) and 25% for men (from 40.7/1000 to 30.5/1000) (Table 1). People aged 85 years and older, and white men and women, experienced the most marked declines in nursing home residence rates (Figures 1 and 2). In 1977, white women had the highest rate of nursing home residence; however, in 1999, that position was held by African-American women. The rate of nursing home residence for African-American women has consistently demonstrated an upward trend since 1985, while that of African-American men has shown a downward trend since 1997 (Figure 2). Compared to their white counterparts, the increase in the rate of nursing home residence for African-American men was apparent about a decade earlier than that of African-American women (Figure 2).
Although being widowed was the most common marital status for residents across all surveys, the proportion of widowed residents decreased throughout the study period, whereas the proportion of married residents showed an overall increasing trend (Figure 3). These demographic changes in marital status were present in all age groups, in both men and women, and in whites and African Americans as well (Tables 2 and 3).
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Figure 3. Percent distribution of nursing home residents aged 65 years and older between 1977 and 1999 in the United States by marital status
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Table 2. Percent Distribution of Nursing Home Residents 65–74 Years, 75–84 Years, and 85 Years of Age and Older in the United States, Between 1977 and 1999, Data Stratified by Marital Status.
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Table 3. Percent Distribution of Nursing Home Residents 65 Years of Age and Older in the United States, Between 1977 and 1999, Data Stratified by Sex and Marital Status.
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Payment Status
Medicaid was the foremost payment source for nursing home residents in all surveys and across all age groups. This held true for both men and women and for all ethnicities evaluated. There was a patent increase in the proportion of Medicaid-covered residents from 1977 to 1999 (Figure 4). Medicaid use was more prevalent among residents aged 65–74 years, women, and African Americans. Of note, in earlier surveys, private payers represented the second most common source of payment for residents of all ages. By 1999, the proportion of residents using private sources had declined considerably (Figure 4, Tables 4–6). For instance, in 1977, 33.5% of residents aged 65–74 years depended on private sources for payment. In 1999, that number had dwindled to 13%.
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Figure 4. Percent distribution of nursing home residents aged 65 years and older between 1977 and 1999 in the United States by payment status
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Table 4. Percent Distribution of Nursing Home Residents 65–74 Years, 75–84 Years, and 85 Years of Age and Older in the United States, Between 1977 and 1999, Data Stratified by Payment Status.
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DISCUSSION
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The number of nursing home residents increased considerably over time in the period analyzed by the study. This finding is consistent with the absolute increase noted in the population of older adults in the United States (4). Although both men and women were affected by this trend, women remain by far the largest segment of nursing home users.
The rate of residence in nursing homes actually declined over the 23-year period studied. Such a decrease is consistent with previously identified national trends (7) and has been attributed to a variety of factors, namely, increased availability and demand for assisted living settings, more widespread use of home care services for the frail elderly, and a reduction in the disability burden of the older population (5,7–11). In a recent systematic review of the literature concerning old-age disability, several measures of impaired functioning were found to have shown significant improvement over the past decade (12), leading to considerable potential impact upon the use of long-term care services. Women, the oldest-old, and whites were the groups with the most accentuated decline in nursing home residence rates.
African-American women demonstrated a consistent trend toward increased nursing home residence during most of the last two decades of the study period. The reasons for this phenomenon are still unclear. Women in general are more likely to be widowed and living alone, and, in addition, African-American women are more likely to live below the poverty line. Among the older population, poverty rates are higher among women (13%) than among men (7%), and among minorities compared with non-Hispanic white persons. In 1998, divorced African-American women aged 65 to 74 years had a poverty rate of 47%, one of the highest rates for any subgroup of older Americans (13). These socioeconomic variables might have indirectly increased the risk of older African-American women to be placed in nursing homes. Even though the rate of nursing home residence for older African-American men has declined over the past decade, it is still approximately 55% higher than the rate for older white men.
The proportion of widowed nursing home residents showed a reduction over time and an increase in that of married residents. This is certainly intriguing in light of the fact that the proportion of women among our aging population is increasing. Furthermore, older women are much more likely to be widowed than are older men. In 1998, about 77% of women aged 85 years or older were widowed, compared with 42% of men (14). This is probably due to a combination of various factors, namely sex differences in life expectancy, the tendency for women to marry men who are slightly older, and higher remarriage rates for older widowed men than widowed women (15). Of note, in 1977, the ratio of male to female nursing home residents who were widowed was 1 to 1.8. In 1999, that ratio was 1 to 2.3. The male to female ratio of the rates of nursing home residence in 1977 and 1999 were, respectively, 1 to 1.66 and 1 to 1.62.
Medicaid continues to be the most important payment source for nursing home residents. In spite of its ongoing growth, private nursing home insurance still accounts for a relatively small percentage of nursing home usage (16). The proportion of residents covered by private insurance clearly declined over time, particularly in those aged 65–74 years. The government remains largely responsible for the funding streams related to nursing home care, a fact corroborated by the growing presence of Medicaid as a primary payer in the 1999 survey.
The percentage of older Americans in poverty declined from 13% in 1974 to 8% in 1998, as did the percentage in the low-income group from 35% in 1974 to 27% in 1998 (17). However, in 1998, persons aged 75 years or older were more likely to be poor or have a low income (40%) compared with 27% for those aged 65–74 years (14). Therefore, it is possible that, in the coming decades, as the baby boomers age, the burden of covering the cost of nursing home residence on Medicaid could be overwhelming.
Our study provides an overview of the trends in nursing home utilization in the United States over a 23-year period, based upon the most current nationally representative data available from the National Center of Health Statistics. The analysis encompasses not only purely demographic elements, but also social and economic domains.
However, the study suffers from several limitations. Due to the cross-sectional nature of the Nursing Home surveys, residents with short lengths of stay may have been missed. Earlier surveys have shown that about half of all nursing home residents stay 6 months or less, with most short-term nursing home admissions being related to terminal illness, rehabilitation, and subacute medical conditions (18). Our results do not characterize this segment of nursing home care users. Our analysis also fails to characterize Nursing Home utilization by non-African-American ethnic minorities. Furthermore, epidemiological descriptive studies lack the intrinsic ability to assign causation to the phenomena being described. In-depth research is needed to uncover the factors responsible for our study results.
Despite the recent decrease in the rate of nursing home residence among American older adults, the absolute number of residents is still growing. Nursing homes will continue to play a crucial role in providing quality care to a large group of frail, functionally impaired elders. The oldest-old, women, and African Americans are at higher risk for nursing home placement and should be the focus of preventive interventions to enhance their ability to live in the community. Medicaid still provides the greater part of the revenue stream for nursing homes, a fact that suggests that the government will remain a key player in health care decisions involving this long-term care setting.
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Table 5. Percent Distribution of Nursing Home Residents 65 Years of Age and Older in the United States, Between 1977 and 1999, Data Stratified by Sex and Payment Status.
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Table 6. Percent Distribution of Nursing Home Residents 65 Years of Age and Older in the United States, Between 1977 and 1999, Data Stratified by Sex and Payment Status.
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Acknowledgments
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Address correspondence to Wilbert S. Aronow, MD, FGSA, Cardiology Division, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595. E-mail: wsaronow{at}aol.com
Received June 9, 2003
Accepted July 29, 2003
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Abstract
Methods
