Long-Term Care

Although long-term care remains one of the largest uninsured risks facing older Americans, demand for insurance remains low. While there is a long literature estimating a variety of factors that contribute to this low demand, much of it has overlooked the fact that most private long-term care insurance (LTCI) purchases are made within couples, adding a host of additional reasons for low demand. This paper examines the role of financial decision-making power within the couple and the association with LTCI purchase decisions. We document LTCI purchase patterns among married couples and find that, among couples who ever purchase LTCI, they are roughly equally likely to purchase for the woman exclusively (10.0%), the man exclusively (11%), or both (11%). However, among couples where women have more bargaining power, LTCI purchases are more likely overall (40% vs. 33%), and more likely to cover the woman, either exclusively (16% vs. 11%) or as part of both members of the couple (14% vs. 11%), than among couples with more traditional gender roles. In adjusted analyses, we find that women are more likely to be insured when they have more bargaining power. These findings suggest that intra-household bargaining power may be another potential explanation for the particularly low LTCI take-up, especially in the time period in which policies were unisex-priced.

Combining capitation with a cap on health care providers’ average revenue can reduce allocative inefficiency. But the cap may be undercut by health care providers who churn their patient censuses. We investigate this possibility in the U.S. hospice industry, where Medicare pays hospice programs fixed daily rates but caps their average annual revenue. By leveraging variation generated by the cap’s nonlinear design and the transition between fiscal years, we find that programs on track to exceed the cap raise enrollment rates by 5.8 % and live discharge rates by 4.3 % in the fourth quarter. But this churning falls far short of eliminating their financial penalties: it amounts to 10 % of an average program’s excess revenue at most. Marginal enrollees have longer remaining lifetimes and more fragmented hospice spells on average, suggesting weaker intrinsic demand for hospice care. We discuss the cap’s implications for market structure.

Long-term services in the home are predominately provided by family or friends, with a growing proportion of individuals receiving formal care, or paid care by a professional, or a combination of both. However, the relative benefits to the care recipient of who provides the care are largely unknown. A person's use of formal and family care is affected by factors that also may affect their outcomes, complicating the estimation of any causal relationship. Using the 2002-2018 Health and Retirement Study (HRS), we examine three types of home-based care combinations: family only, formal only, and both formal and family care. We use an instrumental variables strategy, using family structure as instruments for both formal care and the combination of formal and family care, to estimate the plausibly causal impact of the care provider on self-reported mental and physical health outcomes. We find that, once the endogeneity of the care provider is accounted for, having both formal and family care leads to better self-rated health, mobility and lower depression compared to people receiving family care only. Receiving formal care only does not affect care recipient outcomes compared to receiving family care only. These results are robust to several sensitivity analyses, including different instrument specifications, subsamples of care recipients that do not have a spouse/partner, among women care recipients, and changing the timing of the measurement of the outcomes. These findings are important to consider as we strive to best meet the growing demand for person-centered, high-quality long-term care in the least restrictive setting possible.

Paid care provided in the home includes important support services for older adults with dementia such as cleaning and personal care assistance. By reducing unmet needs, these services could delay the transition to residential long-term care, but access may differ across racial groups. This study examined the relationship between paid care and transitioning out of the community among Black and White older adults with dementia. Using data from 303 participants (29.4% Black) with probable dementia in the 2011 National Health and Aging Trends Study, competing risk hazards models estimated the association between receiving paid care at baseline and the probability of transitioning out of the community over 8 years (through 2019). Covariate selection was guided by the Andersen model of health care utilization. Paid care was associated with lower risk of transitioning out of the community (subhazard ratios [SHR] = 0.70, 95% CI [0.50, 0.98]). This effect was similar after controlling for predisposing factors and most prominent after controlling for enabling and need for services factors (SHR = 0.65, 95% CI [0.44, 0.95]). There was no racial difference in the use of paid care despite evidence of greater care needs in Blacks. Furthermore, Black participants were less likely to transition out of the community than Whites. Paid care services may help delay transitions out of the community. Future research should seek to explain racial differences in access to and/or preferences for home-based, community-based, and residential care.

Older adults needing assistance with activities of daily living can receive support in various settings. Senior housing communities, such as independent living, assisted living, and continuing care retirement communities, are an increasingly popular option for adults not requiring nursing home-level care. However, limited research exists due to a dearth of data on these types of communities. We use a proprietary data set to describe the market of private pay senior housing and community-level characteristics in 140 metropolitan statistical areas, from 2015 to 2019. Although the number of senior housing communities increased substantially, the supply of senior housing options supporting the continuum of care has not necessarily kept up with population growth. Describing the supply of senior housing communities across the spectrum of levels of care provides a more complete description of the formal noninstitutional long-term care supply among the 140 most populated metropolitan statistical areas.

With ongoing efforts to improve the value of health care in the U.S. and reduce wasteful spending, we examine empirically the value tradeoffs involved in an additional day in a skilled nursing facility (SNF) after hospital discharge. To control for potential endogeneity, we use the percentage of Medicare beneficiaries enrolled in Medicare Advantage in each county-year as an instrument for individuals’ SNF length of stay among Traditional Medicare beneficiaries, as local Medicare Advantage penetration puts downward pressure on SNF length of stay for all SNF patients but does not directly affect utilization management of those enrolled in Traditional Medicare. We also test for heterogeneity in treatment effect across patients by clinical complexity and two non-health-related factors, marital status and nursing home profit status. We find that one additional day in a SNF lowers short-term readmission rates, but this effect is small and heterogeneous across patient-types. The most clinically complex patients (those with the longest predicted SNF stays) benefit the most from an additional SNF day, as do patients whose stays are shorter due to non-health-related factors. The cost savings from reduced readmission rates are small and do not offset the additional SNF costs.

We estimate the causal impact of intensive caregiving, defined as providing at least 80 h of care per month, and work on the mental health of caregivers while considering possible sources of endogeneity in these relationships.

This study examines the effect of Medicaid eligibility expansion under the Affordable Care Act (ACA) on the utilization of nursing home services by younger individuals and those covered by Medicaid.

We estimate the spending attributable to Alzheimer's disease and related dementias (ADRD) to the United States government for the first 5 years post-diagnosis.