Eldercare: Overview

Introduction

In the coming decades, the United States is facing an “age crisis,” in which the number and proportion of older adults in the American population will grow to unprecedented levels. This demographic phenomenon results from the convergence of people now living longer thanks to advances in health consciousness, nutrition, and medical care, and from the baby boomers—the population cohort born amid the unusually high birth rates following World War II—beginning to reach retirement age. One of the most significant issues arising from this demographic shift is the fact that existing eldercare networks, facilities, and governmental systems are insufficient to accommodate the vast increase in demand.

Current methods for providing eldercare include in-home nursing and assistance, relocation of older adults to assisted living and nursing homes, and assistance by family caregivers who live with or help care for older individuals. Caring for older adults can strain caregivers financially and emotionally, and the eldercare industry has become a competitive marketplace where those with higher incomes can often afford far better end-of-life care than those in lower income brackets. Some believe that the industry should be regulated at the state and federal levels to assure standards of care across income levels and to provide more stringent regulations for for-profit care facilities. Others argue that governmental regulation will not necessarily result in better care, that it may result in undue strain on facilities that serve poor communities, and that marketplace competition is important to stimulate advancement.

Understanding the Discussion

Assisted living: Housing for older or disabled people that provide residents with help in daily activities, such as cooking, shopping, or dressing, but typically do not tend to patients with continual nursing needs, though they have medical professionals on staff for emergencies.

Baby boomer: A person born during the period of high birth rates that followed World War II and lasted until approximately the early 1960s.

Gerontology: The study of older people, aging, and the specific problems faced by older people and those participating in eldercare.

Home care: Providing nursing or living assistance within a patient's home.

Private-duty nursing: Nursing care provided in the home by a qualified nurse on a pay-for-service basis and usually paid directly by the client or client's family.

Skilled-nursing facility: Commonly called a “nursing home,” a facility that provides round-the-clock professional nursing care for residents requiring continual medical support or who have significant physical or cognitive deficiencies.

History

Before the nineteenth century, children and extended family members were the primary source of care for older people in the United States. Those without family support were relegated to poorhouses, which were state-funded living facilities that took in older adults and individuals with disabilities. The poorhouse system, while saving many from death on the streets, was a failure for many reasons. Social service investigations of poorhouses in the early nineteenth century revealed widespread corruption, while poorhouses were also a catchall system without specialized care. Orphans and poor older adults were therefore often housed with people experiencing mental illness or drug addiction.

The first specialized homes for older adults and home-nursing programs were started by benevolent and church-based organizations in the early to mid-nineteenth century. The Indigent Widows' and Single Women's Society, established in 1826 in Philadelphia, was among the first nursing homes in the United States, and similar facilities emerged in many cities thereafter. The eldercare industry changed drastically after the Great Depression, as it became increasingly clear that existing facilities could not cope with the vast increase in the needy population. The Social Security Act of 1935 attempted to address this situation, providing federal assistance to older adults to reduce the burden on charitable organizations and poorhouses. Thanks to Social Security benefits, an increasing number of American families could afford private nursing and housekeeping assistance.

From the Great Depression to the end of World War II, birth rates declined across the United States as couples delayed having children or had fewer children due to the financial and political uncertainty of the future. Within a year of the war's end, birth rates increased by more than 20 percent and remained high through the mid-1960s. Demographers have estimated that as many as 79 million babies were born during this “baby boom,” constituting the sharpest increase in the American population in history. The demography of America was also changing due to increased life expectancy brought about by continual advancements in medical care, nutrition, and health consciousness. In 1940, the average life expectancy was sixty-three to sixty-five years, while in 2010, the average life expectancy had increased to more than seventy-eight years.

The Medicaid and Medicare laws of 1964 were a governmental attempt to reduce the burden of medical coverage on older adults and their families. As Medicare benefits also provided funding for nursing and care companies and facilities, between 1965 and 1974, the number of nursing homes in the United States increased by more than 140 percent. By the 1990s, the eldercare industry was a multibillion-dollar industry, with a wide variety of private companies competing for customers as the cost of private nursing and for-profit care continued to increase.

Older individuals who require supplementary care or nursing assistance have several options: live with adult family members who are willing to assist in providing care, hire home aides or in-home nursing specialists, or move into an assisted living facility or nursing home. Family caregivers represent one of the most important sources of help and support for older adults, and the AARP Public Policy Institute estimates that in 2017, family caregivers were providing an estimated $ $470 billion in annual care to parents and family members. According to US Census Bureau estimates from 2016, approximately 3.1 percent of all Americans over sixty-five and 10.6 percent of those over eighty-five lived in group quarters such as eldercare facilities. Of all those sixty-five and older in group quarters during the period 2014–18, 82 percent resided in nursing facilities.

The cost of post-retirement and end-of-life care often exceeds an average family's available resources, especially as older people are living longer than in previous generations. Medicare policies only guarantee coverage for periods of skilled nursing for one hundred days or fewer surrounding a major bout of illness. Medicare covers the cost of some in-home nursing services but does not cover in-home assistants or housekeeping services. Nursing facilities may receive some of their funding from Medicare, while assisted living centers are not covered by Medicare and must be paid for with private insurance or out-of-pocket payments. A variety of for-profit companies provide home and facility-oriented care beyond what is covered by federal insurance programs, such as home housekeeping and basic care services.

Eldercare Today

In 2011, people born in 1946 began reaching the age of sixty-five—meaning the baby boom generation began reaching retirement age. The Pew Research Center projects that by 2030, some 18 percent of the population will be over sixty-five years of age—versus 13 percent in 2010. As the population ages, eldercare facilities will need to expand as well, and many specialists believe that existing insurance and supplementary care systems will be insufficient to cope with increasing demand. Medicare reported its spending increased from $544.5 billion in 2011 to $944.3 billion in 2022, while Medicaid spending grew $406.7 from to $805.7 billion during that period.

As the aging-in-place movement increasingly gained traction in 2010s, more older Americans lived in their own homes in the past. This spurred a shift in greater government funding for in-home care, which cost less than round-the-clock care, as well as a surge in technological innovation. From smartphones designed for the needs of older adults to alert apps to companion robots, the tech industry sought to capitalize on and “disrupt” the in-home elder-care market. Despite that trend, elder and disability care was a $74.6 billion industry in 2023, according to the market-research firm IBISWorld.

Regulation of eldercare facilities and services still varies greatly. Federal regulations require that employees of federally certified nursing homes complete at least seventy-five hours of training, of which sixteen hours must be hands-on, and companies that violate this provision may be subject to federal fines or the loss of Medicare revenues. According to the advocacy group PHI, by 2019 thirty states and the District of Columbia training standards exceeded the federal requirement for nursing assistants. However, companies offering in-home care are regulated mainly at the state level, and laws differ from state to state. According to PHI, thirty-three states require the federal minimum training for home health aides but twenty-one states allow unlicensed companies to provide in-home care and seven states had no training requirements for personal care aides. Home health aides and personal care aides who work for federally certified agencies are typically held to the same standards of training as those working in nursing facilities. Oversight also varies. While some contend that the current regulatory environment is an invitation to elder abuse and exploitation, others argue that free-market development is the best way to ensure the greatest quality of care.

The COVID-19 pandemic of the early 2020s hit eldercare particularly badly, as older adults' immune systems are more vulnerable to infection. Furthermore, congregate settings such as nursing homes and assisted living centers facilitate disease transmission due to factors such as high staff turnover, underpaid staff working multiple jobs, and inadequate infection controls. Over 200,000 residents and staff died as a result of COVID-19 infections; others left nursing homes and assisted living facilities to move in with relatives. Still other older adults similarly opted to live with relatives or age in place if they could. The pandemic also contributed to limited access to healthcare generally; increased isolation, neglect, and elder abuse; financial strain; and a widespread labor shortage in the eldercare industry.

Some saw the pandemic as a ripe opportunity for reforms. In 2023, the federal government imposed the first national minimum-staffing standards for nursing facilities. It made Medicare and Medicaid funds contingent on compliance and announced an initiative to incentivize occupational training in skilled nursing. Industry insiders objected that the new standards were too costly and burdensome, particularly amid the ongoing shortage of qualified nurses. Supporters said the standard would help residents receive better quality care.

These essays and any opinions, information, or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.

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