Population Change

PROLOGUE: When it comes to explaining variations in economic,military, and political power, most students of history arefamiliar with the Napoleonic observation that "geography isdestiny." Students of health care, on the other hand, mightbe more inclined to adopt the phrase, "demography is destiny,"as there is an ample body of evidence to support the notionthat critical measures of health system performance, such asaccess, costs, outcomes, and utilization, vary across a rangeof demographic factors. The papers that follow explore importantaspects of these connections.

In the lead essay David Cutler examines existing research ondisability change among the elderly. The evidence reveals asteady decline in disability among this group for several decades,a trend that Cutler attributes largely to improved medical technologyand behavioral changes. The observation has implications forhealth spending forecasts and the financing of care, but theequation is complicated: "Disability change might lower spendingby about 20 percent from what it would otherwise be. Still,this does not solve Medicare’s financing problems. Medicalcare cost increases, given age and health status, are likelyto be far larger in magnitude than reductions in disabilityand thus will lead to overall spending increases."

Next, Doug Wolf explores broader demographic trends as theyrelate to both the demand for and the supply of elder care.In concert with Cutler, Wolf’s inquiry reveals reducedpressure on the demand side as a result of "a modest declinein the prevalence of care needs." However, Wolf’s analysisof supply-side factors uncovers several challenges that couldnegate demand-side improvements. Among these is "reduced accessto informal chronic care services provided by family members"brought about by the impending prevalence of childlessness amongseveral age groups that are approaching retirement.

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