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Population Change

Population Change: Friend Or Foe Of The Chronic Care System?

Abstract

 
The care needs of the "frail" elderly represent a large part of the chronic care system and are met through a variety of means, including the services of family members. Consequently, projected growth in the elderly population, combined with increasing demands on their shrinking families, seems to imply both demand- and supply-side pressures on the chronic care system. Yet recent downward trends in old-age disability suggest to some that care needs might not grow. I review evidence relevant to these demand- and supply-side factors, with particular attention to the distinction between trends and compositional change, the factors’ respective contributions to declining disability, and their prospects for continuation in the future. I conclude that population change is more likely to be foe than friend of the chronic care system for several decades.

The underlying problems listed above, and their functional consequences, can occur at any age. However, the majority of persons with long-term care needs are age sixty-five or older, and the prevalence of such needs rises sharply with age, such that 45 percent of persons age seventy-five and older experience activity limitations resulting from chronic conditions.¹ I focus on the older age groups for these reasons, and also because much of what we know about chronic care comes from specialized data sources limited to the older population. I have organized the discussion into two areas: factors that influence the demand for elder care services, and those that influence the supply of these services.

Demographic Change And Demand For Services

Top Demographic Change And Demand... Demographic Change And Chronic... A Mixed Picture NOTES

 
Size of the older population. One of the best-known facts about the U.S. population is that it is growing older and is expected to continue to do so for decades. Both the absolute size of the older population and its size relative to younger groups have relevance for the future of elder care. If age-specific utilization patterns were to remain at current levels, then absolute growth would raise demand for care facilities, such as nursing homes, assisted-living facilities, and adult day care centers; for specialized equipment, such as devices that facilitiate independent living; and for service providers, such as geriatric clinicians and care workers. Relative growth in the older population places those likely demand increases into a changing context: The extent to which increased demands will be met, and their associated costs, will depend in part on the competition for resources from other demands, as well as the overall size of the population producing those resources—that is, the labor force.

The U.S. Census Bureau recently produced population projections for the period 1999–2100.² During this 100-year period the total U.S. population is expected (in these "middle-level" projections) to grow at an average annual rate of 0.7 percent. However, the older population will grow at a much faster rate: 1.5 percent per year for the population age sixty-five and older, and 2.2 percent per year for that age eighty-five and older, whose care needs are greatest.

Moreover, growth in the older population will not be uniform over the period: It will be fastest during the years 2030–2050, during which time the baby boomers will be passing through old age. Growth in the population age sixty-five and older during these years will average 3.9 percent per year, then will fall temporarily. Beginning in 2065 the older population is projected to resume a steady growth in both absolute and relative size.

Racial and ethnic composition. During the coming period of growth, the racial and ethnic diversity of the older population (as well as that of the total population) also will undergo major changes, according to the Census Bureau’s projections. Minority groups will become a much larger percentage of the oldest-old population, growing from 14 percent in 2000 to nearly 50 percent in 2100. Among elders, the Hispanic population is projected to be as large as all other minority groups combined by 2070.

This change has implications for future indicators of population health and for chronic care service demands, for several reasons. Mortality rates of African Americans are persistently higher than those of whites, while those of Hispanics and Asians/Pacific Islanders are lower than those of whites; the precise magnitudes and age patterns of these differences are less clear because of data and measurement problems.³ There are also some striking racial/ethnic differences in the prevalence of chronic conditions. Blacks, for example, have higher rates of cerebrovascular disease, diabetes, obesity, and hypertension than whites, while Hispanics have lower rates of some diseases (such as arthritis and hypertension) and higher rates of other diseases (such as diabetes) than whites have.⁴ Disability prevalence estimates tend to exhibit the same racial/ethnic differences as do mortality and disease prevalence patterns, but there are exceptions: Hispanic men appear to have lower, but Hispanic women higher, levels of disability than their white counterparts. Most of these racial differences persist after differences in socioeconomic status are adjusted for statistically.⁵

Furthermore, it is well known that service use and treatment practices differ across racial/ethnic groups, after differences in health status are accounted for. Several explanations have been put forward, including distinctive patterns of users’ attitudes, beliefs, preferences, and behavior—factors that might collectively be referred to as "cultural"—and providers’ discriminatory behavior.⁶ Among the important manifestations of cultural differences across racial/ethnic groups are patterns of household and living arrangements, which in turn have consequences for informal care patterns and formal service use. In particular, minority elders are much less likely than whites are to live alone (including with a spouse only) and much more likely to live with other family members.⁷ Historically, minority elders have been less likely than whites have been to reside in nursing homes, although recent findings suggest some reversal of that pattern. Also, for home and community-based care, both the levels and mixture of service use by type differ by race.⁸

Prevalence of chronic care needs. Growth in the absolute size of the older population translates directly into increased claims on Social Security, and growth in the relative size of the older population creates financial strain on that pay-as-you-go program. However, both sorts of growth do not necessarily translate into parallel claims on chronic care resources: An additional relevant factor is the proportion of the older population needing services.

A question that has received much recent attention is the relationship between mortality and morbidity patterns in old age. For some time it was thought that falling old-age mortality (which contributes to increased life expectancy) would be accompanied by worsening health and rising disability, and evidence from the 1970s seemed to support that view.⁹ More recent research suggests that this is not the case, although it also suggests that relationships among mortality, disease, and disability are complex.

Three of the most recent survey data sources—the National Long-Term Care Survey (NLTCS), the Medicare Current Beneficiary Survey (MCBS), and the National Health Interview Survey (NHIS)—show clear differences in disability levels, reflecting differences in survey methodology (Exhibit 1). All three surveys provide self-reported rather than clinically evaluated disability information and use distinct questions. The NLTCS, for example, asks respondents whether others help them with ADLs and IADLs, whether they use special equipment in those tasks, and whether they need help despite any assistance or equipment use. Thus, it captures both "intrinsic" (or underlying) and realized or "actual" disability, the latter a reflection of capacities for self-care and management, availability of helpers, environmental and behavioral adaptations, as well as underlying problems.¹⁰

View larger version (27K): [in this window] [in a new window] EXHIBIT 1 Trends In Old-Age Disability Prevalence, Various Data Sources, 1982–1999

However, while disability rates have fallen, the prevalence of some chronic conditions, such as osteoporosis, cancer, diabetes, heart disease, arthritis, obesity, glaucoma, and cataracts, have risen. Several reasons have been offered to explain this seemingly paradoxical juxtaposition of trends, including earlier diagnosis and better and more extensive treatment of diagnosed conditions, improved management of known conditions, reduced severity of incident conditions, increased awareness and knowledge of disease among patients, and a greater "medicalization" of conditions previously regarded as inevitable sequelae of aging rather than as disease states.¹² Thus, increases in remaining life expectancy at the oldest ages, combined with decreasing disability prevalence rates, suggest that longer life has not been accompanied by increased disability—at least over the past twenty years.

Trends and compositional change. Some studies have suggested that if the recent downward trends in disability prevalence were to continue, then growth in the absolute numbers of older persons would be offset by reductions in the proportion of that population requiring care, and that, on balance, future elder care demands would not grow.¹³ However, the overall trends in disability partly reflect compositional effects—namely, a changing mix of groups between which there are persistent (although not necessarily fixed) differences in disability levels. The trends are also partly due to changes over time in the prevalence of disability within groups. The latter category of change, associated with the passage of time and hence identified as a true "trend," may, however, simply reflect compositional change along unmeasured dimensions. Moreover, some of the changes of each type are reinforcing while others are offsetting, and some are by their very nature unlikely to continue indefinitely. As a result, extrapolations of trends in disability prevalence should be viewed skeptically.

Some studies have attempted to isolate the effects of compositional change in their analyses of disability trends. Among the compositional factors that have been considered are race and ethnicity, sex, marital status, educational attainment, wealth holdings, and region of residence. Thus, whether recent trends in disability prevalence will continue depends in part on the reasonableness of assumptions concerning the persistence of between- and within-group patterns of disability prevalence. For example, biological and behavioral differences between men and women, including the experience of childbearing, may underlie immutable differences in susceptability to specific diseases and functional limitations, yet the degree of intrinsic differences may be quite different from the differences apparent in recent years.

The role of education. One compositional factor that has received considerable attention in the literature is educational attainment. For many decades successive cohorts of the U.S. population have been better and better educated (Exhibit 2). Differences in health and mortality outcomes by educational level have been documented for many years. A study based on 1960 data showed substantial differentials in mortality by level of education among women but not among men, while more recent studies have shown widening educational differentials in mortality among men but not among women.¹⁴ The previously cited studies on trends in disability prevalence also show that disability is less common among more highly educated than among less highly educated groups. The downward trend in disability over 1982–1996 seems to have occurred only among persons with more than a high school education.¹⁵ Since the educational attainment of the elderly has improved during recent decades, these findings suggest that the positive association between longevity and disability trends since 1980 is not inherent (in contrast to earlier expectations) but simply reflects the growing presence of better-educated persons in the older population among successive cohorts.

View larger version (18K): [in this window] [in a new window] EXHIBIT 2 Educational Attainment Among Persons Ages 35–54, Selected Years 1940–2000

Whether we can anticipate continued downward trends in disability among the highly educated, or even continued differentials in the disability experience of different educational-attainment groups, depends in part on the underlying mechanisms that give rise to the observed educational differentials in health and disability. A number of reasons have been suggested to explain the observed patterns: Better-educated people have higher incomes and may be more likely to have jobs that include generous health insurance benefits, both of which improve access to medical care; they may occupy superior environments, both on and off the job; and they may be better informed about and more readily adopt healthy lifestyles and behavior patterns and be better able to comply with treatment regimens. For some of the hypothesized mechanisms, education has a causal role (for example, higher incomes, better knowledge), while for others the association is merely correlational (for example, aptitudes that facilitate both the acquisition of formal education and the ability to understand and comply with treatments). The relationships also embody reverse causality to some extent: Healthier people, who can anticipate a longer life, may find it rational to invest in more education since the period over which returns on the investment can be enjoyed is longer.

As noted above, within-group trends in disability might reflect within-group compositional change along some other dimension. This possibility, with cautionary implications for any effort to extrapolate recent disability trends, is illustrated in Exhibit 3. In 1974, when this data series begins, there is an inverse relationship between educational attainment and current smoking behavior. This is consistent with some of the hypothesized behavioral consequences of education discussed above. But smoking prevalence has fallen more rapidly among highly educated persons relative to the less highly educated. These data suggest that improvements in the health status of more-educated elders—to the extent that they result from superior health behavior—cannot continue indefinitely, since the possiblity of further improvements in health behavior will eventually vanish. Moreover, differentials in health outcomes by education, to the extent that they reflect differentials in risk factors, may diminish as the less-educated groups eventually catch up to the more-educated groups with respect to those risk factors.

View larger version (14K): [in this window] [in a new window] EXHIBIT 3 Age-Adjusted Prevalence Of Current Smoking Behavior, By Educational Attainment, 1974–1998

Demographic Change And Chronic Care Services

Top Demographic Change And Demand... Demographic Change And Chronic... A Mixed Picture NOTES

 
It is well known that family members are a major source of care and support for older persons with chronic care needs. Commentators on the future of chronic care often observe that a number of social trends, such as increased geographic mobility, rising female labor-force participation, smaller families, falling marriage rates, and rising divorce rates, will "decrease the availability or willingness of family members to provide care" in coming years.¹⁷ Yet available evidence flatly contradicts some of these claims, while presenting, at best, a mixed picture of the import of some others.

Geographic mobility. Most strikingly, available data suggest that for many years the U.S. population has become less, rather than more, mobile. Apart from a brief period in the late 1980s, there has been a steady decline in the annual mobility rate (defined as the percentage of persons changing residence from March in one year to March the next year) from 1950, when the data series began, through 1997–98.¹⁸ Time-series data on the average distance moved, unfortunately, is not available. Yet based on the available evidence, families might not, in fact, be more spatially dispersed at present than they were fifty years ago. Indeed, there has been little change since 1962 in the percentage of older persons with at least one nearby offspring.¹⁹

Female labor-force participation. The increasing presence of women in the paid workforce could be expected to reduce the supply of informal familial care services to elderly parents, if paid work proved to be an effective deterrent to the provision of such care. But the evidence on the effects of this type of time-use competition is mixed. Cross-sectional evidence confirms that the average number of hours spent providing personal care or household assistance to older parents is lower among employed than among nonemployed women. Yet multivariate analyses that control for other correlates of time use find less clear-cut patterns. Some studies have found no evidence that providing parent care reduced married women’s employment or hours of work, while others have found that providing parent care does reduce women’s work hours.²⁰ A study based on longitudinal data found that being employed did not deter women from initiating an episode of parent care, although women who did this worked about four hours per week less, on average, than otherwise comparable women.²¹ Thus, some researchers have concluded that the hours spent by working women in parental care come not out of paid employment but out of other potential uses of time such as housework or leisure.²²

Marriage and divorce patterns. Changing marriage and divorce patterns in the latter half of the twentieth century have been well documented. Available evidence suggests a "retreat" from early marriage among all racial groups and from marriage overall among African American women. Accompanying the waning of marriage is an increase in the proportion of marriages that end in divorce and a reduction in remarriage among divorced persons.²³ Consequently, the oldest-old of the future will have had different lifetime marital experiences, on average, from those of the present: The experience of divorce at some point in the life cycle and the chances of being divorced during old age will increase.

Research has shown that divorce has adverse consequences for resource flows between older parents and their grown children, as well as on the quality of intergenerational relationships. These adverse consequences are more pronounced for divorced fathers than for divorced mothers. Moreover, parent-child relationships are further diminished if the divorced parent remarries. Research has shown that divorced elderly parents are less likely than widowed parents are to occupy shared housing with a child and are less likely to receive help with either personal care or household chores from their children.²⁴ Thus, there is a good deal of evidence to support the claim that the children of tomorrow’s elderly parents may be comparatively less interested in meeting their parents’ chronic care needs than their current counterparts are.

Fertility patterns. With respect to fertility patterns, we find unambiguous evidence supporting an alarmist view of the future of chronic care. The percentage of childless women among the group ages forty to forty-four, a good indication of the ultimate prevalence of childlessness in a cohort, is rising for white, black, and Hispanic women. Moreover, trends in childlessness are diverging across racial groups: During 1981–1998 the average annual increase in childlessness among women ages forty to forty-four was 0.62 percentage points for whites but 0.32 percentage points for blacks and only 0.21 percentage points for Hispanics.²⁵ Thus, racial and ethnic differences in childlessness, and consequently in demands for long-term care resources, are likely to be much more pronounced in the future than they are at present.

While changing marital and fertility patterns can be expected to decrease the supply of chronic care services provided by traditional nuclear-family sources, some have speculated that reduced availability of traditional family assistance may be counterbalanced by the proliferation of nonstandard ties to an increasingly diffuse social network. One simulation study indicates that stepchildren and stepgrandchildren may exist in sufficient numbers to nearly compensate for the losses of one’s own children and grandchildren.²⁶ Although little research has investigated the issue, some studies show a willingness of stepchildren and children-in-law to occupy caregiver roles.²⁷ Whether these more diffuse kin linkages will prove to be as effective a source of support and hands-on care as have biological children in recent decades remains to be seen.

Health workforce supply. A supply-side analysis of the demography of chronic care must consider the formal as well as the informal care sector. Here, too, recent trends suggest possible difficulties ahead. The existence of nursing staff shortages in a variety of health service settings has received growing attention. A recent report from the Centers for Medicare and Medicaid Services, or CMS (formerly HCFA) found that staffing levels fell short of thresholds at which quality of care may be seriously compromised in a substantial percentage of nursing homes.²⁸ The shortage of appropriately credentialed nurses is not, of course, the only reason that facility staffing levels may fall short of desired levels. But supply factors can be expected to become an ever larger problem in the future, thanks to declining enrollments in nursing schools: For six consecutive years enrollments in bachelor’s-level degree programs have declined, while declines have been recorded for three consecutive years for master’s degree programs.²⁹ The U.S. Department of Labor projects above- to well-above-average growth in demand for many health-related professions to the year 2008, including registered nurses, respiratory therapists, speech-language pathologists, nursing aides, and occupational and physical therapy assistants and aides.³⁰ Thus, a relative shrinkage of potential suppliers of informal elder-care services may be accompanied by a shrinkage in the number of formal suppliers of such care, at least in the short run.

A Mixed Picture

Top Demographic Change And Demand... Demographic Change And Chronic... A Mixed Picture NOTES

 
This survey of demographic trends provides a mixed picture of the possible future of elder care in the United States. On the demand side, substantial growth in the number of very old persons seems assured, raising possible concerns about huge increases in care needs. Yet evidence from several sources over the past twenty years consistently shows a modest decline in the prevalence of care needs. Under certain assumptions, projected continuation of these favorable disability trends appears to be sufficient to offset growth in the overall population; this suggests that the size of the population needing chronic care services will stay reasonably constant.

However, optimism based on the demand-side demography of elder care appears to be misplaced. First, the basic facts about disability change are far from complete: The relative roles of underlying pathologies and of the many behavioral responses to those pathologies are not adequately understood. Several untested hypotheses have been advanced to explain the coincidence of rising chronic disease and falling disability.

Furthermore, extrapolation of recent trends in disability prevalence depends on many assumptions, including a continuation of favorable health outcomes among the more highly educated population. Yet the extent to which the educational advantage in health, disability, and survivorship is fixed cannot be isolated with much confidence based on existing knowledge.

The supply side of the chronic care picture seems even less optimistic on balance. The fertility experience of cohorts of women already past childbearing age implies future growth in the prevalence of childlessness among the elderly. This fact, by itself, suggests reduced access to informal chronic care services provided by family members. That reduction may be somewhat offset by care provided in more diffuse family and quasi-family networks, but this effect in turn is likely to be offset by increased demands for formal services.

Growing racial and ethnic diversity among the oldest-old population appears to be inevitable. If past patterns of differential health status and access to health care persist, then growing calls for policy changes tailored to the new diversity seem likely. Additional demographic trends, particularly in childlessness, can be expected to exacerbate differences in service-use patterns, further underscoring the likelihood that existing policy arrangements will be viewed as inadequate.

It is important to recognize that the mix of relevant demographic trends is different in the short run—the next two decades—and in the longer run. While all projections must be viewed with considerable skepticism, key aspects of the near term, such as continued improvements in the educational-attainment distribution of the elderly and modest growth in their overall numbers, imply comparatively modest pressures on the chronic care system. Toward the middle of the twenty-first century, however, more rapid growth in the absolute and relative numbers of elderly persons, combined with possible "saturation" of both the compositional and pure-trend aspects of educational advantages in health and growing childlessness among the disabled elderly, all suggest heightened claims on the public chronic care budget. In any event, both science and prudence appear to indicate a pessimistic answer to the question posed in this paper’s title: Demographic trends point to growing pressures in the arena of elder care, and this has adverse consequences for the chronic care system and especially for public resources within that system. Planning for institutional change to deal with those consequences seems to be in order.

Editor's Notes

 
Doug Wolf is the Gerald B. Cramer Professor of Aging Studies and associate director of the Aging Studies Program at the Maxwell School of Citizenship and Public Affairs, Syracuse University, in Syracuse, New York.

The author thanks Hakan Aykan of the Philadelphia Geriatric Center, who contributed original analysis of data from the 1994 Survey of Aging, and Vicki Freedman, the editors, and three anonymous reviewers for their useful comments and suggestions.

NOTES

Top Demographic Change And Demand... Demographic Change And Chronic... A Mixed Picture NOTES

 

1. R. Stone, Long-Term Care for the Elderly with Disabilities: Current Policy, Emerging Trends, and Implications for the Twenty-first Century (New York: Milbank Memorial Fund, 2000); and National Academy for an Aging Society, Challenges for the Twenty-first Century: Chronic and Disabling Conditions, Profile no. 1, November 1999, <www.agingsociety.org/chronic.pdf>(25 September 2001).
2. U.S. Bureau of the Census, "Projections of the Total Resident Population by Five-Year Age Groups, Race, and Hispanic Origin with Special Age Categories: Middle Series, 1999 to 2100 (Table NP-T4)," <www.census.gov/population/www/projections/natsum.html>(1 August 2001).
3. K. Manton and E. Stallard, "Non-White and White Age Trajectories of Mortality: Evidence from Extinct Cohorts Analyses, 1950 to 1992," in Minorities, Aging, and Health, ed. K. Markides and M. Miranda (Thousand Oaks, Calif.: Sage Publications, 1977); and I. Elo and S. Preston, "Racial and Ethnic Differences in Mortality at Older Ages," in Racial and Ethnic Differences in the Health of Older Americans, ed. L. Martin and B. Soldo (Washington: National Academy Press, 1977).
4. D. Clark and R. Gibson, "Race, Age, Chronic Disease, and Disability," in Minorities, Aging, and Health, ed. Markides and Miranda, 107–126.
5. H. Hazuda and D. Espino, "Aging, Chronic Disease, and Physical Disability in Hispanic Elderly," in Minorities, Aging, and Health, ed. Markides and Miranda, 127–148; and M. Hayward et al., "The Significance of Socioeconomic Status in Explaining the Racial Gap in Chronic Health Conditions," American Sociological Review (December 2000): 910–930.
6. See M. Gornick, "Disparities in Medicare Services: Potential Causes, Plausible Explanations, and Recommendations," Health Care Financing Review (Summer 2000): 23–43; and K. Schulman et al., "The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization," New England Journal of Medicine (25 February 1999): 618–626.
7. C. Himes et al., "Living Arrangements of Minority Elders,"Journal of Gerontology: Social Sciences (January 1996): S42–S48.
8. C. Bishop, "Where Are the Missing Elders? The Decline in Nursing Home Use, 1985 and 1995," Health Affairs (July/Aug 1999): 146–155; L. Burton et al., "The Structure of Informal Care: Are There Differences by Race?" Gerontologist (December 1995): 744–752; andS.P. Wallace et al., "The Impact by Race of Changing Long-Term Care Policy," Journal of Aging and Social Policy 9, no. 3 (1997): 1–20.
9. A. Colvez and M. Blanchet, "Disability Trends in the United States Population, 1966–1976: Analysis of Reported Causes," American Journal of Public Health (May 1981): 464–471.
10. V. Freedman, "Implications of Asking ‘Ambiguous’ Difficulty Questions: An Analysis of the Second Wave of the Asset and Health Dynamics of the Oldest Old Study," Journal of Gerontology: Social Sciences (September 2000): S288–S297.
11. V. Freedman et al., "Aggregate Changes in Severe Cognitive Impairment among Older Americans: 1993 and 1998," Journal of Gerontology: Social Sciences (March 2001): S100–S111.
12. V. Freedman and L. Martin, "Contribution of Chronic Conditions to Aggregate Changes in Old-Age Functioning," American Journal of Public Health(November 2000): 1755–1760; and E. M. Crimmins and Y. Saito, "Change in the Prevalence of Diseases among Older Americans: 1984–1994," Demographic Research 3–9 (11 January 2000), <www.demographic-research.org>(3 August 2001).
13. B. Singer and K. Manton, "The Effects of Health Changes on Projections of Health Service Needs for the Elderly Population of the United States," Proceedings of the National Academy of Sciences (December 1998): 15618–15622; and T. Waidmann and K. Liu, "Disability Trends among Elderly Persons and Implications for the Future," Journal of Gerontology: Social Sciences (September 2000): S298–S307.
14. E. Kitagawa and P. Hauser, Differential Mortality in the United States: A Study in Socioeconomic Epidemiology (Cambridge: Harvard University Press, 1973); J. Feldman et al., "National Trends in Educational Differentials in Mortality," American Journal of Epidemiology (May 1989): 919–933; and S. Preston and I. Elo, "Are Educational Differentials in Adult Mortality Increasing in the United States?" Journal of Aging and Health (November 1995): 476–496.
15. See R. Schoeni et al., "Persistent, Consistent, Widespread, and Robust? Another Look at Recent Trends in Old-Age Disability," Journal of Gerontology: Social Sciences (July 2001): S206–S218.Average annual change in disability prevalence was not significantly different from zero at p <.05 among persons with 0–8 years, 9–11 years, or 12 years of education but was –1.5 percent among those with 13 or more years of schooling.
16. F. Levy and R. Murnane, "U.S. Earnings Levels and Earnings Inequality: A Review of Recent Trends and Proposed Explanations," Journal of Economic Literature (September 1992): 1333–1381.
17. S. Tennstedt, "Family Caregiving in an Aging Society," 29 March 1999, <www.aoa.gov/caregivers/famcare.pdf>(20 September 2001). See also R.J. Angel and J.L. Angel, Who Will Care for Us? Aging and Long-Term Care in Multicultural America (New York: New York University Press, 1997).
18. P. Gober, "Americans on the Move," Population Bulletin (November 1993); and C. Faber, "Geographical Mobility: March 1997 to March 1998," Current Population Reports, Series P20-520 (Washington: Census Bureau, January 2000).
19. According to E. Crimmins and D.G. Ingegneri,"Interaction and Living Arrangements of Older Parents and Their Children," Research on Aging (March 1990): 3–35, in 1962, 76 percent, and in 1984, 72 percent, of parents age sixty-five and older had at least one child living within thirty minutes of their home. In 1994, 73 percent of parents age seventy and older fell into this category. Computations based on the 1994 Survey of Aging graciously supplied by Hakan Aykan, Philadelphia Geriatric Center.
20. See D. Wolf and B. Soldo, "Married Women’s Allocation of Time to Employment and Parental Care," Journal of Human Resources (Fall 1994): 1259–1276; S. Ettner, "The Impact of ‘Parent Care’ on Female Labor Supply Decisions," Demography (February 1995): 63–80; S. Ettner, "The Opportunity Costs of Elder Care," Journal of Human Resources (Winter 1996): 189–205; S. Stern, "Estimating Family Long-Term Care Decisions in the Presence of Endogenous Child Characteristics," Journal of Human Resources (Summer 1995): 551–580; and R.W. Johnson and A.T. Lo Sasso, "The Trade-Off between Hours of Paid Employment and Time Assistance to Elderly Parents at Midlife," 7 February 2000, <www.urban.org/retirement/reports/elderly_parents.pdf>(15 April 2001).
21. E. Pavalko and J. Artis, "Women’s Caregiving and Paid Work: Causal Relationships in Late Midlife," Journal of Gerontology: Social Sciences (July 1997): S170–S179.
22. K. Couch et al., "Time? Money? Both? The Allocation of Resources to Older Parents," Demography (May 1999): 219–232.
23. J.D. Teachman et al., "The Changing Demography of America’s Families," Journal of Marriage and the Family (November 2000): 1234–1246.
24. T. Cooney and P. Uhlenberg, "The Role of Divorce in Men’s Relations with Their Adult Children after Midlife," Journal of Marriage and the Family (August 1990): 677–688; F. Furstenberg et al., "The Effect of Divorce on Intergenerational Transfers: New Evidence," Demography (August 1995): 319–333; and L. Pezzin and B. Schone, "Parental Marital Disruption and Intergenerational Transfers: An Analysis of Lone Elderly Parents and Their Children," Demography (August 1999): 287–297.
25. These rates are based on data found in various issues of U.S. Bureau of the Census, "Fertility of American Women," Current Population Reports, Series P-20.
26. K. Wachter, "Kinship Resources for the Elderly," Philosophical Transactions of the Royal Society of London, Series B (December 1997): 1811–1817.
27. K. Allen et al., "Families in the Middle and Later Years: A Review and Critique of Research in the 1990s," Journal of Marriage and the Family (November 2000): 911–926, especially 919.
28. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, HCFA Report to Congress, 1 August 2000, <www.hcfa.gov/medicaid/reports/rp700hmp.htm>(15 April 2001).See also C.M. Fagin, When Care Becomes a Burden: Diminishing Access to Adequate Nursing (New York: Milbank Memorial Fund, 2001); and P.I. Buerhaus et al., "Implications of an Aging Registered Nurse Workforce," Journal of the American Medical Association (14 June 2000): 2948–2954.
29. American Association of Colleges of Nursing, 2000–2001 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing (Washington: AACN, March 2001).
30. J. Kelinson and P. Tate, "The 1998–2008 Job Outlook in Brief," Occupational Outlook Quarterly (Spring 2000): 2–36.

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