Population ageing in the United States of America: implications for

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© International Epidemiological Association 2002
Printed in Great Britain
International Journal of Epidemiology 2002;31:776–781
Population ageing in the United States of
America: implications for public programmes
Joshua M Wiener and Jane Tilly
Like the rest of the world, the US is an ageing society. This will
place substantial additional pressure on publicly-funded health,
long-term and income support programmes for older people.
This paper analyses the demographic changes that the US faces
and how they will affect those programmes, concentrating
on the factors that may affect the economic burden that these
programmes impose.
to grow by only 33%. The ratio of people ages 16–64 to those
age 65 and over (the aged dependency ratio) is projected to decline
from 5.1 in 2000 to 2.9 in 2050, a 43% decline. The slow growth
in the working age population will mean that there will be
relatively fewer people to pay the taxes necessary to support
public programmes for the older population and fewer people to
provide the services that older people need.
Demographic change and its consequences
for health care
Implications for organization and
delivery of health care
An ageing society
Like the rest of the world, the US is an ageing society (Table 1).
Between 2000 and 2050, the number of older people is projected
to increase by 135%. Moreover, the population aged 85 and
over, which is the group most likely to need health and longterm care services, is projected to increase by 350%. Over this
time period, the proportion of the population that is over the
age of 65 will increase from 12.7% in 2000 to 20.3% in 2050;
the proportion of the population that is age 85 and older will
increase from 1.6% in 2000 to 4.8% in 2050.
Two points are noteworthy about this demographic change.
First, while a significant proportion of the US is elderly, much of
Europe already has a higher proportion of its population that is
over the age of 65. For example, in 2000, 16.0% of the population in the UK and 16.4% of the population of Germany was
over the age of 65.1 Thus, other countries are already having
to cope with the impact of an ageing society to a greater extent
than the US.
Largely as a result of higher fertility rates and immigration,
America’s population, while ageing, is nonetheless likely to
remain distinctly younger than other developed countries.2
Second, the future strains of population ageing in the US
derive not so much from the growth in the elderly population
or the 85 and over population, per se, but rather from the slow
projected growth in the non-elderly, working age population.
Between 2000 and 2050, the population age 16–64 is projected
Table 1 Population of the US, by age, 2000 and 2050 (in millions)
Age
2000
2050
% change
Total
275 306
403 687
46.6
16–64
177 974
236 602
32.9
65+
34 835
81 999
135.4
85+
4312
19 352
349.8
Source: US Bureau of the Census.
The Urban Institute, 2100 M Street, NW, Washington, DC 20015, USA.
E-mail: [email protected]
The ageing of the population will have a major impact on the
organization and delivery of health care. Of particular importance
will be the shift from acute to chronic illnesses and the likely
growing shortage of health care workers, especially nurses and
paraprofessionals.
Shift from acute to chronic illnesses
The ageing population will require focusing on chronic diseases,
such as Alzheimer’s Disease, heart disease, and osteoporosis,
rather than acute illnesses. First, the style of medicine will need
to change from one-time interventions that correct a single
problem to the ongoing management of multiple diseases and
disabilities; doctors and patients will have to have an ongoing
relationship designed to help patients cope with illnesses rather
than curing them.3 Second, with chronic illness often comes
disability, meaning that long-term care services, such as nursing
homes, home health, personal care, adult day care, and congregate housing, will become much more important sources of
care. Third, new ways will need to be found to integrate medical
and long-term care services, a feat that will be difficult in the US
because of the fragmentation of the financing and delivery
systems.4
Health and long-term care workforce issues
There has been increasing concern about the current and future
supply of acute and long-term care workers, especially nurses
and paraprofessional staff, such as certified nurse assistants,
home health aides, and personal care attendants.5–7 Unskilled
paraprofessionals, who provide the bulk of long-term care
services, are overwhelmingly women and disproportionately
drawn from racial and ethnic minorities. Low wages and benefits, hard working conditions, heavy workloads and a job that
has been stigmatized by society make worker recruitment and
retention difficult.
While a short-term recession could temporarily relieve the
worker shortage, the gap between the large projected increase
in demand for acute and long-term care services and the slow
projected growth in the labour force signals a dramatic long-run
imbalance. Because of the ageing registered nurse workforce,
by the year 2020, the registered nurse workforce is forecast
to be roughly the same size as it is today, declining nearly 20%
776
POPULATION AGEING IN THE US: PUBLIC PROGRAMME IMPLICATIONS
below projected workforce requirements.6 To attract additional
workers in the future may require higher wages.
Public programmes for older people
Like other developed countries, the US has large public programmes for the older population that provide health care, long-term
care, and income support. While these account for the vast bulk
of government spending for the older population, there are
also numerous other smaller public programmes that provide
housing, social services, transportation, and additional cash
assistance.
Acute care financing
Acute care services for older people, such as hospital and
physician care, are financed through a mix of public and private
sources. Medicare is a publicly financed and administered, social
insurance programme, with near universal eligibility. In addition
to older people, the programme also covers younger people
with disabilities who have a significant work history. The programme operates as an open-ended entitlement to individuals.
Financing for hospital and some other services (‘Part A‘) is
through a payroll tax of 2.90% (split evenly between workers
and employers) with no cap on the earnings subject to taxation;
financing for physician and some other services (‘Part B‘) is
through premiums paid by beneficiaries and general revenues.
While enrolment in Part B is technically voluntary, virtually
all older people enrol. Medicare expenditures in 2000 totalled
$224 billion, slightly more than 2.2% of gross domestic product
(GDP).8
Medicare covers a fairly broad range of services, but does not
cover prescription drugs outside of institutions, dental services,
or eyeglasses, and has extensive cost-sharing requirements. The
programme covers a limited amount of skilled nursing home
and home health care. Proposals to provide coverage for outpatient prescription drugs for older people was seriously considered in 2000 and 2001. The declining economic situation and
the shift of priorities for spending to anti-terrorism activities in
the wake of the tragedies of 11 September 2001, make enactment of additional benefits unlikely. In the absence of action at
the national level, some states are developing pharmaceutical
assistance programmes for the low-income elderly and disabled
populations who are not eligible for Medicaid, the federal-State
health programme for low-income people or people with high
medical expenses.9
Because of gaps in Medicare coverage, important additional
sources of financing for acute care services for older people
include private supplemental insurance provided by employers
or purchased by individuals, health maintenance organizations,
Medicaid, and out-of-pocket payments. In 1997, only 10% of
Medicare beneficiaries did not have some sort of other thirdparty coverage.10
Medicare beneficiaries have complete freedom-of-choice of
providers, who are overwhelmingly private, non-governmental
organizations or suppliers. An important recent trend has been
the increase and then levelling off during the 1990s of enrolment in health maintenance organizations, which limit the
choice of providers. As of 2000, 16% of Medicare beneficiaries were enrolled in Medicare health maintenance
organizations.11
777
Long-term care financing
Financing for long-term care services, such as nursing home
care and home and community-based services, is through a
combination of Medicaid, Medicare, state-funded programmes,
out-of-pocket payments and private insurance. By far the dominant source of long-term care funding is Medicaid. Approximately
two-thirds of nursing home residents have their care paid by
Medicaid.12 Financial eligibility standards are strict, with Medicaid nursing home residents having to contribute all of their
income towards the cost of care, except for a small personal
needs allowance of about $30 a month. Individuals may keep
only $2000 in financial assets, although the home is generally
an exempt asset. With some exceptions, the Medicaid programme
operates as an open-ended entitlement to individuals. Federal
and state Medicaid long-term care expenditures for older people
with disabilities were about $43 billion in 2000, about 0.4% of
GDP.8,13 Many states also operate their own programmes for
home care, although most are fairly small.
Medicare covers skilled, relatively short-term care provided
by home health agencies and nursing homes, not traditional
long-term care. Private long-term care insurance has been growing steadily since the mid-1980s, but finances ,5% of total
long-term care expenditures.14 The lack of public or private
insurance coverage and the means-tested character of Medicaid
means that out-of-pocket payments account for a large portion
of long-term care expenditures.
Retirement income
Retirement income is financed through a combination of public
and private pensions, savings, and welfare payments. Approximately 44% of households including a person over the age of
65 have private pensions; ,5% of older people receive meanstested welfare payments.11
Publicly-financed retirement pensions are primarily funded
through the national Old-Age and Survivors Insurance
programme, more commonly known as Social Security, which
is a universal income support programme for older people
and is the main source of income for the retired. In addition,
the Disability Insurance programme provides income support to
people with disabilities with a significant work history. Retirees
are eligible for reduced benefits at age 62 and full benefits at age
65. In order to receive benefits, individuals must work for at
least 10 years or be the spouse of an individual who worked for
at least 10 years. Benefit levels vary with an individual’s income
during his or her working life, with lower-income people receiving a higher replacement rate than higher-income people. Unlike
most private pensions, Social Security benefits increase each
year with inflation.
Social Security and the Disability Insurance programmes are
primarily financed by payroll taxes levied on salaries. Employers
and employees each pay 6.2% of earnings for a total of 12.4%
of salary, up to a maximum level, which increases each year
with average wages. In 2000, Social Security and Disability Insurance paid $415 billion in benefits, approximately 4.2% of GDP.15
Economic importance
As the population ages, public expenditures are projected to
grow as a per cent of GDP. Table 2 presents official government
projections for Medicare and Social Security expenditures and
778
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Disability rates
Table 2 Per cent of gross domestic product for Medicare, Social
Security and publicly-funded long-term care, 2000 and 2050
2000
2050
% change
Medicare
2.2
6.0
173
Social Security
4.2
6.5
55
Medicaid long-term care
0.4
0.7
75
Total
6.8
13.2
94
Sources: Authors’ calculations based on: Board of Trustees, The 2001 Annual
Report of Trustees of the Federal Old-Age and Survivor’s Insurance and Disability
Insurance Trust Funds, (Baltimore, MD: Social Security Administration, 2001);
Board of Trustees, 2001 Annual Report of the Board of Trustees of the Federal
Hospital Insurance Trust Fund, (Baltimore, MD: Health Care Financing
Administration, 2001); US Congressional Budget Office, Projections of Expenditures
of Long-Term Care Services for the Elderly, (Washington, DC: US Congressional
Budget Office, 1999); and, Wiener JM, Illston LH, and Hanley RJ. Sharing the
Burden: Strategies for Public and Private Long-Term Care Insurance (Washington,
DC: The Brookings Institution, 1994).
projections by Wiener, Illston and Hanley for long-term care
expenditures.16 These estimates are static rather than dynamic
extrapolations of existing patterns of use and cost. Overall,
Medicare, Social Security, and the Medicaid funding for longterm care are projected to grow from 6.8% of GDP in 2000
to 13.2% in 2050. Health and long-term care programmes are
projected to increase from 2.6% of GDP in 2000 to 6.7% of GDP
in 2050.
In addition to the sharply greater number of beneficiaries, the
large increase in GDP for health and long-term care is a function
of three factors. First, demographic pressures raise spending for
Medicare more than in other industrial society’s governmentsponsored health care programmes because the American programme only covers the elderly and some people with disabilities.
All other health programmes in developed countries cover the
entire population. Between 2000 and 2050, the proportion of
the American population that will receive its health care through
Medicare will increase by about 50%.
Second, older people have higher average expenditures than
do younger people. For example, in 1995, per capita personal
health expenditures for a person aged 65 and older were 4.6
times those of people under age 65, a ratio that has been steadily
growing since at least 1966.17
Third, Medicare and long-term care expenditures as a proportion of GDP is projected to increase more than Social Security
because of the assumption that average health care costs per
person will increase considerably faster than per capita GDP.
Projections of Medicare costs 50 years into the future depend
heavily on this assumption, which is very uncertain and has
fluctuated wildly. For example, because of changes primarily in
assumptions of the rate of increase in health care costs, Medicare
was estimated to be 7.8% of GDP in 2050 in the government
projections made in 1997, but 4.8% of GDP in estimates made
in 2000—a difference of more than the cost of the entire
Medicare programme in 2000.18.19
Factors potentially affecting the
economic burden
A number of factors, including changing disability rates, the
size of the economy and efforts at privatization may affect how
much of an economic burden these programmes impose in the
future.
Some researchers have found evidence of declining disability
rates, which might moderate the growth in the use of acute
and long-term care services. For example, using the National
Long-Term Care Survey, Manton and Gu found that on an
age-adjusted basis, the proportion of the elderly population that
was disabled declined from 26.2% in 1982 to 19.7% in 1999.20
Other researchers using other data have also found evidence
of a decline in disability.21–24 This disability rate decline might
partially explain the reduction in American nursing home use
rates between 1985 and 1995.20,25 These findings are consistent
with research in other countries.26,27 On the other hand,
other researchers have not found this decline in disability or
have found that it relates primarily to less severe levels of
disability.23,28
If these disability declines continue, they could, in theory,
have a major impact on use of both acute and long-term care
services. People with substantial disabilities have three times
the average Medicare expenditure of beneficiaries without
substantial disabilities.29 Singer and Manton estimated that a
continued decline in disability could preserve the long-term
care fiscal stability of Medicare and Social Security.30 However,
even under optimistic assumptions about declines in disability
rates, there is likely to be a substantial increase in demand for
acute and long-term care services because of huge increases in
the absolute numbers of the oldest old.13
Size of the economy
While most public policy has focused on public expenditures
for older people, less attention has been given to the size of
the economy. The Social Security actuaries project that the US
economy will grow from $10 trillion (1012) in 2000 to $111 trillion
in 2050 in nominal dollars.15 The financial burden of public
programmes for older people will partly depend on how fast
the economy grows. For example, in projecting long-term care
expenditures, Wiener, Illston and Hanley estimated that public
long-term care expenditures as a percentage of GDP could triple
from 1993 to 2048 if the US economy were to grow by only
1.5% per year adjusting for inflation, but barely increase at all
if real economic growth were 3.5% per year.16
There are also factors that could increase the number of
workers, including immigration and increased labour force participation, which would provide workers to pay taxes to support
the older population. The US has always had a large number
of immigrants and about 11% of the US population is foreign
born.31 The major limit on the number of immigrants is the
restrictions imposed by the government. The terrorist attacks of
11 September 2001 have sharply undermined evolving support
for immigration liberalization and made the admission of additional immigrants highly unlikely, at least for the time being.32
Even with additional immigration, it is questionable that it would
occur at levels necessary to significantly counteract the impact
of population ageing.33 Increased immigration, of course, raises
a number of difficult issues about integrating a new population
into American society and also questions of how willing this
new foreign-born population will be to pay taxes to support the
ageing native population.
The other factor that could increase the economy is that a
higher percentage of the population could enter the workforce.
POPULATION AGEING IN THE US: PUBLIC PROGRAMME IMPLICATIONS
As workers become more scarce, labour force participation
rates may rise as employers compete for workers. Labour force
participation for women has risen substantially over the last
30 years, but is still well below that of men. In 1998, the labour
force participation of men age 45–54 was 89%, while it was
only 76% for women.34 Higher labour force participation rates
for women, however, may deprive older people of informal
care, increasing demand for paid long-term care services.
Older people themselves also may be a source of additional
workers. In a recent survey, nearly a third of ‘baby boomers’
indicated their desire to work at least part-time during their
retirement years.35
Privatization
Conservatives and some moderates are convinced that
privatization of Medicare, Social Security and long-term care is
necessary to address the future burdens of an ageing population. For Social Security, the main proposal has been to divert
some of the payroll tax to private accounts that could be used to
purchase stocks and bonds. The recent downturn in the stock
market has made this proposal less attractive.
For Medicare, privatization has been proposed mostly through
the introduction of competing private health plans to substitute
for the current system of government funded, but privately
administered health care.36,37 Although proposals vary, most
would have the national government pay a fixed contribution
towards each individual’s health insurance premiums. People
who wanted a more generous health plan would pay the difference between the premium and the government contribution.
The assumption of this strategy is that competition will force
insurers to find ways to control costs while maintaining good
quality care. Opponents fear that health plans would compete
based on risk selection rather than efficiency or quality and that
the government contribution would not keep pace with costs
over time, shifting costs to older beneficiaries. They worry that
the net result would be a two-tiered system, in which wealthier
older people would have significantly better and different coverage than people who are financially less well off.
Similar to the strategy for acute care, conservatives and some
moderates are promoting private long-term care insurance as
a way of financing long-term care, hoping that it will reduce
dependence on public programmes, especially Medicaid. Most
research suggests that only a small fraction of the elderly population can afford good quality policies and that the non-elderly
population is unwilling to voluntarily purchase insurance in
large numbers.16,38
Conclusion
The ageing of the population in the US will place substantial
additional economic burden on public programmes. Looking to
the future, a great deal will depend on the economy and the
political will to control health care costs and pay for these
programmes.
The economy
The economic forecasts have been complicated by tax cuts and
terrorism. President Bush’s tax cut, which was enacted in Spring
2001 and which will reduce government revenues by $2 trillion
over 10 years, has been criticized for not using the then projected
779
budget surplus to shore up public programmes for older people
and, indeed, for depriving the public sector of the funds that will
be needed in the future. Critics also contend that the tax cut will
disproportionately benefit upper-income individuals. On the
other hand, at the time of passage, supporters of the tax cut
asserted that President Bush’s plan would help these programmes by paying off a substantial portion of the public debt
(although not as much as proposed by the critics of the tax cut)
and by preventing the surplus from being spent on other public
programmes.
The terrorist attacks of 11 September 2001 have had at least
two economic consequences. First, they have exacerbated the
economic downturn of 2001 and called into question the rate
of economic growth for the future. Second, it has stimulated
substantial additional government expenditures for domestic
and foreign anti-terrorism activities, precluding government
spending for social programmes and for public debt reduction.
Thus, the vast budget surplus on which the tax cut was premised
is now called into question or is being used for purposes other
than programmes for older people. At the time of writing this
paper (October 2001) the Bush Administration and Congress
seem unwilling to repeal or postpone various elements of the
tax cut. Without the budget surplus, the reduction in public
debt, which was the main strategy for dealing with the ageing
of the population, is now doubtful.
Importance of political decision-making
The ageing of the population will almost certainly impose additional fiscal burdens on the public sector in the US, especially
for health and long-term care. However, health care costs and
their rate of growth depend only partly on demographic forces;
they depend much more on political decision-making. The US
spends more on medical care as a share of GDP than any other
country, in part because it provides more high technology
services but mainly because American insurance funds pay
higher prices than are paid elsewhere. These higher costs mean
that each additional older person requires greater expenditure,
but that is not the direct consequence of an ageing society; it is
the consequence of a political system that creates high health
care costs.
Indeed, the empirical evidence suggests that there is surprisingly little relationship between ageing and national health
care costs, at least in the past. Examining data from 1960 to
1990, Marmour and Oberlander found no correlation across
Organization for Economic Co-operation and Development
nations between ageing populations and growth in medical
costs.39 Analysing eight industrialized countries for the period
1993–1995, Anderson and Hussey found very little correlation
between the percentage of the population that is elderly and
the percentage of GDP spent on health care.1 Gruber and Wise
report that from 1980 to 1991, there was a relatively small
positive relationship between changes in the elderly share of the
population and changes in national health spending.40 The
likely reason is that other policy factors, namely the design of
cost control policies, have been far more important.
The other political dimension is that the ‘affordability’ of any
government programme depends not just on its costs but on the
nation’s willingness to contribute to the support of government
programmes and the extent of other spending obligations.41 As
a political matter, whether any given programme can survive
780
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
fiscal stress depends on its relative popularity.42 On this matter,
there is no doubt: Social Security and Medicare are by far the
most popular domestic social programmes; long-term care is not
as favoured, but still ranks highly. For example, in a poll conducted before passage of the tax cut of 2001, 65% of respondents indicated support for using the projected budget surplus to
preserve Social Security and Medicare or pay off the public debt;
only 18% wanted to cut taxes.43 Voters of all ages, not just older
people, have repeatedly indicated their unwillingness to reduce
benefits or eligibility for these programmes. The often predicted
generational conflict has yet to appear. Whether that will continue to be true in the future will probably be the most important determinant of the economic burden of ageing programmes.
18 Board of Trustees. 1997 Annual Report of the Board of Trustees of the
Federal Hospital Insurance Trust Fund. Baltimore, MD: Health Care
Financing Administration, 2001.
19 Board of Trustees. 2000 Annual Report of the Board of Trustees of the
Federal Hospital Insurance Trust Fund. Baltimore, MD: Health Care
Financing Administration, 2000.
20 Manton KG, Gu X. Changes in the prevalence of chronic disability in
the United States black and non-black population above age 65 from
1982 to 1999. Proc Nat Acad Sci 2001;98:6354–59.
21 Freedman VA, Martin LG. Understanding trends in functional limita-
tions among older Americans. Am J Public Health 1998;88:1457–62.
22 Freedman VA, Martin LG. Contribution of chronic conditions to
aggregate changes in old-age functioning. Am J Public Health 2000;90:
1755–60.
23 Liao Y, McGee DL, Cao G, Cooper RS. Recent changes in the health
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