Will you still need me, will you still feed me, when I'm 64?"
The Beatles may or may not have been thinking about nursing homes and the like when they posed that question to their youthful listeners in 1967. And the American baby boomers, who were among those listeners, certainly won't be thinking they're old until long past age 64. Try 94. Or maybe 104.
For the boomer generation, the answer to the question of long-term care might be blowing in the winds of demographic change.
While most baby boomers will still be too young to need long-term care as early as 2020, many will probably be thinking about it. And when they do, the long-term-care options available to them may look very different from those available today.
"I would hope there are a lot of options and choices for people, more so than there are today," says Robyn Stone, whose job as executive director of the Institute for Policy Research at the American Association of Homes and Services for the Aging is to look at the future of long-term-care services.
Assisted-living facilities are likely to serve all but the most critically ill residents. As in other sectors, technology is likely to play a bigger role in the future in providing care: telemedical "home health" visits could replace live nurses; robots could roam the floors of facilities helping with tasks such as turning and bathing bed-bound patients .
But perhaps the biggest change will be the sheer growth of the market and the boutiquing of services that target specific populations.
Imagine a company that provides respite care to Latino families, who in general prefer taking care of their own. When stress on family members gets too much, an aging mother could be entrusted for a week or two to a Spanish-speaking care team and a cook who knows how to make a decent tamale.
As any demographer will tell you, the U.S. population is changing dramatically. The population will become both older and more ethnically and racially diverse during the next two decades and beyond.
Minorities won't be as old, on average, as whites, because of a combination of immigration, higher fertility and lower life expectancy. But poorer health may mean they need more services. Toni Miles, a family practice professor at the Health Sciences Center at the University of Texas at San Antonio, says that today minorities are more likely to "hit the age of 65 with the physiology of an 85-year-old." While the long-term-care industry in 1999 can get by with few minority-targeted services, some experts say change is on the way.
Changes by the numbers
Demographics in large part has long determined the business of long-term care. With more elderly people, demands for services will grow. Many of the boomers who will be elderly in a few decades are accustomed to a market that caters to their needs, and the narrow range of options that is tolerated today is not likely to be as acceptable to them.
With greater numbers of minority elders, long-term-care enterprises will have to start paying more attention to the cultural, culinary and linguistic needs of specific minorities. Such change is already taking place on a small scale in some corners of the country.
Of course, much more than demographics will influence how long-term care develops. New technology will allow people with health conditions that now require institutional care to be treated in their own homes. Advances in medicine will make the elderly stronger and healthier, giving them a better chance against heart disease and cancer, currently the top two killers of people over age 65.
Such advances could actually increase demand for long-term care, as the number of those living with, rather than dying from, such diseases increases. On the other hand, the cumulative effects of better diets and more exercise may prevent or delay onset of such diseases.
Access to care for the elderly could also be affected if the use of private long-term-care insurance picks up speed. But so far that market has been sluggish, and some experts think that even the availability of tax incentives wouldn't prompt the young and healthy to buy it.
But of the many factors that will influence the future of long-term care, population shifts are crucial.
In 2020, the Census Bureau projects that 16.5% of the nation's population will be over 65, compared with 12.7% in 1999. The median age will also rise to 37.6 from 35.5 estimated for this year.
These national figures mask the likelihood that demographic change will affect different parts of the country unevenly. The speed of industry response may depend greatly on location.
Twenty years from now, the population's age will vary greatly on region and race, although all regions and races are expected to be older. In Florida, for instance, 26.3% of the population is expected to be 65 or older in 2025, the year for which the Census Bureau has published state-specific projections. That compares with 18.6% in 1995. Both proportions are the highest in the nation. By contrast, 13% of California's population will be elderly in 2025, only slightly more than the 11% estimated in 1995.
Racially, too, the picture looks different. Whites in 2020 will be the oldest group, with a median age of 41.8, compared with today's 38. Hispanics will be younger, at 28.1 years, but still older than today's median of 26.4.
While their aggregate numbers may be dwarfed by those of the majority population even in 2020, the needs of minority elders are likely to drive industry change. That's because many minorities, particularly African-Americans, already have much higher rates of chronic illnesses, including diabetes and high blood pressure.
Minorities often don't receive adequate treatment for their chronic diseases, Miles says, because of a combination of economics and lack of access. Minorities are also often subject to health hazards that go with jobs on the lower-end of the pay scale -- including the frequent occupational injuries by workers in menial jobs and those that involve hard labor.
All of this may make minorities more likely to need long-term care earlier in their lives than their white counterparts.
Across all races, longevity and health status are likely to improve, researchers say. In fact, mortality statistics have been improving steadily since early this century. And recent reports from the Centers for Disease Control and Prevention show bounding gains in life expectancy, especially for African-Americans.
In 1967, when the Beatles recorded their ode to old age, 64-year-old American women could expect to live about 16 more years, and 64-year-old men could expect to live an additional 13. By 1996, 64-year-old women had added three more years to their expected life spans, and men had added another two and a half years.
African-Americans born today, with 70.2 years of expected life, will still be outlived by whites, who have 76.8 years of expected life. But the gap has narrowed since 1970, the first year for which life expectancy for blacks was tracked separately. Then, whites could have expected to live to 71.7 years, and blacks to 64.1. Researchers have no doubts that life spans will continue to increase in the coming decades.
Fewer on the disabled list
The elderly are also less likely to be disabled than in years past.
A study published in 1997 by a group of Duke University researchers found that disability rates among the elderly declined dramatically from 1982 to 1994. They suggested better nutrition, improved public sanitation, lower levels of smoking and higher levels of education all contributed to the improvements.
Disability rates fell faster in more recent years, the analysis found, prompting many in the industry to speculate that the elderly in the 21st century might be much more mobile and self-reliant than those in similar age groups today.
In view of these expected trends, the Assisted Living Federation of America recently affiliated with the National Association of Senior Living Executives, a group that represents the independent-living industry.
Karen Wayne, ALFA's president, says that while "assisted living is still our primary focus as the cornerstone of long-term care . . . we need to look beyond what many would call long-term care" to keep people healthy and independent as long as possible.
By most accounts minorities are more likely to take care of elderly family members at home, and the long-term-care industry has been slow to target them as consumers.
Latinos, for instance, tend not to seek long-term-care services outside the family, says Michael Guerrero, policy director of the Washington-based National Hispanic Council on Aging. Guerrero says he is not aware of any long-term-care facilities that cater exclusively to Latinos today, although he says some may exist.
But even given Latinos' current preference for taking care of their own, Guerrero says there are always some elderly for whom families are unable to care.
Val Halmandaris, president of the National Association for Home Care, insists that "demography is destiny," his way of saying that home care, broadly defined, will grow at breakneck speed in the 21st century. Halmandaris also believes there will be a growing role for adult day care and respite care, both of which support families taking care of elderly relatives in the home.
The growth will benefit minorities by creating better access and better jobs. In 2020, he predicts, there will be "more employment opportunities for minorities (in home health) in ownership and management."
Although anecdotal information is the only kind available, minorities today provide much of the direct home health and other long-term care, but play only limited roles on the business side.
Stone agrees that consumer demand will create more options. Affordable housing with healthcare and other services may be one industry response to growing demand from less affluent elderly. Assisted living has until recently focused primarily on the well-to-do.
She also hopes for a greater role for home care. "Home health needs to become the norm, rather than the exception," she says.
She expects more public programs to allow recipients to make their own long-term-care choices. Some states already are experimenting with such systems today, she says. But Stone also envisions a schism among long-term-care services because of increasing economic disparity among racial and ethnic groups. Accordingly, services might be even less evenly divided among an increasingly diverse population.
While the recent booming economy has made it difficult for nursing homes to retain staff, a future downturn probably would reverse that trend. Stone says it is likely that minorities are more likely to serve in the long-term-care industry than be served by it.
As for public policy, Stone doesn't see any sweeping changes to overhaul the nation's fragmented long-term-care system. Instead, she predicts more private-sector solutions in response to the demands of demographics.
"I think we'll muddle through incrementally," she says.