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by Carol Raphael, President and Chief Executive Officer Visiting Nurse Service of New York
Presented at the New York Citizens' Committee on Aging November 13, 2002 Conference WOMEN AND AGING: ISSUES FOR LIFE
As women age, their socioeconomic status, health needs and role in caregiving influence how they access long-term care services. Yet the burdens in financing, accessing and delivering services fall on women. Better policies are needed to address the health care needs of aging women.
Long-term care today is a gender issue because of its disproportionate utilization by women. Key utilization statistics indicate that women make up two out of three physician visits, six of ten surgeries and comprise 75% of nursing home residents and 66% of home health care patients.1 Most have low incomes, are elderly and live alone. Of the 32 million elderly Americans, women comprise 59% of this group aged over 65, and 76% of those aged 85 and older.2 Life expectancy is also increasing. There are 3.5 million people who are 85 and older and that number is expected to double by 2020.3 In New York City alone, the number of residents over 85 increased by 19% in the last 10 years, and the average income of an elderly citizen is $10,450.4
As women age, their health care needs change and their risk of needing community and institutional long-term care increases. Women are more likely than men to have chronic conditions5 and in 2002, it cost $503 billion to treat the 125 million people who live with chronic illnesses.6 And despite the 1.5% annual decline in the prevalence of disability, it is estimated that 8.5 million elderly have functional disabilities; by 2030, this number is expected to double.7 At the Visiting Nurse Service of New York (VNSNY), for instance, 65% of the patients are women with an average age of 79. Thirty seven percent of patients have two or more chronic conditions, 22% have cognitive impairments and 49% have deficiencies in four to six Activities of Daily Living.8 Thus, an older, sicker population with multiple chronic conditions has significant health care needs.
Yet accessing health care services pose multiple burdens. First, long-term care funding streams do not adequately address health care needs. Financed primarily by public dollars, these funds are threatened by budget cuts. Despite the $134 billion spent on long-term care,9 comprehensive coverage is limited to the poor. The Medicare benefit has a short-term, post-acute focus and does not provide needed long-term supportive services. Similarly, while Medicaid financed 45% of long-term costs,10 its eligibility and benefits vary by state and are designed to help the indigent. Long-term health insurance, too, poses significant limitations because it is costly and is less utilized - it covered only 5% of the population in 1998.11
Second, the service delivery system, made up of multiple providers and sites, is hard to navigate. One in five elderly living in the community with long-term care needs reports an inability to obtain appropriate care.12 The system needs to better serve the client (i.e. the patient-family unit) by providing efficient, quality medical and non-medical assistance services.
Third, there are formal and informal workforce issues. Women are pivotal in the long-term care workforce making up over 95% of nurses and home health aides.13 Yet, by 2005 in New York, demand for nurses will exceed supply by 17,000; this gap will double by 2015.14 Paraprofessional shortages are expected to be in the range of 20% to 30% by 2010.15 Similarly, the "informal workforce" 27 million family caregivers (of which 75% are women) provide $257 billion in unpaid services.16 They, too, face burdens: 24% change their work status to deliver care, 54% have more than one chronic condition and 51% have high depressive symptoms.17
How will these issues affect the future?
- Increasing health care needs will put a financial strain on women. Many will deplete their savings and risk pauperization to rely on Medicaid. High out-of-pocket expenditures may push 11% of Medicare beneficiaries into poverty.18
The inadequacies in long-term care will fall heavily on women. Female caregivers continue to fill gaps within the system by becoming coordinators of transitions and providers of direct care.
What can be done?
- Women need to work toward incremental change to obtain affordable long-term care policies and tax relief incentives. Change must also come by way of expansion of integrated community models that are focused on "supportive care" services.
- Women need to promote investing in "human capital" to lessen the workforce burdens.
- Enhanced support and education must be given to all caregivers.
- Society has not decided whether the long-term care burden is an individual or societal problem. This issue needs to be tracked as we determine and carry out appropriate solutions.
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1 Craine's Health Pulse. 2002
2 Administration on Aging. "Older Women Factsheet: 2002"
3 Heartland Institute, "Long-Term Care Legislation Introduced." April 2002.
4 Berkey-Gerard, Mark, "NYC's Elderly." GothamGazette.com. October 14, 2002.
5 AARP Public Policy Institute
6 Institute for Health and Aging, "Chronic Care in America: a 21st Century Challenge." 2001.
7 Implications for the 21st Century." Millbank Memorial Fund. August 2000.
8 VNSNY internal data, 2001.
9 JFK School of Government, Harvard University and the Commonwealth Fund, "In Pursuit of Long Term Care: Ensuring Access, Coverage and Quality." Bipartisan Congressional Health Policy Conference. January 17-19, 2002.
10 Kaiser Commission on Medicaid and the Uninsured, "Issue Paper February 2001."
11 JFK School of Government and the Commonwealth Fund
12 JFK School of Government and the Commonwealth Fund
13 American Hospital Association
14 New York State Board of Regents Blue Ribbon Task Force on the Future of Nursing, September 2001.
15 Paraprofessional Healthcare Institute, "Policy Brief: A Preventable Labor Crisis in Long Term Care."
16 National Family Caregiving Association's Family Caregiving Statistics for 2002.
17 Family Caregiving Alliance Clearinghouse, "Factsheet: Selected Caregiver Statistics."
18 Medicare Payment Advisory Commission, "Report to Congress: Assessing Medicare Benefits." June 2002.