LONG-TERM CARE AND WOMEN

Many older persons today are healthier, better educated, and wealthier than earlier generations. Still, a significant number of older persons are economically and physically vulnerable—especially older women.

Long-term care is, in essence, a women's issue. This is because it is predominantly women who need care and provide care. Women make up 75 percent of all nursing home residents age sixty-five and older. Two-thirds of consumers who receive home-care services are women, and nearly two out of three prescriptions are filled out for women. Women have a greater likelihood of suffering from illness or disability than men, and women are overwhelmingly the caregivers for relatives and friends who need assistance with daily activities in the home.

Several factors contribute to the increased vulnerability of women as they age. For one thing, women have a longer life expectancy than men, about seven years. Women who reached age sixty-five in the year 2000 could expect to live an average of nineteen more years, compared to thirteen years for men. Women make up 72 percent of the population age eighty-five and older. Because women live longer than men, nearly four out of five people age eighty-five and older who receive help for two or more disabling conditions are women.

Secondly, many older women live alone. This occurs because women often outlive their husbands, while their children live in different communities and their families are scattered. In 1998, nearly 60 percent of women age sixty-five and older were either widowed, divorced, or had never married, compared to 25 percent of older men. Widows in 1998 outnumbered widowers four to one (8.4 million widows, 2 million widowers.) Of the elderly widows, seven in ten lived alone.

An additional factor is that women often have lower incomes than men. Being able to live an independent life depends on having enough income to meet needs. Women age 65 and older are twice as likely to be poor as are older men. According to an AARP study on the impact that pay inequality and segregation in low-paying jobs have on the retirement income of women, "by the time women are in their fifties, they have spent fewer years working, have earned less over their lifetimes, and have held lower quality jobs than similar-aged men" (Mitchell et al.).

High costs of long-term care

Long-term care is costly. In 1999, the average annual cost of care in a nursing home was $56,000. Persons of moderate income and limited savings can exhaust their money if they pay out-of-pocket for nursing home care, and they then must turn to Medicaid, the federal-state program that pays for medical care for poor people. Medicaid covers the costs of nursing-home care for poor people or for people who become impoverished as a result of paying nursing-home bills.

In 1997, of the 1.5 million elderly nursing-home residents, about three-fourths were women with a mean age of eighty-five, according to data from the 1997 National Nursing Home Survey (see Gabrel, 2000). The survey reported that 38 percent of women nursing-home residents had Medicaid as their primary source of payment when they entered the nursing home, but the care of about 57 percent of women residents was paid for by Medicaid.

Senior housing called assisted living has rapidly become an alternative to nursing homes for people who need only assistance with daily activities like bathing and dressing, rather the skilled nursing and around-the-clock care of a nursing home. But assisted living can cost as much as $2,000 or $3,000 a month.

Home care can be very costly as well—the average cost of a home-care visit in 1998 was $77. Consider the situation of an eighty-two year-old woman who lives alone and fractures her hip. Medicare will pay for much of her hospital stay, but will pay for only a short stay in a nursing home if she needs rehabilitation before she can go home. At home, she might qualify for limited home health care, paid for by Medicare, but soon she will face paying out-of-pocket if she needs the help of a home-care aide to bathe and dress or to clean house and shop.

Women age sixty-five and older who are Medicare beneficiaries still face high out-of-pocket costs, averaging $2,520 a year in 1999— or about 20 percent of income, on average. This compares to $2,320 in out-of-pocket costs (17 percent of income) for older men.

Married women, who are more likely to outlive their husbands than vice versa, must also face the prospect that a couple's joint income could be severely depleted if a husband enters a nursing home, where costs can quickly eat up their income and savings. A wife will not be forced to sell their house to pay her husband's nursing home bills, however. In 1988, Congress enacted provisions, as part of the Medicaid law, that prevent a spouse from becoming impoverished when one member of a couple enters a nursing home. These provisions are known as spousal impoverishment protection. If a wife remains at home when her husband enters a nursing home, she is able to retain about half the family's assets, up to about $87,000 and up to about $2,175 a month of income (in 2001). The amounts are indexed each year for inflation.

Long-term care insurance may be an option to protect oneself against the high costs of long-term care services. However, long-term care insurance premiums increase with age and so must be initiated well before individuals may perceive a need for coverage. While a fifty-five year-old in the year 2000 might pay $1,500 a year for comprehensive benefits, a person who first purchases coverage at age seventy-five might pay $5,000 to $6,000 a year. In addition, even if she can afford a policy, an older woman with a pre-existing condition or disability may not be able to get coverage at all.

These numbers tell us that because of their longer lives and the high costs of care, older women face the prospect that an illness or a disabling condition can thrust them into difficult circumstances, or even into poverty. Their ability to continue living an independent life can thus be threatened. As they grow older, they are more likely to need long-term care services, and their ability to pay for such services becomes more uncertain.

The challenges of caregiving

More than seven out of ten unpaid caregivers are women. A 1996 national telephone survey conducted by the National Alliance for Caregiving and AARP showed the considerable burdens of caregiving on older women. The study reported that the average age of caregivers was forty-six, with about one in four caregivers being between fifty and sixty-four. More than one in ten of the caregivers was sixty-five or older.

Caregiving involves a range of activities, from helping a family member every day with bathing, dressing, and eating to providing transportation to a doctor or paying bills and handling other financial matters. Almost half of all the caregivers surveyed provided at least eight hours of care a week. Women caregivers made up almost four-fifths of the caregivers providing more than forty hours a week of care.

The future

Advances in public health and medical technology promise more productive and independent lives for all Americans in the future. Women, in particular, should benefit from potential breakthroughs in treating osteoporosis, arthritis, Alzheimer's disease, and stroke. However, these advances may well push the cost of health care and long-term care even higher, which could limit access to services for many women. It is clear that the future will continue to present major challenges to women to stay healthy and independent as they age, to find the resources to assist them if they need long-term care services, and to balance the demands of caregiving with their own needs.

Barbara J. Coleman

See also Caregiving, Informal; Economic Well-Being; Long-Term Care Financing; Long-Term Care Insurance; Medicaid-Medicare; Widowhood.

BIBLIOGRAPHY

Choudhury, S., and Leonesio, M. V. "Life-Cycle Aspects of Poverty Among Older Women." Social Security Bulletin 60, no. 2 (1997): 17–36.

Costello, C. B.; Miles, S.; and Stone, A. J., eds. The American Women: 1999–2000. New York: W. W. Norton & Company, 1998.

Gabrel, C. S. "Characteristics of Elderly Nursing Home Current Residents and Discharges: Data from the 1997 National Nursing Home Survey." Advance Data, no. 312. Hyattsville, Md.: National Center for Health Statistics, 2000.

Gibson, M. J., and Brangan, N. "Out-of-Pocket Spending on Health Care by Women Age 65 and Over in Fee-For-Service Medicare: 1998 Projections." In Public Policy Institute Fact Sheet (FS72). Washington, D.C.: AARP, 1998.

Gibson, M. J., and Foley, L. "FYI: Out-of-Pocket Spending on Prescription Drugs by Women and Men Age 65 and Older: 1999 Projections." In Public Policy Institute FYI. Washington, D.C.: AARP, 2000.

Mitchell, O.; Levine, P. B.; and Phillips, J. W. "The Impact of Pay Inequality, Occupational Segregation, and Lifetime Work Experience on the Retirement Income of Women and Minorities." Public Policy Institute Issue Paper (#9910). Washington, D.C.: AARP, 1999.

National Alliance for Caregiving/AARP. Family Caregiving in the U.S.: Findings from a National Survey. Washington, D.C.: NAC/AARP, 1997.

Smeeding, T. M.; Estes, C. L.; and Glasse, L. "Social Security Reform and Older Women: Improving the System." Income Security Policy Series Paper, no. 22. Syracuse, N.Y.: Syracuse University Center for Policy Research, 1999.

Spraggins, R. E. "Women in the United States: A Profile." Current Population Reports. Washington, D.C.: U.S. Bureau of the Census, 2000.

U.S. Bureau of the Census. "Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050." Current Population Reports, Series P-25, No. 1130. Washington, D.C.: U.S. Bureau of the Census, 1996.