AARP Public Policy Institute INSIGHT on the Issues The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers Donald Redfoot, Lynn Feinberg, and Ari Houser AARP Public Policy Institute The majority of long-term services and supports are provided by family members. But the supply of family caregivers is unlikely to keep pace with future demand.  The following report defines a “caregiver support ratio” as the number of potential caregivers aged 45–64 for each person aged 80 and older. The report uses this support ratio to estimate the availability of family caregivers during the next few decades.  In 2010, the caregiver support ratio was more than 7 potential caregivers for every person in the high-risk years of 80-plus.  By 2030, the ratio is projected to decline sharply to 4 to 1; and it is expected to further fall to less than 3 to 1 in 2050, when all boomers will be in the high-risk years of late life. Understanding the effects of the relative adult children) to arrange, coordinate, size of the baby boom (those born and provide LTSS is expected to decline between 1946 and 1964), compared to dramatically and overall care burdens preceding and succeeding age cohorts, is will likely intensify—especially as baby essential to anticipating the demand for boomers move into late old age. long-term services and supports (LTSS) for this cohort and the potential Family Caregivers: The Backbone availability of family caregivers. of Long-Term Services and Tracking the availability of potential Supports caregivers provides a roadmap of the magnitude and timing of the challenges Family caregivers—including family that we will face in the next few members, partners, or close friends 1— decades, as the caregiver gap widens. are a key factor in the ability to remain in one’s home and in the community People aged 80 years and older are the when disability strikes. More than two- most likely to need LTSS. As the thirds (68 percent) of Americans believe population in this age group increases that they will be able to rely on their during the next 20 years, the number of families to meet their LTSS needs when people in the primary caregiving years they require help, 2 but this belief may (ages 45–64) is projected to remain flat, collide with the reality of dramatically due in part to changing family size and shrinking availability of family composition. As a result, the availability caregivers. of potential family caregivers (mostly The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers If fewer family members are available to More than 8 in 10 are caring for a relative provide everyday assistance to the or friend aged 50 or older. 4 growing numbers of frail older people, more people are likely to need Cohort size also affects the availability institutional care—at great personal of paid direct care workers, such as cost—as well as costs to health care and nurse aides, home health aides, and LTSS programs. Greater reliance on personal and home care aides. Paid fewer family caregivers to provide caregivers often provide essential, home- and community-based services hands-on help to family caregivers could also add to costs borne by family struggling to provide good care to loved members and close friends—in the form ones. More than half (57 percent) of of increasing emotional and physical home health aides are aged 45 and strain, competing demands of work and older. 5 Direct care workers who are self- caregiving, and financial hardships. employed or working directly for private households are, on average, 48 years In recent years, the role of family old. 6 caregivers has greatly expanded from coordinating and providing personal care We used ages 80 and older as our and household chores to include medical measure of the risk of needing LTSS. or nursing tasks (such as wound care and Seven in 10 (70.5 percent) people aged administering injections). These difficult 80 and older had some kind of nursing tasks were provided in hospitals disability in 2010, compared to one in and nursing homes and by home care five (19.7 percent) people aged 45–54. 7 providers, but increasingly, family More than half (55.8 percent) of people members are called on to perform these aged 80 and older have a severe tasks with little training or professional disability, and nearly one in three support. 3 As health care and LTSS shift (30.2 percent) need assistance from from institutional to home-based care, others with one or more activities of the burdens on family caregivers will daily living (ADLs), such as bathing, likely increase without adequate dressing, or using the toilet, or supportive services for caregiving instrumental activities of daily living families. (IADLs), such as using the telephone, preparing meals, or paying bills. 8 Measuring the Future Availability This Insight on the Issues uses data from of Family Caregivers Regional Economic Models, Inc. (REMI) to calculate a national caregiver One basic measure of the potential support ratio as well as caregiver support availability of caregivers is the ratio of ratios for each state by dividing the the number of people in the most population aged 45–64 by the population common caregiving age range divided by aged 80 and older. The REMI model the number of older people most at risk of uses historical data for 1990 through needing LTSS. To calculate this ratio, we 2010, and the model’s most current used the ages of 45–64 as the most population projections are used to common age range for caregivers. The calculate the ratios from 2011 to 2050. A “average” family caregiver is a 49-year- brief summary of the assumptions of the old woman who works outside the home projections can be found in Appendix A. and spends about 20 hours per week See Appendix B for national and state providing unpaid care to her mother for historical and projected caregiver nearly 5 years. Nearly two-thirds of support ratios. family caregivers are female (65 percent). 2 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers Caregiver Support Ratios Are 1990–2010 Projected to Decline Dramatically Despite large increases in the oldest as Boomers Transition from population, the caregiver support Caregivers to Care Recipients ratio increased slightly as boomers The following discussion of findings is boosted family caregiving. organized by 20-year periods, each of Despite the attention given to the graying which is characterized by distinctive of the baby boomers and their potential trends (see Figure 1). Each section looks future effect on health care and LTSS, at the implications of changes in the little attention has been paid to the role caregiver ratio and other drivers of that boomers have already played and are change in LTSS demand, to anticipate still playing as caregivers for their aging the challenges we will face as a nation to parents. From 1990 to 2010, the 80-plus meet that demand. population increased by 62 percent, but the number of potential caregivers aged  The period from 1990 to 2010 was 45–64 increased more rapidly—by marked by boomers aging into the 77 percent—as boomers aged into the prime caregiving years, with the peak caregiving years (see Figure 2). result that the caregiver ratio was high and increasing. As a result, the number of potential  The period from 2010 to 2030 will caregivers for every person aged 80- be a period of transition as boomers plus increased from 6.6 in 1990 to 7.2 age into old age and the caregiver in 2010, the year in which the caregiver ratio declines—especially when the ages of 45–64 corresponded to the ages oldest boomers begin to reach age 80 of the baby boomers. in the 2020s. Research has demonstrated the critical  The period from 2030 to 2050 will importance of family support in include all remaining boomers aging maintaining independence and reducing into the high-risk years of 80-plus, nursing home use among older people and the caregiver ratio is expected to with disabilities.9 The increasing continue to drift downward. caregiver support ratio, declining rate of Figure 1 Caregiver Support Ratio, United States 8.0 7.0 6.0 Boomers turn 45 5.0 Boomers turn 65 Boomers turn 80 4.0 3.0 2.0 1.0 0.0 1990 2000 2010 2020 2030 2040 2050 Source: AARP Public Policy Institute calculations based on REMI (Regional Economic Models, Inc.) 2013 baseline demographic projections. Note: The caregiver support ratio is the ratio of the population aged 45–64 to the population aged 80-plus. 3 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers Figure 2 Projected Age 45–64 Population, U.S. (millions) 120 100 Boomers turn 45 80 Boomers turn 65 60 40 20 0 1990 2000 2010 2020 2030 2040 2050 Source: AARP Public Policy Institute calculations based on REMI (Regional Economic Models, Inc.) 2013 baseline demographic projections. widowhood (due, in large part, to the of disabilities who live in the community narrowing longevity gap between men suggest that such support has been a and women), along with socioeconomic critical factor in the dramatic decline of improvements and declines in institutionalization and Medicaid use disability, 10 have been major factors in during the past couple of decades. 14 favorable trends in the use of LTSS during the 1990s and 2000s. Between Trends varied somewhat from state to 1984 and 2004, institutional use declined state, but generally exhibited favorably by 37 percent among the older high caregiver support ratios. The ratio population, as the number of older increased or stayed the same in 39 states people living in the community with two and the District of Columbia, and or more needs for assistance with ADLs increased by 1.0 or more potential rose by two-thirds. 11 caregivers per person aged 80-plus in 21 states. The caregiver ratio decreased These trends have had major in the other 11 states, but only 3 states implications for public programs that with high ratios to start with (Alaska, provide LTSS assistance. Medicaid costs Hawaii, and Nevada) saw declines of for institutional care would have been an more than 0.5 caregivers for each person estimated $24 billion higher in 2004 had aged 80-plus (see Appendix B). utilization rates remained unchanged after 1984. 12 By 2010, the number of The increase in the caregiver support older people who received Medicaid ratio reflects fertility patterns among the assistance for nursing home services had cohorts who aged into the 80-plus range declined by 26 percent from its peak in between 1990 and 2010. The cohort who 1995, which translates into savings of turned 80 years old in 1990 came into tens of billions of dollars per year. 13 adulthood as the Great Depression of the 1930s struck. Because it was not a While it is impossible to document the favorable time for family formation or exact portion of these savings that is due childbearing, nearly one in four to family caregiving, the high rates of (24.2 percent) women aged 80–84 in family support among the growing 1990 never had any children. By 2010, number of older people with high levels the percentage of women aged 80–84 4 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers who were childless had dropped by more 2010–2030 than half to 11.6 percent, as women who The caregiver support ratio is expected had come into adulthood in the post– to plummet as boomers transition from World War II years gave birth to the caregivers into old age. baby boom. The average number of children borne by women aged 80–84 The decades of the 2010s and 2020s will increased from 2.3 in 1990 to 3.1 in be a period of transition, as boomers age 2010. 15 out of the peak caregiving years and the oldest boomers age into the 80-plus The most important predictor of having high-risk years. someone to count on when an individual needs help in LTSS is being married, The departure of the boomers from the because spouses and adult children most peak caregiving years will mean that the often arrange, coordinate, and provide care population aged 45–64 is projected to and social support. Spousal support has increase by only 1 percent between 2010 increased as the rates of widowhood and 2030. During the same period, the declined dramatically during the 1990s 80-plus population is projected to and 2000s. In 1990, 8 out of 10 women increase by a whopping 79 percent. (81 percent) aged 85-plus were widowed—a rate that declined to The number of potential caregivers per 73 percent among women aged 85-plus in person aged 80-plus is expected to decline 2010. Among women aged 75–84, the fairly slowly during the 2010s—from 7.2 decline was even sharper—from to 6.1 by 2020—as the declining numbers 65 percent to 46 percent. of boomers in the prime caregiver ages will be offset somewhat by the relatively Among men aged 85-plus, the small cohorts turning 80-plus who were widowhood rate declined from born during the birth dearth of the Great 40.5 percent to 36 percent; the rate Depression. But the pace of the decline is declined from 21 percent to 14 percent expected to accelerate during the 2020s— among those aged 75–84. 16 from 6.1 to 4.1 in 2030—especially when the oldest boomers start turning 80 years old in 2026 (see Figure 3). Figure 3 Projected Age 80+ Population, U.S. (millions) 40 35 Boomers turn 80 30 25 20 15 10 5 0 1990 2000 2010 2020 2030 2040 2050 Source: AARP Public Policy Institute calculations based on REMI (Regional Economic Models, Inc.) 2013 baseline demographic projections. 5 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers In all states, the projected ratio of percentage of frail older people who have potential caregivers to people aged 80 only one or two adult children is projected and older will decline between 2010 and to increase from 38 to 49 percent. 21 2030 (see Appendix B). Sixteen states are projected to experience declines of These numbers suggest that the 50 percent or more in the caregiver ratio increasing frail older population will by 2030. have fewer potential family caregivers on whom they can rely. The declining caregiver ratio once again reflects changes in the fertility rates of 2030–2050 successive cohorts. Only 11.6 percent of The caregiver ratio is expected to the women who were 80–84 years old in decline further as boomers complete 2010 were childless, but that will the transition to the high-risk years of increase to 16.0 percent for those who 80 and older. are 80–84 years old in 2030. 17 The average number of children has declined Meeting the LTSS needs of the baby from 3.1 among women aged 80–84 in boom has been called “the 2030 2010 to 2.0 among women who will be problem,” 22 because of the large in that age group in 2030. number of boomers who are entering late old age at that time. The steep Further declines in widowhood are likely to decline in the caregiver support ratio be offset by increases in divorce for future that accelerated in the 2020s will cohorts of older women and men. As a continue through the 2030s, as boomers result, the percentage of women who are cascade over the 80-year-old threshold. projected to spend 10 years or more The 80-plus population is projected to unmarried after age 65 will decrease only increase by 44 percent between 2030 slightly, from 64 percent (among the cohort and 2040, while the number of of women who will be 80–89 years old in caregivers aged 45–64 is projected to 2010) to 60 percent (among women who increase only 10 percent. In the 2040s, are that age in 2030). This percentage will the ratio is expected to begin to bottom remain fairly constant among succeeding out, as the population aged 80-plus is cohorts. Among men in these age cohorts, projected to increase 17 percent and the the percentage who are projected to spend aged 45–64 population increases 10 years or more unmarried will increase 8 percent. substantially, from 29 to 36 percent.18 The caregiver ratio is projected to The impact of these demographic changes decrease from 4.1 to 2.9 between 2030 will be further complicated by recent data and 2050, when all boomers will enter the that indicate the declines in disability rates high-risk years of late old age. Once may have stalled and even reversed among again, all 50 states and the District of the young old and pre-retirees, largely Columbia are expected to experience because of increases in obesity. 19 The further declines in the caregiver support implications of these trends can be ratio (see Appendix B). observed in projections of future demand for LTSS. The number of “frail older The percentage of women who remain people” (those aged 65-plus with any childless is projected to increase from disability) is projected to increase from 16.0 percent, among those aged 80–84 in 11 million in 2010 to 18 million in 2030. 20 2030, to 18.8 percent of those of the The percentage of frail older people who same age in 2050, and the average are childless is projected to rise from 14 to number of children will decrease 18 percent during this period, and the slightly, from 2.0 to 1.9. 23 Projecting 6 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers marital status that far into the future is The supply of family caregivers is difficult, but the increased rates of unlikely to keep pace with demand to divorce after age 50 suggest less marital assist the growing number of frail stability in old age among boomers. The older people in the future. In just divorce rates of people aged 50 and 13 years, as the baby boomers age older doubled between 1990 and 2010, into their 80s, the decline in the especially among boomer cohorts. 24 caregiver support ratio will shift from a slow decline to a free fall. One in three baby boomers are currently unmarried, an increase of 50 percent From 7 potential caregivers per frail since 1980. 25 Boomers are a substantial older person today, the caregiver ratio is part of the 1.2 million people aged 65 or projected to shrink to just 4 in 2030. The older who will live alone and will have care gap is expected to widen even more no living children or siblings in 2020, up as the ratio continues declining to 2.9 by from 682,000 in 1990. 26 Childlessness 2050, when we have three times as many among the older population with people aged 80 and older as there are disabilities is projected to increase to today. These national trends will be 21 percent in 2040, and another reflected in major declines in the 49 percent will have only one or two caregiver support ratio in all 50 states children. 27 and the District of Columbia. Rising demand and shrinking families to Conclusion provide support suggest that the United Demography is not destiny28—the policy States needs a comprehensive person- decisions we make during the next and family-centered LTSS policy that decade will make a big difference in our would better serve the needs of older ability to meet the challenges associated persons with disabilities, support family with the aging of the baby boom. But and friends in their caregiving roles, and demographic trends certainly define the promote greater efficiencies in public challenges we will face and establish the spending. The challenges that face us are magnitude of the solutions that will be real, but they are not insurmountable—if needed. The year 2010 was a watershed, we begin now to lay the foundation for a as the caregiver support ratio climaxed better system of LTSS and family and began a long, steep decline that will support for the future. define the demand for LTSS for older people for decades to come. 7 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers Appendix A. Methodology We used data from Regional Economic among the states in the same proportion Models, Inc. (REMI) PI+ v1.4 model to as the last historical year. Interstate calculate a national caregiver support ratio migration is a calculation of the model as well as caregiver support ratios for each and is responsive to macroeconomic state (see Appendix B), by dividing the conditions and historical interstate population aged 45–64 by the population migration data. Additional detail on the aged 80 and older. The REMI model uses methodology is available at historical data for 1990 through 2010, and http://www.remi.com. projects demographic and economic conditions from 2011 to 2060. The table in Appendix B below gives historical (1990 and 2010) and projected The demographic projection component (2030 and 2050) caregiver support ratios of the REMI model incorporates birth for each state and the nation as a whole. and survival rates by sex, race, age, and One may observe that the state-to-state state. It also includes international and variation is much higher in the historical interstate migration by sex, race, age, years than in the projected years. This is and state. to be expected, as the projections represent a “middle case” based on Birth and survival rates are calculated by assumptions that are uniform across taking the changes in birth and survival states. The moderating influence of rates from the Census Population many years of such projections reduces Projection Assumptions file (national interstate variance in the projected ratio. data only). These changes are applied to In actuality, states are likely to deviate the last historical year birth and survival from the baseline projection in rates by sex, race, age, and state to form unpredictable ways; because of this, it is the forecasted state-level rates. not recommended to draw comparative inferences for the small differences in The international migration projections caregiver support ratios among states in by race for the country (also from the 2030 or 2050. census assumptions file) are divided 8 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers Appendix B. Caregiver Support Ratios by State, 1990–2050 Support Ratio, by Year State 1990 2010 2030 2050 United States 6.6 7.2 4.1 2.9 Alabama 6.8 7.8 3.9 3.2 Alaska 26.2 18.3 5.3 3.1 Arizona 6.8 7.0 2.6 1.8 Arkansas 5.6 7.0 3.9 3.2 California 7.6 7.7 4.4 2.7 Colorado 8.0 9.3 4.5 2.7 Connecticut 6.4 6.3 3.9 2.8 Delaware 7.9 7.4 3.5 2.8 District of Columbia 6.6 7.0 6.4 4.0 Florida 4.9 5.5 2.9 2.3 Georgia 8.5 10.1 4.8 3.1 Hawaii 8.7 6.1 2.9 2.1 Idaho 6.5 7.6 4.0 3.0 Illinois 6.5 7.1 4.9 3.3 Indiana 6.6 7.2 4.3 3.2 Iowa 4.6 5.6 3.3 2.3 Kansas 4.9 6.3 3.8 2.7 Kentucky 6.7 8.0 4.1 3.1 Louisiana 7.4 8.3 4.4 3.4 Maine 5.9 6.9 3.4 3.0 Maryland 8.6 8.1 4.2 2.8 Massachusetts 5.6 6.4 4.4 3.2 Michigan 7.3 7.0 4.1 3.3 Minnesota 5.4 6.9 4.3 2.7 Mississippi 6.2 8.0 4.1 3.3 Missouri 5.4 6.9 3.8 2.9 Montana 6.2 7.1 3.5 2.9 Nebraska 4.6 6.1 4.1 2.8 Nevada 12.4 10.0 3.4 2.0 New Hampshire 6.8 8.1 3.8 2.9 New Jersey 7.1 6.8 4.3 2.9 New Mexico 8.0 8.0 3.2 2.5 New York 6.5 6.6 4.8 3.5 North Carolina 7.7 8.0 3.9 2.7 North Dakota 4.5 5.5 4.2 3.0 Ohio 6.8 6.7 4.0 3.3 Oklahoma 5.8 7.4 3.8 3.1 9 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers Support Ratio, by Year State 1990 2010 2030 2050 Oregon 6.0 6.9 3.9 2.8 Pennsylvania 6.0 5.8 3.9 3.3 Rhode Island 5.3 5.7 3.9 3.0 South Carolina 8.6 8.3 3.6 2.9 South Dakota 4.4 5.8 3.9 2.9 Tennessee 6.9 8.1 4.1 3.2 Texas 7.6 9.2 4.8 3.0 Utah 7.6 8.3 5.8 3.4 Vermont 6.3 7.5 3.4 2.9 Virginia 8.4 8.5 4.2 2.8 Washington 6.9 7.9 4.4 2.8 West Virginia 6.2 6.8 3.4 3.1 Wisconsin 5.5 6.7 4.0 2.9 Wyoming 7.8 8.7 3.9 2.6 Source: AARP Public Policy Institute calculations based on REMI (Regional Economic Models, Inc.) 2013 baseline demographic projections. Note: Data for 1990 and 2010 are historical; data for 2030 and 2050 are projected. Because of the uncertainty inherent in any model-based long-term population projections, we do not recommend comparing states for 2030 or 2050. 10 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers Endnotes 1 The term family caregiver is broadly defined and refers to any relative, partner, friend, or neighbor who has a significant relationship with, and who provides a broad range of assistance for, an older person or an adult with chronic or disabling conditions. 2 T. Thompson et al., Long-Term Care: Perceptions, Experiences, and Attitudes among Americans Age 40 or Older (Chicago, IL: The Associated Press-NORC Center for Public Affairs Research, 2013). Accessed at http://www.apnorc.org/PDFs/Long%20Term%20Care/AP_NORC_Long%20Term%20Care%20Perception_ FINAL%20REPORT.pdf. 3 S. C. Reinhard, C. Levine, and S. Samis, Home Alone: Family Caregivers Providing Complex Chronic Care (Washington, DC: AARP; New York, NY: United Hospital Fund, October 2012). Funded by The John A. Hartford Foundation. 4 National Alliance for Caregiving (NAC) and AARP, Caregiving in the U.S. 2009 (Bethesda, MD: NAC [National Alliance for Caregiving]; Washington, DC: AARP, November 2009). Funded by the MetLife Foundation. 5 G. Khatutsky et al., Understanding Direct Care Workers: A Snapshot of Two of America’s Most Important Jobs (Washington, DC: Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, March 2011). 6 PHI (Paraprofessional Healthcare Institute), Who Are Direct-care Workers? Facts 3 (New York, NY: PHI, February 2011 Update). 7 M. W. Bault, Americans with Disabilities: 2010 (Washington, DC: U.S. Census Bureau, U.S. Department of Commerce, July 2012). 8 Ibid. 9 C. Noel-Miller, “Spousal Loss, Children, and the Risk of Nursing Home Admission,” Journal of Gerontology 65B(3) (2010) pp. 270–280. See also D. Lakdawalla and T. Philipson, “Aging and the Growth of Long-Term Care,” Working Paper No. 6980 (Washington, DC: National Bureau for Economic Research, 1999). 10 D. Redfoot and A. Houser, More Older People with Disabilities Living in the Community: Trends from the National Long-Term Care Survey, 1984–2004, AARP Public Policy Institute Report No. 2010-08 (Washington, DC: AARP, September 2010). For the most recent update on disability trends among the very old, see also V. Freeman, B. Spillman, P. Andreski, J. Cornman, E. Crimmins, E. Kramarow, J. Lubitz, L. Martin, S. Merkin, R. Shoeni, T. Seeman, and T. Waidman, “Trends in Late Life Activity Limitations in the United States, An Update from Five National Surveys,” Demography, Vol. 50, Issue 2 (April 2013), pp. 661–671. 11 Ibid. 12 Ibid. 13 D. L. Redfoot, The Good News about Medicaid Costs and an Aging Population (June 28, 2013). AARP Public Policy Institute blog: http://blog.aarp.org/2013/06/28/the-good-news-about-medicaid-costs-and-an- aging-population/. 14 A. Houser, M. J. Gibson, and D. L. Redfoot, Trends in Family Caregiving and Paid Home Care for Older Persons with Disabilities in the Community: Data from the National Long-Term Care Survey, AARP Public Policy Institute Report No. 2010-09 (Washington, DC: AARP, September 2010). 15 D. L. Redfoot and S. M. Pandya, Before the Boom: Trends in Long-Term Supportive Services for Older Americans with Disabilities, AARP Public Policy Institute Report No. 2002-15 (Washington, DC: AARP, 2002). On cohort fertility rate comparisons, see also S. E. Kirmeyer and B. E. Hamilton, “Childbearing Differences among Three Generations of U.S. Women,” NHCS Brief No. 68 (Washington, DC: National Center for Health Statistics, August 2011). 16 Ibid. Updated with data from the U.S. Census Population data for 2010. 11 The Aging of the Baby Boom and the Growing Care Gap: A Look at Future Declines in the Availability of Family Caregivers 17 Redfoot and Pandya, op cit. 18 R. Johnson, “Private Resources and the Financing of Long-Term Care,” presentation to the Institute of Medicine Forum on Aging, Disability, and Independence, June 12, 2013. 19 See Freeman et al., op cit. See also D. Lakdawalla, D. Goldman, J. Bhattacharya, M. Hurd, G. Joyce, and C. Panis, “Forecasting the Nursing Home Population,” Medical Care 41(1) (2003), pp. 8–20. INSIGHT on the Issues 20 These projections are from the Urban Institute’s DYNASIM3 model. See M. M. Faureault and K. E. Smith, A Primer on the Dynamic Stimulation of Income Model, DYNASIM3 (Washington, DC: Urban Institute, 2004). Accessed at http://www.urban.org/UploadedPDF/410961_Dynasim3Primer.pdf. 21 R. W. Johnson, D. Toohey, and J. M. Weiner, Meeting the Long-Term Care Needs of the Baby Boomers: How Changing Families Will Affect Paid Helpers and Institutions (Washington, DC: The Urban Institute, May 2007). 22 J. R. Knickman and E. K. Snell, “The 2030 Problem: Care for Aging Baby Boomers,” Health Services Research 37(4) (2002), pp. 849–884. 23 Redfoot and Pandya, op cit., updated with data from the U.S. Census fertility tables at http://www.census.gov/hhes/fertility/data/cps/2010.html. 24 S. L. Brown and I-Fen Lin, “The Gray Divorce Revolution: Rising Divorce among Middle-aged and Older Adults, 1990–2010,” Journals of Gerontology Series B: Psychological Sciences and Social Sciences 67(6) (2012), pp. 731–741. 25 I. Fen-Lin and S. L. Brown, “Unmarried Boomers Confront Old Age: A National Portrait,” The Gerontologist 52(2) (2012), pp. 153–165. 26 R. Stone, Long-Term Care: Coming of Age in the 21st Century, Wisconsin Family Impact Seminars (1999). Accessed at http://www.familyimpactseminars.org/s_wifis12c01.pdf. 27 Johnson et al., op cit. 28 Insight on the Issues 85, August 2013 R. Friedland and L. Summer, Demography Is Not Destiny (Washington, DC: National Academy on an Aging Society, January 1999). AARP Public Policy Institute, 601 E Street, NW, Washington, DC 20049 www.aarp.org/ppi. 202-434-3910, ppi@aarp.org © 2013, AARP. Reprinting with permission only. 12