In-Home Care for Frail Childless Adults

Brief #1 from The Retirement Project Discussion Paper series

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Introduction

Adult children are a crucial source of care for frail older Americans, especially for widowed and divorced people who cannot turn to spouses for help. Informal care options are limited for frail unmarried adults without children, however. Some may turn to friends, charitable organizations, or other family members for help. Others may purchase home care from paid providers. But some frail childless adults may receive inadequate care in the community or be pushed into nursing homes. Although most people with long-term care needs have children who can provide help, declining fertility rates will increase the number of frail childless Americans in coming decades. This article examines the receipt, amount, and source of care for frail older adults without children and compares their care to that received by older adults with children.

Unpaid and Paid Help

Most frail older adults live in the community, not in nursing homes, and rely on help from family and friends. In 2002, about 8.7 million Americans age 65 and older living at home reported disabilities, representing 27 percent of the older community-dwelling population (Johnson and Wiener 2006). About 6 percent, or 2 million, were severely disabled. By comparison, only about 1.5 million older people lived in nursing homes in 2002 (Spillman and Black 2006). About 3 in 5 frail older adults living at home received unpaid help from family or friends with personal care assistance or household chores and errands (Johnson and Wiener 2006). Adult children, children-in-law, and grandchildren accounted for 63 percent of the caregivers of disabled adults age 50 and older in a 2003 national survey (National Alliance for Caregiving and AARP 2004). Only 17 percent of caregivers were caring for their friends.

Paid providers sometimes supplement, or even replace, in-home care from family and friends (Li 2005), but limited public financing has curbed the growth of paid care. The use of paid home care services increased rapidly in the 1980s and early 1990s (Liu, Manton, and Aragon 2000). It then declined after the 1997 Balanced Budget Act tightened Medicare financing of home health care. In 1999, only 34 percent of older community-dwelling care recipients obtained care from paid providers, down from 43 percent in 1994 (Spillman and Black 2005). Medicare coverage of in-home care is restricted to skilled nursing care provided on a part-time or intermittent basis to homebound adults, and to personal care assistance provided by home health aides for those who are also receiving skilled care. It does not include homemaker services or personal care for people who do not receive skilled nursing care. Medicaid covers a variety of nonmedical and social services and supports designed to enable persons with disabilities to remain in the community. These services have grown rapidly in recent years, with expenditures nearly doubling from 1998 to 2003 (Government Accountability Office 2005). However, people must satisfy strict income and asset tests to qualify for Medicaid coverage.

Home care services are expensive for those with too much income or wealth to qualify for Medicaid. Home health aides charged $19 per hour on average in 2004 (Metlife 2005). Most private long-term care insurance policies now cover home care, but only about 1 in 10 older Americans had long-term care insurance in 2002 (Johnson and Uccello 2005).

Home Care for Childless Adults

Relatively little is known about care arrangements for frail older adults without children, partly because most caregiving studies have focused on help from children, ignoring childless adults. One previous study, based on 1993 data, found that frail older adults with children were more likely to receive informal help and less likely to receive paid help than those without children (Norgard and Rodgers 1997). The authors did not, however, find that the presence of a child significantly affected the likelihood that frail older adults received any care. Aykan (2003), who also examined 1993 data, concluded that childless adults are no more likely to receive skilled home health care than those with children. Other research has found that the number of children increased the chances that frail older adults with children received help from their offspring (Wolf and Soldo 1990). A closer look at care outcomes for childless adults is warranted. The existing studies used data that are now more than 10 years old. Further, these studies did not examine who provides care to childless adults, the amount of care obtained by care recipients, or care provided to unmarried childless adults, who are likely most vulnerable because they cannot turn to spouses or children for help.

Indirect evidence of the importance of informal care from children can be found in nursing home entry studies. Childless women (but not men) appear more likely to enter nursing homes than those with children (Aykan 2003), nursing home admission rates decline with the number of children (Freedman 1996), and frail older adults who do not receive informal care from their children are more likely to enter nursing homes in later years than those who receive informal care (Lo Sasso and Johnson 2002).

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Disclaimer: The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.