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ATHE
GAGING
POPULATION
IN THE
TWENTY_ FIRST
CENTURY
Statistics for Health Policy
Dorothy M. Gilford, Editor
Pane} on Statistics for an Aging Population
Sam Shapiro, Chair
Committee on National Statistics
Commission on Behavioral anct Social Sciences and Education
National Research Council
NATIONAL ACADEMY PRESS
Washington, D.C. 1988
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NationalAcademy Press · 2101 Constitution Avenue,N.W. · Washington, D. C. 20418
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of the
National Academy of Sciences, the National Academy of Engineering, and the Institute of
Medicine. The members of the committee responsible for the report were chosen for their
special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors, according to procedures
approved by a Report Review Committee consisting of members of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine.
The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated to the
fil~l`.r~n~ of science and technology and to their use for the general welfare. Upon the
_ _ _ _ . . . .. . ., ~ · ~ =~- AL _ A _ _ ~ ~ ., ~ ~ A ^ ~^
authority of the charter granted to it by the Congress In loner cue Car:, bias ~ ~-,,-~=
that requires it to advise the federal government on scientific and technical matters. Dr. Frank
Press is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of
the National Academy of Sciences, as a parallel organization of outstanding engineers. It
is autonomous in its administration and in the selection of its members, sharing with the
National Academy of Sciences the responsibility for advising the federal government. The
National Academy of Engineering also sponsors engineering programs aimed at meeting
national needs, encourages education and research, and recognizes the superior achievements
of engineers. Dr. Robert M. White is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to
secure the services of eminent members of appropriate professions in the examination of policy
matters pertaining to the health of the public. The Institute acts under the responsibility
given to the National Academy of Sciences by its congressional charter to be an adviser to the
federal government and, upon its own initiative, to identify issues of medical care, research,
and education. Dr. Samuel O. Thier is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916
to associate the broad community of science and technology with the Academy's purposes
of furthering knowledge and advising the federal government. Functioning in accordance
with general policies determined by the Academy, the Council has become the principal
operating agency of both the National Academy of Sciences and the National Academy
of Engineering in providing services to the government, the public, and the scientific and
engineering communities. The Council is administered jointly by both Academies and the
Institute of Medicine. Dr. Frank Press and Dr. Robert M. White are chairman and vice
chairman, respectively, of the National Research Council.
This project was supported with funds from the Veterans Administration and six agencies
of the U.S. Department of Health and Human Services: the Health Care Financing Adminis-
tration, the National Center for Health Statistics, the National Institute of Mental Health, the
National Institute on Aging, the Office of the Assistant Secretary for Planning and Evaluation,
and the Social Security Administration.
library of Congress Cataloging-in-Publication Data
National Research Council (U.S.). Panel on Statistics
for an Aging Population.
The aging population in the twenty-first century.
Bibliography: p.
1. Aged Diseases-United States-Statistics.
2. Aged-Medical care United States-Statistics.
3. Aged Diseases-United States-Forecasting.
4. Health planning-United States. I. Gilford,
Dorothy M. II. Title. [DNLM: 1. Aged-United States-
Statistics. 2. Health Policy-United States.
3. Health services for the aged-United States.
WT 100 N2775a]
RA408.A3N37 362.1'9897'00973021 88-15151
ISBN 0-309-03881-2
Printed in the United States of America
First Printing, May 1988
Second Printing, November 1988
Third Printing, October 1989
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PANES ON STATISTICS FOR AN AGING POPULATION
SAM SHAPIRO (Chair), Health Services Research and Development
Center, Johns Hopkins University
DAN GERMAN BLAZER II, Department of Psychiatry, Duke
University Medical Center
LAURENCE G. BRANCH, School of Public Health, Boston University
NEAL E. CUTLER, Department of Political Science, University of
Southern California
JEANNE E. GRIFFITH, Congressional Research Service, Library of
Congress
ROBERT LOUIS KAHN, Institute for Social Research, University of
Michigan
GARY G. KOCH, Department of Biostat~tics, University of North
Carolina
JUDITH RICE LAVE, Graduate School of Public Health, University of
Pittsburgh
KENNETH G. MANTON, Center for Demographic Studies, Duke
University
DOROTHY P. RICE, Aging Health Policy Center, University of
California, San Franc~sco
JOHN W. ROWE, Department of Gerontology, Harvard University
ETHEL SHANAS, Department of Sociology (emeritus), University of
Lois, Chicago
JAMES H. WARE, Department of Biostat~tics
Public Health
DOROTHY M. GILFORD, Study Director
CAROLYN ROGERS, Research Associate
ANNE M. SPRAGUE, Research Assistant
LILLIAN GURALNICK, Consultant
THOMAS JABINE, Consultant
JANE TAKEUCHI, Consultant
CARLO TTA MOLITOR, Administrative Secretary
· ~-
111
, Harvard School of
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Liaison Representatives
RONALD P. ABELES, National Institute on Aging
MICHELE ADLER, Department of Health and Human Services
BARBARA J. BURNS, National Institute of Mental Health
PAUL GAYER, Department of Health and Human Services
JUDITH KASPER, Health Care Financing Administration
BARRY LEBOWITZ, National Institute of Mental Health
PHYLLIS THORBURN, Veterans Administration
MELINDA UPP, Social Security Administration
JOAN VAN NOSTRAND, National Center for Health Statistics
1V
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COMMITTEE ON NATIONAL STATISTICS
BURTON H. SINGER (Chair), Department of Epidemiology and
Public Health, Yale University
JAMES O. BERGER, Statistics Department, Purdue University
DAVID H. BLACKWELL, Department of Statistics, University of
California, Berkeley
NORMAN M. BRADBURN, University of Chicago
LOUIS GORDON, Department of Mathematics, University of
Southern California
JERRY A. HAUSMAN, Department of Economics, Massachusetts
Institute of Technology
F. THOMAS JUSTER, Institute for Social Research, University of
Michigan
GRAHAM KALTON, Survey Research Center, University of Michigan
NAN M. LAIRD, Department of Biostatistics, Harvard School of
Public Health
JANE M. MENKEN, Office of Population Research, Princeton
University
JOHN W. PRATT, Graduate School of Business, Harvard University
S . JAMES PRESS, Department of Statistics, University of California,
Riverside
COURTENAY M. SLATER, CEC Associates, Washington, D.C.
KENNETH W. WACHTER, Department of Demography, University of
California, Berkeley
MIRON L. STRAP, Director
EDWIN D . GOLDFIELD, Senior A ssociate
MICHELE W . ZINN, Administrative Associate
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Contents
PREFACE
1 Introduction and Summary of Recommendations
2 Social, Economic, and Demographic Changes Among
the Elderly
3 Health Status and Quality of Life
4 Health Transitions and the Compression of Morbidity
5 Health Promotion and Disease Prevention
6 Quality of Care
7 Long-term Care
8 The Financing of Health Care Services for the Elderly
9 Health Services Utilization
10 Enhancing the Utility of Statistical Systems
11 Statistical Methodology for Health Policy Analysis
REFERENCES
APPENDICES
A Background Papers
B Effects of Budgetary Constraints on Federal Statistical
Programs
Descriptions of Data Bases Mentioned in the Panel's
Recommendations
D Long-term Health Care Minimum Data Set
. .
V11
1X
1
52
65
94
108
126
135
150
178
202
236
259
279
281
287
313
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~- -
V111
Descriptions of Data Bases Mentioned in the Panel's
Reco~runendations
D Long-term Health Care Minimum Data Set
E Acronyms
F Biographical Sketches
CONTENTS
287
313
316
319
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Preface
Concern about the aged has surfaced in recent years with such
dramatic force and recognition by so many that the national re-
sponse will have consequences far into the future, as has been true
in past years. During the Great Depression, 01d Age and Survivors
Insurance (Social Security) was legislated to create a partnership of
workers, employers, and government to make certain that income
would not end for workers and their dependents simply because of
advanced age. In 1965, after debates about national health insur-
ance, Medicare was legislated to increase the access of the aged to
health services by reducing economic barriers to care. While not as
dramatic or comprehensive as these economic and health care mea-
sures, the Older Americans Act in 1965 and subsequent amendments
opened the door to social and health-related programs that reach the
elderly at the grass roots.
Today, the aged hold a central position in the preoccupation of
policy makers in the legislative and executive branches of government
about costs, organization, and quality of health services. This results
from a conjunction of circumstances representing a mix of knowns
and unknowns about the aged. We can describe with considerable
certainty the growth of the elderly population that will follow from
the present age composition of the population and the increases in
life expectancy being experienced at every age, including the elderly.
We also know that the need for institutional and noninstitutional
health care and the related costs are high among the aged, generally,
and that these increase substantially with advancing age.
1X
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x
PREFA CE
But we are far from certain about the nature of the changes in
health and functional status that may be under way among the aged,
i.e., whether increases in longevity are associated mainly with longer
periods of chronic illness and prolongation of dependency or with
additional years of well-being and independent functioning. Further-
more, it is not certain how current and future policies designed to
change the structure of the health care system and the costs and
financing of health services affect access to care, the quality of care,
and the quality of life for the elderly.
The issues involved are complex, but we are fortunate to have
strong data systems that can be directed to meet the needs for
information. This report is the product of a study that takes stock
of specific questions faced in developing health policy for the elderly
and charts a course for producing information from the existing
national data systems to arrive at answers. The conclusions and
recommendations represent the end point of a Tong process.
ORIGIN OF THE STUDY
The Panel on Statistics for an Aging Population was established
in September 1984 under the aegis of the Committee on National
Statistics and within the National Research Council to study the
adequacy of current statistical information and methodology, partic-
ularly in the area of health and medical care, for an aging population.
The panel's study is an outgrowth of an initiative throughout the Na-
tional Academy of Sciences in aging begun in 1982 and coordinated
by the Institute of Medicine. A standing committee, the Committee
on an Aging Society, was established to develop a program of stud-
ies to address the major societal issues resulting from the changing
demographics of the U.S. population.
In April 1983 the Academy complex sponsored a conference to
determine whether the available statistics are adequate for policy
analysis for the aging society or whether a study on this topic was
warranted. The conference participants included representatives of
several federal agencies and of organizations concerned with aging,
congressional staff, and researchers on aging. The conferees iden-
tified a substantial number of problems with data on aging and
strongly endorsed the need for a thorough study of the problems
and the changes, large and small, that would increase the utility of
national data systems. The task was seen as being of major propor-
tions, and funding for a panel to study the issues was obtained from
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PREFACE
X1
the Veterans Administration and six agencies of the Department of
Health and Human Services: the Office of the Assistant Secretary for
Planning and Evaluation, the National Center for Health Statistics,
the National Institute on Aging, the National Institute of Mental
Health, the Health Care Financing Administration, and the Social
Security Administration. Panel members included individuals long
experienced in health matters and drawn from many disciplines in-
cluding statistics, health sciences, social sciences, and medicine (see
Appendix F for biographical sketches).
EARLY PANEL ACTIVITIES
Pane! members initially identified 12 issue areas relevant to the
charge and commissioned experts in these areas to prepare back-
ground papers (Appendix A). These became working documents
throughout our deliberations and were drawn on extensively in the
preparation of this report. They represent significant contributions
in themselves and will be published in a separate volume by the
National Center for Health Statistics.
To identify data gaps, detailed knowledge of existing data sets
was needed. The pane! therefore developed a compilation of de-
scriptions of available data sets relative to the health of the elderly,
since existing inventories were out of date. The resulting volume,
Inventory of Data Sets Related to the Health of the Elderly, describes
117 data sets and was published by the U.S. Senate Subcommittee
on Aging in connection with the June 1986 Hearings on Statistical
Policy for an Aging America.
To obtain advice from a wide range of experts and interested per-
sons and organizations, the panel sponsored a one-day symposium in
September 1985. The purpose of the symposium was to stimulate dis-
cussion about statistical problems encountered by policy makers and
members of the research community in addressing issues concerned
with an aging population. The panel's commissioned papers served
as the focus of the symposium. More than 100 persons participated,
including congressional staff, researchers on aging, and representa-
tives from federal agencies, professional societies, and public interest
groups.
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·-
X11
PREFACE
CONCURRENT ACTIVITIES
During the course of the study, several major events related
to the panel's charge took place. One was the Summit on Aging-
Related Statistics, cosponsored by the National Institute on Aging
and the Bureau of the Census, on May 2, 1986. The purpose of
the summit was to determine how the federal statistical system can
provide the data needed to answer policy questions for an aging so-
ciety in a cost-efficient manner. To this end, participating agency
directors prepared statements of their views of the vital issues re-
garding the elderly and agreed to establish an Interagency Forum on
Aging-Related Statistics to encourage cooperation among the federal
agencies in the development and coordination of data on the older
population. Special attention was given to the areas of demography,
epidern~ology, health service utilization and costs, and socioeconomic
characteristics of the elderly. The forum, now with multiagency par-
ticipation, provides an important, ongoing mechanism for assessment
by those targeted by the specific recommendations in this report and
the measures needed to effect changes in data systems and in the
production and analysis of information.
The other major event was a joint hearing on Statistical Policy
for an Aging America held on June 3, 1986, by the Subcommittee on
Aging of the U.S. Senate Committee on Labor and Human Resources
and the Subcommittee on Energy, Nuclear Proliferation, and Gov-
ernment Processes of the U.S. Senate Committee on Governmental
Affairs. The hearing examined the need to link data collection and
research to planning and policy development, promote research co-
ordination among the federal data collection agencies, and improve
data accessibility, data quality, policy relevance, and the dissemina-
tion of aging-related statistics. The pane] chair gave testimony on
the concerns and preliminary conclusions of the panel.
A third related development is that a number of federal agencies
have already taken steps to implement some of the panel's ideas a
fact that is not surprising, since in the course of the study some
agency heads shared with the pane} their long-range plans in a most
beneficial interactive process. Staff members from the seven spon-
soring agencies not only provided current information on agency
activities, but also heard the pane! discussions that led to the rec-
ommendations. In addition, staff from several agencies briefed us on
plans for specific surveys; some of our recommendations are in fact
our endorsement of aspects of these plans. Most of our recomrnenda-
tions regarding surveys are for continuing surveys; continuity remains
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PREFACE
· ·-
X111
an important aspect of the recommendations, even though we have
evidence that the first implementation steps have been taken.
ACKNOWLEDGMENTS
The report as a whole represents contributions from every mem-
ber of the panel. Many of the chapters were drafted and redrafted
by pane! members, and ah chapters were subjected to detailed re-
view at numerous sessions. The pane! divided itself into working
groups, which determined the structure and most of the substance
of the report; the pane! is particularly indebted to the chairs of
the three working groups for their efforts. The Working Group on
Health and Related Issues and Data Requirements, chaired by Daniel
Blazer II, identified topics the pane} should consider. The Working
Group on Improvement of Data Resources for Policy Analysis of Ag-
ing, chaired by Dorothy Rice, developed the recornrnendations to fill
the data gaps. The Working Group on Statistical Methodology for
Health Policy Analysis, chaired by Gary Koch, took responsibility
not only for the chapter on statistical methodology, but also for much
of the material on health transitions and longitudinal studies found
in other chapters.
The pane! profited greatly from the perspectives provided by the
liaison representatives of the seven federal agencies who sponsored
the study; they were always ready to respond to questions raised
by the panel. The liaison representatives, and in addition Jacob
Feldman of the National Center for Health Statistics and Richard
Suzman of the National Institute for Aging, deserve special thanks
for their willingness to share with the pane! their in-depth knowI-
edge of health data and research related to the elderly. Early in
the study, Leo Selker, who as a National Research Council fellow
in residence at the Institute of Medicine, participated in the panel
activities, contributed material for the demography chapter, and pro-
vided effective coordination with the Institute's activities related to
the elderly. Joan Van Nostrand of the National Center for Health
Statistics deserves our special appreciation not only for her manage-
ment skill as monitor of a project complicated by multiple agency
funding, but also, and more important, for her many contributions to
the panel's activities and deliberations. Her advice and suggestions
contributed significantly to the panel's report.
Our report also benefited from frequent dialogues with the Com-
m~ttee on National Statistics, which was chaired by Steven Fienberg
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XIV
PREFA GE
during our study, and thoughtful comments from the reviewers for
the committee as well as reviewers for the Commission on Behavioral
and Social Sciences and Education. Burton Singer, the current chair
of the committee, was particularly helpful in drafting material for the
sections on designs and strategies for longitudinal data analysis for
the chapter on statistical methodology. The panel appreciates the
encouragement and administrative assistance received from Edwin
D. Goldfield, director of the Committee on National Statistics while
the study was under way, and from Miron Straf, the committee's
director while the report was being prepared for publication. The
report was markedly improved by the helpful suggestions made by
Christine McShane, editor, and by the skillful reorganization of one
chapter by Eugenia Grohman, associate director for reports, of the
Commission on Behavioral and Social Sciences and Education.
The panel's support staff at the National Research Council was
dedicated and effective. Thanks are due to Carolyn Rogers, who was
on detail to the project staff from the Census Bureau for the first
year of the study, during which she drafted material for the demog-
raphy chapter; to Cariotta Molitor who, in addition to satisfying
all the secretarial demands for a large study, handled the logistics
for the symposium and the numerous meetings of the panel and its
working groups; and to Anne Sprague, who managed the final stages
of preparing the report for publication. Three consultants made
special contributions to the report: Lillian GuraInick had primary
responsibility for compiling the Inventory of Data Sets Related to the
Health of the Elderly and also assisted in collecting information and
redrafting parts of the report; Thomas Jabine prepared the section
on record linkage; and Jane Takeuchi drafted much of the material on
health promotion and disease prevention in addition to the material
on health care expenditures.
The individual most responsible for originating the study and
bringing it to a successful conclusion is Dorothy Gilford, the study
director. Only an experienced hand could have overcome the dif-
ficulties a complex project of this type involves, and she had the
wisdom, patience, and, in the end, the energy to bring the report to
completion. Personally, and as chair of the panel, ~ am indebted to
her.
Finally, ~ feel privileged to have had the opportunity to chair a
panel that worked so well together and gave so much more time than
could have been anticipated. ~ am confident that their efforts will
have a lasting influence on the availability of information required
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on ~
to develop health policy and to evaluate the exact of the measures
adopted.
Saw Sbaplro, Cb~lr
Panel on Statistics for
~ ^glog Population
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