contacts, 71 percent of hospitalizations, and 82 percent of all the days that older people spent in bed because of health conditions (National Center for Health Statistics, 1981a). Among the 1.5 million nursing home residents in 1985, more than four-fifths (82.1 percent) were reported by their next of kin at the time of admission as being dependent in one or more activities of daily living. More than half (50.5 percent) were dependent in four or more ADLs (National Center for Health Statistics, 1989b).

In addition, current medical service, social services, and entitlement programs for persons with disabling conditions are not well coordinated at the national and state levels and offer uncertain benefits with regard to restoring persons with disabling conditions to their highest levels of functioning. Assessments of the effectiveness of these programs are largely unsatisfactory because the evaluations usually measure traditional medical outcomes (physiological and biochemical results) rather than quality of life.

Health services research is needed for the development and application of improved methodologies to measure the effectiveness of the health and social service systems on maintaining those persons with disabling conditions at maximal functional capacity and quality of life.

Several estimates of the high economic costs of disability in the United States are now available. Chirikos (1989) estimates aggregate economic disability losses at $176.8 billion in 1980, as shown in Table 2-6. Included are:

  1. net consumption attributable to disability, that is, the difference in medical care utilization and costs before and after the disabling condition occurred. This amounts to $90.6 billion, 51 percent of the total, and includes expenditures for hospital, medical, and institutional care of people with disabilities, paid household work, and non-health-care spending;

  2. primary market time, or the value of reduced productivity on the part of persons with chronic disability, valued at $68.4 billion, or 39 percent of the total; and

  3. secondary market time, or the value of productivity losses for members of the households of persons with disabilities, valued at $17.7 billion, or 10 percent of the total.

    Disability losses for males were significantly higher than for females—$115 billion and $62 billion, respectively. Losses for the working population were estimated at $112 billion; losses for dependents were estimated at $65 billion.

Berkowitz and Greene (1989) used a different approach for estimating the cost of disability. They estimated disability expenditures in 1986 for the



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