touches on the health status of, and use of health services by, this segment of the population. It concludes with a brief discussion of the implications for society in meeting these needs for health care services in the next century. The main purpose of this chapter is to provide a general perspective for understanding the implications of these population changes on the demands for health care services in hospitals and nursing homes and the supply of an adequate nursing workforce to provide these services.

Growth Of The Population

The population of the United States has increased by 12 million people, or 5.1 percent, since the 1990 census. Recent projections issued by the Bureau of the Census indicate that the population is expected to reach 276 million by the year 2000, and 392 million in 2050, amounting to a more than 50 percent increase since 1990 (Bureau of the Census, 1993a). The high level of immigration is a major factor contributing to the projected growth of the U.S. population.

The U.S. population is aging and the population in the 21st century will be older than it is now. The growth of the older population may be considered as one of the most important developments of the twentieth century. In 1900, there were 3.1 million people 65 years of age and older, or 1 in 25 persons. In 1994 this number was around 33 million or 1 in 8 persons (Bureau of the Census, 1995b). Yet the growth to date is just the beginning of the aging of America. In fact, the population 65 years of age and older is growing more slowly between 1990 and 2010 than at any time in a period of nearly 130 years. This reflects the aging of the low fertility generations of the 1920s and 1930s (see Figure 2.1). The elderly population, however, is projected to continue to increase both in numbers and as a proportion of the total population. It is projected to more than double by the middle of the next century, increasing from nearly 34 million, or 13 percent of the total population, to 80 million in 2050, or nearly 20 percent of the population. Most of the increase is expected to occur between 2010 and 2030, when the ''baby-boom" generation enters the elderly years (see Figure 2.1).

While this rate of growth is projected to drop after 2030, there will continue to be a large proportion of elderly persons in the population. About 40 to 50 years from now it is likely that there will be more elderly persons than young persons (under 15 years of age) in the United States. These projections take on added importance when the age distribution and the racial and ethnic composition of the projected elderly population are considered.

The elderly population is growing older. The population aged 85 and older is the fastest growing age group in the U.S., and it is projected to be nearly six times as large by 2050 as this age group was in 1990 (see Figure 2.2). It is also the most rapidly growing age group among the elderly population. Fewer children and increasing life expectancy have contributed to this shift in the population composition. A 65-year-old person can expect to live another 17 years, and



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