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United States General Accounting Office: 


Before the Special Committee on Aging, U.S. Senate. 

For Release on Delivery: 
Expected at 9:30 a.m. 
Thursday, March 21, 2002: 

Long-Term Care: 

Aging Baby Boom Generation Will Increase Demand and Burden on Federal 
and State Budgets: 

Statement of David M. Walker: 
Comptroller General of the United States: 


Mr. Chairman and Members of the Committee: 

I am pleased to be here today as you discuss the effects of the aging 
baby boom generation on the demand for long-term care services and the
challenges that increased demand will bring for federal and state 
budgets. In general, the aging of the baby boom generation will lead to 
a sharp growth in federal entitlement spending that, absent meaningful 
reforms, will represent an unsustainable burden on future generations. 
As the estimated 76 million baby boomers born between 1946 and 1964 
become elderly, Medicare, Medicaid, and Social Security will nearly 
double as a share of the economy by 2035. We have been able to sustain 
these entitlements in the past with low depression-era birth rates and 
a large postwar workforce. However, absent substantive reform of 
entitlement programs, a rapid escalation of federal spending for Social 
Security, Medicare, and Medicaid beginning in less than 10 years from 
now is virtually certain to overwhelm the rest of the federal budget. 

Most attention has been focused on the need for Social Security and
Medicare reform in order to maintain their viability and ability to meet
programmatic commitments. As I have testified before various
committees, Social Security and Medicare’s Hospital Insurance trust 
funds will face cash deficits not long after the first baby boomers are 
eligible to retire. While these are important issues, a broader focus 
should also include Medicaid, particularly as it involves financing 
long-term care. Long-term care includes an array of health, personal 
care, and supportive services provided to persons with physical or 
mental disabilities. It relies heavily on financing by public payers, 
especially Medicaid, and has significant implications for state budgets 
as well as the federal budget. 

My remarks today will focus on (1) the pressure that entitlement 
spending for Medicare, Medicaid, and Social Security is expected to 
exert on the federal budget in coming decades; (2) how the aging of the 
baby boom population will increase the demand for long-term care 
services; and (3) how these trends will affect the current and future 
financing of long-term care services, particularly in federal and state 
budgets. I will also highlight several considerations for any possible 
reforms of long-term care financing. 

In summary, as more and more of the baby boom generation enters
retirement over the coming decades, entitlement spending for Medicare,
Medicaid, and Social Security is expected to absorb correspondingly 
larger shares of federal revenue and threatens to crowd out other 
spending. The aging of the baby boomers will also increase the demand 
for long-term care and contribute further to federal and state budget 
burdens. Estimates suggest the future number of disabled elderly who 
cannot perform basic activities of daily living without assistance may 
be double today’s level. Current problems with the provision and 
financing of long-term care could be exacerbated by the swelling 
numbers of the baby-boom generation needing care. These problems 
include whether individuals with disabilities receive adequate 
services, the potential for families to face financially catastrophic 
long-term care costs, and the burdens and social costs that heavy 
reliance on unpaid care from family members and other informal 
caregivers create coupled with possibly fewer caregivers available in
coming generations. Long-term care spending from all public and private
sources, which was about $137 billion for persons of all ages in 2000, 
will increase dramatically in the coming decades as the baby boom 
generation ages. Spending on long-term care services just for the 
elderly is projected to increase at least two-and-a-half times and 
could nearly quadruple in constant dollars to $379 billion by 2050, 
according to some estimates. Without fundamental financing changes, 
Medicaid—which pays over one-third of long-term care expenditures for 
the elderly—can be expected to remain one of the largest funding 
sources, straining both federal and state governments. 

In considering any long-term care financing reforms in light of these
anticipated demands for assistance and budgeting stresses, it is 
important to keep in mind that long-term care is not just about health 
care. It also comprises a variety of services an aged and/or disabled 
person requires to maintain quality of life—including housing, 
transportation, nutrition, and social support to help maintain 
independent living. Given the challenges in providing and paying for 
these myriad and growing needs, several considerations for shaping 
reform proposals include: 

* determining societal responsibilities;
* considering the potential role of social insurance in financing;
* encouraging personal preparedness;
* recognizing the benefits, burdens, and costs of informal caregiving;
* assessing the balance of state and federal responsibilities to ensure
adequate and equitable satisfaction of needs;
* adopting effective and efficient implementation and administration of
reforms; and; 
* developing financially sustainable public commitments. 


Long-term care includes many types of services needed when a person has
a physical or mental disability. Individuals needing long-term care have
varying degrees of difficulty in performing some activities of daily 
living without assistance, such as bathing, dressing, toileting, 
eating, and moving from one location to another. They may also have 
trouble with instrumental activities of daily living, which include 
such tasks as preparing food, housekeeping, and handling finances. They 
may have a mental impairment, such as Alzheimer’s disease, that 
necessitates supervision to avoid harming themselves or others or 
assistance with tasks such as taking medications. Although a chronic 
physical or mental disability may occur at any age, the older an 
individual becomes, the more likely a disability will develop or 

According to the 1999 National Long-Term Care Survey, approximately 7
million elderly had some sort of disability in 1999, including about 1
million needing assistance with at least five activities of daily 
living. Assistance takes place in many forms and settings, including 
institutional care in nursing homes or assisted living facilities, home 
care services, and unpaid care from family members or other informal 
caregivers. In 1994, approximately 64 percent of all elderly with a 
disability relied exclusively on unpaid care from family or other 
informal caregivers; even among elderly with difficulty with five 
activities of daily living, about 41 percent relied entirely on unpaid 

Nationally, spending from all public and private sources for long-term 
care for all ages totaled about $137 billion in 2000, accounting for 
nearly 12 percent of all health care expenditures.[Footnote 1] Over 60 
percent of expenditures for long-term care services are paid for by 
public programs, primarily Medicaid and Medicare. Individuals finance 
almost one-fourth of these expenditures out-of-pocket and, less often, 
private insurers pay for long-term care. Moreover, these expenditures 
do not include the extensive reliance on unpaid long-term care provided 
by family members and other informal caregivers. Figure 1 shows the 
major sources financing these expenditures. 

Figure 1: Medicaid Is the Largest Funding Source for Long-Term Care: 

[See PDF for image] 

This figure is a pie-chart depicting the following data: 

Funding Sources for Long-Term Care: 
Medicaid (public payer): 45%; 
Medicare (public payer): 14%; 
Other public: 3%; 
Private insurance: 11%; 
Other private: 4%; 
Out-of-pocket: 23%. 

Note: Amounts do not include unpaid care provided by family member or 
other informal caregivers or expenditures for nursing home and home 
health services provided by hospital-based entities. 

Source: GAO analysis of 2000 data from the Centers for Medicare and 
Medicaid Services and The MEDSTAT Group. 

[End of figure] 

Medicaid, the joint federal-state health-financing program for low-
income individuals, continues to be the largest funding source for long-
term care. Medicaid provides coverage for poor persons and to many 
individuals who have become nearly impoverished by “spending down” 
their assets to cover the high costs of their long-term care. For 
example, many elderly persons become eligible for Medicaid as a result 
of depleting their assets to pay for nursing home care that Medicare 
does not cover. In 2000, Medicaid paid 45 percent (about $62 billion) 
of total long-term care expenditures. States share responsibility with 
the federal government for Medicaid, paying on average approximately 43 
percent of total Medicaid costs. Eligibility for Medicaid-covered long-
term care services varies widely among states. Spending also varies 
across states—for example, in fiscal year 2000, Medicaid per capita 
long-term care expenditures ranged from $73 per year in Nevada to $680 
per year in New York. For the national average in recent years, about 
53 to 60 percent of Medicaid long-term care spending has gone toward 
the elderly. In 2000, nursing home expenditures dominated Medicaid long-
term care expenditures, accounting for 57 percent of its long-term care 
spending. Home care expenditures make up a growing share of Medicaid 
long-term care spending as many states use the flexibility available 
within the Medicaid program to provide long-term care services in home- 
and community-based settings.[Footnote 2] Expenditures for Medicaid 
home- and community-based services grew ten-fold from 1990 to 2000—from 
$1.2 billion to $12.0 billion. 

Other significant long-term care financing sources include: 

* Individuals’ out-of-pocket payments, the second largest payer of long-
term care services, accounted for 23 percent (about $31 billion) of 
total expenditures in 2000. The vast majority (80 percent) of these 
payments were used for nursing home care. 

* Medicare spending accounted for 14 percent (about $19 billion) of 
total long-term care expenditures in 2000. While Medicare primarily 
covers acute care, it also pays for limited stays in post-acute skilled 
nursing care facilities and home health care. 

* Private insurance, which includes both traditional health insurance 
and long-term care insurance,[Footnote 3] accounted for 11 percent 
(about $15 billion) of long-term care expenditures in 2000. Less than 
10 percent of the elderly and an even lower percentage of the near 
elderly (those aged 55 to 64) have purchased long-term care insurance, 
although the number of individuals purchasing long-term care insurance 
increased during the 1990s. 

Absent Reform, Spending for Medicaid, Medicare, and Social Security 
Will Put Unsustainable Pressure on the Federal Budget: 

Before focusing on the increased burden that long-term care will place 
on federal and state budgets, it is important to look at the broader 
budgetary context. As we look ahead we face an unprecedented demographic
challenge with the aging of the baby boom generation. As the share of 
the population 65 and over climbs, federal spending on the elderly will 
absorb a larger and ultimately unsustainable share of the federal 
budget and economic resources. Federal spending for Medicare, Medicaid, 
and Social Security are expected to surge—nearly doubling by 2035—as 
people live longer and spend more time in retirement. In addition, 
advances in medical technology are likely to keep pushing up the cost 
of health care. Moreover, the baby boomers will be followed by 
relatively fewer workers to support them in retirement, prompting a 
relatively smaller employment base from which to finance these higher 
costs. Under the 2001 Medicare trustees’ intermediate estimates, 
Medicare will double as a share of gross domestic product (GDP) between 
2000 and 2035 (from 2.2 percent to 5.0 percent) and reach 8.5 percent 
of GDP in 2075. The federal share of Medicaid as a percent of GDP will 
grow from today’s 1.3 percent to 3.2 percent in 2035 and reach 6.0 
percent in 2075. Under the Social Security trustees’ intermediate 
estimates, Social Security spending will grow as a share of GDP from 
4.2 percent to 6.6 percent between 2000 and 2035, reaching 6.7 percent 
in 2075. (See figure 2.) Combined, in 2075 a full one-fifth of GDP will 
be devoted to federal spending for these three programs alone. 

Figure 2: Projected Federal Spending for Medicaid, Medicare, and Social 
Security Will Double as a Share of GDP by 2035: 

[See PDF for image] 

Social Security, Medicare, and Medicaid Spending as a Percent of GDP: 

[See PDF for image] 

This is a line graph with three stacked lines (Social Security, 
Medicaid, and Medicare). The vertical axis represents percent of GDP 
and the horizontal axis represents fiscal years 2000 through 2080. 
The following data is depicted: 

Social Security: 4.229; 
Medicaid: 1.23; 
Medicare: 2.277; 
Total: 7.736. 

Social Security: 4.334; 
Medicaid: 1.322; 
Medicare: 2.433; 
Total: 8.089. 

Social Security: 4.409; 
Medicaid: 1.44; 
Medicare: 2.523; 
Total: 8.372. 

Social Security: 4.371; 
Medicaid: 1.501; 
Medicare: 2.56; 
Total: 8.432. 

Social Security: 4.283; 
Medicaid: 1.516; 
Medicare: 2.629; 
Total: 8.428. 
Social Security: 4.254; 
Medicaid: 1.457; 
Medicare: 2.7; 
Total: 8.411. 

Social Security: 4.28; 
Medicaid: 1.383; 
Medicare: 3.072; 
Total: 8.735. 

Social Security: 4.29; 
Medicaid: 1.401; 
Medicare: 3.185; 
Total: 8.876. 

Social Security: 4.24; 
Medicaid: 1.449; 
Medicare: 3.255; 
Total: 8.944. 

Social Security: 4.26; 
Medicaid: 1.490; 
Medicare: 3.333; 
Total: 9.083. 

Social Security: 4.32; 
Medicaid: 1.531; 
Medicare: 3.414; 
Total: 9.265. 

Social Security: 4.36; 
Medicaid: 1.578; 
Medicare: 3.49; 
Total: 9.428. 

Social Security: 4.44; 
Medicaid: 1.630; 
Medicare: 3.588; 
Total: 9.658. 

Social Security: 4.54; 
Medicaid: 1.683; 
Medicare: 3.694; 
Total: 9.917. 

Social Security: 4.65; 
Medicaid: 1.739; 
Medicare: 3.806; 
Total: 10.195. 

Social Security: 4.76; 
Medicaid: 1.799; 
Medicare: 3.918; 
Total: 10.477. 

Social Security: 4.86; 
Medicaid: 1.864; 
Medicare: 4.044; 
Total: 10.768. 

Social Security: 4.976; 
Medicaid: 1.930 
Medicare: 4.183; 
Total: 11.089. 

Social Security: 5.08; 
Medicaid: 2.2; 
Medicare: 4.331; 
Total: 11.611. 

Social Security: 5.2; 
Medicaid: 2.2; 
Medicare: 4.483; 
Total: 11.883. 

Social Security: 5.31; 
Medicaid: 2.3; 
Medicare: 4.642; 
Total: 12.252. 

Social Security: 5.41; 
Medicaid: 2.3; 
Medicare: 4.809; 
Total: 12.519. 

Social Security: 5.22; 
Medicaid: 2.4; 
Medicare: 4.988; 
Total: 12.608. 

Social Security: 5.61; 
Medicaid: 2.4; 
Medicare: 5.173; 
Total: 13.183.		 

Social Security: 5.71; 
Medicaid: 2.5; 
Medicare: 5.359; 
Total: 13.569. 

Social Security: 5.8; 
Medicaid: 2.6; 
Medicare: 5.547; 
Total: 13.947. 

Social Security: 5.89; 
Medicaid: 2.6; 
Medicare: 5.739; 
Total: 14.229. 

Social Security: 5.97; 
Medicaid: 2.7; 
Medicare: 5.935; 
Total: 14.605. 

Social Security: 6.05; 
Medicaid: 2.7; 
Medicare: 6.131; 
Total: 14.881. 

Social Security: 6.12; 
Medicaid: 2.8; 
Medicare: 6.322; 
Total: 15.242. 

Social Security: 6.17; 
Medicaid: 2.8; 
Medicare: 6.505; 
Total: 15.475. 

Social Security: 6.22; 
Medicaid: 2.9; 
Medicare: 6.682; 
Total: 15.802. 

Social Security: 6.27; 
Medicaid: 2.9; 
Medicare: 6.851; 
Total: 16.021. 

Social Security: 6.3; 
Medicaid: 3; 
Medicare: 7.017; 
Total: 16.317. 

Social Security: 6.32; 
Medicaid: 3.1; 
Medicare: 7.279; 
Total: 16.669. 

Social Security: 6.33; 
Medicaid: 3.1; 
Medicare: 7.34; 
Total: 16.77. 

Social Security: 6.34; 
Medicaid: 3.2; 
Medicare: 7.498; 
Total: 17.038. 

Social Security: 6.34; 
Medicaid: 3.3; 
Medicare: 7.643; 
Total: 17.283. 

Social Security: 6.34; 
Medicaid: 3.3; 
Medicare: 7.774; 
Total: 17.414. 

Social Security: 6.33; 
Medicaid: 3.4; 
Medicare: 7.894; 
Total: 17.624. 

Social Security: 6.31; 
Medicaid: 3.4; 
Medicare: 8.01; 
Total: 17.72. 

Social Security: 6.3; 
Medicaid: 3.5; 
Medicare: 8.121; 
Total: 17.921. 

Social Security: 6.28; 
Medicaid: 3.6; 
Medicare: 8.229; 
Total: 18.109. 

Social Security: 6.27; 
Medicaid: 3.6; 
Medicare: 8.334; 
Total: 18.204. 

Social Security: 6.25; 
Medicaid: 3.7; 
Medicare: 8.437; 
Total: 18.387. 

Social Security: 6.24; 
Medicaid: 3.7; 
Medicare: 8.54; 
Total: 18.48. 

Social Security: 6.23; 
Medicaid: 3.8; 
Medicare: 8.64; 
Total: 18.67. 

Social Security: 6.22; 
Medicaid: 3.8; 
Medicare: 8.737; 
Total: 18.757. 

Social Security: 6.21; 
Medicaid: 3.9; 
Medicare: 8.829; 
Total: 18.939. 

Social Security: 6.2; 
Medicaid: 3.9; 
Medicare: 8.916; 
Total: 19.016. 

Social Security: 6.2; 
Medicaid: 4; 
Medicare: 9.002; 
Total: 19.202. 

Social Security: 6.19; 
Medicaid: 4.063; 
Medicare: 9.008; 
Total: 19.261. 

Social Security: 6.19; 
Medicaid: 4.127; 
Medicare: 9.172; 
Total: 19.489. 

Social Security: 6.19; 
Medicaid: 4.192; 
Medicare: 9.256; 
Total: 19.638. 

Social Security: 6.2; 
Medicaid: 4.258; 
Medicare: 9.344; 
Total: 19.802. 

Social Security: 6.2; 
Medicaid: 4.325; 
Medicare: 9.439; 
Total: 19.964. 

Social Security: 6.21; 
Medicaid: 4.393; 
Medicare: 9.538; 
Total: 20.141. 

Social Security: 6.21; 
Medicaid: 4.462; 
Medicare: 9.634; 
Total: 20.306. 

Social Security: 6.22; 
Medicaid: 4.533; 
Medicare: 9.728; 
Total: 20.481. 

Social Security: 6.23; 
Medicaid: 4.604; 
Medicare: 9.82; 
Total: 20.654. 

Social Security: 6.23; 
Medicaid: 4.676; 
Medicare: 9.91; 
Total: 20.816. 

Social Security: 6.24; 
Medicaid: 4.75; 
Medicare: 10; 
Total: 20.99. 

Social Security: 6.24; 
Medicaid: 4.825; 
Medicare: 10.087; 
Total: 21.152. 

Social Security: 6.24; 
Medicaid: 4.901; 
Medicare: 10.175; 
Total: 21.316. 

Social Security: 6.25; 
Medicaid: 4.978; 
Medicare: 10.262; 
Total: 21.49. 

Social Security: 6.25; 
Medicaid: 5.056; 
Medicare: 10.349; 
Total: 21.655. 

Social Security: 6.25; 
Medicaid: 5.136; 
Medicare: 10.429; 
Total: 21.815. 

Social Security: 6.25; 
Medicaid: 5.217; 
Medicare: 10.502; 
Total: 21.969. 

Social Security: 6.26; 
Medicaid: 5.299; 
Medicare: 10.574; 
Total: 22.133. 

Social Security: 6.26; 
Medicaid: 5.383; 
Medicare: 10.648; 
Total: 22.291. 

Social Security: 6.26; 
Medicaid: 5.467; 
Medicare: 10.718; 
Total: 22.445. 

Social Security: 6.27; 
Medicaid: 5.553; 
Medicare: 10.784; 
Total: 22.607. 

Social Security: 6.27; 
Medicaid: 5.641; 
Medicare: 10.845; 
Total: 22.756. 

Social Security: 6.27; 
Medicaid: 5.73; 
Medicare: 10.906; 
Total: 22.906. 

Social Security: 6.27; 
Medicaid: 5.82; 
Medicare: 10.964; 
Total: 23.054. 

Social Security: 6.27; 
Medicaid: 5.912; 
Medicare: 11.022; 
Total: 23.204. 

Note: These estimates do not include the state share of Medicaid. 

Projections based on intermediate assumptions of the 2001 Old-Age, 
Survivors, and Disability Insurance, Hospital Insurance, and 
Supplementary Medical Insurance Trustees’ Reports and on the 
Congressional Budget Office’s (CBO) January 2002 long-term Medicaid 

Source: Office of the Actuary, Centers for Medicare and Medicaid 
Services; the Office of the Chief Actuary, Social Security 
Administration; and CBO. 

[End of figure] 

To move into the future with no changes in federal health and retirement
programs is to envision a very different role for the federal 
government. Our long-term budget simulations serve to illustrate the 
increasing constraints on federal budgetary flexibility that will be 
driven by entitlement spending growth. Assume, for example, that last 
year’s tax reductions are made permanent, revenue remains constant 
thereafter as a share of GDP, and discretionary spending keeps pace 
with the economy. Under these conditions, spending for net interest, 
Social Security, Medicare, and Medicaid would consume nearly three-
quarters of federal revenue by 2030. This will leave little room for 
other federal priorities, including defense and education. By 2050, 
total federal revenue would be insufficient to fund entitlement 
spending and interest payments.[Footnote 4] (See figure 3.) 

Figure 3: Medicare, Medicaid, Social Security, and Net Interest Will Put
Unsustainable Pressure on the Federal Budget: 

[See PDF for image] 

This figure is a combined stacked vertical bar and line graph, 
depicting the following data: 

Year: 2000; 
Medicare and Medicaid: 4% of GDP; 
Social Security: 5% of GDP; 
Net interest: 2% of GDP; 
All other spending: 8% of GDP; 
Revenue: 22% of GDP. 

Year: 2030; 
Medicare and Medicaid: 8% of GDP; 
Social Security: 6% of GDP; 
Net interest: 3% of GDP; 
All other spending: 8% of GDP; 
Revenue: 20% of GDP. 

Year: 2050; 
Medicare and Medicaid: 9% of GDP; 
Social Security: 8% of GDP; 
Net interest: 11% of GDP; 
All other spending: 9% of GDP. 
Revenue: 20% of GDP. 

Source: GAO’s January 2002 analysis. See U.S. General Accounting 
Office, Budget Issues: Long-Term Fiscal Challenges, GAO-02-467T 
(Washington, D.C.: February 27, 2002). 

[End of figure] 

Beginning about 2010, the share of the population that is age 65 or 
older will begin to climb, with profound implications for our society, 
our economy, and the financial condition of these entitlement programs. 
In particular, both Social Security and the Hospital Insurance portion 
of Medicare are largely financed as pay-as-you-go systems in which 
current workers’ payroll taxes pay current retirees’ benefits. 
Therefore, these programs are directly affected by the relative size of 
populations of covered workers and beneficiaries. Historically, this 
relationship has been favorable. In the near future, however, the 
overall worker-to-retiree ratio will change in ways that threaten the 
financial solvency and sustainability of these entitlement programs. In 
2000, there were 4.9 working-age persons (18 to 64 years) per elderly 
person, but by 2030, this ratio is projected to decline to 2.8. 
[Footnote 5] This decline in the overall worker-to-retiree ratio will 
be due to both the surge in retirees brought about by the aging baby 
boom generation as well as falling fertility rates, which translate 
into relatively fewer workers in the near future. 

Social Security’s projected cost increases are due predominantly to the
burgeoning retiree population. Even with the increase in the Social
Security eligibility age to 67, these entitlement costs are anticipated 
to increase dramatically in the coming decades as a larger share of the
population becomes eligible for Social Security, and if, as expected,
average longevity increases. 

As the baby boom generation retires and the Medicare-eligible population
swells, the imbalance between outlays and revenues will increase
dramatically. Medicare growth rates reflect not only a rapidly 
increasing beneficiary population, but also the escalation of health 
care costs at rates well exceeding general rates of inflation. While 
advances in science and technology have greatly expanded the 
capabilities of medical science, disproportionate increases in the use 
of health services have been fueled by the lack of effective means to 
channel patients into consuming, and providers into offering, only 
appropriate services. Although Medicare cost growth had slowed in 
recent years, in fiscal year 2001 Medicare spending grew by 10.3 
percent and is up 7.8 percent for the first 5 months of fiscal year 

To obtain a more complete picture of the future health care entitlement
burden, especially as it relates to long-term care, we must also
acknowledge and discuss the important role of Medicaid. Approximately
71 percent of all Medicaid dollars are dedicated to services for the 
aged, blind, and disabled individuals, and Medicaid spending is one of 
the largest components of most states’ budgets. At the February 2002 
National Governors Association meeting, governors reported that during 
a time of fiscal crisis for states, the growth in Medicaid is creating 
a situation in which states are faced with either making major cuts in 
programs or being forced to raise taxes significantly. Further, in a 
2001 survey, 24 states cited increased costs for nursing homes and 
home- and community-based services as among the top factors in Medicaid 
cost growth.[Footnote 6] Over the longer term, the increase in the 
number of elderly will add considerably to the strain on federal and 
state budgets as governments struggle to finance increased Medicaid 
spending. In addition, this strain on state Medicaid budgets may be 
exacerbated by fluctuations in the business cycle, such as the recent 
economic slowdown. State revenues decline during economic downturns, 
while the needs of the disabled for assistance remain constant. 

Baby Boom Generation Will Greatly Expand Demand for Long-Term Care: 

In coming decades, the sheer number of aging baby boomers will swell the
number of elderly with disabilities and the need for services. These
overwhelming numbers offset the slight reductions in the prevalence of
disability among the elderly reported in recent years. In 2000, 
individuals aged 65 or older numbered 34.8 million people—12.7 percent 
of our nation’s total population. By 2020, that percentage will 
increase by nearly one-third to 16.5 percent—one in six Americans—and 
will represent nearly 20 million more elderly than there are today. By 
2040, the number of elderly aged 85 years and older—the age group most 
likely to need long-term care services—is projected to more than triple 
from about 4 million to about 14 million (see figure 4). 

Figure 4: Elderly Population Will More than Double by 2040: 

[See PDF for image] 

This figure is a stacked vertical bar graph depicting the following 

Elderly Population Will More than Double by 2040: 

Year: 2000; 
65 to 84 years old: 30.5%; 
85 and older: 4.3%; 
Total: 34.8%. 

Year: 2020; 
65 to 84 years old: 47%; 
85 and older: 6.8%; 
Total: 53.8%. 

Year: 2040; 
65 to 84 years old: 62.9%; 
85 and older: 14.3%; 
Total: 77.2%. 

Source: Bureau of the Census, “Projections of the Total Resident 
Population by 5-Year Age Groups and Sex With Special Age Categories: 
Middle Series,” selected years 2000 to 2040 (Jan. 2000). 

[End of figure] 

It is difficult to precisely predict the future increase in the number 
of the elderly with disabilities, given the counterbalancing trends of 
an increase in the total number of elderly and a possible continued 
decrease in the prevalence of disability. For the past two decades, the 
number of elderly with disabilities has remained fairly constant while 
the percentage of those with disabilities has fallen between 1 and 2 
percent a year. Possible factors contributing to this decreased 
prevalence of disability include improved health care, improved 
socioeconomic status, and better health behaviors. The positive 
benefits of the decreased prevalence of disability, however, will be 
overwhelmed by the sheer numbers of aged baby boomers. The total number 
of disabled elderly is projected to increase to between one-third and 
twice current levels, or as high as 12.1 million by 2040. 

The increased number of disabled elderly will exacerbate current 
problems in the provision and financing of long-term care services.
Approximately one in five adults with long-term care needs and living in
the community reports an inability to receive needed care, such as
assistance in toileting or eating, often with adverse consequences. 
[Footnote 7] In addition, disabled elderly may lack family support or 
the financial means to purchase medical services. Long-term care costs 
can be financially catastrophic for families. Services, such as nursing 
home care, are very expensive; while costs can vary widely, a year in a 
nursing home typically costs $50,000 or more, and in some locations can 
be considerably more. Because of financial constraints, many elderly 
rely heavily on unpaid caregivers, usually family members and friends; 
overall, the majority of care received in the community is unpaid. 
However, in coming decades, fewer elderly may have the option of unpaid 
care because a smaller proportion may have a spouse, adult child, or 
sibling to provide it. By 2020, the number of elderly who will be 
living alone with no living children or siblings is estimated to reach 
1.2 million, almost twice the number without family support in 1990. 
[Footnote 8] In addition, geographic dispersion of families may further 
reduce the number of unpaid caregivers available to elderly baby 

Spending for Long-Term Care for Elderly Could Nearly Quadruple by 2050: 

Currently, public and private spending on long-term care is about $137
billion for persons of all ages, and for the elderly alone is projected 
to increase two-and-a-half to four times in the next 40 to 50 
years—reaching as much as $379 billion in constant dollars for the 
elderly alone, according to one source.[Footnote 9] (See fig. 5.) 
Estimates of future spending are imprecise, however, due to the 
uncertain effect of several important factors, including how many 
elderly will need assistance, the types of care they will use, and the 
availability of public and private sources of payment for care. Absent 
significant changes in the availability of public and private payment 
sources, however, future spending is expected to continue to rely 
heavily on public payers, particularly Medicaid, which estimates 
indicate pays about 36 to 37 percent of long-term care expenditures for 
the elderly. 

Figure 5: Projected Long-Term Care Expenditures for the Elderly Could 
Nearly Quadruple by 2050: 

[See PDF for image] 

This figure is a stacked multiple vertical bar graph depicting the 
projected long-term care expenditures for the elderly to 2050 (dollars 
in billions[B]). 

Data is represented in the following categories for CBO projections for 
the years 2000, 2020, and 2040: 
Non-Medicaid spending, assuming more private insurance; 
Non-Medicaid spending, assuming same level of private insurance; 
Medicaid spending; 
Total spending, assuming more private insurance; 
Total spending, assuming same level of private insurance. 

Data is represented in the following categories for ASPE/Lewin 
projections[A] for the years 2000, 2025, and 2050: 
Non-Medicaid spending; 
Medicaid spending. 

[A] ASPE/Lewin did not report separate estimates for different 
assumptions about the role of private insurance. 

[B] Projections are in constant dollars. 

Sources: CBO, “Projections of Expenditures for Long-Term Care Services 
for the Elderly” (Washington, D.C.: March 1999) and ASPE/Lewin, 
published in Urban Institute, “Long-Term Care: Consumers, Providers, 
and Financing, A Chart Book,” (Washington, D.C.: March 2001), with 
additional information provided by ASPE on projected Medicaid spending. 

[End of figure] 

One factor that will affect spending is how many elderly will need
assistance. As I have previously discussed, even with continued 
decreases in the prevalence of disability, aging baby boomers are 
expected to have a disproportionate effect on the demand for long-term 
care. Another factor influencing projected long-term care spending is 
the type of care that the baby boom generation will use. Currently, 
expenditures for nursing home care greatly exceed those for care 
provided in other settings. Average expenditures per elderly person in 
a nursing home can be about four times greater than average 
expenditures for those receiving paid care at home.[Footnote 10] The 
past decade has seen increases in paid home care as well as in assisted 
living facilities, a relatively newer and developing type of housing in 
which an estimated 400,000 elderly with disabilities resided in 1999. 
[Footnote 11] It is unclear what effect continued growth in paid home 
care, assisted living facilities, or other care alternatives may have 
on future expenditures. Any increase in the availability of home care 
may reduce the average cost per disabled person, but the effect could 
be offset if there is an increase in the use of paid home care by 
persons currently not receiving these services. 

Changes in the availability of public and private sources to pay for 
care will also affect expenditures. Private long-term care insurance 
has been viewed as a possible means of reducing catastrophic financial 
risk for the elderly needing long-term care and relieving some of the 
financial burden currently falling on public long-term care programs. 
Increases in private insurance may lower public expenditures but raise 
spending overall because insurance increases individuals’ financial 
resources when they become disabled and allows the purchase of 
additional services. The number of policies in force remains relatively 
small despite improvements in policy offerings and the tax 
deductibility of premiums. However, as we have previously testified, 
questions about the affordability of long-term care policies and the 
value of the coverage relative to the premiums charged have posed 
barriers to more widespread purchase of these policies.[Footnote 12] 
Further, many baby boomers continue to assume they will never need such 
coverage or mistakenly believe that Medicare or their own private 
health insurance will provide comprehensive coverage for the services 
they need. If private long-term care insurance is expected to play a 
larger role in financing future generations’ long-term care needs, 
consumers need to be better informed about the costs of long-term care,
the likelihood that they may need these services, and the limits of
coverage through public programs and private health insurance. 

With or without increases in the availability of private insurance, 
Medicaid and Medicare are expected to continue to pay for the majority 
of long-term care services for the elderly in the future. Without 
fundamental financing changes, Medicaid can be expected to remain one 
of the largest funding sources for long-term care services for aging 
baby boomers, with Medicaid expenditures for long-term care for the 
elderly reaching as high as $132 billion by 2050. As I noted 
previously, this increasing burden will strain both federal and state 

Considerations for Reforming Long-Term Care Financing: 

Given the anticipated increase in demand for long-term care services
resulting from the aging of the baby boom generation, the concerns about
the availability of services, and the expected further stress on 
federal and state budgets and individuals’ financial resources, some 
policymakers and advocates have called for long-term care financing 
reforms. As further deliberation is given to any long-term care 
financing reforms, I would like to close by suggesting several 
considerations for policymakers to keep in mind. 

At the outset, it is important to recognize that long-term care 
services are not just another set of traditional health care services. 
Meeting acute and chronic health care needs is an important element of 
caring for aging and disabled individuals. Long-term care, however, 
encompasses services related to maintaining quality of life, preserving 
individual dignity, and satisfying preferences in lifestyle for someone 
with a disability severe enough to require the assistance of others in 
everyday activities. Some long-term care services are akin to other 
health care services, such as personal assistance with activities of 
daily living or monitoring or supervision to cope with the effect of 
dementia. Other aspects of long-term care, such as housing, nutrition, 
and transportation, are services that all of us consume daily but 
become an integral part of long-term care for a person with a 
disability. Disabilities can affect housing needs, nutritional needs, 
or transportation needs. But, what is more important is that where one 
wants to live or what activities one wants to pursue also affects how 
needed services can be provided. Providing personal assistance in a 
congregate setting such as a nursing home or assisted living facility 
may satisfy more of an individual’s needs, be more efficient, and 
involve more direct supervision to ensure better quality than when 
caregivers travel to individuals’ homes to serve them one on one. Yet, 
those options may conflict with a person’s preference to live at home 
and maintain autonomy in determining his or her daily activities. 

Keeping in mind that policies need to take account of the differences
involved in long-term care, let me offer several considerations as you 
seek to shape effective long-term care financing reforms. These 

* Determining societal responsibilities. A fundamental question is how 
much the choices of how long-term care needs are met should depend upon 
an individual’s own resources or whether society should supplement those
resources to broaden the range of choices. For a person without a
disability requiring long-term care, where to live and what activities 
to pursue are lifestyle choices based on individual preferences and
resources. However, for someone with a disability, those lifestyle 
choices affect the costs of long-term care services. The individual’s 
own resources—including financial resources and the availability of 
family or other informal supports—may not be sufficient to preserve 
some of their choices and also obtain needed long-term care services. 

Societal responsibilities may include maintaining a safety net to 
satisfy individual needs for assistance. However, the safety net may 
not provide a full range of choices in how those needs are met. Persons 
who require assistance multiple times a day and lack family members to 
provide some share of this assistance may not be able to have their 
needs satisfied in their own homes. The costs of meeting such extensive 
needs may mean that sufficient public support is available only in 
settings such as assisted living facilities or nursing homes. More 
extensive public support may be extended, but decisions to do so should 
carefully consider affordability in the context of competing demands 
for our nation’s resources. 

* Considering the potential role of social insurance in financing.
Government’s role in many situations has extended beyond providing a
safety net. Sometimes this extended government role has been a result of
efficiencies in having government undertake a function, and in other 
cases this role has been a policy choice. Some proposals have 
recommended either voluntary or mandatory social insurance to provide 
long-term care assistance to broad groups of beneficiaries. In 
evaluating such proposals, careful attention needs to be paid to the 
limits and conditions under which services will be provided. In 
addition, who will be eligible and how such a program will be financed 
are critical choices. As in defining a safety net, it is imperative 
that any option under consideration be thoroughly assessed for its 
affordability over the longer term. 

* Encouraging personal preparedness. Becoming disabled is a risk. Not
everyone will experience disability during his or her lifetime and even
fewer persons will experience a severe disability requiring extensive
assistance. This is the classic situation in which having insurance to
provide additional resources to deal with a possible disability may be
better than relying on personally saving for an event that may never 
occur. Insurance allows both persons who eventually will become 
disabled and those who will not to use more of their economic resources 
during their lifetime and to avoid having to put those resources aside 
for the possibility that they may become disabled. 

The public sector has two important potential roles in encouraging
personal preparedness. The first is to adequately educate people about 
the boundaries between personal and societal responsibilities. Only if 
the limits of public support are clear will individuals be likely to 
take steps to prepare for a possible disability. Currently, one of the 
factors contributing to the lack of preparation for long-term care 
among the elderly is a widespread misunderstanding about what services 
Medicare will cover. The second public sector role may be to assure the 
availability of sound private long-term care insurance policies and 
possibly to create incentives for their purchase. Progress has been 
made in improving the value of insurance policies through state 
insurance regulation and strengthening the requirements for policies 
qualifying for favorable tax treatment through the Health Insurance 
Portability and Accountability Act of 1996. However, long-term care 
insurance is still an evolving product, and given the flux in how long-
term care services are delivered, it is important to monitor whether 
long-term care insurance regulations need adjustments to ensure that 
consumers receive fair value for their premium dollars. 

* Recognizing the benefits, burdens, and costs of informal caregiving.
Family and other informal caregivers play a critical role in supplying 
the bulk of long-term care to disabled persons. Effective policy must 
create incentives and supports for enabling informal caregivers to 
continue providing assistance. Further, care should be taken to avoid 
creating incentives that result in informal care being inappropriately 
supplanted by formal paid services. At the same time, it is important 
to recognize the physical, emotional, and social burdens that providing 
care impose on the caregiver and its economic costs to the caregiver 
and to society. Caregiving may create needs in caregivers themselves 
that require respite or other relief services. In addition, caregiving 
can conflict with caregivers’ employment, creating economic losses for 
caregivers and society. Such losses in productivity will become even 
more important in the coming decades as the proportion of the 
population that is working-age declines. 

* Assessing the balance of federal and state responsibilities to ensure
adequate and equitable satisfaction of needs. Reforms in long-term care
financing may require reevaluating the traditional federal and state
financing roles to better ensure an equitable distribution of public 
support for individuals with disabilities. The variation across states 
in Medicaid spending per capita on long-term care is in part reflective 
of differences among states in generosity of services as well as their 
fiscal capacity. Given these differences, having states assume primary 
responsibility for financing long-term care subjects individuals to 
different levels of support depending on where they live. In addition, 
because states’ revenues are sensitive to the business cycle and states 
generally must have balanced budgets, their services become vulnerable 
during economic downturns. 

* Adopting effective and efficient implementation and administration of
reforms. Proposed reforms to better meet the increasing demand for long-
term care within budget constraints will be successful only if they are
administratively feasible, effectively reach targeted populations and 
unmet needs, and efficiently provide needed services at minimum cost 
while complementing already available services and financing sources. 

* Developing financially sustainable public commitments. Finally, as I
earlier noted, absent reform, existing federal entitlement commitments 
for Medicaid, Medicare, and Social Security will represent an 
increasing and potentially unsustainable share of the economy. States, 
too, are concerned about their budgetary commitments for long-term care 
through their share of the Medicaid program. Before committing to any 
additional public role in financing long-term care, it is imperative to 
provide reasonable assurance that revenues will be available to fund 
its future costs. 

Mr. Chairman, this completes my prepared statement. I would be happy to
respond to any questions you or other members of the committee may
have at this time. 

Contacts and Acknowledgments: 

For future contacts regarding this testimony, please call William J. 
Scanlon or Kathryn G. Allen at (202) 512-7114. Other individuals who 
made key contributions include JoAnne R. Bailey, Linda Baker, John E. 
Dicken, Karen Doran, Romy Gelb, Rick Krashevski, James McTigue, Jr., and
Melissa Wolf. 

[End of section] 


[1] Based on our analysis of data from the Office of the Actuary of the 
Centers for Medicare and Medicaid Services and The MEDSTAT Group. These 
figures include long-term care for all people, regardless of age. 
Amounts do not include expenditures for nursing home and home health 
services provided by hospital-based entities, which are counted 
generally with other hospital services. 

[2] Through Medicaid home-and community-based services, states cover a 
wide variety of nonmedical and social services and supports that allow 
people to remain in the community. These services include personal 
care, personal call devices, homemakers’ assistance, chore assistance, 
adult day health care and other services that are demonstrated as cost-
effective and necessary to avoid institutionalization. In their home- 
and community-based services programs, however, states often limit 
eligibility or the scope of services in order to control costs. 

[3] Private long-term care insurance commonly includes policies that 
provide coverage for at least 12 months of necessary services—as 
demonstrated by an inability to perform a certain number of personal 
functions or activities of daily living—provided in settings other than 
acute-care hospital units. 

[4] For additional discussion of our long-term simulations, see U.S. 
General Accounting Office, Budget Issues: Long-Term Fiscal Challenges, 
[hyperlink,] (Washington, 
D.C.: February 27, 2002). 

[5] The specific ratios for the programs differ because of differences 
in the respective covered populations. Specifically, for Social 
Security, the ratio of covered workers to beneficiaries in 2000 was 
3.4. Under the 2001 Trustees’ intermediate estimates, this ratio is 
projected to decline to 2.1 by 2030. For Medicare Hospital Insurance, 
the ratio was 4.0 in 2001 and was projected to decline to 2.3 by 2030 
under the 2001 Trustees’ intermediate estimates. 

[6] Vernon Smith and Eileen Ellis, “Medicaid Budgets Under Stress: 
Survey Findings for State Fiscal Year 2000, 2001 and 2002,” prepared 
for The Kaiser Commission on Medicaid and the Uninsured (Washington, 
D.C.: The Henry J. Kaiser Family Foundation, Oct. 2001). 

[7] Judith Feder et al., “Long-Term Care in the United States: An 
Overview,” Health Affairs, May/June 2000, pp. 40 to 56. 

[8] “Aging into the 21st Century,” prepared by Jacob Siegel for the 
Administration on Aging, U.S. Department of Health and Human Services, 
May 1996. 

[9] Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. 
Department of Health and Human Services, who contracted with The Lewin 
Group, as published in Urban Institute, “Long-Term Care: Consumers, 
Providers, and Financing, A Chart Book,” (Washington, D.C.: March 

[10] Data from the Medical Expenditure Panel Survey show that the 
average annual expenditures for home health care for all elderly 
individuals was $6,041 in 1996 compared to average annual expenditures 
for nursing home care of $20,116 for those 65 to 69 years and $25,765 
for those 90 years and older. 

[11] Kenneth Manton and Xi Liang Gu, “Changes in the Prevalence of 
Chronic Disability in the United States Black and Nonblack Population 
Above Age 65 from 1982 to 1999,” Proceedings of the National Academy of 
Sciences of the United States of America, May 22, 2001, pp. 6354 to 

[12] U.S. General Accounting Office, Long-Term Care: Baby Boom 
Generation Increases Challenge of Financing Needed Services, 
[hyperlink,] (Washington, 
D.C.: Mar. 27, 2001) and Long-Term Care Insurance: Better Information 
Critical to Prospective Purchasers, [hyperlink,
bin/getrpt?GAO/T-HEHS-00-196] (Washington, D.C.: Sept. 13, 2000). 

[End of section] 

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