Population aging and the demand for long-term care: measurement, forecasts, and determinants

Abstract

Population aging is widely expected to increase the demand for long-term care (LTC). The magnitude of that demand, however, has largely been projected using metrics of population aging that reflect chronological age but not health. This dissertation reframes that demand as a question of population health, from the measurement of aging to its consequences for individuals. The first study reconceptualizes aging as a health phenomenon. Drawing on the Global Burden of Disease 2023, it derives two health-based metrics for 204 countries and 509 subnational locations, 1990 to 2023. Of 314 causes, 140 are classified as age-related. The burden of these conditions declined across all regions, through falling mortality rather than any compression of morbidity, and equivalent age, the age at which a population matches the global average 65-year-old, ranged from 42 to 77 years in 2023, a spread attributable more to differences in disease burden than to age structure. The second study forecasts LTC spending for the same countries to 2050, drawing on the morbidity of older adults alongside demographic and economic drivers. Global spending is forecasted to more than triple, from $1.1 trillion to $3.9 trillion, and to rise from a tenth to nearly a fifth of total health expenditure. Spending remains concentrated in high-income countries, and in more than 80% of countries the care implied by population need exceeds what their economies are likely to supply. The third study examines who enters formal nursing facility care and why. Using the US Health and Retirement Study (1996 to 2022) and a staggered difference-in-differences design, it estimates the effect of five acute health shocks on nursing facility entry among 27,842 adults aged 65 and older. Against a shock-free baseline of about 10%, the increase ranged from 7.0 percentage points after cancer to 15.1 after hip fracture. It was greatest among those without informal care and in poorer physical and cognitive health, whereas wealth and insurance were the weakest modifiers. The findings of this dissertation indicate that the demand for long-term care is shaped by both the size of older populations and their health, and that who receives it depends on the support around them more than on their economic resources. Preparing for that demand will require measures of aging that reflect population health, financing established before old-age dependency peaks, and support directed to those at greatest risk of entering institutional care.