Change is the process by which the future invades our lives. – Alvin Toffler, Future Shock
New laws, such as the Affordable Care Act, and new regulations or high-level policy changes can have a sudden and substantial impact on the health care delivery system. While the effects may unfold more gradually, a change driver such as shifting population demographics also has a substantial impact.
Over a sustained period, the US population has aged and become more culturally diverse. I believe that these population trends have found, and will continue to find expression in the adaptations that will be required of healthcare and human service provider systems.
First the facts
According to the US Census Bureau, by 2030 more than 20 percent of U.S. residents are projected to be age 65 and over, compared with 13 percent in 2010 and 9.8 percent in 1970. Census forecasting methodology is complex, reflecting things such as variable birth, death and net migration rates. Birth and death rates themselves are complicated subjects, reflecting both societal factors and advances in medicine, among other things, but the overall trend seems indisputably clear.
The census bureau projects that this trend in the relative growth of the over 65 population will continue through at least 2060. (These patterns are not necessarily the same in all other countries for an assortment of reasons. The largest increases in absolute numbers of older persons will occur in developing countries, according to the Centers for Disease Control and Prevention (CDC).)
So the aging of the US population is one demographic trend to pay attention to, but not the only one. In the United States as a whole, the white non-Hispanic/Latino percent of the population is declining, while Hispanic, Asian and Black populations grow. The U.S. is projected to become a majority-minority nation for the first time in 2043. While the non-Hispanic white population will remain the largest single group, no group will make up a majority.
It’s worth noting that the shift to a more diverse nation is happening more quickly in some places than in others – there is considerable variation in this overall national trend in specific US states and counties, suggesting that different communities are and will be facing different rates of change and change dynamics.
I believe that the combined effects of these trends on the healthcare provider community will continue to gradually fan out in a number of directions, among which will be:
- The demand side in the chronic, long term care services sector
- The type and complexity of conditions seen by the primary care sector as aging baby boomers walk through the clinic door
- Likely workforce shortage and challenges
There are perhaps less obvious implications, such as the aging of family caregivers of clients in the IDD sector who may no longer be able to count on these family resources for essential community supports.
Where population trends and provider systems meet
The demand side in the chronic, long-term-care services sector
The number of Americans who need long-term care is expected to increase to approximately 27 million in 2050. The Centers for Disease Control (CDC) has said that “the demands associated with long-term care might pose the greatest challenge for both personal/family resources and public resources.”
What will this look like? Long-term services and supports (LTSS) refers to the types of assistance provided to people with functional or cognitive limitations to help them perform routine daily activities. According to a Congressional Budget Office report, about 80 percent of elderly people receiving such care live in the community; the remaining 20 percent obtain assistance in institutional settings. In the community, elderly people with functional limitations receive assistance primarily from family members and friends; they may also pay for assistance from long-term care workers, such as home health aides.
Taken together, these data suggest that the need for community-based long- term services and supports will increase; that the burden on family caregivers will continue to increase; that the demand for home health services is likely to increase; and that there will be some increased demand for institutional alternatives such as assisted living.
The type and complexity of conditions seen by providers in the primary care sector
The CDC has observed that “…The world also has experienced an epidemiologic transition in the leading causes of death, from infectious disease and acute illness to chronic disease and degenerative illness.” The CDC finds that 80% of all persons aged >65 years have at least one chronic condition, and 50% have at least two (such as diabetes or Alzheimer’s disease).
Such chronic conditions can also lead to disability, requiring the type of long-term services and supports mentioned above. As the population continues to age, primary care caseloads will likely see an increase in the number of people with multiple chronic conditions and disability. This is significant for many reasons; notably that the cost of healthcare tends to rise in populations with multiple chronic conditions.
Workforce shortage and recruitment considerations
The provider community will have to continue to retool to be responsive to ethnic-cultural needs and expectations of a more culturally diverse population. This may also have substantial implications for workforce recruitment. For example, different cultures have different norms and beliefs regarding whether and how issues such as mental health problems are or should be understood and discussed. Cultural beliefs can influence beliefs about the origins and nature of mental illness, and shape attitudes towards the mentally ill. Different cultures may experience different levels of stigmatization for the same problem, and this in turn can affect whether or not individuals choose to seek treatment and whether or not to accept treatments that are offered.
A truly responsive and effective provider system must recruit and develop a workforce that is attuned to cultural differences, or fail to optimize access and outcomes for significant segments of the population. There are already challenges in some communities where healthcare workforce recruitment struggles to keep up with healthcare workforce needs. This extra dimension of needing to also recruit professionals who can respond to the growing cultural communities they serve may add significantly to that challenge.