Bob Long: We all know it's coming. Some Baby Boomers have retired and many others are preparing for that day. But as the boomers reach their 70s, 80s, and beyond, how are we going to meet their health care needs? How will we meet their needs for appropriate places to live? I'm Bob Long. Welcome to Stats and Stories, a program that looks at the statistics behind the stories and the stories behind the statistics, and our focus this time is on issues of our aging population and just what lies ahead for them. Before we talk to our special guest about this issue, we asked our Stats and Stories reporter Emily Sullivan to chat with a couple of people who deal with this issue on a regular basis.

Emily Sullivan: They were known for bucking a system of traditional values in the 1960s. Now the Baby Boomers are in the news again. The largest generation in nearly a century is growing older, but nursing home occupancy rates are decreasing. The Director for Community Relations for Lifespan in Hamilton, David Mancuso, says the reasons behind this trend are simple.

David Mancuso: I don't know that a lot of people years ago really asked older adults what they wanted. I mean, I think it was just like here's what you do when you get old. You move into a nursing home. We need to ask that question, what do they want? A lot of the research that's coming out of the Scripps Gerontology Center right now is suggesting that older adults in Ohio and Butler County prefer home and community based services rather than nursing home levels of care.

Sullivan: Mancuso says the next step is to prepare for these changes and enable older adults to age comfortably. Miami University economics professor John Bowblis studies the effects of regulatory policies on elderly care. He says the recent financial crisis created complications. Because Medicaid makes up the largest part of the state budget, it was the first to get cut, affecting nearly 60% of all nursing home patients. While i-home and assisted living options seem to be sufficient and popular alternatives now, Bowblis' research makes him cautious about the future.

John Bowblis: What we can say is that by the age of 85, about one in every two people is going to use a nursing home at some time. So if we believe that those trends are static, meaning that they sort of stay the same, we're going to see a spike in about 10 to 15 years.

Sullivan: The question is whether we will be ready for this spike. Bowblis says the continuing decrease in nursing home occupancy could lead to capacity problems down the road.

Bowblis: What I'm concerned about is: are there enough nursing home beds that are going to be available in ten years? Right now is seems like everything's okay. What we need to do is make sure that we're planning and we're not letting facilities even though we need them in the future.

Sullivan: The Scripps Gerontology Center at Miami University has been a major player in pushing these issues forward in the legislature. In collaborating with Scripps, Bowblis believes Ohio is ahead of the curve.

Bowblis: Ohio tends to be one of the cutting-edge states to deal with these issues. So as a state as a whole, are we prepared? I think there's more that we need to do, but we're more on the frontier that other states. We're dealing with those issues a lot better than other states.

Sullivan: Scripps and Bowblis have collaborated for the past four years in this area and plan to continue conducting research. They are giving organizations like Lifespan the necessary data to forecast future trends and plan accordingly. For Stats and Stories, I'm Emily Sullivan.

Long: Thank you Emily. And joining us now on Stats and Stories for our discussion of the aging population, the man who comes up with these ideas for our monthly topics, Miami University Statistics Department Chair John Bailer and our special guest Suzanne Kunkel. And Suzanne is the director of the Scripps Gerontology Center, which is well known, as Emily alluded to, for its research on making lives better for our seniors. I have to throw in a disclaimer here Suzanne, I have a vested interest in this as a Baby Boomer, but I do think it's a great topic, because a lot of people know we have this huge bubble of people who either are retiring, or have already retired, and what's going to happen? What does your research show us about that particular issue?

Suzanne Kunkel: Well, one of the incontrovertible facts that our research shows and the research of other scholars as well, is that our population is aging. Nothing is going to stop the rapid aging of our population, the unprecedented number of people who will cross that threshold of the magic age of 65, so the growth of the older population is very clear. What's interesting are all the other questions related to, why does that matter? What does that mean? What will life be like? What are the changes we need to make as individuals, as communities, as societies? How should families prepare? So population aging, individual aging is a reality and the other questions are all about, well what does that mean? What do we do?

Long: John Bailer…

John Bailer: Suzanne, quick question. You said that age sixty-five seems to be like that magic age for a lot of discussions of this. And as we talk more about people staying in the workforce longer and the workplace longer, why did 65 get this, almost magical cut-point value? And do you anticipate that changing in terms of our mindset and the future?

Kunkel: Very definitely. Sixty-five really became that magic age, partly because it was the eligibility age for retirement benefits, and in the days that we had mandatory retirement, it was the age at which you were expected to retire. It had everything to do with eligibility, but underneath that were some assumptions about 65 being a good marker for a significant accumulation of changes that maybe made us not as valuable in the workplace. All of that is up for grabs these days. In fact, there are people who talk about “65 is the new 55, or the new 45,” and that's because we're living longer, we're living healthier, we are more interested in a wide range of options, so 65 still remains that administrative marker for lots of things. There are some programs that you are eligible for when you're sixty. There are some issues, such as the nursing home issue, in which 65 is not the age we should be looking at, we should be looking at 85. So what is old? When are you old? Why does it matter? It's all up for grabs.

Bailer: I like the idea of this assertion that 65 is the new 55, given as I'm approaching this. I have a vested interest in how this is reinterpreted. As someone who is a demographer, I'd like you to tell us a little bit about what that means. I would think that when 65 was set, there was a certain expectancy of life in the population; there was a certain typical life span. And so when you think about when 65 was set as this magic cut-point, what was the expectancy of life at that time? And has that changed?

Kunkel: That's a great question, and before I answer that, I do want to say that one interesting thing that research has shown, and anecdotally we know when we ask people, “Well what is the cut-off for old?” We tend to say an age that is about 15 years older than we are. I'm 61, so for me, mid-seventies. But you're point about the marker for age being related to life expectancy is exactly where this idea that 65 is the new 45 or the new 50 comes from. The demographers that have worked on this idea of prospective longevity; they're looking at how long we can expect to live, and then looking backwards from that to come up with new markers for “when are you old?” It is related to how long we are expected to live. So 65 was old when it became established as that marker. Well, we used 65 for Social Security in the 1930s, and life expectancy wasn't much more than that, actually. So the expected length of life has a lot to do with when we think old age begins, or when we think we can afford to make programs eligible to older people.

Long: I think one of the great questions, and the two of you, the questions you've been talking about here kind of ties into this, but from the studies you are talking about, I might retire at 65, 66, 67, but as far as the impact that we're really going to see on health care, that doesn't really come until much later. Things I know from my own family, and watching how things happen.

Kunkel: Absolutely, and I'm glad to have the opportunity to talk about this issue of health care for lots of reasons. First of all, absolutely, when we're talking about providing care for people as they age, we're generally talking about long term care, to help with activities of daily living, to help with getting by in your everyday life. We're not talking about the type of health care we use for the rest of our life; acute care, when we get sick, we get fixed, but for people in later life, it's about managing chronic conditions, and living well with whatever conditions you happen to have. The vast majority of us will be dealing with chronic conditions. There's another side to health and health care that I think deserves equal attention and that is health promotion and health prevention. So if we talk about the 85+ population, what are the long-term care systems we need in place? How many people are going to need nursing home care, even if it's just for short-term rehab? What does that industry need to do? What other options do we have for providing in-home care? That's a whole set of questions, very important that we do a lot of work in that, but if we think about aging as covering a very large number of decades of life, what your average 60-year-old needs, or 65-year-old wants, we're not talking about long-term care. We're not talking about health promotion. We're talking about continued engagement in our communities; we're talking about opportunities to continue to contribute.

Bailer: As a follow-up to that, you talk about these big ideas and thinking about planning. There's sort of a planning dimension to this. There sure is a stat part of story for this, so how do you and some of your colleagues at the Scripps Gerontology Center use information, and what kind of information do you use? And how would you use some of these data, this information, to make these types of projections?

Kunkel: We do a lot of work for the state of Ohio, and in particular, on exactly this question of projecting the size of the older population, projecting the proportion of that population that will have some health care needs, and then making that information as widely available as we possibly can. So recently, based on the 2010 census, we made maps showing how each county in Ohio has changed over time and is projected to change over time. So we use census data and then we use traditional census techniques to project the older population based on how long we can expect to live, and on migration. One of the interesting things when you're looking at population change is that at the county level, people moving in and out has a big impact on the relative size of the older population, so our county maps are wide-spread; they're on the walls of offices all over the state for agencies that are planning services for older adults.

Long: You're listening to Stats and Stories, where we talk about the statistics behind the stories, and the stories behind the statistics. And we're focusing today on the whole issue of providing care for our aging population. I'm Bob Long. With me are our regular panelists, Miami University Statistics Department Chair John Bailer and the Director of Miami's Scripps Gerontology Center Suzanne Kunkel. We also thought it would be interesting to go out on the street and find out what people know about these issues. So we wanted to ask a few folks on the street what percentage of our population is currently at retirement age.

Man on the street #1: I'm going to go with about 35.3%.

Woman on the street #1: Probably, maybe, I'd say 40%.

Man on the street #2: Thirty percent. Right around there.

Woman on the street #2: I'm going with 30%.

Man on the street #3: I'd say I only think about, maybe 35%.

Man on the street #4: Three thousand people a day, 5%?

Long: All right Suzanne, now we'll ask you, the expert, what about that? People that are currently at the retirement age.

Kunkel: I'd have to say it's a complicated question to answer, because retirement age is defined, it's a definitional issue, so I think what most people mean when they say people at the retirement age, they are thinking 65. It goes back to when are we old? But even the Social Security program in the United States, one of the programs that was built around that age, 65, things have changed. You have to be older now to qualify for your full Social Security benefits. So if someone wanted to know what proportion of our population is retirement age, I would say, “Well what age is that?” If we want to know what proportion is 65 right now, it's about 13% of our population is age 65 and above. And that is going to increase steadily until all the Baby Boomers reach that magic marker and at that point we'll be between 20-22% of the population will be 65+.

Long: John Bailer…

Bailer: In other parts of the world, they're certainly challenged with this, and some places in the world, there is even a more dramatic shift to this. So what are the consequences of this type of transition? There are going to be additional demands, perhaps on the state budget that will come from this. Are there things that are learned from other international aging issues that might inform things that we see here?

Kunkel: That's a great question, and one of the topics we are increasingly focusing on at the Scripps Gerontology Center is global aging. My first short answer, I want to tie it back to the definition of what is old. So when you look at international data on the aging population, you will often see 60 used as the cut-off age because life expectancy is so much shorter, so 60 is a marker for old age in countries where life expectancy may be 40 or 60; that's one point. The other point is that we have so much to learn from what's happening in other countries around the world and population aging is happening absolutely everywhere. It's happening at a different pace; it's happening within a different cultural context. One of the challenges for some of the developing countries is that they are going to age so much more rapidly than the United States did, or in Western Europe. So demographers use 7% of the population being older as a marker for a young society and then when we move up to the 14% that 60 or 65 and above, then we're old. It will take the US about 75 years to make that transition. In France, it took 110 years to make that transition. We have countries that are going to make that change in 20 years. Thailand, Korea, a number of other Asian countries are making that transition from a young society to an old society in 25 years or less.

Bailer: So that sounds like some issues related to changes in birth rates, or fertility. So you had said, as a demographer or a demographic perspective, can you tell us, what is a demographer? What kind of stuff do you do as a demographer?

Kunkel: Well, I hope my major professor will listen to this definition I memorized. Demography is the study of the size, distribution, and composition of a population as shaped by fertility, mortality, migration, or changes in the characteristics of a population. So it's everything related to pictures of people.

Bailer: As a follow-up, there's a lot of factors here at play, so from the perspective of trying to represent and do prediction in this type of context, you've got rates that you probably have to get some kind of estimate of them, these different migration patterns, fertility, mortality, all these other components, so there's some uncertainty. When you've reported some of these estimates, thirteen percent or these other percentages, how does uncertainty play out in this, and how do we communicate that uncertainty to a broader community?

Kunkel: As in some other fields of study, we rely heavily on our assumptions and making our assumptions clear. So you're right, in just predicting the size of the older population or the size of any age group, we have to know about fertility, we have to about mortality, and we have to know about migration. Every one of those factors requires some assumptions about what's going to happen. We use trend data, what's happened in the past. We are actually pretty good about predicting mortality because that trend has been pretty steady in one direction. Migration, when you're talking about a county, anything can happen. So if an industry shuts down, you lose a lot of your working-age population, and now you're left with a higher proportion of older people, so migration is a little less predictable, but again, there are techniques where we use census in tracking the amount of change that a particular unit has experienced. One of the tricky ones is fertility, that's a little bit less predictable. There are so many factors that affect decisions about how many kids to have. And then when you want to look at things like well, what are the characteristics of the population? What's the health status? What's the disability level? That again, we have to go to all the good data sources that we have and then we have to make clear our assumptions.

Long: As we're talking here, it brings me back to a study I saw a few months ago talking about the age of retirement in different countries around the world. I was trying to draw on the fact that well, in certain countries, you retire at age 62, and if you do, you live longer, and if you work longer, as we're kind of doing in this country, what kind of things do you see? When I saw that, I thought, well is that really true? As you mentioned, there are other things about mortality rates in other countries that are totally different from our own.

Kunkel: Well, some countries don't have retirement ages because retirement is simply not a fact of life. People don't live long enough, and there are not formal retirement systems in place to even make the question of how old do you have to be before you can retire even relevant. There's that whole set of countries where retirement is not a formal stage of life, now is supported with any kind of public funds. Then you have the set of countries that have a lot of network, a lot of policies in place to support the citizens of those countries. Those tend to be the countries with earlier retirement ages and good pension benefits, but even those countries are now facing the demographic reality that there are too many people drawing on a system that is not funded well enough. So there are changes taking place in every retirement system to deal with the growth of the aging population.

Long: You're listening to Stats and Stories, and we're focusing today on what the future holds for our current senior citizens, as well as those who have to take care of them. We're talking to the children, my own children that have to deal with that. I'm Bob Long and with me today, our regular panelist, Miami University Statistics Department Chair John Bailer and the Director of Miami's Scripps Gerontology Center Suzanne Kunkel. Before we get to our next set of questions, we also wanted to see what people thought about how much of the state budget here in Ohio actually goes toward the care of our seniors today.

Man on the street #5: Five percent, that's my guess. I have no idea.

Woman on the street #3: I'd say maybe 20% of the budget.

Man on the street #6: I'm going to stick to my guns, 30%.

Man on the street #7: Forty percent.

Woman on the street #4: I have no idea I want to guess a low percentage. I'd say, 10%?

Man on the street #8: I'd say only 40-45%, maybe less because I know Ohio ain't big on the retirees and helping them along, for whatever reason.

Long: So Suzanne, we'll ask you that question, not that we expect you to have an exact statistics, but roughly how much of the budget goes to elderly care in Ohio?

Kunkel: Well again, a good question, a complicated question. The closest we can come to answering that question is to focus on Medicaid because Medicaid is the public program that helps to fund long-term care for older adults. Right now, about 30% of the state budget is Medicaid, but Medicaid also covers health care for people who are poor, no matter their age. It turns out that of that 30% of the state budget, a significant amount of that goes to pay for long-term care, and there we're talking about care for older adults. So it's one of the reasons that all the demographic work is so useful, projecting the impact on the state budget, projecting the impact on the existing service system. Frankly, it is not appropriate for the aging Baby Boomers, we cannot sustain the system that we currently have, or the state budget would be entirely consumed by Medicaid. That's an exaggeration, but not much of one.

Bailer: So you're talking about the central support at a state level. But as individuals, we might be thinking about this, planning; planning not only for us, but perhaps for loved ones, as we think about care for aging. So there are some dimensions of this. Certainly there has got to be things that we think about, how much should we be setting aside? Should we be banking on the fact that we might need long-term care at some point in our future, and be purchasing insurance because we are thinking about risks of this occurring. How would we judge the quality of some of the care providers, and how do we go about systematically studying and evaluating quality of care providers?

Kunkel: I'm noticing a theme in all of those questions, John, and that would be: do we have data? Do we have numbers? Can we assess our risk? And the answer is yes, yes, yes. We do have information on that. There is also though, this interesting psychological dimension to planning and how hard that is for us to really envision our own future as older people, but we certainly should be, as you heard from John Bowblis, when we get to be in our eighties, about half of us are going to use some kind of long-term care. And actually, it's an even higher percentage if you consider the care we get from our family members. So the vast majority of us are going to have some sort of need for assistance for activities of daily living when we reach our eighties. What we should be planning for is a fair certainty that we're going to need so sort of help, so then you have to start thinking about well what are my options? Long-term care insurance is a growing industry. It makes lots of sense to insure for something that is very likely to occur, but the challenge is that we want other options. We want our kids to take care of us. We want to maybe self-fund, hoping for the eventuality that we won't need long-term care insurance. The whole concept of insurance, and what we insure for, what we insure against, and why we do insure for some things and not for others is a really interesting issue, but certainly if we looked ahead, and we all want to live long enough, and we all want to live healthy, we don't want to think that we might need long-term care. But the fact is, we should be planning for it.

Bailer: So what we're all kind of doing is this risk projection. So Bob has talked about having long life in his family history…

Long: Yeah. Great-grandmother, 94. Grandfather that was 94. My dad died a year ago at age 90. My mom is now 90, so I'm looking at all this. The thing that I find interesting is that there are certain families, though where maybe cancer, or heart disease are constant risks, so is it possible that sometimes as you're planning the future, you're thinking well, my partner's health situation may be worse than mine, maybe does that person need more long-term care? Does it make more sense to do that and maybe I should look at other options?

Kunkel: There definitely a lot of options that people have to consider and you raise one very important point, and that is who are you planning for? Are you planning for your household? You and a spouse? You and a partner? Are you planning just for yourself? And how do you factor in all the possible risks that you will be facing? I guess the most important thing about long-term care planning is that we should be planning for it and we should be thinking about it and talking about it and having those conversations now. The last thing you want to do it wait until there is a crisis that forces you to make a decision because you can't stay at home or alone any longer. Planning, thinking, stating your preferences, working it out with the people around you who are going to help you make this happen is really a good idea.

Bailer: So as part of this show, we call it Stats and Stories, I guess I'd like to see what your take is on what statistical ideas are key to understanding and planning and thinking about aging. And then, also, to complement that, what's the story that you would tell, if you could reach out and share ideas in sort of both these arenas, what would those be?

Kunkel: With respect to long-term care planning, or…

Bailer: To anything. You get a blank check here Suzanne.

Kunkel: Oh my gosh, that's dangerous, but I'll take it. I guess looking at things from a population perspective, we have huge decisions and opportunities ahead of us as an aging society, as an aging state, as an aging community, and there's just no denying the fact that we are reaching an unprecedented stage by having so many older people, so I don't know if that's statistical, really it's arithmetic. We've got a lot of numbers that we should be dealing with in terms of maximizing opportunities, but also in terms of planning. At the individual level, I think we all are interested in what's going to happen to me, and going back to Bob's question, well how do I factor in that in my family cancer is common, but in my partner's family, it's not common, and who's going to need what? You can look at all the data; there's plenty of data about how much is your risk increased if your father had a certain kind of cancer. You can look at all of that, but at the end of the day, information is really valuable, data is valuable, assessment of risk is valuable, but it comes down to a human process of figuring out what risk am I willing to live with, what risk ask I willing to ask my family to live with, and what am I going to do about that?

Long: Interesting thought I had, because Baby Boomers, we got knocked around sometimes for being naughty in the 1960's but the interesting thing I find is my parent's generation was very closed-off; there were certain things you don't talk about. I don't want to say they didn't plan for the aging process, but it seems to me that I'm much more likely to involve my children. How important, as a demographer, would you say, you mentioned how a lot of the time, the family is your responsibility, as a child, you're taking care of that elderly parent, and that's what they expect of you.

Kunkel: There's a line that's hard not to cross between demography and social gerontology here, but in terms of family expectations, that's really a cultural issue, and in America, it is the case that our family and friends tend to provide the vast majority of care that we receive, the non-medical care that we receive. But if you're depending on your family the same way our parents depended on their family, you're probably taking a pretty big risk because there are fewer kids, and the kids are more mobile. It's not that our cultural values have eroded, or we don't care about our aging parents, but the realities of the economy and where you have to move to get a job means the availability of family care-givers has decreased significantly over the past several decades.

Long: That's a great point. John, I'll turn to you as we're about out of time to let you ask our last question here today.

Kunkel: I know he's going to make it a hard one.

Long: I saved the best for last here.

Bailer: Oh never, never. I think about this and you're trying to make plans and make projections of risk, so you're saying there's almost a sure thing and what's my chances, and what kind of variables do I consider as input into this, and I know that I can't measure things perfectly, and I know that I don't have perfect prediction and models, and I might make a mistake. I might make the mistake of buying insurance and I don't need it. I might make the mistake of not buying insurance and needing it. This balancing of the errors, and thinking about that, do you think that people do that? Do you think people do it really informally and in the background of their thinking?

Kunkel: That's a great question, and I do want to just clarify that the certainty of needing long-term care, it's not a 100% certainty, but if we think of the short-term stay following a hip fracture or something like that, it is wise to accept the fact that somebody in your household is probably going to need long-term care; I don't want to say it's 100%. It's important to put those boundaries around that. So do people calculate, do people decide how much risk they're willing to take, how much mistake they're willing to make? I would say in general, not so much. It's more that we go along, day by day, living our lives, dealing with things as we have to. One of the values of the field of gerontology is making us all more aware of what the aging process is, in a good way, and what the aging process might bring, in terms of health challenges. I have colleagues that do research on this very topic of how do people plan? How do people decide to plan? What risks do they take? Why do they take them? What mistakes are they willing to make? But I think in many cases, it's not a rational process of calculating cost and benefits of particular mistakes.

Long: Suzanne Kunkel, we want to thank you very much for sharing all your expertise on this very interesting subject to so many people. Of course, Suzanne is the Director of the Scripps Gerontology Center at Miami University. Thank you again, Suzanne.

Kunkel: It's my pleasure.

Long; And thanks to John Bailer, Chair of the Miami Stats Department, for being with us today. We would also like to remind you that if you have thoughts about our program or have ideas of a future show you'd like to hear, you can email us at statsandstories@miamioh.edu. Be sure to listen for future editions of Stats and Stories, where again we'll talk about the statistics behind the stories, and the stories behind the statistics.