How an Increasingly Diverse Population May Shift the Future of Long-Term Care

Older adults and their families are faced with a number of decisions surrounding the provision of long-term care. One of the most basic decisions is whether that care should be informal—usually provided by family members—or should take place within a formal care system composed of community-based services, residential facilities, and skilled nursing residences. Some of these decisions will be dictated by finances and the level of care needed for an older adult, but cultural values and norms will also play an important role. And as the population of older adults in the United States becomes more diverse, there could be significant implications for the demand for formal long-term care.

The policy implications of how diversity might impact the demand for formal long-term care were recently addressed in an article in the Public Policy and Aging Report. In this article, the authors examine how growing diversity might influence the public-private mix of care. Differing cultural values and norms are going to influence perspectives on what the authors describe as “core social questions about whether families should be considered the care providers of first-resort or whether families should be spared this responsibility by the formal service sector and various forms of long-term care insurance.”

One particular concern from a policy perspective is “whether cultures that emphasize the primacy of families will inhibit the development of public policy initiatives to subsidize the cost of long-term care, particularly care that is delivered at home.” With respect to this question, the authors note that current studies suggest that individuals with strong value orientations toward adult children providing for their parents prefer to rely on personal resources to meet long-term care needs.

Turning to demographic changes in the United States, the authors note that by 2050, nearly 1 in 3 US residents will be Hispanic, compared to 1 in 6 currently. Similarly, the percentage of Asians is expected to increase from 5.1 percent to 8.2 percent of the total US population. Among older adults, it is predicted that by 2050 almost 4 in 10 will be from a minority group, doubling the percentage in 2012. In particular, the Hispanic proportion of older adults is expected to increase from 7.3 percent to 18.4 percent. Hispanic and Asian populations are of particular interest since their proportion of the US population is rising most rapidly, and because these are also the ethnic groups most likely to live in households that include an older parent.

However, the authors caution against making oversimplified assumptions about preferences of minority populations. They note an openness among minorities to accept formal care as a solution to financial difficulties that might be caused by informal caregiving. They also note that values among minority populations are changing over time. For example, more older Asian Americans are reporting that it is acceptable for their children’s success to come at the expense of their caregiving commitment to their parents.

Where there is a cultural willingness to provide support for older family members, there will also likely be political support for informal caregivers in the form of options such as respite, home health services, and cash payments to informal caregivers. The authors note that “this represents a cost-effective leveraging of the existing social resources of older adults.”

The authors also note that those ethnic groups that value a family contribution to caregiving could set the conditions for a hybrid model of care, where there is greater coordination and cooperation between informal caregivers and formal services when the need for formal care emerges. Family members could express their cultural values of caring for parents, while formal services could reduce the heavy burdens that caregiving can sometimes impose on family members. The authors also note that, “Formal services may release the care potential of ethnic minority and immigrant families by allowing them to focus their care on what they do best—providing emotional support, monitoring the well-being of their loved one, and offering household assistance.” Such cooperation has been shown to increase efficiency, reduce caregiver burnout, and prevent institutionalization. However the authors also note that the demand for formal support for such an arrangement already exceeds supply. Significant political support (which minority populations could provide) and public financial resources would be needed to make this a reality for the rapidly growing elderly population.

A growing minority population and the values and norms held by these individuals will likely play an important role in shaping the landscape of long-term care in the United States in the twenty-first century, and policy decisions will need to contribute to this changing landscape in order to meet the needs and preferences of an increasingly diverse American population. Such diversity poses challenges as well as offers opportunities for potentially reducing the load on and demand for formal caregivers. However, the preferences of minority populations need to be heard by policy makers. As this article concludes, “Whether formal services with cultural sensitivities can be expanded to cover the growing and diversifying older population depends not only on political exigencies but also on public demand.”



Silverstein M and Wang R. Does familism inhibit demand for long-term care? Public policy implications of growing ethnic diversity in the United States. Public Policy Aging Report. (2015). prv016 DOI:10.1093/ppar/prv016


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