4 Projection results
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The projection results are presented in three parts. First, we look at future trends regarding the family network. Two important components of this network are presented: living arrangements and number of surviving children. The former provides the number of elderly living with a spouse, the main provider of assistance for those with a disability. The number of surviving children is also very important as those without a spouse may rely in some part on their assistance. The first part of the projection results can be seen as the supply of informal support from the family. Of course, this supply does not represent the whole informal network as friends and neighbours can also provide assistance to disabled elderly. Secondly, results showing possible trends in the disability status of the population are presented. As mentioned previously, our interest is in the assistance elderly people received because of a disability. If there are no disabilities, it is assumed that an individual should be able to perform the activities considered in this research.7 Although, an important proportion of disabled elderly do not require any assistance to perform these activities, projecting their number is the first step in trying to estimate the potential overall demand for services. Finally, the last series of results will show the number and proportion of disabled elderly using different sources of assistance. These results will show if the present patterns of utilization of services would result in a relative increase in the use of formal home care services, which is the main objective of this research.
The projection period extends to 2051, providing an estimate of what the Canadian profile could look like given patterns of home care service utilization observed in 1996. The figures presented show a solid line dividing the period 2001 to 2031 from the period 2031 to 2051. Extending the projected period to 2051 allows an examination of the Canadian context once all the baby boomers will have reached the age of 85. Of course, policies and behaviours will be different than they are nowadays, but the exercise helps in understanding what would happen when the baby boomers enter the oldestold population if the context would remain relatively unchanged. Although most of the analysis covers the 2001 to 2031 period, we will briefly comment on the results for the 2031 to 2051 period.
4.1 Availability of family network: the potential supply of family caregivers
Among the informal network, members of the immediate family are the main providers of assistance to disabled elderly. We are focusing here on two very important aspects of the family having a significant impact on the use of the formal network. First, trends in the proportion of elderly males and females living alone will likely affect the number of disabled elderly using formal home care services. The second aspect of these results looks at the proportion of elderly females who do not have any surviving children. Results presented in section 2.3 showed that the probability of using formal services does not vary greatly among persons who have children. If they have at least one child, the probability of using only the formal network changes very slightly. The main difference is between those who have at least one child and those who do not have any children. Our main interest is then to look at future trends in the number and proportion of those who have no surviving children.
Proportion of elderly persons living alone
Projection results point to a stabilization of the proportion of both elderly males and females living alone in Canada for the period 2001 to 2031. This simulation takes into account the fact that future cohorts of elderly persons will have gone through life with a greater probability of getting a divorce compared to today's elderly persons. This trend could point to an increase in the proportion of those living alone. On the other hand, the simulation also takes into account the fact that the gap in life expectancy favouring females will likely diminish in the future, just as it has been the case in the recent past. This trend, contrary to the increase in the probability of getting a divorce, has the effect of favouring joint survivorship and to lower the probability of living alone among the elderly population living in private households.
As can be seen in figure 3, the proportion of elderly females living alone is significantly higher than the proportion observed among males. This is not surprising considering the age differential at marriage – females marrying on average older males – and the differential in life expectancy favouring females. Also, males tend to remarry in greater numbers than females after a divorce or the death of a spouse. However, it is among females that we observe a decreasing proportion of people living alone, mainly between the 2031 to 2051 period. Over the entire projected period, the gap in the proportion of elderly females and males living alone decreases quite significantly; from 37% versus 16% in 2001 to 30% versus 17% in 2051. A lower proportion of older females living alone should, all other things being equal, lower the pressure on formal home care services in the future. However, results from section 2.3 showed that the effect of having a spouse is not nearly as significant for disabled females as it is for disabled males. Considering patterns of utilization observed in 1996, a significant drop in the proportion of disabled females living alone will lower pressure on formal home care services only if their spouse provides more assistance.
Proportion of elderly women without any surviving children
When we think of population aging we tend to focus on the increasing proportion of those over the age of 65 within the total population and their increasing number, especially when considering the gradual arrival of the baby boomers within that age group starting in 2011. The mechanisms that underlie population aging also have other effects. Lower fertility has been the major contributor of population aging over the last few decades. Its impact on the extent and the nature of the informal support network are also important. Parents of the baby boomers have, by definition, many children. These children have many brothers and sisters, but they also have fewer children. As far as we know now, the latter have few siblings and few children. This trend suggests a change in what will be expected from the formal and informal support networks in the future.
The analysis concentrates on those with no surviving children. As mentioned earlier, the number of children has a significant effect on the probability of using the formal or informal networks. This effect is mainly determined by having no surviving children at all compared to having at least one. Figure 4 shows that for females aged 65 years and over the proportion without any surviving children increases from 16% in 2001 to a high of 30% in 2051. Close to 1 out of 3 elderly women would be without a surviving child.
Although the proportion of elderly women without any surviving children increases steadily over the projected period, it is important to look at the trend in the different age groups. For the younger age group (65 to 74 years of age), the trend follows the one observed for the whole elderly population. However, the other two age groups show a different pattern. For the 75 to 84 age group, up to 2011 there is a downward trend; the proportion of elderly persons in this age group without any surviving children goes from 17% to 15% before moving up and reaching the 65 plus proportion (30%) in 2051. Of special interest is the trend observed for the oldest old (85 plus). This age group is the most vulnerable health wise and they are the ones who have the highest need for assistance. In 2001, this age group is also the one showing the greatest proportion of people without any surviving children. However, this proportion is decreasing from 22% to 16% between 2001 and 2021, before moving up to 28% in 2051. This trend is of course related to the aging of the baby boomers. In the first part of the projected period (2001 to 2021), the 85 and over age group is mainly comprised of the parents of the baby boomers. By definition these older cohorts had many children. However, as these cohorts are slowly replaced by other cohorts who had fewer children, the proportion of those without any surviving children increases. In 2036, results from the projections show that this proportion among the 85 and over age group will be roughly the same as the one observed in 2001. This suggests, at least in the near future, that the cohort, who is most likely to need assistance, will be more likely to have at least one child. In the short term, all other things being equal, this trend should ease the pressure on formal home care services.
Summary
When trying to assess the effect of the changing nature and extent of the family network over the next few decades on the demand for formal home care services, many factors should be considered. The microsimulation model provides a look at two of these factors: living arrangement (allowing us to look at spouseless individual) and the number of surviving children. These two trends point in different directions. First, the proportion of elderly persons living alone will be relatively stable from 2001 and 2031. There is a small increase among men while the trend is fairly stable for women. Since today's older males rely more on their spouse then do older females for assistance for everyday activities, there might be, all other things being equal, a small increase on the pressure for formal home care services. However, based strictly on this first factor, the period 2031 to 2051 seems to indicate a downward pressure as the proportion living alone should slightly decrease. Secondly, when looking at the presence of surviving children, the projections indicate an increasing proportion of elderly women without any surviving children. However, up to 2021, this proportion decreases significantly among the 85 and over population as the parents of the baby boomers constitute most of this age group. For the following period (2021 to 2051) pressure on formal home care services should increase as the baby boomers gradually join the oldest old, although the proportion of older females without any surviving children in 2036 will roughly be the same as observed at the beginning of the projected period.
Of course other important factors will affect the supply of home care services provided by family members. For example, expectations from older parents toward their children may be very different from what has been observed in the recent past. Also, even though we looked at the presence of a surviving child, we have not looked at the geographic proximity of those children. This is an issue that would need to be looked at in the future. The family network of tomorrow's elderly population will also be affected by an increased proportion of divorced individuals. Although the microsimulation takes into account the trend in divorce, we know very little about the assistance provided by stepchildren and children of divorced parents, especially assistance toward fathers. More research is needed in this area to better understand the effect of the changing nature and extent of the family network on the demand for formal home care services.
4.2 Disability status of the elderly population: the demand side
Of course, the main driver of home care services in the future is the number of disabled elderly persons. Demand is measured through changes in the rates of disability and severity among the elderly population and its affect on need for support. Explaining disability is quite complex and our model only accounts for age, sex, marital status, schooling level and province of residence. Factors like lifestyle, income, and past occupation are not accounted for. Nonetheless, the model allows us to project the number of disabled elderly better then a simple age by sex extrapolation.
This section is divided into two subsections. The first part presents results regarding disability among the population 65 and over while the second part shows results for the elderly population needing assistance. As mentioned in section 3.1, the analysis of disability and need for assistance is not part of the microsimulation, but instead based on results from cross-sectional surveys. We are looking at the factors associated with having a disability and not with those who are predictors of the process of disability.
Disability status of the elderly population
Three scenarios were produced to analyze future trends in disability among the elderly population living at home. The first scenario (constant scenario) simply applies the probability of having a given level of disability (none, mild, moderate or severe) as observed in 1996. These probabilities were computed after running a multinomial ordered logistic regression using data from the crosssectional sample of the 1996 National Population Health Survey.
Results of this first scenario show that there is about a ten percentage point difference between males and females in favour of the former (figure 5). For males, the percentage of those 65 and over with a disability varies from a high of 38% to a low of 34%, while for females the percentage varies from 47% to 43%. The trends observed are affected by the arrival of the baby boomers among the younger elderly in 2011 and by their gradual aging to the 85 and over age group in 2031. Younger elderly being in better health than the oldest old, the gradual journey of the baby boomers through the older age groups will affect the proportion of elderly persons having a disability.
As can be seen in figure 5, different scenarios produce very different results. In the case of an expansion scenario, where the probability of having a disability is increased so that persons of a given age have the probability observed for someone 5 years older than them, there is an increase of about 10 percentage points. In the case of the compression scenario – the probability of having a disability being decreased to the level of someone 5 years younger – there is a decrease of about 7 percentage points. As we will see later, the effect on the demand for formal home care services is relatively important depending on the disability scenario.
The proportions mentioned above are strictly for the elderly
population residing in a private household. Of course, in a
compression scenario we would expect less people living in an
institution simply because of lower rates of disability and lower
levels of disability. The opposite should be observed in the
expansion scenario. Table 1 presents the projection results
according to the different scenarios for 3 points in time. If we
consider that persons needing more assistance are those with at
least a moderate disability, adding to that those who live in an
institution, we see a major difference between the scenarios. If
the probability of having a disability stays stable at its 1996
level, 24% of the total elderly population would be in greater need
of assistance in 2001 compared to 23% in 2031, and 26% in 2051. In
the compression scenario, these proportions would respectively be
24%, 18% and 21%. In comparison, the expansion scenario shows
proportions of 24%, 29% and 32%. The difference between these last
two scenarios is very significant: In 2051 it is one out of three
elderly persons that are in greater need of assistance in the
expansion scenario compared to one in five in the compression
scenario. Although the growing number of elderly persons in the
next few decades is going to be the main driver of need for
services, the health of this population can play an important role
on the impact of the aging of the baby boomers on the demand for
home care services and long term care facilities.
The next section looks more closely at the need for assistance
knowing that an important number of those with a disability have no
need for assistance.
The elderly population in need of assistance: numbers versus proportions
The main objective of this research is to estimate the future demand for home care services. Disability is only one measure of the possible demand since not everyone having a disability is in need of assistance. The projections take this process into account so we have a better idea of what the needs could be in the future. As can be seen in figure 6, the proportion of those needing assistance is relatively constant throughout the whole period varying between 15% and 18%, the lowest point being attained in 2021-2026.
Although the proportion of elderly persons needing assistance might provide a rough measure of the health of this population, policy makers and service planners are obviously more interested in the number of elderly who might require home care services than in their proportion. For example, between 2001 and 2021 the proportion of elderly persons needing assistance slightly decreases from 17% to 15%. During the same period their number is increasing quite significantly from 619,000 to close to 950,000, an increase of more than 33%. As far as planning for services, these results are extremely important. The actual increase in numbers is the greatest for the 2021 to 2026 period, the constant scenario showing an increase of more than 160,000 for this period. According to this scenario, by 2031 the number of elderly persons living at home in need of assistance could have more than doubled. The increase then slows down considerably and for the last five-year period of the projections this increase is of only 11,000 people. At that time, the oldest cohorts among the baby boomers have past away and they are slowly replaced by cohorts relatively smaller. However, we would then have more than 1.5 million people in need of assistance. Of course, different scenarios of disability provide other results. These will be discussed in the next section.
4.3 Source of assistance and projected demand
We first looked at an important part of the informal network by studying future trends in the proportion of elderly persons living alone and future trends in the proportion without any surviving children. Then we looked at possible trends in the health of the population by using three scenarios of disability. In the first case, the analysis was done using transition probabilities within the microsimulation model. The second part was done using cross-sectional data looking at factors associated with different levels of disability and need for assistance. By combining these two approaches we get a picture at different points in time of the proportion and number of elderly persons using the three sources of assistance we have identified. Of course, this is all based on the patterns of utilization observed in 1996.
At the national level, data suggest that there will be a relative and absolute increase in the use of the formal network while there will be a relative decrease in the use of the informal network among disabled elderly for the period 2001 to 2031. In fact, during this period, the gap between the proportion of those using only the informal network and those using only the formal network almost disappears (figure 7). Moreover, when looking at future trends regarding disabled females we observed that the proportion using strictly the formal network may become more important than the proportion using strictly the informal network.
The impact of future trends in disability on the demand for home care services
Earlier, we mentioned the importance of numbers over proportions when planning for home care services. We also saw (figure 6) that the number of disabled elderly in need of assistance could possibly double between 2001 and 2031. These numbers reflected the impact of keeping constant the probabilities of having a disability observed in 1996. Our scenarios of compression and expansion of disability were specifically designed to estimate the effect of the health of the elderly population on the future demand for home care services. Using the constant probabilities scenario, the average annual growth rate of the population in need of assistance is 2.5% for the period 2001 to 2031 (table 2). The pressure on the formal network being greater than for the informal network, this growth rate increases to 2.7% for the former compared to 2.2% for the latter.
It is interesting to note the effect of different trends in the health status of the elderly population. In the case of an improvement in the health status of this population (according to the hypothesis presented in this document earlier), the average annual growth rate could be as low as 1.9% for the population in need and 2.1% for the use of formal home care services. On the contrary, an expansion of disability would increase significantly the annual growth rate of disabled elderly needing assistance between 2001 and 2031. The scenario presented in this document shows that it could increase up to 3.1% annually. As for the use of formal home care services, it could go up as high as 3.4% annually. Of course, the effect of population health also reflects on the growth in the number of elderly persons living in an institution. According to our scenarios, it could vary between 2.9% and 3.3%.
Policies regarding institutionalisation of disabled elderly will obviously have an impact on the number of people needing home care services. Future policies regarding institution versus home care issues being very difficult to predict, our results are based on data observed in 1996 regarding the rates of institutionalisation by age, sex and marital status while taking into account the probability of getting into an institution considering the level of disability of the person.
7 . For a definition of disability and the type of activities considered, refer to the text box "Definitions".
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