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The Rise in Old-Age Longevity and the Market for Long-Term Care
老年寿命和长期照顾市场的上升
DARIUS LAKDAWALLA AND TOMAS PHILIPSON
In many countries around the world, the demographic transition into reduced fertility and mortality has forced the private and public sectors to grapple with the care of rapidly aging populations. Since 1960, the share of the U.S. population above 65 years of age has grown substantially, from about 9 percent to 14 percent. Other developed countries have experienced even more rapid growth. For example, in many European nations, the elderly population accounts for nearly one-fifth of the total population, and growth in this share has been larger than in the United States over the past few decades. As the elderly population has grown，the share of GDP devoted to long-term care for the elderly has grown as well. This rapid growth has stimulated interest in the study of how private markets for long-term care function and how they are affected by various forms of public intervention.
在世界上许多国家中，人口统计学在降低人口增殖和死亡率上的转变迫使私营和公共部门关注迅速增长的老龄化群体。从1960年开始，美国人口中超过65岁的人群比例迅速从9%增长到14%。其他发达国家的增长更快。例如，在许多欧洲国家，老年人口数量占据了总人口数将近五分之一，这一比例的增长比过去几十年美国的增长比更大。随着老龄人口的增加，致力于长期照顾老人的国内生产总值的份额也有所增长。这种快速增长刺激了对私人市场长期护理如何运作以及如何受到各种形式的公共干预影响的研究的兴趣。
Concern about the importance of long-termcare has further intensified, because several key market forces in the United States have combined to exert tremendous upward pressure onthe market output of long-term care. First, the share of output that is publicly financed by Medicaid has grown enormously, from about 24 percent of 1971 nursing home bed-days to about 65 percent of 1991 bed-days. Second, from 1920 to 1940, birth rates fell by almost 30 percent. Compared to her 1970 counterpart, a 70-year-old in 1990 had far fewer children to care for her in lieu of a nursing home. Third,compounding the effects of declining fertility,the rising human capital, wages, and labor-force participation of young to middle-aged women has increased the opportunity cost of family-produced care, which is provided predominantly by daughters rather than sons. In 1970,53 percent of women between the ages of 40 and 55 participated in the labor force, but by 1990 this labor-force participation rate had climbed to 74 percent. Finally, towards the mid-1980rsquo;s, entry and investment barriers in the nursing home industry, erected by Certificate of Need laws, were relaxed considerably; the resulting increase in the supply of nursing home beds served to expand the output of long-term care even more. Since this combination of forces has worked to drive up per capita market demand and supply, one would suspect that long-term care output should have grown faster than the elderly population.
因为美国的几个关键市场力量对长期护理的市场产出产生了巨大的上涨压力，对长期护理的重要性的关注进一步加剧。首先，医疗援助公开资助的输出份额大大增加，从1971年养老院床位的约24％增加到1991年床位的65％。第二，从1920年到1940年，出生率下降了近30％。与1970年的相对比例相比，1990年的70岁老人的孩子相对于来说要少一些，代替养老院。第三，加强生育率下降，人力资本上涨，工资和劳动力参与对年轻妇女的影响，增加了家庭护理的机会成本，而这些机会成本主要由女儿而不是儿子提供。 1970年，55.3％的40岁至55岁的妇女作为劳动力，但到1990年，这一劳动力参与率已经攀升到了74％。最后，到八十年代中期，由“需求法”建立的养老院工业进入和投资壁垒大大放宽了;因此，护理床位供应量的增加，有助于扩大长期护理产量。由于这种力量结合，推动了人均市场需求和供给的增长，可以认为长期护理的供应应该比老年人增长得快。
美国经济回顾
图1.家庭居民护理相关增长维持老年人口相对增长
However, Figure 1 demonstrates that this has not been the case in the United States over the last few decades. The figure compares the growth since 1971 in current nursing home residents to the growth in the population over the age of 75. From Figure 1, we learn that growth in nursing home residents has rapidly decelerated since 1971 in spite of constant rates of elderly population growth: specifically, in the mid-1970rsquo;s, the resident population grew at a 4.8-percent annual rate; by the early 1980rsquo;s, this annual growth rate had plummeted by almost two-thirds to 1.7 percent; finally, during the late 1980rsquo;s and early 1990rsquo;s, the growth rate dropped further, to a mere 0.4 percent per year. Nursing home growth has decelerated in spite of relatively stable growth rates for the elderly population: the population over 75 has grown at a roughly constant annual rate of 2.7 percent for the past two decades. As a result of these divergent trends, the resident population grew at twice the rate of elderly population during the 1970rsquo;s, but at less than half of this rate during the 1980rsquo;s and early 1990rsquo;s. In fact, per capita output contracted so sharply during the 1980rsquo;s that it more than offset the growth that occurred during the 1970rsquo;s. It is remarkable that, from 1971–1995, per capita output fell by almost 20 percent overall, in spite of the many forces which should have pushed it upwards. Figure 1 thus poses the central question of this paper: why did per capita output change course during the 1980rsquo;s, and how did it contract so sharply in the presence of many forces that should have pushed it higher?
然而，图1表明，过去几十年来美国并非如此。该图比较了1971年以来在现有养老院居民对75岁以上人口增长的增长。从图1可以看出，自从1971年以来，养老院居民的增长率迅速下降，尽管老年人口率不变增长：具体来说，在70年代中期，常住人口年增长率为4.8％;到八十年代初，这一年度的增长率已经急剧下降了三分之二，达到百分之一点七。最后，在20世纪80年代末到90年代初，增长率进一步下降到每年仅0.4％。尽管老年人口增长率相对稳定，但护理院的增长却有所放缓，75岁以上的人口在过去二十年以每年2.7％的速度增长。由于这些不同的趋势，常住人口在20世纪70年代增长了老年人口的两倍，但在1980年代和90年代初期，这个比例不到一半。事实上，1980年代以前，人均收入大幅度下滑，抵消了20世纪70年代的增长。值得注意的是，从1971年至1995年，人均产量总体下降了近20％，尽管有许多力量应该推动其增长。图1因此构成了本文的核心问题：为什么在1980年代的人均产出会变化，又如何在许多推动其增长的力量的存在下如何急剧收缩呢？
Motivated by this question, this paper analyzes the relationship between aging and the growth of long-term care markets. We argue that aging may actually decrease the per capita demand for market care if it raises the supply of nonmarket care produced by other elderly persons. This effect may be counteracted or reinforced by changes in the incidence of disability among the elderly. However, the important point is that disability reduction has not only a direct negative effect on nursing home demand, but also an indirect supply effect, because it expands the supply of nonmarket care by other elderly people. Significantly, an elderly person who has no demand for care may in fac
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