Who We Are: Implications of the 2010 Census for Health Care, Part 1

In Article 1, Section 2, of the U.S. Constitution can be found a provision that states that an "enumeration" of the population is to be conducted every 10 years in order to properly apportion the House of Representatives according to where people live. This was the origin of the U.S. Census. The first one was conducted in 1790, and we have done it every 10 years since.

What did the Census of 2010 find out? On April 1 of last year, there were 308,745,538 people residents in the United States; that was a 9.7 percent increase over 10 years earlier.

People are moving south and west. The center of population (that is, the spot where half of the population lives east of it and half lives west) is now near Plato, Mo. In 1790, it was near Chestertown, Md.

The population also is getting more racially and ethnically diverse. Texas has joined California, Hawaii and New Mexico as a "minority-majority" state. Latinos remain the largest ethnic group, followed by African-Americans. Here's the breakdown:

Source: Population Reference Bureau, 2011

Massive Internal Migration

Although immigration to the United States has become a political football, what attracts less attention (except for those interested in congressional reapportionment) is internal migration — that is, people who move from one place to another within the country. The 2010 Census tells us that the only state that lost population between 2000 and 2010 was Michigan — not surprising in the face of the near-collapse of the auto industry. Its population declined by 0.6 percent. The big population winner during the decade was Nevada, with a 35.1 percent increase — although some of that is likely eroding due to the effects of the popped housing bubble; Las Vegas was one of the ground zero sites for that misery. Other top population-growth states included Arizona (24.6 percent increase), Utah (23.8 percent), Idaho (21.1 percent) and Texas (20.6 percent).

People tend to go where the jobs are and where housing is cheaper, and that probably accounts for these findings. Also, older folks like to retire in warm, affordable spots. But things can change in a hurry (ask the people of New Orleans), and some of these figures could be misleading; jobs are scarce in most places these days, and home ownership is cheap only if you can get a mortgage loan, which not many people have been able to do since 2008.

On the metropolitan level, the fastest-growing areas in 2010 were Palm Coast, Fla.; St. George, Utah; Las Vegas-Paradise, Nev.; Raleigh-Cary, N.C.; and Cape Coral-Fort Myers, Fla. Much of that growth was fueled by retirement relocation, in all likelihood.

An Aging Nation

Speaking of which, the youngest baby boomer will be 47 this year. The median age of the United States is now older than 37. One in eight Americans, more or less, is older than 65; one in three is 50 or older. The aging of America can be ascribed to the graying of the boomers, of course, despite birth rates among most minority groups that are much higher than those of non-Latino whites. Those birth rates aren't enough to compensate for more than 70 million people becoming seniors within the next few years.

The country of the young isn't so young anymore, and it is only going to get older.

Source: U.S. Census Bureau, 2011

But the pace of aging varies enormously by state; between Utah, our youngest state (it has the highest birth rate in the nation) and Maine, our oldest state (it has a largely white, long-lived population and a lot of retirees, and many of its young people have left in search of jobs elsewhere), the difference in median age is 13.5 years.

If you drill down into regions, counties and cities, even more striking gaps can be found. Learn more at www.census.gov.

There is also something called the age-dependency ratio, which is simply how many people there are who are either younger than 18 or 65-plus for every 100 people aged 18 to 64, the latter group being the working population who likely are supporting these groups, one way or another. The lowest age-dependency ratios for people older than 65 were found by the census to be, not surprisingly, in the younger states, such as Alaska, Georgia, Texas and Utah. The highest were in Florida, Maine, Vermont and West Virginia — all old states.

The states with the lowest dependency ratios for people younger than 17 were more of a mixed bag — Alaska, Colorado, New Hampshire and Vermont topped the list. The highest — for the most part, no surprise — were Arizona, Idaho, South Dakota and Utah, although the South Dakota finding was somewhat unexpected.

This stuff does all fit together, if you think about it.

Men and Women

The Census Bureau uses a term known as sex ratio to measure the proportion of men to women in any given area. Historically, more male babies are born than female babies (105 to 100), but because mortality is higher for males in every age group, and because women tend to outlive men, in the older age ranges, women are in the majority — after age 85, they are in the vast majority. Indeed, according to the Census Bureau, at age 89, there are twice as many women as there are men.

In addition, most men older than 65 are married with a spouse present, and most women in the same age group are not.

The place with the highest ratio of women to men (111.8) is Fort Lauderdale, Fla., followed by Tempe, Ariz., and Wichita Falls, Texas. The place with the lowest ratio of women to men (85.9) is Pembroke Pines, Fla., followed by Jackson, Miss., and Miami Gardens, Fla. Before anyone starts packing his or her bags to go seeking a mate, however, be aware that these local data can be skewed by specific situations. These include there being men's or women's prisons in the area, or military bases, or universities, or it could be the presence of a large gay or lesbian community.

The good news from this census is that the traditional female advantage in longevity — historically, five to seven years — is narrowing, because men are living longer.

Still, aging, says Bruce Clark, D.P.H., cofounder of Age Wave, is "a women's issue." And although this may well change in coming decades, right now, he's right. Why? Because older women are far more likely to live alone than are older men. As it is, 31.4 million people live alone in the United States — 27 percent of all households — and most of them are women.

Also — again, this will change over time — as of now, many women older than 65 were never in the workforce and have limited financial resources. Others may have spent the family nest egg caring for a spouse who is now deceased. Still others have been divorced or widowed and have little money. They are highly vulnerable in terms of health care expenses and other costs.

It has become more common for older folks to continue to work; 40.2 percent of people older than 55 were still in the work force in 2010. But we can't assume that the reason is that they love their jobs; in many cases, it's because they lost their retirement savings in the recent stock market/housing debacle. I fly on airplanes a lot (as opposed to flying some other way, I suppose), and I cannot help but notice that more and more flight attendants are in my age group — and I'm in my early 60s.

The current political debate over raising the eligibility age for Medicare and Social Security (or getting rid of both programs altogether) must take into consideration that for millions of older people, especially aging women, these programs may constitute the only safety net they have — not to mention the specter of severe chronic disease, including dementia, for which very few families are prepared.

Issues for Health Care

In discussing the implications of this changing society for the health care system, one is tempted to ask, "How much time have you got?" I will mention only a few challenges for which we should be prepared.

One is caregiving. Most family caregivers in this country are women, and they do not get enough support. More than a few are "sandwich" caregivers trying to balance responsibilities for both children and aging parents.

Another group of caregivers that is rarely mentioned is grandparents; the Census Bureau reports that 2.7 million grandpas and grannies are "responsible for most of the basic needs of one or more grandchildren" who live with them. The majority (1.7 million) are grandmothers. In addition, 1.6 million grandparents who are caring for their grandchildren are still in the labor force.

"Informal" caregivers — and there's nothing informal about it if you're doing it — are aging just like the loved ones for whom they are caring, and the time is coming when they may not be able to do the job anymore. That's assuming that there is a family member or friend who will care for every frail, aging person in the first place, and that is not the case. Fractured families, relatives separated by thousands of miles, the swath cut by AIDS, and the significant number of people who never married or had children all have ended the myth of a family caregiver for everyone. Who will care for those who are left out?

The health care system also is going to have to get its head around care for the chronically ill, which, in most cases, is a population it has avoided like the plague. These patients usually are not lucrative, they're boring for many providers trained in our acute care-focused clinical education environment, and they're depressing. In a curative-obsessed system, people who aren't going to get any better don't make most people's day.

But acute care is not going to be the center of the universe anymore. Whatever happens to the Affordable Care Act, or Medicare, or Medicaid, or accountable care organizations, the appeal of bundled payments to payers is irresistible. Payers don't want to carry risk (perhaps risk is what they're supposed to be in business to manage, but that's for another time); they want to transfer it to patients, providers, anyone. So just write a check for what you think this episode of care should be worth, and wash your hands of it.

In one way or another, the future of provider payment is going to be a lump sum for the entire sickness experience of the patient, and if that ends up being 10 years, well, that's how it's going to be.

Providers are going to have to form partnerships to create a complete continuum of care — acute, subacute, chronic, end of life, the whole banana. Generally speaking, health care organizations have not thought that way, but the demographics are telling us that they aren't going to have a choice.

Two areas of particular concern in this shifting landscape are hospice and palliative care, because more and more older patients are choosing them at the end of their days. The problem is that there is a rapidly increasing for-profit presence in these fields, and there have been scandals, and regulation has been erratic. In addition, even if available hospice care is superb, it still can be like pulling teeth to get providers — especially oncologists — to refer patients to these services, because it feels to the physician like failure. Yes, there should always be room for hope, but also there should always be room for understanding that, at some point, there is nothing more that acute care can do.

I believe that demographic trends also are going to cause, sooner or later, a shift of power in the clinical professions. Right now — and anyone who watches television, or listens to the radio, or uses the Internet, or reads periodicals, can attest to this — the focus is on denial of aging. Get that Botox, lift that neck, take that Viagra. But in the long term, the winners are going to be specialists in the diseases and conditions of aging, not cosmetic surgeons. The question is how long it will take for our medical and nursing schools to get the message that this is the future.

Finally, we are going to be faced with a whole bunch of end-of-life issues. Think of all those people who, despite our pleading, have not executed living wills or health care powers of attorney, so the hospital doesn't know what to do — or, even worse, the family is divided over what should happen to Granny. There is the question of physician-assisted suicide. There's the debate over euthanasia.

And while all this roils around us, we should also be trying to promote healthy aging, with the full and deep knowledge that death is inevitable, and helping people live to 85 or 90 doesn't change that ultimate equation. All we can do is try to help them live well.

Demographics are fact, not opinion or possibility. I sure hope that our health care system will be ready for what is to come.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express.