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Where Are the Missing Elders? The Decline in Nursing Home Use, 1985 and 1995

Despite America's aging population, nursing home use has increased less than expected since 1985. In her Commonwealth Fund-sponsored analysis appearing in the July/August issue of Health Affairs,Where Are the Missing Elders? The Decline in Nursing Home Use, 1985 and 1995,” Christine E. Bishop of the Brandeis Institute for Health Policy points to the need for better data to determine whether elderly people who are not in nursing homes are receiving adequate support and needed services.

Bishop reports that the proportion of people age 65 and older staying overnight in nursing homes fell by more than 8 percent from 1985 to 1995. The decline was most striking for those over age 85, a population comprising more than half the total elderly nursing home population.

The author discusses five possible trends that may be responsible for the decline in use:

  • The National Long-Term Care Survey found that disability had declined substantially from 1984 to 1994: by the latter year, the proportion of elders experiencing at least one difficulty with an activity of daily living had fallen by 14.5 percent. This trend, however, cannot account for the full drop in nursing home use.
  • According to the 1995 National Nursing Home Survey, the nursing home population is slightly more disabled now than it was in 1985. This shift suggests a changing role for nursing facilities, which are becoming more selective as they increasingly focus on patients with greater disability and post-acute care needs.
  • In the aggregate, the occupancy rate of nursing home beds has been falling, from 92 percent in 1985 to 87 percent in 1995. Lack of capacity was not forcing elders to remain in other settings.
  • Use of Medicare home health care is up. Formal, paid home care may have filled 1995 care gaps for some people who would have been nursing home residents in 1985.
  • The U.S. census classifies assisted-living facilities as households, not institutions, making it difficult to estimate whether the "missing elders" have found quasi-institutional arrangements that are meeting their needs. Only new surveys could capture trends in special residences and provide insight into the adequacy of care in these settings.

Bishop concludes that population-based surveys with sound identification of care environments are necessary, and that statistics centered on people with disabilities and their care, rather than on particular traditional sites of care, could better track how well disability needs are being met.

Facts and Figures

  • The National Nursing Home Survey indicated that in 1995 there were 222,000 empty nursing home beds-90,000 more than in 1985.
  • In 1995, more than 9 percent of all aged Medicare beneficiaries used Medicare home health care, up from 5 percent in 1985.
  • Black elderly people were found to have a higher rate of nursing home use than whites, reversing previous trends.

Publication Details



C. E. Bishop, "Where Are the Missing Elders? The Decline in Nursing Home Use, 1985 and 1995," Health Affairs, July/Aug. 1999 18(4):146––55.