The Broad Spectrum of Long-Term Care
Long-term care (LTC) is not a single location but a wide range of services designed to meet a person's health or personal care needs over a long period. For a comprehensive picture of how many people live in long-term care in the US, one must look beyond just nursing homes to include assisted living, residential care, and even those receiving services at home. National data paints a picture of a system serving millions, with a notable shift in recent years toward non-institutional settings.
Nursing Home Residency Trends
For many, long-term care is synonymous with nursing homes. As of 2020, there were 1.3 million Americans in nursing homes, a figure that had been experiencing a gradual decline even before the COVID-19 pandemic. The pandemic significantly accelerated this decline, with resident counts dropping steeply in 2020-2021 before beginning a slow recovery that has not yet reached pre-pandemic levels. Demographically, nursing home residents are predominantly female, over the age of 65 (especially 85+), and often require significant assistance with daily living activities (ADLs). A high percentage also relies on Medicaid to cover costs.
The Rise of Assisted Living and Residential Care
For those who need some help but not the intensive skilled nursing care of a nursing home, assisted living and residential care communities are a popular choice. In 2022, there were over 1 million residents in assisted living facilities and other residential care communities across the United States. This sector is characterized by a high proportion of residents aged 85 and older, most of whom are female and non-Hispanic white. Residents typically require assistance with a few ADLs, such as bathing or walking. The growth in this segment reflects both the aging of the population and the desire for more independent, home-like settings.
The Shift to Home and Community-Based Services (HCBS)
Long-term care is increasingly delivered in the home or other community settings. This trend is a major factor in understanding why the nursing home population has not recovered its pre-pandemic levels. Data shows that millions receive HCBS, often preferring to age in place. In 2021, among Medicaid users receiving long-term services and supports (LTSS), 75% were receiving HCBS exclusively. This shift is influenced by policy changes aimed at rebalancing institutional bias and by an increasing availability of support services that allow individuals to remain in their communities.
Demographics and Health Needs
The demographics of the long-term care population reflect the health challenges of an aging society.
Who is most likely to be in institutional care?
- Age: Institutionalization is significantly more common at older ages. While only a small fraction of those aged 65-74 reside in institutions, that number jumps considerably for those 85 and older.
- Gender: Females are overrepresented in nursing homes and assisted living, largely due to their longer life expectancy.
- Health Conditions: Cognitive impairments like dementia, high blood pressure, and heart disease are common among residents. The need for help with activities of daily living (ADLs) is a primary driver for entry into these facilities.
- Race and Ethnicity: The population is predominantly non-Hispanic White, though it is becoming more diverse over time.
The Pandemic's Lasting Influence
The COVID-19 pandemic was a watershed moment for the long-term care industry, with profound and lingering effects on the resident population. Early outbreaks and high mortality rates led to steep declines in occupancy. The pandemic also highlighted systemic vulnerabilities, including chronic staffing shortages that continue to plague facilities. These factors have undoubtedly contributed to the ongoing shift away from institutional care for those who can receive adequate support elsewhere.
Comparing Long-Term Care Settings
| Feature | Nursing Homes | Assisted Living | Home & Community-Based Care |
|---|---|---|---|
| Level of Care | High; 24/7 skilled nursing and medical care. | Moderate; assistance with ADLs, but less intensive medical care. | Variable; depends on individual needs, can include visiting nurses, home health aides, adult day care. |
| Resident Profile | Typically older (85+), higher medical complexity, often need extensive ADL help. | Older (often 85+), less complex medical needs, need limited ADL help. | Diverse ages, may have disabilities or chronic conditions, goal is to maintain independence. |
| Typical Cost | Highest of the three; significant out-of-pocket, Medicaid often involved. | Lower than nursing homes, but still substantial. Mix of private pay, insurance, and sometimes Medicaid. | Can be most affordable, but costs vary widely depending on services. Heavy reliance on Medicaid waivers and family caregivers. |
| Residential Setting | Often larger, more institutional, hospital-like setting. | Smaller, more home-like communities, private or semi-private apartments. | The individual's own home, or a family member's home. |
Conclusion: Looking Beyond the Numbers
The number of people in long-term care is significant and growing, driven by an aging population. However, it's a dynamic figure that reflects evolving preferences and healthcare policy. While nursing homes still play a critical role, their populations have been impacted by recent trends. Meanwhile, the number of people in assisted living and receiving home and community-based services continues to rise. This complex picture emphasizes the need for comprehensive planning, not only for individuals and families but for the broader healthcare system to meet the diverse needs of a large and growing population requiring long-term care and support. For further reading on the policy and demographic factors driving these changes, the Kaiser Family Foundation (KFF) provides insightful analysis.
