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Our Island Home Future A Future Demographic PerspeciveOur  Island  Home’s  Future:  A  Demographic  Perspective     Peter  A.  Morrison   December  8,  2015     As  the  Town  modernizes  Our  Island  Home  (OIH)  to  meet  today’s  standards,  thought  should  be   given  to  refining  its  fit  with  tomorrow’s  demographic  landscape.    That  future  landscape   highlights  one  option  for  immediate  consideration  and  further  choices  to  contemplate  in  the   future.    The  following  technical  analysis  is  intended  to  inform  these  choices.    In  what  follows,  I   describe  the  evolving  demographic  context  likely  to  affect  OIH  20  years  into  the  future  and   estimate  the  likely  magnitude  of  potential  future  need  for  the  services  OIH  now  offers.       Based  on  this  analysis,  I  see  a  strong  case  for  preserving  the  future  option  to  expand  OIH.     Looking  20  years  ahead,  potential  demand  for  OIH  beds  will  intensify  sharply,  possibly   prompting  taxpayers’  support  for  that  option.    Thereafter,  other  complex  choices  may  arise  as   beds  become  scarce.       Nantucket  is  one  of  a  few  communities  offering  its  elderly  residents  access  to  local  care  at   local  taxpayer  expense.    That  collective  consensus  reinforces  universally  held  principles  of   family  responsibility  within  the  complex  affiliations  that  define  present-­‐day  families.    The  Town   will  soon  finalize  decisions  affecting  availability  of  such  care  in  future  decades.    It  behooves  us   to  look  into  what  the  future  holds,  and  how  to  refine  our  concept  of  OIH’s  mission  on  our   collective  behalf.   Simply  put,  here  is  what  the  future  holds.    Nantucket  likely  will  be  home  to  many  more   seniors,  who  will  likely  enjoy  unprecedented  longevity.    A  rising  proportion  of  Nantucket   residents  will  be  their  80s  and  90s  as  the  baby  boom  generation  matures  into  those  ages.    This   demographic  surge  will  boost  the  absolute  number  of  elderly  residents  who  cannot  live   independently—from  roughly  63  today  to  roughly  103  by  2035.    The  appendix  that  follows   provides  technical  details  supporting  this  projection.     For  some  seniors,  family  members  with  the  emotional  will  to  care  for  their  elderly  will  find   they  have  no  practical  means  of  doing  so.       Against  this  demographic  backdrop,  what  are  the  limits  and  realistic  future  possibilities  for   OIH  to  sustain  its  core  mission?    Today,  OIH  meets  the  needs  of  41  such  residents,  most  (but  not   all)  of  them  elderly.    Twenty  years  from  now,  Nantucket’s  elderly  population  will  surely    2   overwhelm  its  capacity.    With  that  demographic  future  in  mind,  what  are  the  priorities  of   today’s  taxpayers?       • Future  capacity:  Are  45  beds  the  permanent  upper  limit  of  what’s  wanted?    Or  do  today’s   taxpayers  want  to  maintain  the  option  to  add  another  15-­‐bed  pod  at  some  future  time?    At   this  conceptual  design  stage  of  OIH,  this  choice  deserves  immediate  consideration.   Two  distant—and  more  complex-­‐-­‐choices  may  present  themselves  as  the  future  unfolds:         • Standards  for  admission:    Who  among  us  would  be  entitled  to  an  available  bed  at  OIH-­‐-­‐and   to  the  peace  of  mind  among  that  occupant’s  family  members  on  island-­‐-­‐at  taxpayers’   expense?    Would  preference  be  given  to  those  elderly  who  have  a  well-­‐established  network   of  local  support  in  place?     • Length  of  stay.    Would  admission  to  OIH  guarantee  lifelong  residence,  regardless  of  one’s   cognitive  or  health  status?    Would  an  occupant  who  no  longer  recognizes  any  visiting  family   member  or  acquaintance  be  entitled  to  stay  on,  postponing  entry  by  another  deserving   occupant  whose  existing  network  of  local  support  is  strained  to  the  breaking  point?     Unless  the  latter  two  choices  can  be  arrived  at  through  future  deliberation,  they  will  in  most   instances  ensue  tacitly.          3   APPENDIX   SUPPORTING  DATA  AND  ANALYSIS     1.    Persons  65  and  older,  especially  those  80  and  older,  will  comprise  an  increasing   proportion  of  Nantucket’s  future  residents.   How  many  Nantucket  residents  65  and  older  will  there  be  in  the  future?    No  one  can  say  for   sure,  but  a  plausible  scenario  can  be  derived  from  the  Commonwealth’s  official  population   projection  for  Nantucket,  summarized  in  Table  1.1         Table  1.  Projected  Population  of  Nantucket,  by  Age    Noteworthy  points:   • In  the  next  20  years,  Nantucket’s  total  (all  ages)  population  is  projected  to  increase  13%.     • Persons  65  and  older,  by  comparison,  are  projected  to  increase  56%.   • Persons  80  and  older,  while  comparatively  few,  may  increase  80%.     2.    As  Nantucket’s  population  ages,  the  number  of  elderly  residents  needing  assistance  with   activities  of  daily  living  will  increase  markedly,  and  accelerate  after  2030.       One’s  ability  to  perform  certain  routine  everyday  activities  without  needing  assistance  often   declines  markedly  after  about  age  80.2    Needing  the  help  of  other  persons  becomes  imperative:   with  bathing  or  showering,  dressing,  eating,  getting  in  or  out  of  bed  or  chairs,  using  the  toilet,   including  getting  to  the  toilet,  and  getting  around  inside  the  home.    Needing  help  with  such   activities  rises  sharply  with  advancing  age  (see  Figure  1  and  Table  2  below).                                                                                                                       1  Massachusetts’  State  Data  Center,  the  UMass  Donahue  Institute  (UMDI),  publishes  population   projections  for  all  Massachusetts  municipalities  at  5-­‐year  intervals  to  2035.    Accessed  at:   http://pep.donahue-­‐institute.org     2  The six basic “activities of daily living” (ADLs) are: eating, bathing, dressing, toileting, transferring (walking) and continence. An individual's ability to perform ADLs is important for determining what type of long-term care (e.g. nursing-home care or home care) and coverage the individual needs (i.e. Medicare, Medicaid or long-term care insurance).    4     Figure  1   Source:  DHHS,  Administration  on  Aging,  A  Profile  of  Older  Americans:  2011,  Figure  9.           Table  2.    Period  Prevalence  of  Limitations  in     Activities  of  Daily  Living  by  Age:  2003-­‐2007     (civilian  noninstitutionalized  population)         Noteworthy  points:   1. Prevalence  of  2+  ADLs  increases  sharply  from  75-­‐84  to  85+.   2. Growth  of  residents  85+  after  2030  implies  accelerating  growth  in  assistance  needs.   Total None 1 2+ 65#74 100.0%97.1%0.7%2.2% 75#84 100.0%93.9%1.4%4.7% 85+100.0%82.2%4.7%13.2% Source:6CDC,!Limitations!in!Activities!of!Daily!Living!and! Instrumental!Activities!of!Daily!Living,!2003;2007,6Table64. %-Distributions-of-No.-of-Limitations-in-ADLs Limitations-in-Activities-of-Daily-Living-(ADL) Age-Group  5         Table  3.    Projected  Increase  in  Nantucket’s  Noninstitutionalized     Population  65+  With  Limitations  in  Two  or  More  Activities  of  Daily  Living                        Source:  Morrison’s  calculations  applying  Table  2  prevalence  rates  to  Table  3  projected  population.         A  straightforward  demographic  projection  quantifies  the  future  in  store  (see  Table  3).    Simply   put,  Nantucket’s  noninstitutionalized  population  65  and  older  is  projected  to  increase  33%  by   2025,  46%  by  2030,  and  56%  by  2035.    Assuming  that  the  prevalence  rates  shown  in  Table  2   remain  constant  in  the  future,  this  noninstitutionalized  population  65+  will  generate  28%  more   members  who  experience  limitations  in  2  or  more  ADLs  by  2025,  47%  more  by  2030,  and  63%   more  by  2035.     To  grasp  the  significance  of  these  changes,  imagine  substituting  today's  population  of  10,667   persons  with  their  projected  counterpart  population  in  2035  (12,004  such  persons).    What   would  change?    The  13%  increase  in  overall  numbers  conceals  a  56%  increase  in  persons  65   and  older  (Table  1  above,  comparing  “All  ages”  with  “65+”).    Furthermore,  the  56%  increase  in   overall  elderly  persons  65+  itself  conceals  a  63%  increase  in  persons  with  limitations  in  2  or   more  ADLs  (Table  3  above,  comparing  “Total  65+  population”  with  “Total  65+  Estimated  with   Limitations  in  2+  ADLs”).         In  short,  Nantucket  would  be  home  to  just  13%  more  residents,  but  the  number  of  elderly   among  them  possibly  unable  to  live  independently  without  assistance  would  increase  from  63   to  103—a  63%  increase.    By  way  of  comparison,  OIH  has  41  residents  (late  2015),  37  of  whom   are  65+.                6     3. The  structural  changes  detailed  above  appear  to  be  independent  of  whether  one  defines   Nantucket’s  “resident  population”  according  to  the  Census  Bureau’s  concept  or  the   Town  Clerk’s  concept.     The  Census  Bureau  defines  Nantucket’s  resident  population  as  persons  who  report  Nantucket   as  their  “usual  place  of  residence”  on  April  1.    That  definition  undoubtedly  excludes  many   additional  Nantucket  residents.    The  Town  Clerk’s  annual  census  identifies  many  more   residents,  based  on  a  more  inclusive  definition  (including  eligibility  to  vote).    The  substantial   differences  between  these  two  sources  raises  the  possibility  that  one  or  the  other  definition   may  prove  misleading  about  the  future  elderly.    To  explore  this  possibility,  I  compare  age-­‐ specific  data  from  each  source  in  Table  4.       Table  4.    Age  Distribution  of  Nantucket  Residents  55  and  Older     Based  on  Census  Bureau  and  Town  Census  Enumerations         Noteworthy  points:   1. Town  Census  (2015)  and  Census  complete  count  (2010)  closely  agree  in  relative  terms   (compare  “%  of  55+”  columns).   2. Agreement  between  Town  Census  (2015)  and  MA  State  Data  Center’s  2015  projected   elderly  distribution  is  even  closer  (data  not  shown).   3. Scale  differences  are  apparent  (see  “Town  minus  U.S.  Census”  column)  but  do  not  distort   relative  agreement.          7     4. The  concept  of  “healthy  life  expectancy”  (HLE)  offers  a  useful  objective  starting  point  for   setting  future  priorities  in  coming  years.     Healthy  life  expectancy  (HLE)  is  a  population  health  measure  that  combines  mortality  data   with  morbidity  or  health  status  data  to  estimate  expected  years  of  life  in  good  health  for   persons  at  a  given  age.    HLE  accounts  for  quantity  and  quality  of  life  and  can  be  used  to   describe  and  monitor  the  health  status  of  populations.         Life  expectancy  (LE)-­‐-­‐expected  years  of  life  at  a  given  age-­‐-­‐is  the  average  remaining  years  of   life  a  person  can  expect  to  live  on  the  basis  of  the  current  mortality  rates  for  the  population.   HLE  estimates  the  equivalent  healthy  years  that  a  person  can  expect  to  live  on  the  basis  of   the  current  mortality  rates  and  prevalence  distribution  of  health  status  in  the  population.     The  state-­‐specific  HLE  for  65-­‐year-­‐old  Massachusetts  residents  is  13.8  years  (males)  and   15.9  years  (females).3    Simply  put,  one  expects  a  population  of  65-­‐year-­‐old  males  to  have,  on   average,  13.8  “healthy”  future  years  of  life  expectancy.    The  corollary  is  that  78.8  years  of   age  marks  the  stage  of  life  at  which  OIH  becomes  relevant  to  the  remaining  non-­‐healthy   years  of  life.    For  females,  the  corresponding  age  marking  the  conclusion  of  HLE  is  80.9   years  of  age  (i.e.,  65  plus  15.9).         In  round  numbers,  then,  age  79  for  men  and  age  81  for  women  are  objective  criteria  for   anticipating  the  average  age  of  the  onset  of  need  for  a  stay  at  OIH.    For  any  particular   individual,  of  course,  that  onset  may  occur  at  a  younger  or  older  age.     The  corresponding  entire  life  expectancy  (LE)  for  65-­‐year-­‐old  Massachusetts  residents  is   18.2  years  (males)  and  20.9  years  (females).        These  LE’s  mean  that  at  age  78.8,  the  average   male  faces  an  additional  4.4  non-­‐healthy  years  of  life;  and  that  at  age  80.9,  the  average   female  faces  an  additional  5.0  non-­‐healthy  years  of  life.      Again,  these  durations  may  be   shorter  or  longer  for  any  particular  individual.    However,  they  furnish  objective  measures   for  anticipating  future  durations  of  stay  at  OIH  by  those  needy  elderly  who  gain  admission.     In  round  numbers,  then,  the  duration  of  stay  would  be  around  4.4  -­‐  5.0  years  for  the  average   would-­‐be  OIH  resident.         5. Our  Island  Home  capacity  vs.  current  and  projected  future  need.     OIH  currently  has  41  residents,  27  of  them  ages  80  or  older.    This  population  of  27   corresponds  roughly  to  persons  who  are  passing  through  non-­‐healthy  years  of  life   expectancy,  and  whose  average  duration  of  stay  at  OIH  will  be  4.4  -­‐  5.0  years.         These  27  residents  comprise  7.2%  of  all  373  persons  80  and  older,  as  enumerated  by  the   Town  Clerk’s  census  (see  “80+”  row  in  Table  5).    These  data  imply  that  OIH  now  meets   roughly  7%  of  the  latent  need  for  assistance  among  Nantucketers  as  they  live  out  their   remaining  non-­‐healthy  years  of  life  expectancy.      We  can  anticipate  a  52%  increase  in                                                                                                                   3  Source:    CDC,  “State-­‐Specific  Healthy  Life  Expectancy  at  Age  65  Years  —  United  States,  2007–2009,”   MMWR  (access  at  www.cdc.gov/mmwr/index.html  )    8   Nantucket’s  population  80  and  older  by  2030  and  an  80%  increase  by  2035  (see  Table  1   above).    Those  increases  imply  that  a  fixed  OIH  capacity  (27  persons  80+)  would  meet  a   declining  percentage  of  this  latent  need  for  assistance:    from  7%  in  2015  to  just  5.2%  (2030)   and  4.4%  (2035).     Contemplating  this  scenario  opens  our  eyes  now  to  the  necessity  of  refining  our  collective   priorities  and  vision  of  Our  Island  Home’s  place  in  the  community.    Otherwise,  we  could  face   the  prospect  of  one  needy  population  segment  (e.g.,  persons  80+)  crowding  out  another,   with  no  explicit  public  consensus  on  how  to  balance  competing  needs  of  younger  and  older   residents.     The  ultimate  justification  for  focusing  a  modest  amount  of  local  support  on  a  need  of  far   broader  proportions  could  be  a  continuing  local  commitment  to  what  families  alone  do   best—care  for  their  own  members,  whatever  their  age—and  to  sustaining  that  function   within  Island-­‐resident  families.               Table  5.  Our  Island  Home  Residents  vs.  Town  Census  and  U.S.  Census  Counts    Observations:   1. Today,  ages  75+  account  for  19-­‐21%  of  census  populations  but  83%  of  OIH  residents.     2. Populations  generate  OIH  residents  at  noticeable  rates  starting  around  ages  75+.