Health, Quality of Life, and Economic Impacts of Home Care Vouchers for Middle-Income Adults

Abstract The Support at Home pilot program provided financial support for home care services by middle-income adults with disabilities in San Francisco to support aging in place. This presentation reports the results of the mixed-methods evaluation of the program, which incorporated administrative records, surveys of clients and comparison group members, surveys of informal caregivers of clients, surveys of the care providers hired by clients, and focus groups with clients and with informal caregivers. Outcome measures included the Older People’s Quality of Life Questionnaire, Patient Health Questionnaire-2, an adapted Burden Scale for Family Caregivers, and self-reported falls, emergency department visits, and hospitalizations. Analyses included pre-post chi-squared and t-test comparisons and comparisons of changes between the client and comparison groups. Multivariate regression analyses were conducted to control for demographic differences between the groups. An economic analysis was conducted to learn whether changes in costs associated with medical appointments, emergency department visits, and hospitalizations were greater than the costs of the program, including both voucher and administrative costs. Results indicated statistically significant positive changes in personal stress and financial stress, but not in the composite quality of life score. There also were statistically significant reductions in attendance at medical appointments, falls, emergency department visits, and hospitalizations. The focus group data supported the findings regarding personal and financial stress, and also indicated that clients and their caregivers perceived positive quality of life benefits. The economic analysis indicated substantial cost savings from the program due to reduced use of medical services.

comprehensive population-level dataset to examine LTSS needs, unmet needs, and uses of LTSS in California. Initial findings show that 50% of participants report spending less on food, while 40% report cutting down on saving for retirement, receiving and borrowing money from others, and experiencing a decline in household income. More than 20% note that they could not make rent or mortgage payments, had debt due to medical bills, and had to spend less on prescription medications or medical care. We also find significant disparities in financial strain by age, gender, poverty, and disability type; however, no significant disparities by race/ ethnicity. This study is among the first to examine disparities in various financial strain types for people who need LTSS in California. The findings have policy implications for the Master Plan for Aging (MPA), which serves as a blueprint to build environments that promote an age-friendly California. The growing cost of healthcare services has been a concern for many countries in the world. In China, medical expenditures can account for as much as 65% of per capita income in some low-GDP counties in 2011. One of the primary goals of the New Rural Cooperative Medical Insurance (NRCMI) is to provide financial protection and alleviate the financial burdens of rural residents in China. This paper examined whether NRCMI participation impacted the incidence of catastrophic health expenditure (CHE) among middle-aged and older adults (45 years old and above) using the China Household Income Project 2007 rural data and an instrumental variable estimation method in two provinces where there was heterogeneity in NRCMI implementation schedule. The results show that NRCMI enrollment could not impact the likelihood of experiencing CHE among middle-aged and older adults. However, NRCMI participation increased the actual amount of medical expenses in one province but not in the other. Although none of the prior studies have used instruments and village fixed effects or take endogeneity issues into account to investigate the impact of NRCMI on relative financial burden among recipients, the results found in this study are generally aligned with the prior findings, especially with those using quasi-experimental studies. Findings from this study provide empirical evidence to the policymakers that the effect of NRCMI participation on financial protections is limited despite its broad population coverage. The limited effects are probably due to the low reimbursement rate and more utilization of expensive healthcare services.

HEALTH, QUALITY OF LIFE, AND ECONOMIC IMPACTS OF HOME CARE VOUCHERS FOR MIDDLE-INCOME ADULTS
Joanne Spetz, Laura Wagner, Jacqueline Miller, Susan Chapman, and Connie Kwong, University of California, San Francisco, San Francisco, California, United States The Support at Home pilot program provided financial support for home care services by middle-income adults with disabilities in San Francisco to support aging in place. This presentation reports the results of the mixed-methods evaluation of the program, which incorporated administrative records, surveys of clients and comparison group members, surveys of informal caregivers of clients, surveys of the care providers hired by clients, and focus groups with clients and with informal caregivers. Outcome measures included the Older People's Quality of Life Questionnaire, Patient Health Questionnaire-2, an adapted Burden Scale for Family Caregivers, and self-reported falls, emergency department visits, and hospitalizations. Analyses included pre-post chi-squared and t-test comparisons and comparisons of changes between the client and comparison groups. Multivariate regression analyses were conducted to control for demographic differences between the groups. An economic analysis was conducted to learn whether changes in costs associated with medical appointments, emergency department visits, and hospitalizations were greater than the costs of the program, including both voucher and administrative costs. Results indicated statistically significant positive changes in personal stress and financial stress, but not in the composite quality of life score. There also were statistically significant reductions in attendance at medical appointments, falls, emergency department visits, and hospitalizations. The focus group data supported the findings regarding personal and financial stress, and also indicated that clients and their caregivers perceived positive quality of life benefits. The economic analysis indicated substantial cost savings from the program due to reduced use of medical services.

THE INFLUENCE OF MARITAL STATUS AND GENDER ON FINANCIAL WELL-BEING Jing Geng, Virginia Tech, Blacksburg, Virginia, United States
Research consistently documents gender differences in financial status in later life, and some also examine marital status in this regard. However, the subjective aspects of financial well-being are less well-explored, especially as this relates to both gender and marital status in the U.S. Using a gender-sensitive approach, this study examines the extent to which gender and marital status affect the financial well-being of older American adults. Different from previous studies that use only objective measures of financial well-being, this study also takes a subjective assessment in terms of financial satisfaction into account so that the role of marital status and gender in both objective measures and subjective assessments can be identified. This study uses the 2014 Health and Retirement Study and employs ordinary least squares regressions and ordinal logistic regression analyses. Examining those aged 65 and over, the sample varies from N=10,325 (financial well-being) to 4,280 (financial satisfaction). Differences in gender and marital statuses across all objective measures of financial well-being show up, with women being disadvantaged while the married (regardless of gender) being advantaged. Concerning financial satisfaction, being divorced and separated were negatively related to financial satisfaction for both men and women. These findings indicate that both marital status and gender are important indicators of financial well-being in later life.

WHOM CAN I RELY ON? THE IMPACT OF CHINA'S PUBLIC PENSION PROGRAM EXPANSION ON THE EXPECTATIONS FOR OLD-AGE SUPPORT Qian Zhang, Beijing Normal University, Beijing, Beijing, China (People's Republic)
Aging is a global trend and China is no exception. Older people in China mostly rely on their adult children for oldage support. This traditional provision pattern of old-age support, however, is challenged by hundreds of millions of internal migrant workers. They relocate from rural to urban regions for better employment and are no longer able to provide old-age support to their older parents in rural areas. The aim of this study was to determine the impacts of China's public pension program expansion in rural areas on older people's expectations for old-age support. Utilizing the natural experiment of program expansion, this study identified an instrumental variable as the county adoption of the pension program. In addition, the study analyzed a nationally representative longitudinal dataset CHARLS with fixed effects model. Results from the statistical model showed that given the participation in the pension program, older adults reported more reliance on pension for old-age support financially and less reliance on children. Heterogeneous effects were found for older adults living together with children and older adults living independently. These important findings suggest that the government partially assumes the responsibility for the old-age support of adult children in the traditional sense. The potential benefits of this study provide a policy implication for developing countries to alleviate oldage support problems and enable internal migration for economic development.

ASSOCIATION BETWEEN ADVANCE CARE PLANNING FOR OLDER ADULTS AND FAMILY CAREGIVERS' SENSE OF SECURITY
Masumi Shinohara, 1 Mariko Sakka, 2 Asa Inagaki, 2 Taisuke Yasaka, 2 Chie Fukui, 2 Maiko Noguchi-Watanabe, 2 Ayumi Igarashi, 2 and Noriko Yamamoto-Mitani, 2 1. University of Tokyo, Bunkyo, Tokyo, Japan, 2. The University of Tokyo, Bunkyo, Tokyo, Japan Family caregivers' (FCs') sense of security benefits older adults who receive homecare. Advance care planning (ACP) is reported to have positive effects on FC's experience, but it might differ depending on FCs' kin relationships with the older adults. We examined whether ACP for older adults in homecare settings is associated with FCs' sense of security. Further, we assessed whether such an association depends on their status as spouses or as adult children. We conducted a secondary analysis of data from a prospective cohort study in Japan. The participants were older adults who used homevisit nursing services, their FCs, and the nurses who cared for them. The FCs were asked to answer a sense of security questionnaire, and nurses were asked whether ACP was conducted. Multivariate logistic regression analyses were performed to examine the association between ACP implementation and positive changes in the sense of security scores