%0 Journal Article %J Journal of the American Geriatrics Society %D Forthcoming %T Money may matter: Financial hardship and its association with satisfaction of care among people living with dementia. %A Miller, Katherine E M %A White, Lindsay %A Coe, Norma B %A Khandelwal, Nita %K Dementia %K Finances %K Life Satisfaction %X Financial hardship is a multidimensional construct that includes, but is not limited to, out-of-pocket costs. Financial hardship has mostly been studied in patients with cancer and is independently associated with decreased treatment adherence,1 worse quality of life,2 worse psychological and physical symptoms,2, 3 and mortality4 — outcomes of great importance to people living with dementia (PLWD) as well. However, there are limited data specifically examining the prevalence or the impact of financial hardship among PLWD. Our objectives are to estimate the prevalence of financial hardship among PLWD and describe measures of satisfaction with life and with health care among PLWD, compared to a cancer cohort. %B Journal of the American Geriatrics Society %G eng %R 10.1111/jgs.18723 %0 Journal Article %J Alzheimer's & Dementia %D Forthcoming %T Public spending on acute and long-term care for Alzheimer's disease and related dementias. %A Norma B Coe %A White, Lindsay %A Oney, Melissa %A Basu, Anirban %A Larson, Eric B %K longitudinal costs %K Medicaid %K Medicare %K Spending %X

INTRODUCTION: We estimate the spending attributable to Alzheimer's disease and related dementias (ADRD) to the United States government for the first 5 years post-diagnosis.

METHODS: Using data from the Health and Retirement Study matched to Medicare and Medicaid claims, we identify a retrospective cohort of adults with a claims-based ADRD diagnosis along with matched controls.

RESULTS: The costs attributable to ADRD are $15,632 for traditional Medicare and $8833 for Medicaid per dementia case over the first 5 years after diagnosis. Seventy percent of Medicare costs occur in the first 2 years; Medicaid costs are concentrated among the longer-lived beneficiaries who are more likely to need long-term care and become Medicaid eligible.

DISCUSSION: Because the distribution of the incremental costs varies over time and between insurance programs, when interventions occur and the effect on the disease course will have implications for how much and which program reaps the benefits.

%B Alzheimer's & Dementia %G eng %R 10.1002/alz.12657 %0 Journal Article %J J Gerontol B Psychol Sci Soc Sci %D 2023 %T Gender of study partners and research participants associated with differences in study partner ratings of cognition and activity level. %A Stites, Shana D %A Gurian, Anna %A Coykendall, Cameron %A Largent, Emily A %A Harkins, Kristin %A Karlawish, Jason %A Coe, Norma B %K activity level %K Cognition %K gender %X

OBJECTIVE: Studies of Alzheimer's disease (AD) typically include "study partners" (SPs) who report on participants' cognition and function. Prior studies show SP reports differ depending on the relationship between the SP and participant, that is, spouse or adult child. Adult children SPs are typically female. Could differing reports be due to gender? Knowing this may help explain variability in measurement.

METHODS: The Aging, Demographics and Memory Study (ADAMS) enrolled a subset of participants from the Health and Retirement Study (HRS). Each participant had a SP. Bivariate and multivariable regression models compared 718 SP-participant dyads.

RESULTS: In analyses of four groups defined by SP and participant gender, dyads composed of two women were less likely to identify as White (75.8%, 95%CI 70.4 to 80.5) than dyads composed of two men (93.3%, 95%CI 81.2 to 97.8). In analyses adjusted for severity of cognitive and functional impairment, women SPs rated women participants as more active than they rated men, mean 2.15 (95%CI, 2.07 to 2.22) versus mean 2.30 (95%CI, 2.24 to 2.37), respectively, on a 4-point scale. Similarly, men SPs rated women participants as more active than they rated men, mean 2.1 (95%CI, 2.0 to 2.2) and mean 2.4 (95%CI, 2.3 to 2.5), respectively. In an analysis of cognitively unimpaired participants, women SPs rated participants' memory worse than men SPs did (p<0.05).

DISCUSSION: SP and participant gender influence SPs' reports of another person's cognition and activity level. Our findings expand what is understood about how non-disease factors influence measures of disease severity.

%B J Gerontol B Psychol Sci Soc Sci %8 2023 Feb 15 %G eng %R 10.1093/geronb/gbad026 %0 Journal Article %J J Am Geriatr Soc %D 2023 %T Rural disparities in use of family and formal caregiving for older adults with disabilities. %A Miller, Katherine E M %A Ornstein, Katherine A %A Coe, Norma B %X

BACKGROUND: As federal and state policies rebalance long-term care from institutional settings to home- and community-based settings, reliance on formal (paid) and family (unpaid) caregivers for support at home nationally has increased in recent years. Yet, it is unknown if use of formal and family care varies by rurality.

METHODS: Using the Health and Retirement Study, we describe patterns in receipt of combinations of formal and family home care and self-reported expectation of nursing home use by rurality among community-dwelling adults aged 65+ with functional limitations from 2004 to 2016.

RESULTS: Older adults residing in rural areas are more likely to receive any family care than those in urban areas. From 2004 to 2016, a higher proportion of older adults in rural areas receive care from family caregivers exclusively while a lower proportion receive care from formal caregivers exclusively. When examining older adults in urban areas, we find the opposite - a higher proportion of urban adults rely exclusively on formal care and a lower proportion rely exclusively on family care in 2016 compared to 2004.

CONCLUSION: We find that national estimates of sources of caregiving and their changes over time mask significant heterogeneity in uptake by rurality. Understanding how older adults in rural areas are, or are not, receiving home-based care compared to their urban peers and how these patterns are changing over time is the first step to informing supports for family and formal caregivers.

%B J Am Geriatr Soc %8 2023 Apr 20 %G eng %R 10.1111/jgs.18376 %0 Journal Article %J Health Affairs %D 2022 %T Informal Caregivers Provide Considerable Front-Line Support In Residential Care Facilities And Nursing Homes. %A Norma B Coe %A Werner, Rachel M %K Caregiving %K Informal care %X

Informal care, or care provided by family and friends, is the most common form of care received by community-dwelling older adults with functional limitations. However, less is known about informal care provision within residential care settings including residential care facilities (for example, assisted living) and nursing homes. Using data from the Health and Retirement Study (2016) and the National Health and Aging Trends Study (2015), we found that informal care was common among older adults with functional limitations, whether they lived in the community, a residential care facility, or a nursing home. The hours of informal care provided were also nontrivial across all settings. This evidence suggests that informal caregiving and some of the associated burdens do not end when a person transitions from the community to residential care or a nursing home setting. It also points to the large role that families play in the care and well-being of these residents, which is especially important considering the recent visitor bans during the COVID-19 epidemic. Family members are an invisible workforce in nursing homes and residential care facilities, providing considerable front-line work for their loved ones. Providers and policy makers could improve the lives of both the residents and their caregivers by acknowledging, incorporating, and supporting this workforce.

%B Health Affairs %V 41 %P 105-111 %G eng %N 1 %R 10.1377/hlthaff.2021.01239 %0 Journal Article %J Journal of General Internal Medicine %D 2022 %T Observational study of patient characteristics associated with a timely diagnosis of dementia and mild cognitive impairment without dementia. %A White, Lindsay %A Ingraham, Bailey %A Eric B Larson %A Fishman, Paul %A Park, Sungchul %A Norma B Coe %K cognitive impairment %K Dementia %K Diagnosis %K Disparities %X

BACKGROUND: Timely diagnosis of cognitive impairment is a key goal of the National Plan to Address Alzheimer's Disease, but studies of factors associated with a timely diagnosis are limited.

OBJECTIVE: To identify patient characteristics associated with a timely diagnosis of dementia and mild cognitive impairment (MCI).

DESIGN: Retrospective observational study using survey data from the Health and Retirement Study (HRS) from 1995-2016 (interview waves 3-13).

PARTICIPANTS: 4,760 respondents with incident dementia and 1,864 with incident MCI identified using longitudinal measures of cognitive functioning.

MAIN MEASURES: Timely or delayed diagnosis based on the timing of a self or proxy report of a healthcare provider diagnosis in relation to respondents first dementia or MCI-qualifying cognitive score, sociodemographic characteristics, health status, health care utilization, insurance provider, and year of first qualifying score.

KEY RESULTS: Only 26.0% of the 4,760 respondents with incident dementia and 11.4% of the 1,864 respondents with incident MCI received a timely diagnosis. Non-Hispanic Black respondents and respondents with less than a college degree were significantly less likely to receive a timely diagnosis of either dementia or MCI than Non-Hispanic White respondents (dementia odds ratio (OR): 0.61, 95% CI: 0.50, 0.75; MCI OR: 0.40, 95% CI: 0.23, 0.70) and those with a college degree (dementia OR for less than high school degree: 0.30, 95% CI: 0.23, 0.38; MCI OR: 0.36, 95% CI: 0.22, 0.60). Respondents that lived alone were also less likely to receive a timely diagnosis of dementia (OR: 0.69, 95% CI: 0.59, 0.81), though not MCI. Timely diagnosis of both conditions increased over time.

CONCLUSIONS: Targeting resources for timely diagnosis of cognitive impairment to individuals from racial and ethnic minorities, lower educational attainment, and living alone may improve detection and reduce disparities around timely diagnosis of dementia and MCI.

%B Journal of General Internal Medicine %V 37 %P 2957-2965 %G eng %N 12 %R https://doi.org/10.1007/s11606-021-07169-7 %0 Journal Article %J Journal of the American Geriatrics Society %D 2022 %T Out-of-pocket costs attributable to dementia: A longitudinal analysis. %A Oney, Melissa %A White, Lindsay %A Norma B Coe %K Dementia %K Long-term services and supports %K out-of-pocket costs %X

BACKGROUND: Alzheimer's disease and related dementias (ADRD) affect 5.7 million Americans, and are expensive despite the lack of a cure or even treatments effective in managing the disease. The literature thus far has tended to focus on the costs to Medicare, even though one of the main characteristics of ADRD (the loss of independence and ability to care for oneself) incurs costs not covered by Medicare.

METHODS: In this paper, we use survey data for 2002-2016 from the Health and Retirement Study to estimate the out-of-pocket costs of ADRD for the patient and their family through the first 8 years after the onset of symptoms, as defined by a standardized 27-point scale of cognitive ability. A two-part model developed by Basu and Manning (2010) allows us to separate the costs attributable to ADRD into two components, one driven by differences in longevity and one driven by differences in utilization.

RESULTS: We identified a cohort of 3619 incident dementia cases, 38.9% were male, and 66.9% were non-Hispanic White. Dementia onset was 77.7 years of age, on average. OOP costs attributable to dementia are $8751 over the first 8 years after the onset. These incremental costs are driven by nursing home expenditures, which are largely uninsured in the US. OOP spending is highest for whites and women.

CONCLUSION: The financial burden of ADRD is significant, and largely attributable to the lack of wide-spread long-term care insurance.

%B Journal of the American Geriatrics Society %V 70 %P 1538-1545 %G eng %N 5 %R 10.1111/jgs.17746 %0 Journal Article %J Medical Care %D 2021 %T Demographic Characteristics Driving Disparities in Receipt of Long-term Services and Supports in the Community Setting. %A Travers, Jasmine L %A Naylor, Mary D %A Norma B Coe %A Meng, Can %A Li, Fangyong %A Cohen, Andrew B %K community setting %K Demographics %K Long-term services and supports %K Minority %K race disparity %X

BACKGROUND: Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS).

OBJECTIVE: We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity.

METHODS: We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences.

RESULTS: There were 186 minority older adults (community=75%, NH=25%) and 357 White older adults (community=50%, NH=50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community.

CONCLUSION: Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.

%B Medical Care %V 59 %P 537-542 %G eng %N 6 %R 10.1097/MLR.0000000000001544 %0 Journal Article %J Gerontology and Geriatric Medicine %D 2020 %T Dementia Is Associated With Earlier Mortality for Men and Women in the United States. %A White, Lindsay %A Fishman, Paul %A Basu, Anirban %A Paul K Crane %A Eric B Larson %A Norma B Coe %K Dementia %K gender %K Medicare %K Medicare administrative data %X

Sociodemographic trends in the United States may influence future dementia-associated mortality, yet there is little evidence about their potential impact. Our study objective was to estimate the effect of dementia on survival in adults stratified by sex, education, and marital status. Using survey data from the Health and Retirement Study (HRS) linked to Medicare claims from 1991 to 2012, we identified a retrospective cohort of adults with at least one International Classification of Diseases-ninth revision-Clinical Modification (ICD-9-CM) dementia diagnosis code ( = 3,714). For each case, we randomly selected up to five comparators, matching on sex, birth year, education, and HRS entry year ( = 9,531), and assigned comparators the diagnosis date of their matched case. Participants were followed for up to 60 months following diagnosis. We estimated a survival function for the entire study population and then within successive strata defined by sex, education, and marital status. On average, dementia cases were 80.5 years old at diagnosis. Most were female, had less than college-level education, and approximately 40% were married at diagnosis. In multivariate analyses, dementia diagnosis was associated with earlier mortality for women (predicted median survival of 54.5 months vs. 62.5 months; dementia coefficient = -0.13; 95% confidence interval [CI] = [-0.22, -0.04]; = .003), but even more so among men (predicted median survival of 35.5 months vs. 54.5 months; dementia coefficient = -0.42; 95% CI = [-0.52, -0.31]; < .001). We found substantial heterogeneity in the relationship between dementia and survival, associated with both education and marital status. Both sex and level of education moderate the relationship between dementia diagnosis and length of survival.

%B Gerontology and Geriatric Medicine %V 6 %P 2333721420945922 %G eng %R 10.1177/2333721420945922 %0 Journal Article %J Journal of General Internal Medicine %D 2020 %T Difficulty with Taking Medications Is Associated with Future Diagnosis of Alzheimer's Disease and Related Dementias. %A Douglas Barthold %A Marcum, Zachary A %A Chen, Shuxian %A White, Lindsay %A Ailabouni, Nagham %A Basu, Anirban %A Norma B Coe %A Gray, Shelly L %K Alzheimer’s disease and related dementias %K cognitive screening %K medication management %X

BACKGROUND: Medication management requires complex cognitive functioning, and therefore, difficulty taking medications might be an early sign of cognitive impairment and could be a risk factor for Alzheimer's disease and related dementias (ADRD). Accordingly, people with difficulty taking medications may benefit from more detailed cognitive screening, potentially aiding in the diagnosis of ADRD, which is underdiagnosed. We are unaware of evidence on medication management difficulties that precede a real-world ADRD diagnosis in the USA.

OBJECTIVE: Examine the association between difficulty taking medications and subsequent real-world ADRD diagnoses.

DESIGN: Case-control study, using Health and Retirement Study (HRS) survey data linked to Medicare claims.

PARTICIPANTS: A total of 1461 HRS respondents with an ADRD diagnosis observed from 1993 to 2012 (cases), matched by year of birth, wave of HRS entry, and sex to 3771 controls with no ADRD diagnosis.

MAIN MEASURES: We examined the association between diagnosis of ADRD and self-reported difficulty taking medications in the preceding years (1-2 and 3-4 years prior to case definition). Control individuals were assigned the index date from their matched case. Conditional logistic regressions adjusted for age, sex, race, education, and comorbidities.

KEY RESULTS: Compared with matched controls, cases had higher prevalence of difficulty taking medications 1-2 years prior to diagnosis (11.0% versus 2.3%), and 3-4 years prior to diagnosis (5.8% versus 2.3%). Adjusted analyses showed that compared with individuals without ADRD, those with an ADRD diagnosis had more than four times higher odds of difficulty taking medications 1-2 years prior (OR = 4.56 (CI 3.30-6.31)), and more than two times higher odds of difficulty taking medications 3-4 years prior (OR = 2.41 (CI 1.61-3.59)).

CONCLUSIONS: Odds of medication difficulty 1-2 years prior were more than four times greater for individuals with ADRD diagnoses compared with those without ADRD. Medication management difficulties may prompt further cognitive screening, potentially aiding in earlier recognition of ADRD.

%B Journal of General Internal Medicine %G eng %R 10.1007/s11606-020-06279-y %0 Journal Article %J Innovation in Aging %D 2020 %T Out-of-Pocket Costs Attributable to Dementia: A Longitudinal Analysis %A Oney, Melissa %A White, Lindsay %A Norma B Coe %K Alzheimer disease %K Dementia %K Out-of-pocket medical expenses %X Alzheimer’s disease and related dementias (ADRD) affects 5.5 million Americans, and is expensive despite the lack of a cure or even treatments effective in managing the disease. The literature thus far has tended to focus on the costs to Medicare, despite the fact that one of the main characteristics of ADRD (the loss of independence and ability to care for oneself) incurs costs not covered by Medicare. In this paper, we use survey data for 2002-2014 from the Health and Retirement Study to estimate the out-of-pocket costs of ADRD for the patient and their family through the first 8 years after onset of symptoms, as defined by a standardized 27-point scale of cognitive ability. A two-part model developed by Basu and Manning (2010) allows us to separate the costs attributable to ADRD into two components, one driven by differences in longevity and one driven by differences in utilization. We consider total out-of-pocket expenditures, as well as out-of-pocket expenditures by category (i.e. hospital, nursing home, doctor, prescription drug, and other). Our results suggest that the out-of-pocket costs of ADRD are quite substantial over the first 8 years after onset. We also find that out-of-pocket spending is decreasing over the first 8 years, similar to the trend seen in Medicare expenditures. The results of this study highlight the financial burden of ADRD, particularly for the population paying out-of-pocket for care. %B Innovation in Aging %V 4 %P 475-476 %@ 2399-5300 %G eng %N Suppl 1 %R 10.1093/geroni/igaa057.1539 %0 Journal Article %J Health Services Research %D 2019 %T Medicare expenditures attributable to dementia. %A Lindsay L Waite %A Fishman, Paul %A Basu, Anirban %A Paul K Crane %A Eric B Larson %A Norma B Coe %K Cognition & Reasoning %K Dementia %K Medicare linkage %K Medicare/Medicaid/Health Insurance %X

OBJECTIVE: To estimate dementia's incremental cost to the traditional Medicare program.

DATA SOURCES: Health and Retirement Study (HRS) survey-linked Medicare part A and B claims from 1991 to 2012.

STUDY DESIGN: We compared Medicare expenditures for 60 months following a claims-based dementia diagnosis to those for a randomly selected, matched comparison group.

DATA COLLECTION/EXTRACTION METHODS: We used a cost estimator that accounts for differential survival between individuals with and without dementia and decomposes incremental costs into survival and cost intensity components.

PRINCIPAL FINDINGS: Dementia's five-year incremental cost to the traditional Medicare program is approximately $15 700 per patient, nearly half of which is incurred in the first year after diagnosis. Shorter survival with dementia mitigates the incremental cost by about $2650. Increased costs for individuals with dementia were driven by more intensive use of Medicare part A covered services. The incremental cost of dementia was about $7850 higher for females than for males because of sex-specific differential mortality associated with dementia.

CONCLUSIONS: Dementia's cost to the traditional Medicare program is significant. Interventions that target early identification of dementia and preventable inpatient and post-acute care services could produce substantial savings.

%B Health Services Research %G eng %1 http://www.ncbi.nlm.nih.gov/pubmed/30868557?dopt=Abstract %R 10.1111/1475-6773.13134 %0 Journal Article %J Health Economics %D 2018 %T 2SLS versus 2SRI: Appropriate methods for rare outcomes and/or rare exposures %A Basu, Anirban %A Norma B Coe %A Cole G. Chapman %K Clinical trials %K Health Care Outcomes %K Insurance %K Monte-Carlo Simulations %X This study used Monte Carlo simulations to examine the ability of the two‐stage least squares (2SLS) estimator and two‐stage residual inclusion (2SRI) estimators with varying forms of residuals to estimate the local average and population average treatment effect parameters in models with binary outcome, endogenous binary treatment, and single binary instrument. The rarity of the outcome and the treatment was varied across simulation scenarios. Results showed that 2SLS generated consistent estimates of the local average treatment effects (LATE) and biased estimates of the average treatment effects (ATE) across all scenarios. 2SRI approaches, in general, produced biased estimates of both LATE and ATE under all scenarios. 2SRI using generalized residuals minimized the bias in ATE estimates. Use of 2SLS and 2SRI is illustrated in an empirical application estimating the effects of long‐term care insurance on a variety of binary health care utilization outcomes among the near‐elderly using the Health and Retirement Study. %B Health Economics %V 27 %P 937 - 955 %8 Jan-06-2018 %G eng %U http://doi.wiley.com/10.1002/hec.v27.6http://doi.wiley.com/10.1002/hec.3647http://onlinelibrary.wiley.com/wol1/doi/10.1002/hec.3647/fullpdfhttps://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1002%2Fhec.3647 %N 6 %! Health Economics %R 10.1002/hec.v27.610.1002/hec.3647 %0 Journal Article %J Health Economics %D 2018 %T 2SLS vs 2SRI: Appropriate methods for rare outcomes and/or rare exposures %A Basu, Anirban %A Norma B Coe %K Health Care Outcomes %K Monte-Carlo Simulations %X Using Monte-Carlo simulations, we compare the two-stage least-squares estimator with two-stage residual inclusion estimators, with varying forms of residuals, to estimate the local average treatment effect parameter for a binary outcome and endogenous binary treatment model in the presence of binary covariates and a binary instrumental variable. We vary the rarity of both the outcome and the treatment and find different estimators to produce the least bias in different settings. We develop guidance for applied researchers and illustrate the utility of this guidance with estimating the effects of long-term care insurance on a variety of binary health care use outcomes among the near-elderly using the Health and Retirement Study. %B Health Economics %V 27 %P 937-955 %G eng %U https://onlinelibrary.wiley.com/doi/abs/10.1002/hec.3647 %N 6 %9 Journal %! Health Econ. %R 10.1002/hec.3490 %0 Journal Article %J Journal of the American Geriatrics Society %D 2018 %T A Comprehensive Measure of the Costs of Caring for a Parent: Differences According to Functional Status %A Norma B Coe %A Meghan M. Skira %A Eric B Larson %K Caregiving %K Informal care %K Well-being %X Approximately 34 million family and friends provided unpaid care to individuals aged 50 and older in 2015. It is difficult to place a value on that time, because no payment is made to the caregiver, and multiplying caregiving hours by a wage does not account for the value of lost leisure time, implications for future employability and wages, or any intrinsic benefits accrued to the care provider. This study used a dynamic discrete choice model to estimate the costs of informal care provided by a daughter to her mother, including these other costs and benefits not typically accounted for, and compared these cost estimates for 4 categories of the mother's functional status: doctor-diagnosed memory-related disease, limitations in activities of daily living (ADLs), combination of both, cannot be left alone for 1 hour or more. We studied women aged 40 to 70 with a living mother at the start of the sample period (N=3,427 adult daughters) using data from the Health and Retirement Study (1998–2012). The primary outcome was the monetized change in well-being due to caregiving, what economists call “welfare costs.” We estimate that the median cost to the daughter's well-being of providing care to an elderly mother ranged from $144,302 to $201,896 over 2 years, depending on the mother's functional status. These estimates suggest that informal care cost $277 billion in 2011, 20% more than estimates that account only for current foregone wages. © 2018, Copyright the Author Journal compilation © 2018, The American Geriatrics Society %B Journal of the American Geriatrics Society %V 66 %P 2003 - 2008 %8 Jan-10-2018 %G eng %U https://pubmed.ncbi.nlm.nih.gov/30222183/ %N 10 %! J Am Geriatr Soc %R 10.1111/jgs.15552 %0 Report %D 2017 %T Comparing 2SLS vs 2SRI for Binary Outcomes and Binary Exposures %A Basu, Anirban %A Norma B Coe %A Cole G. Chapman %K Economics %K Health Services Utilization %K Long-term Care %X This study uses Monte Carlo simulations to examine the ability of the two-stage least-squares (2SLS) estimator and two-stage residual inclusion (2SRI) estimators with varying forms of residuals to estimate the local average and population average treatment effect parameters in models with binary outcome, endogenous binary treatment, and single binary instrument. The rarity of the outcome and the treatment are varied across simulation scenarios. Results show that 2SLS generated consistent estimates of the LATE and biased estimates of the ATE across all scenarios. 2SRI approaches, in general, produce biased estimates of both LATE and ATE under all scenarios. 2SRI using generalized residuals minimizes the bias in ATE estimates. Use of 2SLS and 2SRI is illustrated in an empirical application estimating the effects of long-term care insurance on a variety of binary healthcare utilization outcomes among the near-elderly using the Health and Retirement Study. %B NBER Working Paper Series %I National Bureau of Economic Research %C Cambridge, MA %8 09/2017 %G eng %U http://www.nber.org/papers/w23840.pdf %R 10.3386/w23840 %0 Report %D 2015 %T Does Retirement Impact Health Care Utilization? %A Norma B Coe %A Gema Zamarro %K Health Conditions and Status %K Healthcare %K Retirement Planning and Satisfaction %X The objective of this paper is to estimate the causal effect of retirement on health care utilization. To do so, we use data from the 1992-2008 waves of the Health and Retirement Study (HRS) and the 2004-2006 waves of the Survey of Health, Aging, and Retirement in Europe (SHARE).In particular, we estimate the causal impact of retirement on health care utilization as measured by: doctor visits, visits to a general practitioner, nights in the hospital, and preventative care use. This paper uses panel data and instrumental variable methods, exploiting variation in statutory retirement ages across countries, to estimate the causal effects. Cross-country comparisons allow us to examine the role of a health care system s use of the general practitioner as a gate keeper to specialists in this relationship. We find that while retirement is associated with increased health care use, our causal estimates show that retirement leads to fewer doctor visits in both the US and continental Europe. Nights in the hospital are unaffected by retirement status. Further we find that health care systems with primary care physicians who act as gatekeepers are particularly effective at decreasing doctor visits at retirement. Therefore, we conclude that increasing the statutory retirement age to help the solvency of the retirement systems will also increase doctor visits as individuals continue to work longer. In the US, the burden of this increased utilization will likely be borne by private insurance companies and public insurance to the extent it covers working individuals in their 60 s. European evidence suggests that this increase in doctor visits due to delayed retirement will be particularly evident in health systems without strong gatekeeper roles for general practitioners. %I Los Angeles, CA, Center for Economic and Social Research, University of Southern California %G eng %4 health/retirement/health care utilization/preventive care %$ 999999 %0 Book Section %B Safety Nets and Benefit Dependence %D 2014 %T What Impact Does Old-Age Pension Receipt Have on the Use of Public Assistance Programs Among the Elderly? %A Norma B Coe %A April Yanyuan Wu %E Carcillo, Stéphane %E Immervoll, Herwig %E Stephen P. Jenkins %E Königs, Sebastian %E Tatsiramos, Konstantinos %K Health Conditions and Status %K Public Policy %K Retirement Planning and Satisfaction %K Social Security %B Safety Nets and Benefit Dependence %I Emerald Group Publishing %C Bingley, UK %P 259-290 %G eng %4 social Security/old age pensions/retirement planning/Public assistance %$ 999999 %! What Impact Does Old-Age Pension Receipt Have on the Use of Public Assistance Programs Among the Elderly? %0 Journal Article %J Research on Aging %D 2013 %T The Asset and Income Profiles of Residents in Seniors Housing and Care Communities: What Can Be Learned From Existing Data Sets %A Norma B Coe %A Melissa A. Boyle %K Health Conditions and Status %K Healthcare %K Housing %K Retirement Planning and Satisfaction %X The authors use existing, nationally representative surveys to assess the economic characteristics of individuals in three categories of seniors housing and care facilities: independent living communities (ILCs), assisted living residences (ALRs), and continuing care retirement communities (CCRCs). The findings highlight the strengths and weaknesses of using the Health and Retirement Study, National Long-Term Care Survey, and Medicare Current Beneficiary Survey to describe this segment of the population. The results suggest that residents in ILCs and ALRs have lower average incomes than the average costs of these care communities. Conversely, CCRC residents have higher incomes and more assets than those living in private homes, suggesting that CCRCs attract the wealthiest seniors. However, longitudinal analysis is prohibited by the small sample sizes. %B Research on Aging %I 35 %V 35 %P 50-77 %G eng %N 1 %4 Aging/Housing/Living arrangements/Long-term care/Assisted Living/retirement planning %$ 69134 %R 10.1177/0164027511434331 %0 Journal Article %J Journal of health economics %D 2013 %T The effect of informal care on work and wages %A Courtney Harold Van Houtven %A Norma B Coe %A Meghan M. Skira %K Demographics %K Employment and Labor Force %K Healthcare %K Income %K Medicare/Medicaid/Health Insurance %X Cross-sectional evidence in the United States finds that informal caregivers have less attachment to the labor force. The causal mechanism is unclear: do children who work less become informal caregivers, or are children who become caregivers working less? Using longitudinal data from the Health and Retirement Study, we identify the relationship between informal care and work in the United States, both on the intensive and extensive margins, and examine wage effects. We control for time-invariant individual heterogeneity; rule out or control for endogeneity; examine effects for men and women separately; and analyze heterogeneous effects by task and intensity. We find modest decreases-2.4 percentage points-in the likelihood of working for male caregivers providing personal care. Female chore caregivers, meanwhile, are more likely to be retired. For female care providers who remain working, we find evidence that they decrease work by 3-10hours per week and face a 3 percent lower wage than non-caregivers. We find little effect of caregiving on working men's hours or wages. These estimates suggest that the opportunity costs to informal care providers are important to consider when making policy recommendations about the design and funding of public long-term care programs. %B Journal of health economics %I 32 %V 32 %P 240 %G eng %N 1 %4 Informal care/Caregivers/Labor force participation/Labor economics/Labor supply/Compensation and benefits/Working hours/wage rates/Long-term care of the sick/gender Differences %$ 69750 %0 Report %D 2013 %T How Important Is Medicare Eligibility in the Timing of Retirement? %A Norma B Coe %A Khan, Mashfiqur R. %A Matthew S. Rutledge %K Medicare/Medicaid/Health Insurance %K Public Policy %K Retirement Planning and Satisfaction %K Social Security %X Eligibility for Medicare at age 65 is widely viewed as an important factor in retirement decisions. However, it has been difficult to quantify the influence of Medicare because eligibility for Medicare came at the same age as Social Security s Full Retirement Age (FRA). The recent rise in the FRA, along with other changes, has decoupled the age-related incentives in the two programs, making it easier to estimate the effect of Medicare eligibility on the timing of retirement. This brief, based on a recent study, provides such estimates of the importance of Medicare on retirement decisions. %I Boston, Center for Retirement Research at Boston College %G eng %4 Medicare/retirement planning/social Security/Public Policy %$ 69314 %0 Report %D 2013 %T Sticky Ages: Why is Age 65 Still a Retirement Peak? %A Norma B Coe %A Khan, Mashfiqur R. %A Matthew S. Rutledge %X When Social Security’s Full Retirement Age (FRA) increased to age 66 for recent retirees, the peak retirement age increased with it. However, a large share of people continue to claim their Social Security benefits at age 65. This paper explores two potential explanations for the “stickiness” of age 65 as a claiming age: Medicare eligibility and workers’ lack of knowledge about their future Social Security benefits. First, we analyze the impact of Medicare eligibility by comparing two groups – one has an FRA of exactly 65; the other, between age 65 and 2 months and age 66. We find that the group with later FRAs who do not have access to retiree health benefits through their employer are more likely to claim Social Security at age 65. We interpret this finding as evidence that Medicare eligibility persuades more people to retire, because they can begin receiving federal health coverage. Individuals without access to retiree health insurance at work are 7.5 percentage points more likely to retire soon after their 65th birthdays and are 5.8 percentage points less likely to delay retirement until the FRA than those with that insurance. This result fits into extensive research showing that access to health insurance is an important component of the retirement decision. On the question of whether misinformation about Social Security benefits may drive individuals to claim at age 65, we find that some individuals are unable to accurately forecast their retirement benefits. However, our analysis suggests that there is no relationship between this confusion and the age 65 peak for claiming Social Security. %B Center for Retirement Research at Boston College Working Paper Series %I Center for Retirement Research at Boston College %C Boston, MA %G eng %U http://crr.bc.edu/working-papers/sticky-ages-why-is-age-65-still-a-retirement-peak/ %0 Report %D 2012 %T Do Income Taxes Affect the Progressivity of Social Security? %A Norma B Coe %A Karamcheva, Zhenya %A Richard W Kopcke %A Alicia H. Munnell %K Income taxes %K Social Security %X Policymakers have designed Social Security to be a progressive retirement program that replaces a larger share of monthly earnings for low- and middleincome workers than for high earners. However, previous research has found that, although the Disability Insurance (DI) component of Social Security is very progressive, the Old-Age and Survivors Insurance (OASI) component may be less progressive than intended. One reason is that high earners tend to live longer than low earners. Since Social Security pays an annuity that lasts throughout retirement, it benefits high earners with greater longevity. Social Security’s progressivity may also be %B Center for Retirement Research at Boston College Briefs %I Center for Retirement Research at Boston College %C Boston, MA %G eng %U https://crr.bc.edu/briefs/do-income-taxes-affect-the-progressivity-of-social-security/ %0 Journal Article %J Health Econ %D 2012 %T The effect of retirement on cognitive functioning. %A Norma B Coe %A von Gaudecker, Hans-Martin %A Maarten Lindeboom %A Jürgen Maurer %K Age Factors %K Aged %K Aging %K Cognition %K Decision making %K Humans %K Longitudinal Studies %K Male %K Mental Recall %K Middle Aged %K Occupations %K Retirement %K Socioeconomic factors %K Time Factors %X

Cognitive impairment has emerged as a major driver of disability in old age, with profound effects on individual well-being and decision making at older ages. In the light of policies aimed at postponing retirement ages, an important question is whether continued labour supply helps to maintain high levels of cognition at older ages. We use data of older men from the US Health and Retirement Study to estimate the effect of continued labour market participation at older ages on later-life cognition. As retirement itself is likely to depend on cognitive functioning and may thus be endogenous, we use offers of early retirement windows as instruments for retirement in econometric models for later-life cognitive functioning. These offers of early retirement are legally required to be nondiscriminatory and thus, inter alia, unrelated to cognitive functioning. At the same time, these offers of early retirement options are significant predictors of retirement. Although the simple ordinary least squares estimates show a negative relationship between retirement duration and various measures of cognitive functioning, instrumental variable estimates suggest that these associations may not be causal effects. Specifically, we find no clear relationship between retirement duration and later-life cognition for white-collar workers and, if anything, a positive relationship for blue-collar workers.

%B Health Econ %I 21 %V 21 %P 913-27 %8 2012 Aug %G eng %N 8 %1 http://www.ncbi.nlm.nih.gov/pubmed/21818822?dopt=Abstract %3 21818822 %4 Cognitive Impairment/Decision Making/Well Being/labor Force Participation/early Retirement/DISABILITY/DISABILITY/retirement planning/early Retirement %$ 62726 %R 10.1002/hec.1771 %0 Report %D 2012 %T Great Recession-Induced Early Claimers: Who Are They? How Much Do They Lose? %A Norma B Coe %A Matthew S. Rutledge %K Recession %K Social Security %X During the Great Recession, more older workers have claimed Social Security benefits early. This paper addresses two important policy questions: Who are these early claimers? How much retirement income have they lost as a result of claiming early? Using the Health and Retirement Study (HRS) we estimate a discrete-time hazard model that makes claiming Social Security benefits a function of age, personal characteristics, and the national unemployment rate. We project that high unemployment rates during the Great Recession led to a 5-percentage-point increase in the probability of claiming early relative to a less severe recession such as the 2001-2003 downturn, and this increase was nearly uniform across socioeconomic groups. Our estimates also suggest that while the Great Recession did impact the claiming decision, it did not cause a dramatic change in benefits. “Great Recession Claimers” – those whom we simulate were likely to claim early during the Great Recession but would not have in a milder downturn – filed for Social Security only 6 months earlier, on average, than they would have in a minor recession. This modest change in timing reduced their monthly Social Security benefit checks by $56, or 4.6 percent of average monthly benefits, and the Social Security replacement rate fell by 1.7 percentage points relative to a more typical recession. The benefit reduction resulted from the combined effect of the actuarial reduction for early claiming and the foregone opportunity to continue working and increase the wage base used for calculating benefits. %B Center for Retirement Research at Boston College Working Papers %I Center for Retirement Research at Boston College %C Boston, MA %G eng %U https://crr.bc.edu/working-papers/great-recession-induced-early-claimers-who-are-they-how-much-do-they-lose/ %0 Report %D 2011 %T How Does the Personal Income Tax Affect the Progressivity of OASI Benefits? %A Norma B Coe %A Karamcheva, Zhenya %A Richard W Kopcke %A Alicia H. Munnell %K Methodology %K Public Policy %K Social Security %X This study calculates the impact of federal income taxes on the progressiveness of the Old Age and Survivors Insurance (OASI) program. It uses the Health and Retirement Study (HRS) data linked with the Social Security Earnings Records to estimate OASI contributions and benefits for individuals and households, before and after income taxes, for three birth cohorts. It uses two measures of progressivity: redistribution by decile (the difference between the share of total benefits received and the share of total taxes paid) and effective progression (the change in the Gini coefficient). Under both measures, the results without the income tax confirm previous findings: Social Security is progressive on an individual basis, but that progressivity is dramatically cut when one calculates it on a household basis. Adding income taxes could make the program either more or less progressive. On the one hand, the tax treatment of contributions makes the system even less progressive than generally reported. On the other hand, the taxation of benefits makes it more progressive. The net result is that adding the personal income tax to the analysis makes Social Security more progressive than without taxes, on both the individual and household bases. Importantly, however, the impact of taxation on redistribution increases significantly among younger cohorts. Under current law, the Social Security system becomes more progressive over time. %B Center for Retirement Research at Boston College Working Papers %I Center for Retirement Research at Boston College %C Boston, MA %G eng %U https://crr.bc.edu/working-papers/how-does-the-personal-income-tax-affect-the-progressivity-of-oasi-benefits/ %4 Public policy/social security/Gini coefficient/taxation/income tax %$ 69554 %0 Report %D 2010 %T Children and Household Utility: Evidence from Kids Flying the Coop %A Norma B Coe %A Anthony Webb %K children %X Using consumption and wealth data from the Health and Retirement Study (HRS), this paper explores the impact of children leaving home on household consumption. We find that households maintain their household-level consumption, despite the fact that the number of individuals in the household has decreased, increasing per-capita consumption. Further, we find no evidence of increases in total net wealth, or any of its components, after children leave the household. These findings suggest that households do not dramatically change their savings or consumption patterns when their children fly the coop. Those households who are already behind in their retirement preparations will remain at risk of entering retirement with insufficient wealth to maintain their pre-retirement standard of living. %I Center for Retirement Research at Boston College %G eng %U https://crr.bc.edu/working-papers/children-and-household-utility-evidence-from-kids-flying-the-coop-ii/ %0 Report %D 2010 %T Measuring the Spillover to Disability Insurance Due to the Rise in the Full Retirement Age %A Norma B Coe %A Haverstick, Kelly %K Disability %K disability insurance %K Retirement Age %X The increase in the full retirement age in the Social Security program provides exogenous variation in the generosity in the Social Security Disability Insurance (SSDI) program, based only on birth year. We exploit this variation to estimate how responsive SSDI applications are to the financial incentive to apply. We find that a 1-percentage-point decrease in the retirement-to-disability benefit ratio leads to a 0.25-percentage-point increase in the SSDI application rate for the sample, which represents an 8-percent increase in applications per two years. When weighted to account for sampling design, we estimate that this change in the financial incentive accounted for about 5 percent of the SSDI applications in 2009. However, we do not find a corresponding increase in SSDI receipt based on the financial incentives… %I Center for Retirement Research at Boston College %G eng %U https://crr.bc.edu/working-papers/measuring-the-spillover-to-disability-insurance-due-to-the-rise-in-the-full-retirement-age/ %0 Report %D 2009 %T Actual and Anticipated Inheritance Receipts %A Norma B Coe %A Anthony Webb %K Adult children %K Consumption and Savings %K Net Worth and Assets %X Using data from the Health and Retirement Study, we compare actual inheritances received during the period 1994 to 2004 with the amounts that, in 1994, households anticipated receiving within 10 years. We find little evidence of systematic forecasting errors. The factors affecting inheritance receipt also affect expectation formation. Although the distribution is highly skewed, inheritances are generally modest in amount and uncorrelated with lifetime income, and therefore have almost no effect on various measures of inequality. We find no evidence that households anticipating receipt of an inheritance save less than that of similar households, although this could reflect unobserved heterogeneity in tastes for saving. %B Center for Retirement Research at Boston College Working Papers %I Center for Retirement Research at Boston College %C Boston %G eng %U https://crr.bc.edu/working-papers/actual-and-anticipated-inheritance-receipts/ %4 household income/savings/wills/inheritance %$ 22090