ANNUAL REVIEW OF GERONTOLOGY AND GERIATRICS Volume 8, 1988 Varieties of Aging Editorial Board Editor-in-Chief M. Powell Lawton, Ph.D. Philadelphia Geriatric Center Philadelphia, Pennsylvania Associate Editors Richard W. Besdine, M.D. John W. Rowe, M.D. University of Connecticut President and Chief School of Medicine Executive Officer Farmington, Connecticut Mount Sinai Medical Center New York, New York Vincent Cristofalo, Ph.D. George L. Maddox, Ph.D. Wistar Institute Duke University Philadelphia, Pennsylvania Durham, North Carolina K. Warner Schaie, Ph.D. The Pennsylvania State University University Park, Pennsylvania Managing Editor Bernard D. Starr, Ph.D. Brooklyn College City University of New York Founding Editor Carl Eisdorfer, Ph.D., M.D. University of Miami School of Medicine Miami, Florida ANNUAL REVIEW OF Gerontology and Geriatrics Volume 8, 1988 Varieties of Aging George L. Maddox, Ph.D. M. Powell Lawton, Ph.D. SPECIAL VOLUME EDITORS SPRINGER SCIENCE+BUSINESS MEDIA, LLC Copyright© Springer Scicnce+Bnsiness Media New York Originally pnblished by 1988 by Springer Publishing Company, Inc. in 1988 Softcover reprint of the hardcover 1st edition 1988 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Science+Business Media, LLC 88 89 90 91 92 I 5 4 3 2 I ISBN 978-3-662-37651-5 ISBN 978-3-662-38443-5 (eBook) DOl 10.1007/978-3-662-38443-5 Contents Preface vii Introduction ix Contributors XV Forthcoming Contents, Volume 9 xvi Orientations Chapter 1 Differential Gerontology and the Stratified Life Course: Conceptual and Methodological Issues 3 DALE DANNEFER Chapter 2 The Changing and Heterogeneous Nature of Aging and Longevity: A Social and Biomedical Perspective 37 LISA F. BERKMAN The Social Distribution of Societal Resources Chapter 3 A Different Perspective on Health and Health Services Utilization 71 FREDRIC D. WOLINSKY AND CONNIE LEA ARNOLD Chapter 4 The Economic Situation of Older Americans: Emerging Wealth and Continuing Hardship 102 MARILYN MooN Chapter 5 Convergence, Institutionalization, and Bifurcation: Gender and the Pension Acquisition Process 132 ANGELA M. O'RAND Chapter 6 Gender and Ethnicity Differences in Psychological Well-Being 156 NEAL KRAUSE v vi CONTENTS Some Policy Implications of Population Heterogeneity Chapter 7 Better Options for Work and Retirement: Some Suggestions for Improving Economic Security Mechanisms for Old Age · 189 YuNG-PING CHEN Chapter 8 Planning Long-Term Care for Heterogeneous Older Populations 217 KENNETH G. MANTON Chapter 9 Insuring Long-Term Care 256 ALICE M. RIVLIN, JOSHUA M. WIENER AND DENISE A. SPENCE Index 283 Contents of Previous Volumes 293 Preface With the appearance of Volume 8 of the Annual Review of Gerontology and Geriatrics it is appropriate to acknowledge the tremendously creative work of founding Editor-In-Chief Carl Eisdorfer. Dr. Eisdorfer's leadership was evident in every phase of the production of the past seven volumes. The most notable of all his contributions came in the generative phase of each, where ideas flowed in bewildering profusion, yet were processed to end up with a coherent set of chapters and authors to constitute each of the volumes. His leadership will be missed, but his continuing interest will remain expressed as he contributes in the role of Founding Editor for the continuing series. The Annual Reviews of the future will build on Dr. Eisdorfer's tradition. In a field that includes so many disciplines, it would be unrealistic to represent a true cross-section of these disciplines in every volume. The series will thus continue to produce volumes that sample segments of the totality, the breadth of each segment varying over the years. The present Volume 8, for example, while it includes content of interest to health-care professionals and geriatric practitioners, samples its chapters from the segment defined by sociology, economics, and social policy. Volume 9 is in process and will represent a particularly broad segment of all gerontology and geriatrics by focusing on "clinical gerontology," based on the clinical research from geriatrics, medicine, psychiatry, exercise physiology, counseling, health ser vice organization, and self-help. Yet another variation on the theme will come in a later volume designed to provide a scholarly presentation of the current status of a number of issues in the biology aimed toward the multi disciplinary audience for this series. Over the long range, the many faces of gerontology and geriatrics will be covered, but without slavish adherence to a formula. The Associate Editors join me in hoping that suggestions for future directions will be provided by readers. M. Powell Lawton Editor-in-Chief Vll Introduction Demographers, epidemiologists and historians have regularly documented the very large differences in how people age, how they experience aging, and when they die among societies and across time. The observed differences appear to be explained substantially by factors external to the individual, factors such as the stability of food supply, the provision of clean water, the adequacy of public sanitation, and the availability of effective immunization against, or medical treatment for, one or another epidemic or chronic disease. Intra-societal differences, however, are a more complex matter and a rela tively less studied one. This volume of the Annual Review focuses attention precisely on the neglected documentation and explanation of heterogeneity of how people grow older within a society. The society of special interest is the United States in relatively recent decades, although some of the chapters include instructive comparisons with other societies. In the opening section, sociologist Dale Dannefer and epidemiologist Lisa Berkman orient the reader to processes of resource allocation within a society which produces and maintains a system of socioeconomic stratifica tion. An individual's social address in a system of stratification is indexed in part by income and level of formal education achieved. But the correlates of one's social address in a society are also easily recognizable by status-related differential life expectancy, patterns of sickness and utilization of health resources, and perceptions of self as socially effective and socially integrated. Dannefer notes that gerontologists, possibly as a reflection of the immaturity of their field, have preferred to pursue broad scientific generalizations about processes of aging and about older adults; consequently they have not been sufficiently interested in documenting and explaining heterogeneity in later life. He makes a strong case for both the theoretical and practical values of differential gerontology. Gerontologists have tended to be keenly aware of the relevance and interaction of both intrinsic and extrinsic factors in deter mining the course of aging processes. Precisely to the extent that external factors are assumed to condition the expression and experience of aging, one might expect gerontologists to celebrate observed diversity as evidence of what happens when intrinsic biological factors are conditioned in their development and expression by sociocultural and environmental factors. And, if the present is an expression of the past, then the present anticipates IX x INTRODUCTION the future. Can alternative futures of aging be anticipated and pursued? If aging processes are modifiable, then the answer is affirmative. Acceptance of the modifiability of aging processes logically leads to a discussion of public policy options in terms of the possible beneficial effects on achieving and maintaining well-being in later life. Lisa Berkman illustrates the application of the perspective of social and behavioral epidemiology to the study of human aging. The tradition of epidemiology is exquisitely multidimensional and multivariate in its focus on the interaction of a host in a particular environment responding to a challenge of one sort or another. For the epidemiologist, the adequacy of an individual's response is reflected in the outcomes we describe as health or illness. Berkman is particularly interested in illustrating more than the classic finding of epidemiology that socioeconomic factors are powerful predictors of health and illness. She also reviews a broad range of new evidence about the effects of socioenvironmental and behavioral factors on the physiologic mechanisms as individuals age and the preventive and mediating effects of social support systems on the health of older adults. In the second section of the volume, four chapters document and inter pret the heterogeneity of the ways adults age in the United States. Fredric Wolinsky and Connie Arnold (Chapter 3) document heterogeneity in health and health-services utilization among older adults but focus specifically on the need for a new perspective in the study of this heterogeneity. It is not enough, they argue, simply to "cut the deck" by new and different ways of subclassifying older adults. Scientific evidence and explanatory models must increasingly take into consideration that many of the processes of aging in which we are interested are best conceptualized as processes and as complex multivariate interactions. Wolinsky and Arnold clearly illustrate some basic problems in the mismeasurement of variables and mis-specification of models intended to explain health and health-services utilization in later life. Age, they find in their analysis, is a weak explanatory variable. Their analysis focuses attention rather on the importance of correct assessment of health needs and the relatedness of institutional and noninstitutional care. These observations lead then to a recommendation of a "fundamental restructuring of health care" to assure uniform access to services, particularly primary care services. They go beyond this general recommendation to argue specifi cally that a system of national health insurance has particular merits in an aging society. Marilyn Moon's theme in Chapter 4 is nicely captured in the subtitle, "Emerging Wealth and Continuing Hardship." It is neither possible nor particularly useful, she concludes, to try to capture the economic situations of heterogeneous older adults with aggregated data describing "the elderly." The most important conclusion about the economic situation of older adults in the contemporary United States may be the persistence of a large minority