living can vary considerably depending on theamenities and services provided, industry sur- veys by Genworth Financial put the average an-nual cost of assisted living care at $34,000 in2009, compared to $74,000 per year for a semi-private room in a nursing home.
An important point from a public policy per-spective is that the development of the assistedliving industry has occurred largely withoutthe influence of government financing or regu-lation. As such, there is no single regulatory or licensure category for assisted living facil-ities, which makes it difficult to estimate theindustry
s actual size. With this caveat, one re-cent study estimated that there were approxi-mately 38,000 assisted living facilities and975,000 units nationwide in 2007 (a
may contain more than one bed, as in the caseof married couples).
In contrast, the nursinghome industry had approximately 16,100 facil-ities and 1.7 million beds nationwide in 2004.
Previous efforts to collect assisted living sup-ply data have largely been at the state level.
These studies have identified much variationin assisted living supply across states; however,examining potential within-state variation or correlations between assisted living supply andmarket-level characteristics has not been pos-sible. In this study we used county-level assistedliving supply data that we collected from indivi-dualstates.Specifically,wemergeda2007cross-sectionofassistedlivingdatawithothermarket-level data on nursing homes and populationsociodemographic traits, to gain a fuller under-standing of the distribution of assisted livingfacilities nationally.
Study Data And Methods
ASSISTED LIVING DATA
There are no national dataon assisted living facilities; however, there areseparatedatasourcesacrossstates,suchasstatelicensure registries. The authors collected de-tailed state-by-state supply data that includedfacilityname,location,andcapacity(units).Our data include a national cross-section for 2007.Reflectingitsimprecisedefinition,assistedliv-ing across states includes a wide range of licen-sure categories for congregate residential facil-ities beyond just
(for example,residential care facilities, community living ar-rangements, and personal care homes). Simi-larly,statedefinitionsfor
canvary.Somestates include only one bed per unit, and othersinclude more than one.To ensure comparability with previous find-ings and as a check for the comprehensivenessofourdatacollection,weusedpreviousNational AcademyforStateHealthPolicycompilationsof state-level assisted living supply data as a guideto data collection and as a basis for compari-son.
We provide more detailed informationabout our data collection procedures and licen-sure categories included, by state, in an onlineappendix.
For the analyses below, we limitedour supply data to facilities with twenty-five or more units, in an attempt to focus on facilitiespurposely built to be assisted living and to ex-clude small group homes (for example, adultfoster care facilities).
NURSING HOME DATA
Weusednursinghomedatafrom the Online Survey, Certification, and Re-porting (OSCAR) system for all Medicaid- andMedicare-certified facilities (96 percent of allfacilities nationwide).Collectedand maintainedby the Centers for Medicaid and MedicaidServices (CMS), OSCAR data indicate whether nursing homes are in compliance with federalregulatory requirements and include facility-reported information about facility, resident,and staffing characteristics. Following an initialsurvey, states arerequiredto survey facilities nolessthaneveryfifteenmonths,andtheaverageisabout twelve months.Usingdatafrom2007andearlier,weincludedthe most recent survey observation for 15,792nursing homes in our analyses. For these facil-ities, we also merged information from the Nur-sing Home Compare database (available onlinefrom http://www.medicare.gov/NHCompare/)
in particular, the 5-Star quality rating foreachfacility, which is a composite measure based onstaffing levels, inspection results, and clinicaloutcomes.
We obtained data on var-ious county characteristics from the 2007 Bu-reau of Health Professions Area Resource File(ARF). This file contains data on a range of pop-ulation characteristics at the county level, in-cluding socioeconomic data, as well as availabil-ity of medical professionals and services.
All analyses used a 2007 nationalcross-section of data. Using the assisted livingsupply data we collected, we first described thesupplyofassistedlivingfacilitiesandunitsatthestate level, including the penetration of assistedliving units per 1,000 people age sixty-five andolder. For the county-level analyses, we mergedassistedliving,nursinghome,andARFvariablesinto a single county-level observation. Acrossthese analyses, assisted living penetration (thatis,thenumberofunitsper1,000elderlypeople)is the primary variable of interest.Our choice of the county as the
for assistedlivingwaspartlypragmatic,becausethe ARFdataarereportedatthecountylevel.Yetthisdistinction is also consistent with the previousliterature on the nursing home market.
HEALTH AFFAIRSJANUARY 2010 29:1