Will your state face a growing informal care gap?

In North Dakota, about 13 percent of residents ages 15 to 64 live alone.

In the District of Columbia, the percentage of residents who live by themselves in what the Census Bureau calls “nonfamily households” is about 20 percent.

Someday, those statistics could contribute to a hole in the supply of long-term care (LTC). Policymakers are hoping neighbors, cousins, nieces, nephews, friends, children, roommates, and, above all, spouses will provide enough free help to keep frail older and moderate disabled people in their homes, without costly home care services, as long as possible. “Informal care” can maximize the quality of life of older people and people with disabilities and minimize the amount of paid, “formal care” they use.

See also: Busy Lives: How You Can Help Caregiving Clients.

Insurers recognize the protective role of having a spouse by offering discounts for married consumers who buy private long-term care insurance (LTCI).

The SCAN Foundation has estimated that about 44 million U.S. residents were providing informal care for adults ages 50 and older in 2009, and that 87 percent of the adults who needed long-term care were getting the services from informal caregivers. In June 2013, the Congressional Budget Officers said replacing the casual, blue-jeans brand of informal care delivered in the United States in 2011 with formal, paid, tuxedo-level care would have cost $234 billion.

One rip in the knees of blue jeans care: Fewer Americans seem likely to have ready access to family caregivers. Fewer are marrying. The percentage of U.S. residents ages 35 and older who have never married bottomed out around 6 percent in 1980 and climbed to 12 percent in 2010.

The likelihood that U.S. adults will have children, either inside or outside of a marriage, is also falling. The percentage of U.S. women ages 40 to 44 who have no children jumped to 18 percent in 2008, from 10 percent in 1976. Meanwhile, in 2010, 27 percent of U.S. households were one-person households, up from fewer than 10 percent in 1950.

Rose Kreider and Jonathan Vespa, the authors of a recent paper on the rise of the one-person U.S. household, say the number of one-person households is increasing partly because Americans are making more money and can afford to live on their own.

But the result is that men – who historically have benefited heavily from getting informal care from their wives – are much less likely to be on track to get wife care. In 2010, about 34 percent of U.S. one-person households consisted of men younger than 65, up from 24 percent in 1970.

Access to spouse care – or having the traits needed to have a spouse in the first place – can affect easy-to-measure acute medical care outcomes as well as LTC costs. Dr. Ayal Aizer of Harvard Medical School and other cancer researchers reported in the Journal of Clinical Oncology in September 2013 that having a spouse had an obvious effect on the life expectancy of patients with cancer. At any given time, a married patient with cancer was 20 percent more likely to be alive than a patient with cancer and no spouse.