What explains different rates of nursing home admissions? Comparing the United States to Denmark and the Netherlands

The share of older adults residing in a nursing home is much higher in the Netherlands and Denmark than in the US, while in the US, perhaps surprisingly, individuals are much more likely to be admitted to a nursing home. We explore reasons for the higher US admission rates and aim to understand to what extent these differences are due to (i) differences in the composition of the population aged 65+ or (ii) differences in LTC system features. We use data from HRS and SHARE merged to administrative data to compare total nursing home admission rates and long-term nursing home admission rates in The Netherlands (N = 1,800) and Denmark (N = 1,859), with comparable rates from the US (N = 6,553). We use decomposition techniques to quantify the differences in determinants of nursing home admissions. We find that elders in the US are more likely to be disabled, but even after adjusting for disability, they are more likely to be admitted to a nursing home. Because nearly half of these stays in the US are for fewer than 20 days, there is a shorter average length of stay; by contrast in the Netherlands and Denmark nursing home admissions are generally much longer term. These findings indicate that nursing home admissions are not solely determined by personal characteristics; also system and cultural differences are important reasons why nursing home use varies across countries.