Showing papers by "Urban Institute published in 2010"

Clarifying Sources of Geographic Differences in Medicare Spending

Abstract: BACKGROUND Although geographic differences in Medicare spending are widely considered to be evidence of program inefficiency, policymakers need to understand how differences in beneficiaries' health and personal characteristics and specific geographic factors affect the amount of Medicare spending per beneficiary before formulating policies to reduce geographic differences in spending. METHODS We used Medicare Current Beneficiary Surveys from 2000 through 2002 to examine differences across geographic areas (grouped into quintiles on the basis of Medicare spending per beneficiary over the same period). We estimated multivariate-regression models of individual spending that included demographic and baseline health characteristics, changes in health status, other individual determinants of demand, and area-level measures of the supply of health care resources. Each group of variables was entered into the model sequentially to assess the effect on geographic differences in spending. RESULTS Unadjusted Medicare spending per beneficiary was 52% higher in geographic regions in the highest spending quintile than in regions in the lowest quintile. After adjustment for demographic and baseline health characteristics and changes in health status, the difference in spending between the highest and lowest quintiles was reduced to 33%. Health status accounted for 29% of the unadjusted geographic difference in per-beneficiary spending; additional adjustment for area-level differences in the supply of medical resources did not further reduce the observed differences between the top and bottom quintiles. CONCLUSIONS Policymakers attempting to control Medicare costs by reducing differences in Medicare spending across geographic areas need better information about the specific source of the differences, as well as better methods for adjusting spending levels to account for underlying differences in beneficiaries' health measures.

Frequency and severity approaches to indexing exposure to trauma: The Critical Incident History Questionnaire for police officers

Abstract: In the past decade questions concerning the impact of critical incidents on emergency services personnel in general, and police officers in particular, have moved beyond qualitative accounts (eg, Violanti & Paton, 1999) to quantitative inquiry (eg, McCaslin, Metzler, et al, 2006) For example, studies have investigated the common sense notion that the dangerous aspects of being a first responder (eg, exposure to life threat) increase the likelihood that these individuals will experience trauma-related symptoms (Marmar et al, 1999; McCaslin, Rogers, et al, 2006) Research has shown elevations of symptoms of posttraumatic stress disorder (PTSD) in these groups (eg, Carlier, Lamberts, & Gersons, 1997; Gersons, 1989; Maia et al, 2007; McFarlane & Papay, 1992) Research has also examined what factors are linked to symptomatic distress, both general and posttraumatic In a prospective study of 223 officers, Hodgins, Creamer, and Bell (2001) reported that stable preexisting characteristics such as personality traits, gender, and trait dissociation predicted nonspecific symptomatic distress, but that severity of exposure was a stronger predictor of posttraumatic stress symptoms Partially replicating the Hodgins report is a study of New Zealand police recruits and officers that found that higher cumulative frequency of critical incidents was a risk factor for PTSD (Buchanan, Stephens, & Long, 2001) In pointing to the role of exposure to critical incidents on the job as a predictor of posttraumatic distress, these studies highlight two methods by which exposure can be indexed: (a) mere frequency, and (b) a modification of raw frequency that takes into account that incidents differ in their impact of severity Carlier and colleagues (1997) presented an initial effort to scale traumatic stressors in police, but this work was not further developed to contrast types of incidents Critical incidents experienced by emergency service personnel have not been systematically scaled as comprehensively as they have been for combat exposure (eg, King, King, Vogt, Knight, & Samper, 2006) As a result, a clear understanding of the consequences of using only frequency information, only severity information, or a combination of the two, is lacking It is not known what differences would emerge if the two following approaches were compared: (a) quantifying cumulative exposure using only information about the frequency of exposure to critical incidents, an approach that implies all incidents have equal potential to produce symptoms; and (b) quantifying cumulative exposure by weighting incidents by the degree of their severity or potential to cause symptoms We were unable to locate any study in which the impact of including information about the severity of the critical incident was examined systematically in police samples or in other trauma subgroups Frequency of exposure plays a role in predicting the development of PTSD symptoms (eg, Vasterling et al, 2010) Severity of exposure also is important (Dickstein et al, 2010) It appears that severity has only been quantified in a nomothetic manner—judging severity independent of whether one had experienced the event being judged We were unable to locate any study in which differences in the judgment of event severity or risk potential was based only on input from those who had experienced the event—an alternative that we term an idiographic approach Comparing these approaches addresses whether the severity rating of an event is a consensually held judgment or a more idiosyncratic and potentially biased one In this article we have two related goals: (a) to describe the development of a quantitative approach to indexing cumulative exposure to critical incidents in police officers, and (b) to better understand the impact of frequency and severity on the measurement of cumulative exposure We explored the impact of exposure frequency and severity for the set of incidents, examined idiographic and nomothetic scaling of severity, and present reliability and validity data describing the variety of summary indices Based on the findings that severity of events predicts symptomatic response (eg, Dickstein et al, 2010), we hypothesized that less frequent events would be appraised by officers as more severe or more likely to cause distress We did not have a strong rationale to favor either the nomothetic or the idiographic approach to measuring severity, but we did expect that a severity weighting would be an important component of any final index We hypothesized that the relationship of cumulative critical incident exposure would be more strongly related to general psychiatric and PTSD symptoms than it would be to stress from organizational and routine nontraumatic work stressors because of the special status of trauma exposure Finally, to bolster the construct validity of the measure of cumulative exposure, we needed to demonstrate that it would be (a) modestly to moderately correlated with years of service on the force, and (b) years of service would be unrelated to symptom measures Taken together these results would show that it is greater exposure, not just longer duration of service and longer opportunity to be exposed, that leads to PTSD symptoms

US approaches to physician payment: the deconstruction of primary care.

Abstract: The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary care payment play such a prominent role in the PCMH discussion. FFS payment for office visits has never effectively rewarded all the activities that comprise prototypical primary care and may contribute to the “hamster on a treadmill” problems in current medical practice. Capitation payments are associated with risk adjustment challenges and, perhaps, public perceptions of conflict with patients’ best interests. Most payers don’t employ and therefore cannot generally place physicians on salary; while in theory such salary payments might neutralize incentives, operationally, “time is money;” extra effort devoted to meeting the needs of a more complex patient will likely reduce the services available to others. Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well. Yet, the conceptual alternative payment approaches, modified fee-for-service (including fee bundles), capitation, and salary, each have their own problems. Accordingly, new payment models will likely be required to support restoration of primary care to its proper role in the US health care system, and to promote and sustain the development of patient-centered medical homes.

Using Performance on the Job to Inform Teacher Tenure Decisions

Abstract: The notion that some high stakes need to be attached to direct measures of teachers’ class-room performance as a control for quality in the work force is an idea gaining traction in public education. One such proposal prescribes low-ering the barriers to entry into teaching while simultaneously being more selective about which teachers are retained when they become eligible for tenure (Robert Gordon, Thomas J. Kane, and Douglas O. Staiger 2006; Eric A. Hanushek 2009).

Health Services Research and Data Linkages: Issues, Methods, and Directions for the Future

Abstract: Research on pressing health services and policy issues requires access to complete, accurate, and timely patient and organizational data. However, in the United States, health-related datasets are created and held by diverse—often unrelated—public and private organizations and individual researchers. To overcome incomplete data from a single source, skilled researchers take months or years to acquire, link, and extract meaningful information from a myriad of secondary datasets. Through data linkage it is possible to get more complete information without the time and cost burden of additional and often duplicate primary data collection. Typical core datasets that are often linked and the information they contain are described in Table 1. Table 1 Commonly Linked Databases We provide an overview of commonly linked files and describe a generic process for linking datasets. We categorize the major agents (i.e., who owns and controls data and who carries out the data linkage) into three areas: (1) individual investigators, (2) government-sponsored linked databases, and (3) public–private partnerships that facilitate use and linkage of data owned and controlled by private organizations. These different agents shape whether and how readily disparate datasets can be accessed, linked, and mined by researchers. We also describe challenges that may be encountered in the linkage process, and the benefits of combining secondary databases with primary qualitative and quantitative sources. Throughout the paper, we use cancer care research to illustrate our points. Cancer provides an excellent example because of its high prevalence and societal burden. As a result, several publicly and privately sponsored efforts have collaborated to create a data infrastructure that extends beyond traditional data systems. We conclude with recommendations to strengthen the existing data infrastructure. New strategies are needed to develop more accessible and comprehensive data systems to support the next generation of health services and policy research, including comparative effectiveness research.

Race, Gender, and Teacher Testing: How Informative a Tool Is Teacher Licensure Testing?:

Abstract: Virtually all states require teachers to undergo licensure testing before participation in the public school labor market. This article analyzes the information these tests provide about teacher effectiveness. The authors find that licensure tests have different predicative validity for student achievement by teacher race. They also find that student achievement is impacted by the race/ethnicity match between teachers and their students, with Black students significantly benefitting from being matched with a Black teacher. As a consequence of these matching effects, the uniform application of licensure standards is likely to have differential impacts on the achievement of White and minority students.

What are the Social Benefits of Homeownership? Experimental Evidence of Low-Income Households

Abstract: We estimate the social benefits of homeownership using an exogenous instrument based on randomly assigned treatment status from a field experiment that subsidized saving for home purchase for low-income renters through Individual Development Accounts (IDAs). This approach attempts to eliminate the potential correlation present in previous analyses between unobserved individual characteristics leading to homeownership and traits leading to provision of social capital or local amenities. Consistent with previous work, we show that homeownership positively affects political engagement in simple probits. Instrumental variable probits, however, show no impact of homeownership on political involvement. IV results for other social outcomes are less conclusive. The analysis suggests that with the use of an exogenous instrument, it is possible to generate results that are different from the previous literature. Our results also suggest that being eligible to open an IDA did not spur households to provide more social capital or local amenities.

Unchecked Provider Clout In California Foreshadows Challenges To Health Reform

Abstract: Faced with declining payment rates, California providers have implemented various strategies that have strengthened their leverage in negotiating prices with private health plans. When negotiating together, hospitals and physicians enhance their already significant bargaining clout. California’s experience is a cautionary tale for national health reform: It suggests that proposals to promote integrated care through models such as accountable care organizations (ACOs) could lead to higher rates for private payers. Because antitrust policy has proved ineffective in curbing most provider strategies that capitalize on providers’ market power to win higher payments, policy makers need to consider approaches including price caps and all-payer rate setting.

Human Service Nonprofits and Government Collaboration: Findings from the 2010 National Survey of Nonprofit Government Contracting and Grants

Abstract: This report explores the results of the 2010 National Survey of Nonprofit-Government Contracting and Grants, a study of human service organizations designed to document the extent of nonprofit-government contracting, processes and problems. It also examines the impact of the recession on these organizations and the cutbacks they have made to keep their programs operating. While contracting problems are not new, many are exacerbated by the deep recession that has reduced government budgets and private contributions. Nearly 33,000 human service nonprofits have government contracts and grants, and 9,000 organizations with expenditures over 100,000 were surveyed for this study.

Girls in the ’Hood: How Safety Affects the Life Chances of Low-Income Girls:

Abstract: Adolescents growing up in high-poverty neighborhoods are at risk for a range of negative outcomes. Girls face specific threats because of their gender—omnipresent harassment, pressure for early sexual initiation, pervasive intimate partner violence, and high risk of sexual assault.This article uses mixed-methods data from the Three-City Study of Moving to Opportunity (MTO) to explore how moving to lower-poverty neighborhoods may have influenced adolescent girls’ life chances. MTO families moved to neighborhoods with lower levels of violent crime overall, but MTO girls also experienced a substantial reduction in the “female fear,” Gordon and Riger’s term for the fear of sexual harassment, coercion, and rape. The authors argue that this change is a plausible explanation for the notable improvements in MTO girls’ well-being.

Sustaining Health Reform In A Recession: An Update On Massachusetts As Of Fall 2009

Abstract: With the passage of national health reform legislation modeled on Massachusetts' 2006 reform initiative, the Bay State continues to provide important lessons for the nation. Most recently, Massachusetts has shown that although it is difficult, sustaining the gains of health reform in a severe recession is possible. The state's uninsurance rate, 4.8 percent for nonelderly adults, remained at a record low in fall 2009. Access to health care improved, and the burden of high health care costs on individuals was reduced. However, challenges remain, as some barriers to care persist and escalating health care costs continue to be an issue.

The Urgency Of Preparing Primary Care Physicians To Care For Older People With Chronic Illnesses

Abstract: Population trends are driving an undeniable imperative: The United States must begin training its primary care physicians to provide higher-quality, more cost-effective care to older people with chronic conditions. Doing so will require aggressive initiatives to educate primary care physicians to apply principles of geriatrics—for example, optimizing functional autonomy and quality of life—within emerging models of chronic care. Policy options to drive such reforms include the following: providing financial support for medical schools and residency programs that adopt appropriate educational innovations; tailoring Medicare’s educational subsidy to reform graduate medical education; and invoking state requirements that physicians obtain geriatric continuing education credits to maintain their licensure or to practice as Medicaid providers or medical directors of nursing homes. This paper also argues that the expertise of geriatricians could be broadened to include educational and leadership skills. These g...

How Much Does Snap Reduce Food Insecurity

Abstract: Nearly 15 percent of all households and 39 percent of near-poor households were food insecure in 2008. The Supplemental Nutrition Assistance Program (SNAP, formerly called the Food Stamp Program) is the cornerstone of federal food assistance programs and serves as the first line of defense against food-related hardship. Using SIPP data, this paper measures SNAP’s effectiveness in reducing food insecurity using an instrumental variables approach to control for selection bias. Our results suggest that SNAP receipt reduces the likelihood of being food insecure by roughly 30 percent and reduces the likelihood of being very food insecure by 20 percent.

Are Sex Offenders Moving into Social Disorganization? Analyzing the Residential Mobility of California Parolees

Abstract: This study focuses on the relationship between returning offender residential mobility and neighborhood structural factors characteristic of socially disorganized neighborhoods. It uses a unique data set that combines information on parolees released in the state of California during the 2005-2006 time period with their geocoded addresses to view the types of neighborhoods they are moving to. The authors find that sex offenders are entering neighborhoods with more concentrated disadvantage and residential instability upon reentry from prison and upon subsequent moves. This effect for sex offender status is particularly strong for whites and Latinos, leading them into more socially disorganized neighborhoods. The authors also find that sex offenders are more likely to enter neighborhoods with more minorities as measured by Latinos and African Americans and less likely to enter neighborhoods with more whites.

Struggling to stay out of high-poverty neighborhoods: housing choice and locations in moving to opportunity's first decade

Abstract: Improving locational outcomes emerged as a major policy hope for the nation's largest low-income housing program over the past two decades, but a host of supply and demand-side barriers confront rental voucher users, leading to heated debate over the importance of choice versus constraint. In this context, we examine the Moving to Opportunity experiment's first decade, using a mixed-method approach. MTO families faced major barriers in tightening markets, yet diverse housing trajectories emerged, reflecting variation in: (a) willingness to trade location – in particular, safety and avoidance of “ghetto” behavior – to get larger, better housing units after initial relocation; (b) the distribution of neighborhood types in different metro areas; and (c) circumstances that produced many involuntary moves. Access to social networks or services “left behind” in poorer neighborhoods seldom drove moving decisions. Numerous moves were brokered by rental agents who provided shortcuts to willing landlords but thereb...

Structuring Payment For Medical Homes

Abstract: Despite widespread interest in the medical home model, there has been a lack of careful assessment of alternative methods to pay practices that serve as medical homes. This paper examines four specific payment approaches: enhanced fee-for-service payments for evaluation and management; additional codes for medical home activities within fee-for-service payments; per patient per month medical home payments to augment fee-for-service visit payments; and risk-adjusted, comprehensive per patient per month payments. Payment policies selected will affect both the adoption of the model and its longer-term evaluation. Evaluations of ongoing demonstrations should focus on payment design as well as on care—and cost.

Who And Where Are The Children Yet To Enroll In Medicaid And The Children’s Health Insurance Program?

Abstract: Kathleen Sebelius, secretary of health and human services, has issued a challenge to enroll the millions of uninsured children eligible for public insurance in Medicaid or the Children’s Health Insurance Program (CHIP). This paper provides estimates of the rates at which children in the various states participated in these programs in 2008 as well as the number who were eligible for them but uninsured. According to our coverage estimates, an estimated 7.3 million children were uninsured on an average day in 2008, of whom 4.7 million (65 percent) were eligible for Medicaid or CHIP but not enrolled. Participation rates varied across states from 55 percent to 95 percent, and ten states had participation rates close to or above 90 percent. Thirty-nine percent of eligible uninsured children (1.8 million) live in just three states—California, Texas, and Florida—and 61 percent (2.9 million) live in ten states. Meeting Secretary Sebelius’s challenge means achieving success in these populous states, in part throug...

Adolescent Psychopathy and the Five Factor Model: Domain and Facet Analysis

Abstract: Given the consideration of callousness as a specifier for Conduct Disorder in the DSM-V, it seems imperative that researchers continue to investigate this personality style in adolescents to determine both its applicability and utility. The present study examined the Youth Psychopathic traits Inventory (YPI; Andershed et al. 2002) and the Interpersonal Adjective Scale Revised-Big 5 (IASR-B5; Trapnell and Wiggins 1990a, b) psychopathy scales in relation to the Five Factor Model (FFM) of personality. Using a sample of adolescent offenders (N = 145), the YPI and IASR-B5 psychopathy scales showed adequate reliability and strong inverse bivariate relations with the FFM domains of Agreeableness (−A) and Conscientiousness (−C). Multivariate analyses, at the facet level, revealed that Tendermindedness (−A) and Assertiveness (+E) explained the association between FFM facets and the YPI, whereas Altruism (−A), Modesty (−A), Straightforwardness (−A), Assertiveness (+E), Warmth (−E), and Deliberation (+C) all uniquely contributed to the IASR-B5 psychopathy scale. Both measures were linked with general and violent recidivism. The authors discuss the implications of these findings in terms of the use of personality to help describe conduct problem youth and the need for future research in this important area.

How to Buy a Medical Home? Policy Options and Practical Questions

Abstract: In this paper, we describe a range of payment options to support the PCMH, identifying their conceptual strengths and weaknesses. These include enhanced FFS payment for office visits to the PCMH; paying additional FFS for “new” PCMH services; variations of traditional FFS combined with new PCMH-oriented per patient per month capitation; and combined capitation payments for traditional primary care medical services as well as new medical home services. In discussing options for PCMH payment reform we consider issues in patient severity adjustment, performance payment, and the role of payments to community service organizations to collaborate with the PCMH. We also highlight some of the practical challenges that can complicate reimbursement reform for primary care and the PCMH. Through this discussion we identify key dimensions to provider payment reform relevant to promoting enhanced primary care through the patient centered medical home. These consist of paying for the basic medical home services, rewarding excellent performance of medical homes, incentivizing medical home connections to other community health care resources, and overcoming implementation challenges to medical home payments. Each of these overarching policy issues invokes a substantial subset of policy relevant research questions that collectively comprise a robust research agenda. We conclude that the conceptual strengths and weaknesses of available payment models for medical home functions invoke a complex array of options with varying levels of real-world feasibility. The different needs of patients and communities, and varying characteristics of practices must also be factors guiding PCMH payment reform. Indeed, it may be that different circumstances will require different payment approaches in various combinations.

A glass half empty? New evidence from the HOPE VI Panel Study

Abstract: The Chicago Housing Authority is midway through its ambitious Plan for Transformation. This paper presents new evidence about how residents have fared since the transformation began. Questions remain about where they are living, the circumstances of their new housing, and how relocation has affected their overall well-being. This paper presents new evidence on resident outcomes from the HOPE VI Panel Study, a national study that includes Chicago. The findings show that those residents who received vouchers are living in better housing in dramatically safer neighborhoods; many report improved mental health; and their children are having fewer behavior problems. But there are also very real reasons for concern. Voucher holders are experiencing economic hardship that may place them at risk for housing instability and the most troubled families are at risk for being left behind in traditional public housing, little better off than they were when the Plan began.

Declining Child Mortality and Continuing Racial Disparities in the Era of the Medicaid and SCHIP Insurance Coverage Expansions

Abstract: OBJECTIVES: We investigated trends in national childhood mortality, racial disparities in child mortality, and the effect of Medicaid and State Children's Health Insurance Program (SCHIP) eligibility expansions on child mortality. METHODS: We analyzed child mortality by state, race, and age using the National Center for Health Statistics' multiple cause of death files over 20 years, from 1985 to 2004. RESULTS: Child mortality continued to decline in the United States, but racial disparities in mortality remained. Declines in child mortality (ages 1-17 years) were substantial for both natural (disease-related) and external (injuries, homicide, and suicide) causes for children of all races/ethnicities, although Black-White mortality ratios remained unchanged during the study period. Expanded Medicaid and SCHIP eligibility was significantly related to the decline in external-cause mortality; the relationship between natural-cause mortality and Medicaid or SCHIP eligibility remains unclear. Eligibility expansions did not affect relative racial disparities in child mortality. CONCLUSIONS: Although the study provides some evidence that public insurance expansions reduce child mortality, future research is needed on the effect of new health insurance on child health and on factors causing relative racial disparities.

Integrating land financing into subnational fiscal management

Abstract: Land assets have become an important source of financing capital investments by subnational governments in developing countries. Land assets, often with billions of dollars per transaction, rival and sometimes surpass subnational borrowing or fiscal transfers for capital spending. While reducing the uncertainty surrounding future debt repayment capacity, the use of land-based revenues for financing infrastructure can entail substantial fiscal risks. Land sales often involve less transparency than borrowing. Many sales are conducted off-budget, which makes it easier to divert proceeds into operating budgets. Capital revenues from sales of land assets exert a much more volatile trend and could create an incentive to appropriate auction proceeds for financing the operating budget, particularly in times of budget shortfalls during economic downturns. Furthermore, land collateral and expected future land-value appreciation for bank loans can be linked with macroeconomic risks. It is critical to develop ex ante prudential rules comparable to those governing borrowing, to reduce fiscal risks and the contingent liabilities associated with the land-based revenues for financing infrastructure.

What the 2008 Stock Market Crash Means for Retirement Security

Abstract: The 2008 stock market crash raises concerns about retirement security, especially since the increased prevalence of 401(k) and similar retirement saving plans means that more Americans are now stakeholders in the equity market than in the past. Using a dynamic microsimulation model, this paper explores the ability of alternate future stock market scenarios to restore retirement assets. The authors find that those near retirement could fare the worst because they have no time to recoup their losses. Mid-career workers could fare better because they have more time to rebuild their wealth. They may even gain income if they buy stocks at low prices and get above-average rates of return. High-income groups will be the most affected because they are most likely to have financial assets and to be invested in the stock market.

How Many Struggle To Get By In Retirement

Abstract: Purpose : This study compared the offi cial poverty rate for adults aged 65 years and older with alternative measures that portray the true resources and needs of older adults. Design and Methods : The analysis used data from the 2004 Health and Retirement Study on income, assets, in-kind transfers, and out-of-pocket medical expenses. It also incorporated the effects of federal and state income taxes on net incomes, and accounted for the potential annuity value of assets in measuring resources. Results : The alternative poverty measures that account for outof-pocket health spending estimate that between 0.3 and 1.5 million more older adults live in poverty than acknowledged by the offi cial measure. Implications : These results highlight the need to update poverty measures so that they better refl ect older adults ’ circumstances. This will become increasingly important as policymakers consider reforms to improve solvency in the Social Security and Medicare programs that may require benefi t cuts or increased cost sharing.

Incorporated but Not IRS-Registered: Exploring the (Dark) Grey Fringes of the Nonprofit Universe:

Abstract: Listings of Internal Revenue Service (IRS)-registered and state-incorporated nonprofits for the same region may differ for a variety of reasons. Using Indiana as a case study, we first describe the distribution of nonprofits across these two listings. We then present findings from a small telephone survey of incorporated nonprofits that are not registered with the IRS for Indiana to explore whether they are excluded from the IRS-listing for statutory, technical, or compliance reasons. We consider several aspects of state incorporation status: date of incorporation and whether active status has been maintained or not. We conclude that researchers need to pay careful attention to the limitations of the IRS registration system when wishing to examine the dimensions of the nonprofit sector at local, state, or regional levels. Our finding, that some nonprofits fail to maintain active incorporation status, points to significant problems of nonprofit capacity.

Work and Retirement Patterns for the G.I. Generation, Silent Generation, and Early Boomers: Thirty Years of Change

Abstract: This study examines how the shifting choices and constraints facing older workers have changed work and retirement patterns over the past 30 years. Health improvements, declines in physical job demands, changes in Social Security rules, and the erosion in traditional defined benefit pension coverage and employer-sponsored retiree health insurance have altered work incentives at older ages. This paper compares labor force exits by older workers born 1913 to 1917 (part of the G.I. Generation), 1933 to 1937 (part of the Silent Generation), and 1943 to 1947 (part of the Baby Boom Generation). The analysis uses 16-year longitudinal panels from the Health and Retirement Study and decades-long administrative earnings records linked to respondents in the Survey of Income and Program Participation.The results show that early boomers worked longer than members of the Silent Generation, and that the pathways older workers follow out of the labor force have become more complex over time. The median retirement age for men was about one-half year higher in the 1943–47 cohort than in the 1933–37 cohort (62 vs. 61.5), but differences were more pronounced at older ages. By age 65, for example, 40 percent of early boomer men had not yet retired, compared with only 20 percent of Silent Generation men. Both male and female workers in the 1933–37 cohort were much less likely than their counterparts in the 1913–17 cohort to follow the traditional retirement path of exiting the labor force from full-time employment and never returning to work.