The affordable care act and long-term care: comprehensive reform or just tinkering around the edges?

The Patient Protection and Affordable Care Act (ACA) includes several provisions that aim to improve prevailing deficiencies in the nation's long-term care system. But just how effective is the ACA likely to be in addressing these challenges? Will it result in meaningful or marginal reform? This special issue of Journal of Aging & Social Policy seeks to answer these questions. The most prominent long-term care provision is the now-suspended Community Living Assistance Services and Supports Act. Others include incentives and options for expanding home- and community-based care, a number of research and demonstration projects in the areas of chronic care coordination and the dually eligible, and nursing home quality reforms. There are also elements that seek to improve workforce recruitment and retention, in addition to benefit improvements and spending reductions under Medicare. This article reviews the basic problems plaguing the long-term care sector and the provisions within the ACA meant to address them. It also includes a brief overview of issue content.     

Globalization or glocalization? Community care in Taiwan and Britain

The initial fascination in the west with the economic achievements of the East Asian 'tiger economies' led to an increasing interest in their social welfare regimes. Theorizing on wide-scale socio-economic change might suggest that in occidental and oriental welfare regimes a process of convergence is underway, as a result of competitive pressures generated by the global economy and as part of the diffusion of social welfare discourses worldwide. A particular case of possible convergence, namely community care policies in Taiwan and Britain in the 1990s, is identified. However, despite superficial similarities in policy and practice developments a more careful examination suggests that, whilst they may be infused with similar rhetoric, the context and content of policy and practice in each country is radically different. This suggests the possibility that whilst the global economy will continue to act as a major constraint on social welfare development, with welfare discourses becoming increasingly globalized, the policy and practice which emerges will continue to be inflected by national contexts and mediated by existing country-specific institutional arrangements; a process of glocalization rather than globalization. Die anfängliche Faszination der ökonomischen Erfolge der ostasiatischen 'Tigerstaaten' auf den Westen hat zu einem verstärkten Interesse an ihrem sozialen und wohlfahrtsstaatlichen Regime geführt. Eine Theoretisierung der großformatigen sozio-ökonomischen Veränderungen könnte zu der Annahme führen, daß als Resultat des durch die globalisierte Ökonomie hervorgerufenen Wettbewerbsdrucks und z.T. durch die Ausbreitung wohlfahrtsstaatlicher Diskurse sowohl in den östlichen als auch in den westlichen Wohlfahrtsstaatsregimes sich ein Prozeß der Konvergenz durchstetzt. Dabei geht es hier um den spezifischen Fall einer möglichen Konvergenz der Sozialarbeit (Community care) in Taiwan und Großbritannien. Trotz der bei oberflächlicher Betrachtung scheinbaren Ähnlichkeiten auf der Ebene politischer und praktischer Entwicklungen zeigt eine gründlichere Untersuchung, daß die sich durchsetzenden Politiken und Praxen auch weiterhin durch den nationalstaatlichen Kontext gebrochen und durch bestehende länderspezifische institutionelle Arrangements mediatisiert werden - obwohl die globalisierte Ökonomie nach wie vor einen wesentlichen Zwang auf die Entwicklung des Wohlfahrtsstaates ausübt und die Diskurse über Wohlfahrt zunehmend globalisiert werden. Es handelt sich also eher um einen Prozeß der Glokalisierung denn um Globalisierung. La fasinación inicial del oeste por los logros económicos de los praises del este asiático (los 'tigres económicos') ha llevado a un interés creciente por sus regímenes de bienestar social. La teoría sobre el cambio socioeconómico a gran escala sugiere que los regímenes de bienestar occidentales y orientales, están en un proceso de convergencia debido a las presiones competitivas generadas por la economia global y como parte de la difusión mundial de los discursos de bienestar social. Se identifica un caso particular de posible convergencia en las política y desarrollos práticos, un examen cuidadoso sugiere que, aunque estén infundidas por una retórica similar, los contextos y contenidos politicos y prácticos en ambos paises son radicalmente diferentes. Esto sugiere la posibilidad de que, mientras que la economía global va a continuar actuando como una gran restricción para el desarrollo del bienestar social, con los discursos siendo cada vez más globales, la política y la prática emergentes seguirán siendo moduladas por los contextos nacionales y mediadas por los acuerdos institucionales especificos de cada país; un proceso de glocalización en lugar de globalización. La fascination initiale des Occidnetaux pour les accomplissements économiques des 'Tigres' de l'Extrême Orient les a conduit à s'intresser de plus près à leurs régimes de sécurité sociale. Si l'on théorise les changements socio-économiques à grande échelle, on peut supposer que les systèmes sociaux occidentaux et asiatiques convergent en raison des pressions exercées par la compétition économique mondiale et de la diffusion à travers le monde des discours sur la sécurité sociale. Les auteurs identifient un cas de possible convergence : les politiques d'aide communautaire à Taiwan et en Grande-Bretagne dans les années 90. Cependant un examen plus attentif des politiques et des pratiques laisse supposer que, même inspirées par une rhétorique similaire, le contexte dans lequel elles apparaissent et leur contenu dans chaque pays est radicalement différent, malgré des similitudes superficielles dans leur évolution. Il parait donc probable que les contextes nationaux et les instituions spécifiques à chaque pays continuent à infléchir politiques et pratiques, et ceci parallèlement aux contraintes majeures imposées à l'évolution des systèmrd sociaux par l'éonomie mondialisée, les discours sur le social devenant de plus en plus généraux.     

Share the Burden or Pass it on?

There are numerous explanations for why Tanzania withdrew from the CRRF (Comprehensive Refugee Response Framework). Being aware that the decision was the sum of multiple coinciding factors the article argues that the decisive features were, firstly, a failed dialogue about the basis and the goals of CRRF between the Tanzanian government and the UN (United Nations); secondly, a disillusion on the Tanzanian side related to the history of international cooperation on refugee issues; and thirdly, a perceived contradiction between the goals of the CRRF and domestic policies, specifically in relation to the agenda of national sovereignty propagated by the incumbent Tanzanian government. Numerous publications on the New York declaration, the CRRF, and the GCR (Global Compact on Refugees) have portrayed the evolution of ideas, principles, and political compromises in question. Yet few analyses highlight which core messages were received on the ground or what impact they had on the very people concerned. This article, therefore will touch only briefly on declarations and statements of the UN and instead focus on a bottom‐up perspective.     

Homelessness and Substance Abuse: Which Comes First?

Abstract

The present paper uses a social selection and social adaptation framework to investigate whether problematic substance use normally precedes or follows homelessness. Clarifying temporal order is important for policy and program design. The paper uses information from a large dataset (n=4,291) gathered at two services in Melbourne, supplemented by 65 indepth interviews. We found that 43% of the sample had substance abuse problems. Of these people, one-third had substance abuse problems before they became homeless and two-thirds developed these problems after they became homeless. We also found that young people were more at risk of developing substance abuse problems after becoming homeless than older people and that most people with substance abuse issues remain homeless for 12 months or longer. The paper concludes with three policy recommendations.     

Fatter or fitter? On rewarding and training in a contest

Competition between heterogeneous participants leads to low-effort provision in contests. A principal can divide her fixed budget between skill-enhancing training and the contest prize. Training can reduce heterogeneity, increasing effort. It also reduces the contest prize, making effort fall. We set up an incomplete-information contest with heterogeneous players and show how this trade-off is related to the size of the budget of an effort-maximizing principal. A selection problem arises implying a cost associated with a win by the inferior player. The principal has a larger incentive to train the laggard, reducing the prize on offer.     

Hostile Worlds or Connected Lives? Research on the Interplay Between Intimacy and Economy

Economic sociologists have devoted most of their attention to the activities of individuals and firms in markets. However, recent attempts have pushed for a better understanding of the relationship between intimacy and economy. Such efforts have been inspired, in large part, by Viviana Zelizer (2000, 2005). In her inquiry on the purchase of intimacy, Zelizer proposed seminal differentiations between the “hostile worlds,” “nothing but,” and “connected lives” perspectives, and advanced a cultural relational analysis of the economy. In this essay, we review research that applies Zelizer's framework, and suggest substantive and analytical avenues for future research on economy/intimacy nexus.     

Giving time or giving money? On the relationship between charitable contributions

This paper studies philanthropic behaviour in terms of money and time contributions for charitable organisations. Using a unique dataset, which is representative of the German population, we examine the pure contributions of individuals who give either money or time as well as joint contributions of individuals who give both money and time. We find that the sequential decisions to give to charity and how much to give can be explained by different socio-economic characteristics. We report particularly pronounced gender differences among pure contributions, an interesting pattern of human capital variables such as income and education, and possible differences in the type of philanthropic goods.     

Preserving or escaping? On the welfare effects of environmental self-protective choices

In modern societies individuals often try to alleviate their personal damages from environmental degradation by increasing their consumption of private goods. Although this “self-protective” behavior is very frequent in industrial economies, insufficient attention has been paid to its economic and environmental consequences. In this paper we show that such a behavior can make everyone worse-off. For this purpose, using as paradigmatic case a two-islands evolutionary model, we prove analytically that environmental “self-protection” may trap the system into an undesirable (Pareto-dominated) situation and discuss a few real-life examples in which this mechanism may have actually occurred. Although the proposed model is deliberately extremely simple, it may provide some interesting insights on an aspect that has been mainly ignored in the literature so far.     

Communication without sender or receiver? On virtualisation in the information process

A communication process can be described in terms of a sender transmitting information to a receiver. What happens if one of the two subject roles in this process is virtualised, i.e. substituted by a machine? Is it still appropriate to refer to this as an information transfer even if its source or target is missing? Can information originate from an unknown sender or be transmitted to a (completely) unknown receiver? Before examining these questions and answering them, one has to clarify what is understood by information. As it turns out, different interpretations of this term lead to considerably different answers to the initially raised questions. We consider these questions particularly important since the continuing dissemination of so called information and virtualisation technologies changes the human communication processes fundamentally. These changes are part of the ongoing formation of an information society and may eventually lead to the formation of a new image of man.     

Community care or therapeutic stalking: two sides of the same coin?

Although the government of the United Kingdom strives to address the needs of individuals engaged in mental health services, its policies must, by their nature, reflect a utilitarian approach. When a client chooses to disengage from services, mental health professionals can find themselves in an ethical dilemma in which adhering to policies can lead them to hyperactive conduct, whereby the client may experience what feels more like stalking behavior than therapeutic care.     

Nursebots to the rescue? Immigration,automation, and care

Abstract

This paper explores the rising cost of care services in affluent countries, with a particular focus on nursing. It suggests that competitive pressures lead to forms of ‘over-commodification’ that can both lower the quality of care and lead to deterioration of the work environment. While immigration and automation can help reduce costs, they can also pose threats to care quality. Care providers and care recipients need to collaborate in efforts to set and enforce high quality standards.     

Migration,technology and care: what happens to the body?

Migration is a social phenomenon impacting upon family life and conceptualisations of care. Simultaneously, technological advances allow families to stay connected. Care issues in the context of disability and aging may affect family relationships and how families develop. What is little understood is how these issues in migrant families affect a ‘family life course’. We use the case of a South African family with a daughter who is deaf and has other impairments. We argue that when communication is foregrounded and other, embodied, aspects of family care are relegated to the background, we lose the opportunity to understand family care patterns. We relate our discussion to broader theoretical questions regarding the body and care in disability studies.     

To work or to care? Working women's decision-making

Recent changes in older people's public care services in Nordic countries in particular in Finland and Sweden are based on implicit expectations that family members will increase their involvement in care. In Nordic countries, the care of small children has been acknowledged to be a social matter that concerns gender equality and the work life participation of both men and women, while the situation of working carers of older people is much less acknowledged. This study addressed the question of how Finnish working women who give care to their older parents argue for and against their decisions of working and caring and the meaning of work and care in these decisions. Majority of the interviewees emphasised the importance of work and refuted the idea of leaving work for care. The decision not to leave work for care was justified with worker identity, commitment to work, having no innate skills to be a carer, availability of support services and other carers and financial necessity. On the other hand, a few interviewees brought forward their willingness to leave work which was justified by constructing care as meaningful and valuable activity as opposed to meaningless paid employment, and with the intensification of work, and with ageing. Lengthy argumentation and several discursive tools indicate that women anticipated moral blame for the decision of giving work primacy over care, but also for leaving work. Thus, working carers balance between contrasting expectations to care and to work.     

What does care have to do with human rights? Analysing the impact on women's rights and gender equality

Unpaid care work is a critical human rights issue, as well as a major obstacle to gender equality and poverty reduction. This article draws attention to the impact of heavy, intensive, and unequal burdens of unpaid care work on the human rights of women living in poverty, and analyses the relevance of international human rights law to decisions on the necessary responses and remedies. The authors present recommendations for policy and practice – both for national/local governments and for development practitioners – based on human rights law and standards.     

Mothers of disabled children: in mourning or on the march?

A traditional psychoanalytic view of parenting a disabled child emphasises responses of shock, grief and depression. Parent activists and social model disability authors dismiss such accounts as destructive and prejudiced, foregrounding structural barriers to accessing services and resources. Further, psychoanalysis is criticised for its anachronistic, ideologically uncritical discourse. Each position brings valuable insights as well as silences. This paper seeks to overcome an assumption of mutual exclusivity by creating a new synthesis, drawing on the work of Winnicott and Kittay. Conclusions are that it is both possible and necessary to allow for ambivalent feelings within parents, while attending to the external, material realities of contextual factors.     

Doing business or leading care work? Intersections of gender,ethnicity and profession in home care entrepreneurship in Sweden

This article critically explores assumptions underpinning Swedish elder care policies that the introduction of market practices in publicly funded eldercare services advances women's entrepreneurship. We argue that gendered privileges and disadvantages are being recreated on tax‐funded home care markets; furthermore, gendered inequalities intersect with ethnicity and profession in the management of small‐scale care companies' dealings with authorities governing home care services and standards for home care work. However, we find that the salience of categories depends on the context in which they emerge. While gender and profession are dominant in management, gender and ethnicity influence interactions with authorities. Only in standards for home care work do all categories simultaneously shape the business approaches of care entrepreneurs. Our analysis, based on data on size and growth of home care companies and interviews with small‐scale care entrepreneurs, suggests that regulations and practices privilege big companies and care entrepreneurs who echo the white, masculine gendering of entrepreneurship as ‘doing business' and disadvantage small‐scale entrepreneurs focusing on leading care work to produce quality care.     

Ideological or religious? Contending visions on the future of Alevi identity

Establishing a coherent collective identity within the modern urban context among people who have different ideological, social and religious orientations, and social and economic backgrounds, is an ongoing struggle within the Alevi community in Turkey. This study tries to understand how alternative positions on Alevi identity dynamically construct the boundaries, moral contents and the new shape of Alevi identity in modern urban contexts through use of various discursive resources. At least two main contending ‘positions’ on Alevi identity try to institutionalise Alevi identity in modern urban contexts, which are ‘Ideological Position’ and ‘Religious Position’. Those discourse positions constitute different visions about the past and the future of the Alevi community as well as the cultural and the political boundaries of Alevi identity. More importantly, those positions resonate in ordinary citizens’ life stories as well as group narratives. This study utilises the analytical frame of ‘positioning theory’ to shed light on the complexities of identity negotiation.     

Juvenile or adult? Negotiating and contesting childhood in the courtroom

Legislative changes during the 1980s and 1990s made it easier to treat juveniles as adults in the U.S. justice system. Research on the sentencing outcomes of juveniles in the criminal court has been somewhat mixed, with some studies showing that they receive severe or long sentences and others showing that many young people receive probation or relatively short jail or prison sentences. Less attention has been placed on the process through which these cases move through the criminal court and the ways in which the labels of “juvenile” and “adult” are negotiated and contested by legal actors. Using both qualitative and quantitative data, this article examines the negotiation of these labels. While it finds that legal rules are important in establishing the potential outcomes in a case, the power of specific actors and the context of specific courtrooms are also important in shaping the negotiations and contestations over these labels. The article provides a framework to understand outcomes and presents ways that advocates can become involved in helping to shape the outcomes of these cases.     

Strengths-based practice: social care’s latest Elixir or the next false dawn?

There has never been such a consensus that social care is in crisis in England. However, it cannot be assumed this will result in fundamental rethinking of the future. Social care continues to search for a miracle cure that will painlessly transform it into a system both personalised and will cost less. The current ‘elixir’ is ‘strengths based practice’. This article suggests, however, that the current depersonalising and wasteful practices which strengths based practice is meant to replace are a product of the system within which practitioners work. There is unlikely to be significant change until that system has changed. If the current sense of crisis translates only into short-term action to keep the system afloat, the elixir will most likely be the prelude to the next false dawn.