Caregivers as Comptrollers

The emphasis on cost containment that was the hallmark of the Reagan Administration and the shining of the burden for long-term care onto the informal sector have had a particularly negative impact on women. Women through caregiving are used to help control the public cost of long-term care. This unwritten policy is unlikely to be successful because of a number of factors: (1) the economic condition of women; (2) the lack of available and affordable community services; and (3) the types of social relationships we now have.     

失能老年人长期护理的需求规模评估、费用测算与经济效应预测

伴随着失能风险的增加,老年人长期护理问题成为人口老龄化研究的新课题.基于CHARLS等相关数据,改进Markov模型,测算2020—2060年失能老年人长期护理需求规模及费用,并预测经济效应,结果表明:(1)老年人数量呈倒"U"形增长趋势,并于2048年左右达到顶峰,约为4.34亿人;失能老年人呈逐年上升趋势,于2060年达到1.84亿人.(2)失能老年人长期护理费用由2020年的3906.57亿元增长到2060年的44973.16亿元,增长11.51倍,其中轻度、中度和重度失能老年人长期护理费用分别增长8.92倍、15.55倍和21.17倍.(3)老年护理劳动力需求量预测显示,由90.33万人上升到228.98万人,增长2.54倍;机构养老护理型床位需求量预测显示,由241.03万张增长到553.11万张,增长2.29倍;老年护理市场直接经济增量预测显示,由3906.57亿元增长到44973.16亿元,增长11.51倍.基于此,本文提出包括坚持"以制度为基础、以服务为核心、以救助为兜底、以法律为准绳"的基本原则,建立失能动态监控机制,完善养老服务财政补贴制度等政策建议.     

Long-Term Care Policy and Financing as a Public or Private Matter in the United States

Summary

Effective approaches to assure adequate resources, infrastructure, and broad societal support to address chronic care needs are volatile and potentially unpopular issues that can result in many losers (those getting far less than they want) and few winners (those who gain access to scarce societal resources for care). In the United States, debates on long-term care involve a complex set of issues and services that link health, social services (welfare), and economic policies that often pit public and private sector interests and values against one another. Yet long-term care policies fill a necessary function in society to clarify roles, expectations, and functions of public, non-profit, for profit, individual, and family sectors of a society. By assessing and developing policy proposals that include all long-term care system dimensions, a society can arrive at systematic, fair, and rational decisions. Limiting decisions to system financing aspects alone is likely to result in unforeseen or unintended effects in a long-term care system that stopgap “fixes” cannot resolve. Three underlying policy challenges are presented: the need for policymakers to consider whether the public sector is the first or last source of payment for long-term care; whether government is seen primarily as a risk or cost manager; and the extent to which choice is afforded to elders and family caregivers with regard to the types, settings, and amount of long-term care desired to complement family care.     

"Circumcision", culture,and health-care provision in Tower Hamlets,London

Tower Hamlets (London, England) has a sizable Somali community whose members maintain close links with their families in Africa. The London Black Women's Health Action Project (LBWAP) was established in Tower Hamlets, in 1982, to address the health needs of Somali women, especially those related to female circumcision. The major focus in the UK has been on protecting girls from undergoing this practice, with little attention to the needs of women who have already been circumcised. Of 200 Somali women interviewed by LBWAP, 61% had been infibulated in their native country by people with no medical training. Among the long-term health consequences were dysmenorrhea, recurrent urinary problems, urethral damage, and painful intercourse. Although deinfibulation can be obtained, both health care professionals and circumcised women tend to be unaware of this service. LBWAP has proposed a study to assess the expressed health care needs of circumcised Somali women and match these desires with actual health care provision. To raise the consciousness of British health care professionals, parallels between female circumcision and the indiscriminate, unnecessary use of episiotomy are being made.     

Long-term care policy and financing as a public or private matter in the United States

Effective approaches to assure adequate resources, infrastructure, and broad societal support to address chronic care needs are volatile and potentially unpopular issues that can result in many losers (those getting far less than they want) and few winners (those who gain access to scarce societal resources for care). In the United States, debates on long-term care involve a complex set of issues and services that link health, social services (welfare), and economic policies that often pit public and private sector interests and values against one another. Yet long-term care policies fill a necessary function in society to clarify roles, expectations, and functions of public, non-profit, for profit, individual, and family sectors of a society. By assessing and developing policy proposals that include all long-term care system dimensions, a society can arrive at systematic, fair, and rational decisions. Limiting decisions to system financing aspects alone is likely to result in unforeseen or unintended effects in a long-term care system that stopgap "fixes" cannot resolve. Three underlying policy challenges are presented: the need for policymakers to consider whether the public sector is the first or last source of payment for long-term care; whether government is seen primarily as a risk or cost manager; and the extent to which choice is afforded to elders and family caregivers with regard to the types, settings, and amount of long-term care desired to complement family care.     

Perceptions about Compliant Flooring from Senior Managers in Long-Term Care

This study explored barriers and facilitators to adoption of compliant flooring as a fall injury prevention strategy within long-term care from the perspective of 18 long-term care senior managers. In-depth interviews were recorded, transcribed, and analyzed using the Framework Method. The most important organizational facilitators to adoption were potential for injury prevention and long-term care staff's openness to change. The most important organizational barriers to adoption were negative effects to long-term care staff and financial considerations (i.e., cost and lack of funding). The most important general organizational considerations were uncertainties about clinical effectiveness, effects on long-term care staff, and flooring performance. Overall, compliant flooring was viewed positively for long-term care. The findings also suggest an opportunity for knowledge translation to inform long-term care senior managers about the existing evidence on compliant flooring.     

Future of Long-Term Care Financing for the Elderly in Korea

ABSTRACT

With rapid aging, change in family structure, and the increase in the labor participation of women, the demand for long-term care has been increasing in Korea. Inappropriate utilization of medical care by the elderly in health care institutions, such as social admissions, also puts a financial burden on the health insurance system. The widening gap between the need for long-term care and the capacity of welfare programs to fulfill that need, along with a rather new national pension scheme and the limited economic capacity of the elderly, calls for a new public financing mechanism to provide protection for a broader range of old people from the costs of long-term care. Many important decisions are yet to be made, although Korea is likely to introduce social insurance for long-term care rather than tax-based financing, following the tradition of social health insurance. Whether it should cover only the elderly long-term care or all types of long-term care including disability of all age groups will have a critical impact on social solidarity and the financial sustainability of the new long-term care insurance. Generosity of benefits or the level of out-of-pocket payment, the role of cash benefits, and the relation with health insurance scheme all should be taken into account in the design of a new financing scheme. Lack of care personnel and facilities is also a barrier to the implementation of public long-term care financing in Korea, and the implementation strategy needs to be carved out carefully.     

Adding Long-Term Care to Medicare

The rancor accompanying the repeal of most of the 1988 Medicare Catastrophic Act reflects both the national need to improve health and long-term care benefits for the elderly and the political obstacles to finding new sources of financing for such benefits. Neither the need nor the obstacles will go away, but policymakers are now likely to look for lower-cost, efficient, and privately funded alternatives. The authors have developed and tested one such approach: the Social Health Maintenance organization (SHMO). Operating since 1985. the SHMO model integrates community-based, long-term care services into the managed,prepaid HMO design. The four test sites are adding long-term care to Medicare at no extra cost to the government and only modest premiums for the 17,000 current members. Although the benefits offer limited protection for long-term nursing home care, they do cover long-term care in community settings, where people tend to prefer to stay. Also, integration of the acute and long-term care s stems improves the ability to respond to the medical needs of frail members, who also have high acute-care use. The SHMO's model of front-end, community-oriented, long-term care benefits integrated with Medicare appears to be a practical, affordable, and clinically appropriate way to address the rising concern with the lack of coverage and services for long-term care.     

Effect of childlessness on nursing home and home health care use

This study examines the likelihood of nursing home and home health care use for childless older Americans. Four research questions are addressed: (1) Are the childless elderly at a greater risk of nursing home and home health care use? (2) Is it childlessness per se or not having children with particular characteristics that affects the likelihood of using these formal long-term care services? (3) Does having additional children beyond the first one have a significant effect on the use of these services? (4) Are the effects of childlessness different on the likelihood of nursing home and home health care use? Longitudinal data from the first (1993) and second (1995) waves of the Asset and Health Dynamics Among the Oldest Old Survey (AHEAD) and multinomial logistic regression models are used for the analyses. Separate models are developed for women and men, each controlling for a variety of demographic, socioeconomic, and health-related characteristics of sample persons. Findings indicate childlessness as an important risk factor, especially for older women's use of nursing home services. Implications of findings for planning for long-term care needs of the baby boom generation are discussed.     

Long-Term Care for Elder Women in Spain: Advances and Limitations

In Spain, elder women are the largest group in need of long-term care. Significant improvements in this issue took place between 2007 and 2011, thanks to the Dependency Law (2006). But severe limitations showed the difficulty of overcoming the historical backwardness of Spanish social policy. This article describes the situation of Spanish people with dependency in activities of daily living. It analyzes changes driven by this law, especially in their impacts on elder women. It assesses the extent to which those changes can alter the traditional model of care. There are three major findings: First, measures promoted by the law have improved the previous situation but are incapable of developing a new model. Care for elders still relies on family, with lack of professionalism, little socialization, and expanding commodification. Second, the current care model is fundamentally detrimental to older women and women caregivers. Third, this kind of model hinders the overcoming of gender inequalities in intrafamily, generational, and social relations.     

Cost, convenience and quality in child care demand

This paper presents an economic analysis of child care use by employed women with children under six years of age. Observations of actual child care choices are used to estimate the relative importance assigned by parents to cost, convenience and quality in child care. On the basis of these estimates, the chances that each type of child care arrangement will be used are predicted. Projections of child care use are presented for a range of potential costs, travel times, child-staff ratios, and family circumstances. This study is unique in employing information not only on child care arrangements already used, but also on the alternative arrangements available to individual families. The child care data were collected in a 1977 survey of New York City employees. Overall, the model correctly predicted 78% of the observed child care choices. The results of the analysis show strong effects of cost in child care choice. The demand for day care centers is especially sensitive to user cost; if centers were available free of charge, for example, there is a 65% chance that the average single working mother in the sample would use one. Travel time and child-staff ratios have small but statistically significant effects on the choice of child care arrangements. Weekend work schedules and presence of infants are also important choice factors. Once costs are accounted for, family income has no significant effect on the type of child care chosen.     

The Value of Adoption

ABSTRACT

Recent work shows that the governmental cost of adoption is about half the cost of long-term foster care for children whose birth parents' rights have been terminated. Because adoption is also associated with greater accumulation of human and social capital, the total savings to government in areas such as special education and criminal justice is of the same magnitude as the child welfare savings. The private benefit to adopted children in terms of additional income earned over their working lives is similarly large. In all, a dollar spent on the adoption of a child from foster care yields about three dollars in benefits.     

Adding long-term care to Medicare: The Social HMO Experience

The rancor accompanying the repeal of most of the 1988 Medicare Catastrophic Act reflects both the national need to improve health and long-term care benefits for the elderly and the political obstacles to finding new sources of financing for such benefits. Neither the need nor the obstacles will go away, but policymakers are now likely to look for lower-cost, efficient, and privately funded alternatives. The authors have developed and tested one such approach: the Social Health Maintenance Organization (SHMO). Operating since 1985, the SHMO model integrates community-based, long-term care services into the managed, prepaid HMO design. The four test sites are adding long-term care to Medicare at no extra cost to the government and only modest premiums for the 17,000 current members. Although the benefits offer limited protection for long-term nursing home care, they do cover long-term care in community settings, where people tend to prefer to stay. Also, integration of the acute and long-term care systems improves the ability to respond to the medical needs of frail members, who also have high acute-care use. The SHMO's model of front-end, community-oriented, long-term care benefits integrated with Medicare appears to be a practical, affordable, and clinically appropriate way to address the rising concern with the lack of coverage and services for long-term care.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Long-Term Care Preferences Among Older Adults: A Moving Target?

ABSTRACT

This study investigates long-term care preferences across three hypothetical scenarios and over one year of time among a sample of disabled older women receiving informal care (n?=?420). Unpaid or paid help in one's home was preferred, given scenarios of instrumental activities of daily living (IADL) and activities of daily living (ADL) needs; nursing home care was most preferred for dementia care. While aggregate preferences for long-term care were relatively stable, there was considerable fluctuation in individuals' preferences over time, with just 52.5%, 44.4%, and 44.6% of participants retaining their initial first choice across IADL, ADL, and dementia scenarios, respectively. Implications of study findings are discussed.     

Invisible labor,invisible bodies: how the global political economy affects reproductive freedom in the Philippines

ABSTRACT

Feminist scholars have critically demonstrated the links between the global political economy, social reproduction and gender-based violence. This article builds on this scholarship by investigating restrictions to reproductive freedom and their connection to the depletion of women’s bodies in the global political economy. Specifically, I use the Depletion through Social Reproduction (DSR) framework to reveal how the work of social reproduction is harnessed to service economic activity at the cost of rights to bodily integrity with the aid of religious fundamentalist ideologies that (re)inscribe discourses of female altruism such as the “self-sacrificing mother” ideal. Drawing on the case of the Philippines, I argue that the control of women’s bodies is integral to the Philippines’ economic strategy of exporting care workers in a competitive global political economy. This strategy is abetted by local Catholic religious fundamentalists who challenge reproductive rights reform at various levels of policy-making and legitimize the lack of investment to sustain social reproduction in the household, community and country as a whole. This article suggests that the neoliberal global economy is increasingly reproduced through women’s labor at the cost of their bodily integrity and reproductive freedoms.     

From “nobody's clapping for us” to “bad moms”: COVID-19 and the circle of childcare in Canada

The COVID-19 pandemic has highlighted the importance of childcare to national economies in general and women's economic participation in particular, spurring renewed interest in childcare policy in many countries that have implemented lockdowns. This paper adopts a circle of care framework to analyzes how COVID-19 has affected paid childcare, unpaid childcare and other paid work, and the relationship between these sectors. Analysis is grounded in the lived experiences of parents and childcare educators, documented through 16 semi-structured interviews during the initial lockdown (March–June 2020) in British Columbia, Canada. Experiences from educators suggest their safety was not prioritized, and that their contributions were undervalued and went unrecognized. Mothers, who provided the majority of unpaid care, not only lost income due to care demands, but struggled to access necessities, with some reporting increased personal insecurity. Those attempting to work from home also experienced feelings of guilt and distress as they tried to manage the triple burden. Similarities of experiences across the circle of care suggest the COVID-19 childcare policy response in BC Canada downloaded care responsibilities on to women without corresponding recognition or support, causing women to absorb the costs of care work, with potential long-term negative effects on women's careers and well-being, as well as on the resilience of the circle of care. Pandemic recovery and preparedness policies that aim to promote gender equality must consider all sectors of the circle of care and the relationships between them.     

Future of long-term care financing for the elderly in Korea

With rapid aging, change in family structure, and the increase in the labor participation of women, the demand for long-term care has been increasing in Korea. Inappropriate utilization of medical care by the elderly in health care institutions, such as social admissions, also puts a financial burden on the health insurance system. The widening gap between the need for long-term care and the capacity of welfare programs to fulfill that need, along with a rather new national pension scheme and the limited economic capacity of the elderly, calls for a new public financing mechanism to provide protection for a broader range of old people from the costs of long-term care. Many important decisions are yet to be made, although Korea is likely to introduce social insurance for long-term care rather than tax-based financing, following the tradition of social health insurance. Whether it should cover only the elderly longterm care or all types of long-term care including disability of all age groups will have a critical impact on social solidarity and the financial sustainability of the new long-term care insurance. Generosity of benefits or the level of out-of-pocket payment, the role of cash benefits, and the relation with health insurance scheme all should be taken into account in the design of a new financing scheme. Lack of care personnel and facilities is also a barrier to the implementation of public long-term care financing in Korea, and the implementation strategy needs to be carved out carefully.     

Long-term care preferences among older adults: a moving target?

This study investigates long-term care preferences across three hypothetical scenarios and over one year of time among a sample of disabled older women receiving informal care (n = 420). Unpaid or paid help in one's home was preferred, given scenarios of instrumental activities of daily living (IADL) and activities of daily living (ADL) needs; nursing home care was most preferred for dementia care. While aggregate preferences for long-term care were relatively stable, there was considerable fluctuation in individuals' preferences over time, with just 52.5%, 44.4%, and 44.6% of participants retaining their initial first choice across IADL, ADL, and dementia scenarios, respectively. Implications of study findings are discussed.     

Cost effectiveness of a school readiness intervention for foster children

ObjectiveMany young children in foster care suffer from emotional and behavior problems due to neglect and abuse. These problems can lead to difficulties in school, and functioning in school is linked to long-term health and development. Early intervention to reduce emotional and behavioral issues can help children successfully transition to school, which can improve long-term outcomes. However, communities need information on relative costs and benefits associated with programs to make informed choices. The objective of this study was to assess cost effectiveness, over 12 months, of the Kids in Transition to School (KITS) intervention compared to usual services available to children in a foster care control group (FCC).MethodRandomized controlled trial of 192 children in foster care entering kindergarten who were randomized to KITS (n = 102) or FCC (n = 90). KITS includes school readiness groups and parent training over 4 months. Main outcomes were days free from internalizing symptoms (IFD), days free from externalizing behavior (EFD), intervention costs, public agency costs, and incremental cost effectiveness.ResultsKITS significantly increased IFD and EFD compared to FCC. Average total cost of the intervention was $932 per family. The intervention did not significantly impact usual services. Average incremental cost effectiveness was $64 per IFD and $63 per EFD.ConclusionsThe cost of KITS is comparable to, or less than, similar programs, and the intervention is likely to provide significant emotional and behavioral benefit and improvement in school readiness for young children in foster care.