Trade-Offs Between Formal Home Health Care and Informal Family CareGiving

Using 1994 National Long Term Care Survey data, we estimated logistic regressions of formal and informal home health care use and hours. Home health care use and intensity were differentially impacted by chronic conditions, are higher for Medicaid enrollees and rural or small town residents, but lower for HMO enrollees. Decreases in the probability of home health care use increased informal instrumental activities of daily living (IADL) support four hours and decreased informal activities of daily living (ADL) support eight hours weekly. IADL caregiving substituted for formal care, but ADL caregiving declined with reductions in formal care. Public policy reducing formal home health care access may reduce informal ADL caregiving and increase informal IADL caregiving, producing net declines in support.     

Transition from Home Care to Nursing Home: Unmet Needs in a Home- and Community-Based Program for Older Adults

A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.     

The Development and Challenges in Health Care Policy and Health Care Financing in Contemporary China

China’s market-oriented reform has had great success in the past few decades. Along with the rapid economic growth of the country, the economic development also influenced various aspects of China’s social, economical, and political life. Recent debate has criticized the overheated market reform in social provision, thus arguing for the return of government interventions. However, in the health care sector, it is inappropriate to attribute all distortions to market imperfection. It is rather the design of the health care system and the lack of government interventions in regulating the health care market that obstruct the functions of health care provision. To examine the proposed hypotheses, the paper focuses on China’s medical care provision, evaluating the actual performance of China’s medical care provision in the environment of economic transition from a multidimensional analysis, hence providing forward-looking suggestions for the design of China’s health care provision. Findings from this study indicate that government interventions are indispensable in regulating the health care market as well as ensuring health care delivery.      

Long-Term Services and Supports for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care

Despite a shift from institutional services toward more home and community-based services (HCBS) for older adults who need long-term services and supports (LTSS), the effects of HCBS have yet to be adequately synthesized in the literature. This review of literature from 1995 to 2012 compares the outcome trajectories of older adults served through HCBS (including assisted living [AL]) and in nursing homes (NHs) for physical function, cognition, mental health, mortality, use of acute care, and associated harms (e.g., accidents, abuse, and neglect) and costs. NH and AL residents did not differ in physical function, cognition, mental health, and mortality outcomes. The differences in harms between HCBS recipients and NH residents were mixed. Evidence was insufficient for cost comparisons. More and better research is needed to draw robust conclusions about how the service setting influences the outcomes and costs of LTSS for older adults. Future research should address the numerous methodological challenges present in this field of research and should emphasize studies evaluating the effectiveness of HCBS.     

Access Barriers to Mental Health Services for Older Adults from Diverse Populations: Perspectives of Leaders in Mental Health and Aging

This project is based on the results of telephone surveys with 52 local, state, and national informed respondents including policymakers, county leaders, planners, and advocates in mental health and aging with a particular focus on the states of California and Florida. This article addresses challenges to access to mental health services for diverse older adults including barriers related to race and ethnicity, socioeconomic status, location, age, gender, immigrant status, language, sexual orientation, and diagnosis. The article also highlights broad themes that emerged including (1) the importance of outreach and transportation tailored to diverse elders, and (2) recruitment of diverse staff and training related to diversity. The article concludes with policy and practice recommendations to reduce these disparities in access to mental health services for diverse populations of older adults.     

Inequitable Access to Health Services for Older Adults with Diabetes: Potential Solutions on a State Level

Diabetes is a serious global public health challenge. The cost for health services for diabetes care has increased 41% over the past 5 years. Despite escalating health expenditure, the United States continues to have higher rates of diabetes than many other developed countries. There is a need for health care reform in the United States not only in reducing health care costs but also in improving the quality of preventative care. This study presents the testing of a multilevel model investigating variables on the individual and state levels to develop a better understanding of the most important contextual pathways that can lead to providing older adults (50+) with type 2 diabetes with the recommended preventative quality care they require. The model was tested using a three-level repeated cross-sectional design with data from various existing data sources, using a national sample of 181,870 individuals aged 50 years and older. Results showed that differences in state health care systems contributed to inequitable access. Specifically, in a state where there was a higher percentage of adults 65 and older coupled with a shortage of health care professionals, the likelihood of receiving the recommended preventative quality care decreased. Also, older adults living in states with a higher percentage of people with diagnosed diabetes but with a lower-than-average annual per capita health care expenditure fared worse in receiving quality preventative care. Last, older adults in wealthy states with higher percentages of uninsured people had the lowest odds of receiving quality preventative care. Health care reform, similar to what is currently promoted by the Patient Protection and Affordable Care Act of 2010, is recommended to improve the performance of all health care systems in all states.     

Beyond Clinical Complexity: Nonmedical Barriers to Nursing Home Care for Rural Residents

We conducted a qualitative content analysis of barriers to nursing home admission for rural residents. Data came from semi-structured interviews with 23 rural hospital discharge planners across five states (Georgia, Idaho, Minnesota, Pennsylvania, and Wisconsin). From those, we identified four themes around nonmedical barriers to rural nursing home placement with particular salience in rural areas: financial issues, transportation, nursing home availability and infrastructure, and timeliness. We also identified policy and programmatic interventions across four themes: loosen bureaucratic requirements, improve communication between facilities, increase rural long-term care capacity, and address underlying social determinants of health.     

Resource Effects on Access to Long-Term Care for Frail Older People

Abstract

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Comparing States' Medicaid Nursing Facilities and Home and Community-Based Services Long-Term Care Programs: Quality and Fit with Inclination,Capacity, and Need

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality.     

Family Home Businesses: Who Buys Health Insurance?

This study uses data from the Cooperative States Regional Research Project NE-167 to examine the factors that influence family home business owners in purchasing health insurance. Results indicate that net business income, full-time work, and a hospital reimbursement rate are positively related to the likelihood of buying health insurance although income from other sources is negatively related to purchasing it. Being male, a contractor, and having more education also indicates a greater probability of buying insurance. Implications for working with self-employed families are discussed.     

Health Care of American Indian Elderly: Determinants of the Perceived Difficulty Obtaining Access to Health Care

This study examines the perceived areas of difficulty in obtaining access to health care and the factors influencing that difficulty among elderly American Indians in a rural environment. One hundred thirty-seven elderly Indians in the Ponca and Pawnee tribes of Oklahoma were interviewed. Four major difficulties are reported: a long waiting period at Indian health centers, difficulty in making appointments to see physicians, language and cultural barriers to communication with the health care providers, and lack of available transportation. The long waiting period is the most serious problem, and lack of transportation is the least serious. The results of probit analysis show that physical health, automobile ownership, education, employment, and the presence of an informal caregiver are related to difficulty obtaining access to health care. Ways to minimize this difficulty are discussed.     

Restoring and Sustaining Home: The Impact of Home Modifications on the Meaning of Home for Older People

ABSTRACT

The importance of a supportive home environment to successful aging has been well-established in the literature, with home modifications increasingly acknowledged as ways of removing barriers to function and increasing independence for older people. Home modification literature and practice primarily focus on the home environment as a physical space in which to perform tasks and on the impact of modification on competencies and function. Home, however, is much more than a physical environment. Within a transactive framework, people and places are seen as engaged in a dynamic, reciprocal relationship through which home becomes a place of significant personal meaning. Through a qualitative framework, this study examines the experience of older people living in the community who are recipients of a home modification service. It explores the impact modifying the physical environment has on their experience of home as a place of meaning and provides insight into how home modifications can strengthen the home as a place of personal and social meaning as well as improve safety and comfort for the older person at home.     

Differential Health and Social Needs of Older Adults Waitlisted for Public Housing or Housing Choice Vouchers

Affordable housing is an important form of income security for low-income older persons. This article describes characteristics of older persons waitlisted for either public housing or a housing choice voucher (HCV; previously Section 8) in Portland, Oregon. 358 persons (32% response rate) completed a mailed survey with questions about demographics, health and housing status, food insecurity, and preference for housing with services. Findings indicate that many waitlisted older persons experienced homelessness or housing instability, poor health, high hospital use, and food insecurity. Public housing applicants were significantly more likely to report lower incomes, homelessness, and food insecurity than HCV applicants. We conclude with policy implications for housing and health agencies that serve low-income older persons.     

Health Insurance for All Long-Term Care Workers: Estimated Costs and Coverage Impacts in Minnesota and Recommendations for States

A major barrier to building a strong workforce to meet the growing need for long-care is lack of affordable health benefits. This study projects impacts of funding health coverage for all long-term care workers in Minnesota. Under the most cost effective model plan design, enrollment in employer-sponsored coverage would increase 73% to 100% for individual coverage and 26% to 42% for family coverage. Total monthly costs would be $698/worker in the commercial market or $634/worker through a new dedicated risk pool. Based on our findings and past research, the authors present recommendations for structuring and implementing a long-term care worker health insurance initiative.     

Challenges of Safe Motherhood: Program and Policy Recommendations

ABSTRACT

This article synthesizes the major findings from research and case studies on safe motherhood and focuses on best practices and changes in public policy. Many factors that negatively influence safe motherhood can be ameliorated—and have been in numerous societies through education, access to resources, public–private partnerships, and grassroots efforts. A model identifying the interrelationship of variable is provided. Policy recommendations are discussed.     

Young African American Males: Barriers to Access to Health Care

African American males continue to experience an unacceptable and disproportionate number of health disparities when compared with other racial and ethnic groups. Young African American males can expect to live the least amount of time when compared to any other ethnic minority or racial sub-group. Understanding the obstacles and barriers that impede access to health care and wellness services among young African American males is essential to begin the process of decreasing health disparities. The goal of this qualitative study was to explore and identify the barriers experienced by young African American males in accessing health care services while also creating a rare opportunity to give voice to young African American males. The study results indicate that young African American males have multiple perceptions of barriers to health care services. Their perceptions fell into three categories: the negative impact of environment or community, lack of finances or no insurance, and distrust of medical practices associated with race history resulting in accessing healthcare as a last resort. Additional research is needed to craft community-based programs to: a) educate young African American males on the importance of preventative strategies to maintain wellness; and b) ensure that the appropriate medical and wellness services are available and reaching young African American males in need.     

Health Status and Health Care Services Among Older Persons in India

Summary

India is characterized by significant rural-based living, population heterogeneity, financial constraints, and reverse sex ratio. Traditions of joint families, life-long physical activity, vegetarianism, and social and spiritual enrichment, all known to promote healthy aging, are widely prevalent. With the increasing pace of population aging, the health of older persons in India has been the focus of recent attention. Existing data indicate a significant morbidity among the aged, much of which may remain subclinical. Considerable variations in morbidity exist with respect to gender, place of residence (rural vs. urban), and socioeconomic status. Rapid demographic transition without a concomitant epidemiological transition is responsible for the dual load of infections and degenerative diseases in older persons, these being common causes of death. Most age-related morbidity is preventable. Health promotion and cost-effective interventions based on the primary health care approach over a lifelong course, especially at the village level, will greatly help towards achieving the goal of healthy aging. The rapidly changing socioeconomic scenario in India also calls for appropriate policy actions to achieve this goal.     

Disparities in Access to Health Care Among Middle-Aged and Older Adults with Disabilities

Disability is increasing among middle-aged adults and, reversing earlier trends, increasing among older adults as well. Disability is experienced disproportionately by Black and lower socioeconomic status (SES) individuals. We used Medical Expenditure Panel Survey data to examine health care disparities in access to health care for middle-aged (31 to 64 years of age) and older (65+ years of age) adults with disabilities by race and ethnicity, education, and income (n = 13,174). Using logistic regression, we examined three measures of potential (e.g., usual source of care), and three measures of realized (e.g., counseling related to smoking) access. Middle-aged and older minority individuals with disabilities had lower relative risks of having usual sources of care and higher relative risks of having suboptimal usual sources of care (e.g., a place rather than a person) than White adults with disabilities. There were SES effects observed for middle-aged adults with disabilities across most measures that were, for certain measures, more pronounced than SES effects among older adults with disabilities. These findings are important, since health resources (e.g., a usual source of care) may mediate relations among disability, morbidity, and mortality. Policy actions that may mitigate the disparities we observed include financial incentives to support access to an optimal usual source of care and mechanisms to foster behavioral interventions related to smoking and exercise. Ensuring that these actions address the specific concerns of individuals with disabilities, such as physical accessibility and provider cultural competency, is essential.     

Health Care for Older Women:

The issue of health care for older women as it relates to their financial resources and health care reimbursement is the focus of this paper. Federal regulations that affect older women and also the role of the medical establishment are examined. Suggestions are given for policy changes on the federal and local levels and for a redirection of the women's health movement. It is suggested that women tend to be seen as burdens to the health care system and face both age and sex discrimination from many health care providers. This is the disease that needs to be cured.     

Social Context and Personal Expenditures for Health Care: Federal Policy and the Experience of Older Adults in the 1970s

The relationship between the intent and the outcome of legislated social policy is discussed. Specifically, this study documents some effects of federal health reimbursement and income policy in the late 1960s and early 1970s on health care behavior and expenditures in the decade 1970-1980. The Longitudinal Retirement History Study (LRHS), containing information on a panel of 6,270 men and unmarried women aged 58 to 63 in 1969, was used to provide information on the personal health expenditures in this decade. Medicare and Medicaid and the indexing of Social Security became operational at the beginning of the study, which permitted the exploration of intended and observed effects of legislation designed to make health care more accessible and affordable for older adults. As policy intended, utilization increased over the decade as indicated by both increases in the number of panelists with health care bills and increases in the size of total bills (constant dollars). Consistent with federal policy to reduce personal costs, out-of-pocket expenditures and the proportion of total bills paid out of pocket decreased. However, the effects of these federal policy initiatives were constrained by reimbursement rules and the social location of users. For instance, even at the end of the 1970s, out-of-pocket health care expenditures across subpopulations persisted. The 1980s and early 1990s have brought increased concern over the cost of health care and renewed concern over access. Data suggest that future proposals aimed at providing universal coverage along with high out-of-pocket costs may not result in equitable programs, and are likely to have a limited impact on constraining health care costs. The LRHS data indicate that utilization increased despite continued high out-of-pocket costs for all except the lower-income groups, who may be limited in their ability to purchase increasingly costly care.