Ways of thinking about the long-term care of the baby-boom cohorts

In examining various ways of thinking about the development of long-term care policy for the baby-boom cohorts, this article discusses the importance of basing long-term care policy discussions on a recognition of social and economic trends, as well as on the informal exchanges of care that occur over life and the diversity within the baby-boom cohorts. The implications of two ways of thinking about challenges posed by the aging of baby boomers--the generational equity/crisis perspective and the generational investment/gradual adjustment perspective are also discussed. It is suggested that the generational equity perspective is consonant with proposals to expand private savings for long-term care contingencies and private long-term insurance and, secondarily, with proposals to expand means-testing for benefits. The second perspective is more consistent with proposals to create new universal services through a traditional social insurance approach, or through a block grant such as the one discussed in the context of the Clinton health care reform plan.     

The generational equity debate: a progressive framing of a conservative issue

This article discusses the generational equity debate in the United States--including its origins and the functions it serves. This debate has emerged in the context of concerns over the aging of the population, budgetary crises, growing health care costs, increased poverty among children, growing economic inequality, and declining faith in institutions. By potentially fragmenting support for Social Security and other social programs, the generational equity approach to framing public policy issues may serve the interests of those conservatives wishing to shrink and restructure the American approach to social welfare. However, the possibility exists that this debate could serve also as a forum to advance progressive ideas about universal access for persons of all ages to income and health benefits and employment opportunities.     

The Generational Equity Debate

This article discusses the generational equity debate in the United States-including its origins and the functions it serves. This debate has emerged in the context of concerns over the aging of the population, budgetary crises, growing health care costs, increased poverty among children, growing economic inequality, and declining faith in institutions. By potentially fragmenting support for Social Security and other social programs, the generational equity approach to framing public policy issues may serve the interests of those conservatives wishing to shrink and restructure the American approach to social welfare. However, the possibility exists that this debate could serve also as a forum to advance progressive ideas about universal access for persons of all ages to income and health benefits and employment opportunities.     

We Can Run But We Can't Hide:

Long-term care costs are not covered to any significant extent by public or private insurance. As a result, nursing home patients often must use their entire life savings to pay for their care and once impoverished turn to welfare in the form of Medicaid, the federal-state health care program for the poor. Private-sector solutions, such as private long-term care insurance, should expand to play a larger role but cannot solve the whole problem by themselves. Reform of the Medicaid program to make the means test less onerous would be desirable, but this approach would retain the welfare stigma. What is needed is a public insurance program to which everyone would contribute and earn the right to benefits when they need them without having to prove impoverishment. Any public insurance program should leave a substantial role for the private sector. Public costs of a social insurance program would be high but not unaffordable, especially since society will incur most of these costs even without an expanded public program.     

Expanding the focus of health insurance education for Medicare beneficiaries

Health insurance education plays an important role in helping consumers make informed decisions about their need for supplemental coverage. This article reviews findings on the knowledge of Medicare beneficiaries about their health insurance coverage. Then, current health insurance education programs are examined with regard to their ability to meet the needs of a competition-based public policy. Barriers outside the control of individuals that impede the growth of the long-term care insurance market are identified and the need for an alternative, broader form of health insurance education is suggested. Changes in the scope and content of health insurance education are proposed that would educate the elderly to their own needs as well as the larger policy issues. An expanded model of education based on the concept of the Swedish study circle is discussed to illustrate the possibility of combining individual knowledge and public debate about complex social issues.     

Expanding the Focus of Health Insurance Education for Medicare Beneficiaries

Health insurance education plays an important role in helping consumers make informed decisions about their need for supplemental coverage. This article reviews findings on the knowledge of Medicare beneficiaries about their health insurance coverage. Then, current health insurance education programs are examined with regard to their ability to meet the needs of a competition-based public policy. Barriers outside the control of individuals that impede the growth of the long-term care insurance market are identified and the need for an alternative, broader form of health insurance education is suggested. Changes in the scope and content of health insurance education are proposed that would educate the elderly to their own needs as well as the larger policy issues. An expanded model of education based on the concept of the Swedish study circle is discussed to illustrate the possibility of combining individual knowledge and public debate about complex social issues.     

Long-term care planning as a cultural system

This paper treats long-term care planning from a cultural perspective, that is, as a cultural system in which components of long-term care interlock culturally and therefore meaningfully. In the introduction and background sections, we provide a context in which long-term care planning may be viewed, based on the finding that relatively few people take advantage of long-term care planning and insurance; we also discuss some earlier work on long-term care from a psychological perspective that emphasizes themes of imagination and self-efficacy. We then examine long-term care from a cultural perspective by identifying and explicating five broad themes that help us better understand the meaning of long-term care planning to Americans. Finally, we use these themes to suggest some important social policy correlates.     

Index insurance and climate risk management: Addressing social equity

Fair distribution of benefits from index insurance matters. Lack of attention to social equity can reinforce inequalities and undermine the potential index insurance holds as a tool for climate risk management that is also pro‐poor. The aims of this article are to: (a) examine social equity concerns raised by index insurance in the context of climate risk management, (b) consider how greater attention can be paid to social equity in index insurance initiatives, and (c) reflect on the policy challenges raised by taking social equity into account as a mechanism for climate risk reduction. The article draws on learning from the CGIAR's Research Program on Climate Change, Agriculture and Food Security (CCAFS) and presents the cases of the Index Based Livelihoods Insurance (IBLI) and Agriculture and Climate Risk Enterprise Ltd. (ACRE) in East Africa. It proposes a framework for unpacking social equity related to equitable access, procedures, representation and distribution within index insurance schemes. The framework facilitates identification of opportunities for building outcomes that are more equitable, with greater potential for inclusion and fairer distribution of benefits related to index insurance. The article argues that systematically addressing social equity raises hard policy choices for index insurance initiatives without straightforward solutions. Attention to how benefits and burdens of index insurance are distributed, suggests the unpalatable truth for development policy that the poorest members of rural society can be excluded. Nevertheless, a focus on social equity—facilitated by the framework—opens up opportunities to ensure index insurance is linked to more socially just climate risk management. At the very least, it may prevent index insurance from generating greater inequality. Taking social equity into account, thus, shifts the focus from agricultural systems in transition per se to systems with potential to incorporate societal transformation through distributive justice.     

Long-Term Care Planning as a Cultural System

Abstract

This paper treats long-term care planning from a cultural perspective, that is, as a cultural system in which components of long-term care interlock culturally and therefore meaningfully. In the introduction and background sections, we provide a context in which long-term care planning may be viewed, based on the finding that relatively few people take advantage of long-term care planning and insurance; we also discuss some earlier work on long-term care from a psychological perspective that emphasizes themes of imagination and self-efficacy. We then examine long-term care from a cultural perspective by identifying and explicating five broad themes that help us better understand the meaning of long-term care planning to Americans. Finally, we use these themes to suggest some important social policy correlates.     

Long-term care insurance: a benefit for the future.

As the cost of long-term and custodial care threatens the resources of many elderly and disabled people, private industry and the government are investigating various ways of funding insurance to pay for such care.     

Financing long-term care with limited resources: combining the resources of the public and private sectors

Under Connecticut's recently implemented public/private partnership to finance long-term care, individuals will no longer need to impoverish themselves in order to receive Medicaid assistance. To encourage those people who can afford to buy a private long-term care insurance policy to do so, the state promises to shield one dollar in assets from Medicaid "spend-down" rules for every dollar a private policy pays out for Medicaid-covered services. This article describes the Partnership, shows how dwindling resources and budget constraints affected the development of this model, and then contrasts Connecticut's experience with that of other states and describes what can be learned from this demonstration.     

Financing reform for long-term care: strategies for public and private long-term care insurance

The way the nation provides for the financing and delivery of long-term care is badly in need of reform. The principal options for change are private insurance, altering Medicaid, and public long-term care insurance. This article uses the Brookings-ICF Long-Term Care Financing Model to evaluate each of these options in terms of affordability, distribution of benefits, and ability to reduce catastrophic out-of-pocket costs. So long as private insurance is aimed at the elderly, its market penetration and ability to finance long-term care will remain severely limited. Affordability is a major problem. Selling to younger persons could solve the affordability problem, but marketing is extremely difficult. Liberalizing Medicaid could help solve the problems of long-term care, but there is little public support for means-tested programs. Finally, universalistic public insurance programs do well in meeting the goals of long-term care reform, but all social insurance programs are expensive and seem politically infeasible in the current political environment.     

Convergence of long-term care planning and retirement planning at the work place

There is an increasing expectation that the private-sector should provide needed solutions to pressing problems in long-term care. Long-term care insurance has figured prominently in recent discussions. Within the long-term care insurance market, the potential of the employer in making such insurance available to employees has been discussed extensively. This paper traces the increasing convergence of retirement planning and long-term care planning at the work place. The long-term care insurance market has come a long way, and the employer-sponsored segment of the market has recorded the highest rate of growth in recent times. Furthermore, the employer-sponsored market is beginning to diversify. Low take-up rates still remain a problem. Recent rapid growth of the market coupled with the federal government's involvement as an employer offering long-term care insurance is bound to expand the market further.     

Long-term care policy and the American family

This article examines current and proposed long-term care policies and the social values of American families by looking at the influence of policy on family behavior. The analysis asks two questions. First, have our policies in recent years supported or undermined family values regarding the care of older members? Second, are our existing family values compatible with home and community-based long-term care reform proposals? Aaron, Mann, and Taylor's (1994) model for policy and changing values provides direction throughout. Findings based on behavior as a proxy for values suggest that current policies influence family values, and in turn, family values influence policies. Future policy is discussed in light of changed values, American family structure, dysfunctional families, individualism and collectivism, and gender neutrality and justice.     

Financing Reform for Long-Term Care

The way the nation provides for the financing and delivery of long-term care is badly in need of reform. The principal options for change are private insurance, altering Medicaid, and 110 FROM NURSJNG HOMES TO HOME CARE public long-term care insurance. This article uses the Brookings-ICE Long-Term Care Financing Model to evaluate each of these options in terms of affordability, distribution of benefits, and ability to reduce catastrophic out-of-pocket costs. So long as private insurance is aimed at the elderly, its market penetration and ability to finance long-term care will remain scverely limited. Affordability is a major problem. Selling to younger persons could solve the affordability problem, but marketing is extremely difficult. Liberalizing Medicaid could help solve the problems of long-term care, but there is little public support for means-tested programs. Finally, universalistic public insurance programs do well in meeting the goals of longterm care reform, but all social insurance programs are expensive and seem politically infeasible in the current political environment. The way the nation provides for the financing and delivery of long-term care is badly in need of reform. No other part of the health care system generates as much passionate discontent as does long-term care. At the heart of the problem is the absence of any satisfactory way to help people anticipate and pay for long-term care. The disabled elderly find, often to their surprise, that the costs of nursing home and home care are not covered to any significant extent by Medicare or private insurance. Instead, they must rely on their own savings or, failing that, turn to welfare in the form of Medicaid. At a national average cost of $40,000 a year for nursing home care, long-term care is a leading cause of catastrophic out-of-pocket health care costs for the elderly. In addition, despite the strong preferences of the disabled for home and community-based services, current financing is highly skewed toward care in nursing homes. While the debate over long-term care reform has many facets, it is primarily an argument over the relative merits of private- versus publicsector approaches. Differences over how much emphasis to put on each sector partly depend on values that cannot be directly proved or disproved. Some believe that the primary responsibility for care of the elderly belongs with individuals and their families, and that government should act only as a payer of last resort for those unable to provide for themselves. The opposite view is that the government should take the lead in ensuring comprehensive care for all disabled older people, regardless of financial need, by providing comprehensive, compulsory social insurance. In this view, there is little or no role for the private sector. Between these polar positions, many combinations of public and private responsibility are possible.     

Building a Humane Society for Older People: Compassionate Policy Making for Integration,Participation, and Positive Ageing Within a Framework of Intergenerational Solidarity

This article explores the global challenge of population aging with a specific focus on the concepts of integration and participation of older people in society within the context of “realizing a society for all ages” as promoted by the United Nations. It is proposed that governments worldwide need to embrace new ways of thinking about population aging that include strategic initiatives for strengthening the social contract that fosters generational interdependence. The meaning of “positive aging” is explored at both the individual and social levels, with implications for quality-of-life issues involving intergenerational relationships. The point is made that while the promotion of positive aging is commendable on both philosophical and health grounds it can be problematic for those older people who for a range of legitimate reasons are unable to fulfill the notion of positive or active aging. The longevity revolution will require the emergence of a more humane society that undertakes to reconceptualize what older age means, together with exploring new ways of enhancing the citizenship status of older people through the development and promotion of innovative intergenerational relationships. A call is made for a wider engagement of the citizenry in the processes involved in the formulation and implementation of policy making.     

Financing Long-Term Care with Limited Resources

Under Connecticut's recently implemented public/private partnership to finance long-term care, individuals will no longer need to impoverish themselves in order to receive Medicaid assistance. To encourage those people who can afford to buy a private long-term care insurance policy to do so, the state promises to shield one dollar in assets from Medicaid "spend-down" rules for every dollar a private policy pays out for Medicaid-covered services. This article describes the Partnership, shows how dwindling resources and budget constraints affected he development of this model, and then contrasts Connecticut's experience with that of other states and describes what can be learned from this demonstration.     

The state and future of social service enterprises—a Finnish case

There has been a rapid increase in private social services in Finland, where the tradition of social care services has placed the main emphasis on public services. The aim of this article is to compare the situation of Finnish social service enterprises in 2001 and 2005/2006, in the light of two national surveys, in order to increase knowledge about the state and the future of such enterprises as providers of social care. Particular attention is paid to the profiles of men and women as entrepreneurs, as these differed somewhat. The composition of private care enterprises and their management remained fairly similar between 2001 and 2005/2006. Most of the enterprises were owned by middle-aged women with an extensive experience of social and health care. The owners of the older enterprises were more pessimistic about the future than the owners of the more recently-established firms. Social workers have not been active in setting up firms, but the public–private processes should be steered and evaluated from the social work perspective, too, because they are actors who have a relevant part to play in the long-term co-operation and development work of public and private social services.     

Warum es kaum Pensionsfonds in Deutschland gibt. Kapitalmarktrisiken,Finanzindustrie und die Politik der Mindestverzinsung

Studies of the rise of private defined-contribution pension plans have traditionally focused on social policy concerns about the allocation of risks and costs for beneficiaries and employers. There is however another dimension of pension privatization, which situates it in the context of financial markets and—more broadly—the economic system. Here, regulations forcing private pension providers to guarantee a minimum rate of return on individuals’ pension assets make a crucial difference for financial markets because they incentivize fund managers to invest a greater chunk of plan portfolios in fixed-income securities and therefore away from equities. While different segments of the financial industry have divergent preferences over minimum return guarantees, politicians are caught in a dilemma: Should they prioritize predictable benefit levels or the development of equity markets? Using the case of the introduction of the German Riester Rente, we argue that, as politicians linked the introduction of private defined-contribution plans with cuts in statutory pensions, insurance firms in coalition with trade unions insisted on minimum guarantees, thereby restricting the expansion of equity markets in Germany.     

Enabling informed consumer choice in the long-term care insurance market.

Provisions in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) may increase private long-term care insurance sales without imposing substantially more stringent consumer-protection features. The ability of consumers to make informed choices when purchasing this complex product is examined in light of these changes. Data were collected through detailed examinations of policies and interviews with industry experts, insurance companies, agents, consumer groups, and regulators. Because of the complexity of this product, the goals of expanding, consumer choice and ensuring that consumers are able to make informed decisions often work against each other. Mechanisms are discussed through which the government can facilitate informed choice and improve consumer protection. The authors contend that, because the government is providing tax incentives that encourage consumers to purchase the product, it has the responsibility to ensure that consumers understand the long-term care insurance they purchase.