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.     

Integrating Sexual Health Services Into Primary Care: An Overview of Health Systems Issues and Challenges in Developing Countries

ABSTRACT

Current attempts to address the high burden of sexual health morbidity and mortality in developing countries remain limited in scale due to a range of health system constraints. We conducted a literature review of the policy and programmatic issues that influence the integration of sexual health into primary care services in developing countries. Forty-seven reports were identified from a search of both peer-reviewed and gray literature. Key issues identified were intersectoral and intergovernmental coordination; management and organizational issues including decentralization, health sector reform, logistics, and referral systems; human resources, including training and support required to increase service scope; relationships between the public and private sectors; and scaling-up and financing issues.     

Global Convergence: Aging and Long-Term Care Policy Challenges in the Developing World

Aging around the world poses a global challenge in eldercare. This challenge is particularly felt in low- and middle-income countries (LMICs), where population aging outpaces the development of aged care policies and services. This Perspective highlights the phenomenon of global convergence in several unsettling trends and challenges shared across LMICs. These include the weakening of informal family care systems for the elderly, growing need for formal long-term care of the frail and disabled who can no longer be adequately supported by family members, and mounting pressures for policy responses to tackle these societal challenges. It is argued that policymakers should take a proactive stance. That is, when family care for the elderly falls short and family caregivers are increasingly under strain, the government should step in and step up support to fill in the gap by developing appropriate policies and a continuum of long-term care services that are accessible and affordable for the majority of older people in need. Three general principles are then suggested with regard to long-term care provision, financing, and quality assurance, which transcend national borders and can be used to guide long-term care policymaking across LMICs.     

Families,Work, and an Aging Population

Abstract

This article examines the intersection of family caregiving, work, and long-term care. Supporting families who provide care in order to minimize negative work effects while enhancing the acceptability of care options is of common concern to employers, state and federal policymakers, and the homecare professionals in the community-based care system. The contribution of families to the long-term care system, how employer policies have developed, how the public policy agenda has addressed family caregiving, and the importance of a more effective partnership on the state level are discussed.     

Organization and Delivery of Long-Term Care in Singapore

Summary

This paper focuses on the Singaporean model of long-term care for older people. With only about 2% of the older population living in institutions, the mainstay of long-term care is community care. The reader is provided an overview of the Singaporean services, including case management, followed by a discussion of the current issues and future challenges. In keeping with the prospect of a rapidly aging population profile, the Singapore government plays a leading role in framing policy and planning for future needs of this sector of the population.     

Vertical Axes on the Long-Term Care Continuum

Abstract

As the continuum of long-term care has expanded, public funding has not accompanied new care options. I detail access, provider profits and resources, and care quality in two types of residential care that fall in the center of the continuum, assisted living and board and care. These two options provide examples of how limited public funding leads to vertical axes, which represent access to services, the resources providers draw on to give care, and the quality of long-term care services, at each service point on the long-term care continuum.     

Fathers in Prison

ABSTRACT

The parenting roles and responsibilities of incarcerated men have not traditionally been considered an important public concern. The impact of criminal justice policies and practices on family functioning has rarely been addressed by policy makers or family scholars and men's family obligations have not been a priority for the individuals responsible for the safety and security of correctional institutions. Similarly, and with few exceptions, fathers in prison have been out of sight and out of mind of community organizations concerned with family life and children's wellbeing. Several recent developments challenge this historical approach to handling parental incarceration and responsible fatherhood initiatives involving incarcerated fathers are being promoted. This article examines the individual and societal issues that must be addressed if responsible fatherhood among incarcerated men is to become a serious social goal. It presents an overview of the complex family roles and relationships of incarcerated men and describes ways in which individual situations and family preferences affect their ability to function as parents. Analyses of prison location strategies and communication regulations and the post-release environment are used to show how public policies influence and shape family relationships and responsible fatherhood. The article concludes with an agenda for research to guide informed and humane policy decisions.     

The social investment approach as a field of job creation. From the ‘recalibration’ to a resurgent trade-off between employment growth and low wage (white) jobs. A comparison between Germany and Italy

The social investment approach emerged as a new welfare paradigm, aimed at reconciling the traditional functions of the welfare supply with a productive social agenda, designed at preparing people to confront the ‘new social risks’, whether they be related to the problem of balancing paid work and family responsibilities, upgrading the skills, preventing inequalities and promoting the availability of in-kind services. In order to achieve these objectives, especially those related to care needs and work-life balance, the adoption of social investment-based strategies necessarily implies an expansion of the jobs related to health and social care services. In more recent years, many studies have analysed the limitations of the social investment policies because of their different redistributive impacts on social groups. Several studies have found a higher use of these policies for high-income families. Another source of criticism on social investment is that spending on these policies would seem to crowd out more traditional passive social expenditures. In this article, we examine another question related to the widespread of this approach: what are the effects of the social investment policies in terms of direct job creation? In fact, one of the more controversial issues, related to social investment policies, is their direct contribution to the labour market in terms of both quantity and quality of work within welfare services. The article analyses these issues focusing on Germany and Italy, two countries that represent not only two different care regimes but also two distinct models regarding job creation strategies in the care sector. In doing so, particular attention will be paid to long-term care policies, as they represent one of the pivotal areas of the social investment approach, both in terms of social services, to address new social risks, and new jobs related to welfare services     

Community Care in Taiwan

SUMMARY

This article explores the policy definitions and the funder roles of central and local governments in community care in Taiwan. The notion of community care has been adopted in Taiwan following the model of Hong Kong but the main question of the article is whether this has resulted in actual service provisions at the community level, forming an alternative to institutional care. The data has been collected from several sources: policy documents, official statistics, surveys, general reports, funding provision reports, and empirical studies. The results show that neither central nor local authorities are seriously involved in caring for elderly people or persons with disabilities in Taiwan's communities. In Taiwan, community care for these groups of people still means, in practice, informal care provided by female family members without any support from public policies.     

Financing Long-Term Care: Examining Decision Outcomes and Systemic Influences from the Perspective of Family Members

This study examined financing long-term care from a micro-level family perspective. Qualitative analysis of interviews conducted with 45 families coping with paying for an elder's long-term care provided insight into what decisions were made as well as what factors influenced those decisions. Family members articulate systemic factors within and outside of the family system influencing three decision making outcomes: (a) using and preserving private resources, (b) Medicaid estate planning and (c) deciding not to decide. Case examples and a discussion of the emerging framework provide insight for researchers working to inform long-term care issues and for educational focused practitioners.     

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.     

The Perspectives of Older Greek-Australians Toward Changes in the Nature of Family Support: Implications for Family Care Policies

Internationally, public policies encourage “aging in place,” and the majority of older Australians requiring care in the community receive informal care, supplemented by publicly subsidized formal services. The effect of contemporary social changes on informal care in aging migrant communities is poorly understood. This articles explores the perceptions of older Greek-Australians toward changes in the nature of family support. Bicultural and bilingual researchers carried out in-depth interviews (n?=?27) and five focus groups (n?=?63 total participants) with older Greek-Australians in modern Greek. While “cultures of care” remain among Greek-Australian families, the means for a family to assist have shifted, and these compromises are met with considerable powerlessness among older Greek-Australians. Implications for policy include the need to better involve older migrants and their families in decisions about their care needs, potentially involving consumer-directed care models. Service providers may also need to adopt the use of new technologies to communicate with increasingly time-pressured family members.     

Hospital Mergers

Abstract

When secular and sectarian (often Catholic) hospitals merge, women's reproductive healthcare services are often put in jeopardy. Some merger efforts are successful and others fail. Several issues arise as a result of this situation. First, what role do women's reproductive rights activists and their supporters play in effecting hospital merger decisions? This question does not assume that all women support women's rights organizations or that all women support a full range of reproductive rights. Secondly, what other factors seem to effect the outcome of merger discussions? In order to answer these questions, it is first necessary to understand the extent of Catholic hospital expansion and the nature of the hospital merger movement itself. These considerations will provide perspective for the two case studies of the American hospital merger movement that provide venues for examining the issues relating to participation and other factors that effect the outcome of merger talks. Cumberland and Baltimore are the two communities examined in this study. Though it would be a mistake to generalize to all merger situations based on these two cases, there are lessons that women's reproductive healthcare advocates can learn from the experiences of these two communities.

The issue of hospital mergers and the availability of reproductive healthcare services for women does raise an additional issue. Private sector decisions are being made that have a direct impact on public services, that is, the availability of a set of healthcare services in communities. This is not the direction that most public policy analysts consider.

The more frequently asked policy questions begin with public policy decisions and ask how they influence non-governmental decisions.     

Social Work Practice with Older Soviet Immigrants

ABSTRACT

With the recent sociopolitical changes in the Former Soviet Union, significant numbers of older Soviets have arrived in the U.S. with their families. Soviet immigrants who enter the U.S. are no longer automatically considered political refugees, which has limited their entitlement to services. Recent changes in public welfare and immigration policy place the responsibility for care of elderly members solely on the family. While caring for older adults is stressful for any family, new immigrants may be especially burdened since they have limited knowledge of services, few coping resources to provide adequate care, and little experience resolving cultural conflicts with their older parent. By using a practice model designed to evaluate late-life caregiving situations, two case scenarios are presented to examine practice and service delivery issues of older Soviet immigrants and their families.     

Emerging Services for Community-Based Long-Term Care in Urban China

Abstract

China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper.     

Achieving Permanence in Foster Care for Young Children: A Comparison of Kinship and Non-Kinship Placements

ABSTRACT

A number of child welfare policies have reinforced the use of kinship care as the most preferred placement for foster children, reflecting the philosophy that maintaining children within their own extended family system contributes to their stability and well-being. Given the growing utilization and legislative emphasis on kinship care along with the push for an immediate implementation of permanency plans for children in foster care, this study examines how the permanency goal under the 1997 Adoption and Safe Families Act (ASFA) is being implemented and achieved. The reunification and permanency placement (adoption or legal guardianship) outcomes of children in relative and non-relative care are analyzed, focusing on the experiences of young children. Based on public child welfare agency data from 2000 to 2003, child, case, and placement variables are explored to identify which set of factors best explains case outcomes. The present study identifies the total length of foster placement (kinship and non-kinship), the length of family maintenance services, and the number of placement changes as the most important variables in determining family reunification and permanent placement (legal guardianship and adoption) outcomes for young children.     

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.