Political Science Perspectives on Aging Policy: A Policy Oriented Curriculum Component
Thomas H. Dennison, Syracuse University
Issues Shaping Health Policy for an Aging Society
I. Demography
- Baby Boomers
- Ethnic and Cultural Diversity
- Family Composition
- Workforce Issues
II. Service Utilization Patterns of the Elderly
- Functional Limitations and Aging
- Consumer Preferences
- Choice
- Acceptability of the Care Model Available
- Health Promotion and Preventative Services
III. Structure of the Service Delivery System
- Fragmentation
- Form follows Financing
- Inter-Organizational Relations
- Education and Training of Professionals
- Caregivers
- Managers
- Policy Makers
IV. Cost of Care
- Affordability of Care
- Public and Private Spending
- Medicare and Medicaid
- Coverage
- Roles and Relationships of State and Federal Governments
The population of the United States is growing older. Not only are people 65 years of age and older the fastest-growing segment of the population, the baby boomers are aging. And as the baby boomers age, we can expect them to have the same kinds of effects on the health care system as they have had on other parts of society. We will feel the full effect of the aging of this group of people by 2030, when the youngest baby-boomer reaches 65, which is well within the working careers of the people who are preparing to work in the arena of public policy that will shape the health care system of the future.
The health care system must begin preparing to meet the needs and the demands of these boomers. Not only will there are more of them, they will be older. By 2030, life expectancy for women will be approaching 90 and life expectancy for men will be approaching 80. The change in the profile of the elderly has a significant effect on the patterns of morbidity and, therefore, the profile services that will be needed. The service profile will, of course, drive costs.
From the outset, it is important to break a discussion of health care for the elderly into two separate, yet quite related, components: acute care and long term care. Logic, of course, would tell us not to divide the discussion of the health care services an elderly person might need into two artificially defined components. However, this is not logic. This is the health care system in America.
The division between long term care and acute care is driven by financing. And the dividing lines are essentially drawn around the differences between Medicare and Medicaid. Medicare pays for acute care. Medicare's basic criteria are that an individual must have a skilled need for coverage to be extended. Therefore, Medicare provides very little coverage for long term care. Medicaid, however, does (in every state except Arizona) provide coverage for long term care in both residential programs and in the home. The policy debate is frequently drawn along the lines of Medicare and Medicaid.
Health Care Spending
Increases in life expectancy in the United States are inevitably accompanied by an increased prevalence in disability and decline in health status and quality of life.1 Even though we have observed decreases in the prevalence of disability associated with chronic disease among older adults2, advancing age is associated with an increase in the number of health conditions that can lead to disability.3
As people live longer, they use acute and long-term care more frequently. Total expenditures for health care from the age of 65 until death increase substantially with longevity, from $31,181 for persons who die at age 65 to more than $200,000 for those who die at age 90.4 However, while the use of acute care services, measured by Medicare spending, increases only modestly with advancing age, the use of nursing homes and other long term care services, paid for either by Medicaid or private dollars, increases dramatically.
Planning for Services for the Elderly
Understanding the nature of the impairments that the elderly will experience is critical in planning for effective services. For example, vision impairment, which is defined as blindness in one eye, blindness in both eyes, or any other trouble seeing, was reported by 18.1 percent of adults aged greater than or equal to 70 years. Over a quarter of people over the age of 85 report limitations in ability to perform activities of daily living (eating, bathing, dressing, toileting, and transferring) and over one-half report limitations in ability to perform instrumental activities of daily living (shopping, cooking, money management, cleaning).5
The services that are developed must reflect these disabilities. The services that are developed must reflect a few other realities. First of all, when elders develop disabilities that disrupt routine activities, they have traditionally not turned to the health care system. They turn to the informal support system of adult children, other relatives, friends and neighbors.6 While we can probably expect that this tendency will continue, changes in the structure and size of families and an increasing number of women in the workforce will likely have an effect on the availability of informal supports. We should note that these informal supports have often been women. In some respects, long term care has been a women's issue.
Another set of realities involves changes in consumer preferences. Nursing home utilization, on a per capita basis, has declined over the past ten to fifteen years.7 Some of the reasons for this decline include lower levels of disability among the elderly, expansion of home care and availability of alternative options such as assisted living. We can expect that consumerism will play even a larger role in the choice of care options as the baby boomers, with a history of individualism, enter the long term care system.
Structural Issues in the Health and Long Term Care System
When an elderly person who has experienced disabilities engages the formal system, some of the glaring gaps and problems in the delivery and financing of long term care become apparent very quickly. These gaps and problems are, in many respects, the direct result of the absence of a coherent policy framework that supports the organization and financing of health care and, specifically, the sharp division between Medicare and Medicaid.
Alternative program options that blend acute and long-term care and integrate Medicare and Medicaid financing, such as the Program for All-Inclusive Care of the Elderly (PACE) which is a model of managed care, have been developed. However, the mainstream of health care remains in two separate camps, each with their own financing stream and each with their own paradigm of service.
This structural fragmentation is underscored by the poorly integrated education and training of the professionals involved in the delivery of health care services. To effectively deal with the range of medical and social needs of the elderly, a multi-disciplinary perspective is necessary. However, we educate the physicians, nurses, social workers, managers and public policy administrators in splendid isolation. And we turn these well-trained individuals loose on a vulnerable population without the tools necessary to understand how to work together effectively.
Policy Issues - Acute Care
Many of the policy issues in acute care services for the elderly revolve around affordability. The government's ability to afford the Medicare program is in the forefront of the debate. The Balanced Budget Act of 1997 is a direct action taken at the federal level to "reform" the Medicare program by expanding choice of options available to enrollees and to strengthen its financial position by reducing payments to providers.8 However, this is only a start of a solution to the problems facing Medicare.9
Affordability of care for individual elderly persons is also part of the debate. The lines converge particularly around the issue of prescription drugs. Most Medicare enrollees do not have adequate coverage for outpatient drug expenditures as Medicare covers only drugs prescribed for inpatient use.10
A broader problem in the delivery of acute care for the elderly is that geriatric medicine has focused primarily only management of acute ad chronic diseases, with much less emphasis on health promotion and prevention of disease.11 Not only could an emphasis on prevention contain costs in the long run, a shift toward preventive care may be more consistent with the demands of the baby boomer population in the coming years.
Policy Issues - Long Term Care
Again, the policy issues begin with financial considerations. In 1996, the Medicaid spending on nursing homes and home care represented approximately 35 percent of total Medicaid spending.12 The costs of long-term care are essentially divided between the Medicaid program and private patient payments, with Medicare and private long-term care insurance representing only a small portion. However, Medicare and Medicaid spending for home and community-based care varies widely from state to state. The financing structure of Medicare and Medicaid creates incentives for the states to shift spending to Medicare and encourages the federal government to develop approaches to shift spending to Medicaid.13
If the cost of long term care to the public purse is to be reduced, the burden will increasingly fall on the individual. Individuals and their families will have to plan and pay for more care through either traditional retirement savings or through the acquisition of risk pooling mechanisms like long term care insurance.
Changes in the demographic makeup of the elderly population and the anticipation of a demanding baby boomer cohort challenge the existing models of care. How to design and deliver long term care services that best meet the needs of today's and tomorrow's disabled elderly and their families are an unmet challenge.
The shift in the composition of the population will result in fewer working age people to care for more elderly individuals. How to recruit, train and retain a workforce necessary to deliver the care has been debated widely. In the context of reduced spending, the challenge becomes enormous.
Summary
A fundamental health policy issue is the need to integrate financing and delivery of long term care. A number of key trends are emerging in long-term care related to financing, new models of service delivery and shifts in consumer expectations and preferences. Taken together, changes occurring in these areas point to a rapidly transforming long-term care landscape. Financing responsibility is shifting away from the federal government to states and individuals and their families. Providers are integrating and managing acute and long-term care services and adding new services to the continuum of care and consumers are thinking more seriously about how to plan and pay for their future care needs and how to independently navigate the long-term care system, and adding new services.14
Endnotes
1 Vita, A.J., R.B. Terry, H.B. Hubert, and J.F. Fries. 1998. "Aging, Health Risks and Cumulative Disability," New England Journal of Medicine, 338:1035-41.
2 Bishop, C.E. 1999. "Where are the Missing Elders? The Decline in Nursing Home Use, 1985 and 1995," Health Affairs, July/August, (18)(4): 146-155.
3 Manton, K.G., L. Corder, and E. Stallard. 1997. "Chronic Disability Trends in Elderly United States Populations: 1982-1994," Proceedings of the National Academy of Science, 94: 2593-98.
4 Spillman, B.C. and J. Lubitz. 2000. "The Effect of Longevity on Spending for Acute and Long-Term Care," New England Journal of Medicine, May 11 (342)(19): 1409-15.
5 Campbell, V.A., J.E. Crews, D.G. Moriarty, M.M. Zack, and D.K. Blackman. 1999. "Surveillance for Sensory Impairment, Activity Limitation, and Health -Related Quality of Life Among Older Adults - United States, 1993-1997," MMWR Surveillance Summaries, December 17 (48)(SS08): 131-56.
6 Logan, J.R. and G. Spitze. 1994. "Informal Support and The Use of Formal Services by Older Americans," Journal of Gerontology: Social Sciences, (49)(1): S25-S34.
7 Bishop, C.E. 1999. "Where are the Missing Elders? The Decline in Nursing Home Use, 1985 and 1995," Health Affairs, July/August, (18)(4): 146-155.
8 Iglehart, J.K. 1999. "The American Health Care System: Medicare," The New England Journal of Medicine, January 38, (340)(4): 327-332.
9 Feder, J. and M. Moon. 1999. "Can Medicare Survive Its Saviors?" The American Prospect, May-June, No. 44: 56-60.
10 Soumerai SB and D. Ross-Degman. 1999. "Inadequate Prescription Drug Coverage for Medic are Enrollees - A Call to Action," New England Journal of Medicine, March 4, (340)(9): 722-728.
11 Rowe, J.W. 1999. "Geriatrics, Prevention and the Remodeling of Medicare," New England Journal of Medicine, March 4, (340)(9):720-721.
12 Iglehart, J.K. 1999. "The American Health Care System: Medicaid," New England Journal of Medicine, February 4, (340)(5): 403-408.
13 Kenney, G., S. Rajan, and S. Soscia. 1998. "State Spending for Medicare and Medicaid Home Care Programs," Health Affairs, January/February, (17)(1): 201-212.
14 Cohen, M.A. 1998. "Emerging Trends in the Finance and Delivery of Long-Term Care: Public and Private Opportunities and Challenges," The Gerontologist, (38)(1): 80-89.
Glossary
Medicare is a federal health insurance program (Title XVIII of the Social Security Act) that provides coverage for the elderly (over the age of 65) and certain disabled individuals who are entitled to Social Security benefits. There are two parts to Medicare. Part A covers most inpatient hospital and nursing home care for a short-term stay as well as certain home health and hospice care. Part B covers other medical and health services such as physician services, diagnostic tests, outpatient hospital services, durable medical equipment and ambulance services.
Medicaid is a form of public assistance established to pay for the institutional and community care for individuals financially unable to pay for their own care. Medicaid (Title XIX of the Social Security Act) is administered by the state government. Medicaid coverage varies widely between states.
Long Term Care is a set of health, personal care and social services delivered over a sustained period of time to persons who have lost or never acquired some degree of functional capacity.
Acute Care involves clinical interventions to address specific health problems.
Reading List
Spillman, B.C. and J. Lubitz. 2000. "The Effect of Longevity on Spending for Acute and Long-Term Care," New England Journal of Medicine, May 11, (342)(19): 1409-1415.
Bishop, C.E. 1999. "Where are the Missing Elders? The Decline in Nursing Home Use, 1985 and 1995," Health Affairs, July/August, (18)(4): 146-155.
Iglehart, J.K. 1999. "The American Health Care System: Medicare," New England Journal of Medicine, January 38, (340)(4): 327-332.
Soumerai, S.B. and D. Ross-Degman. 1999. "Inadequate Prescription Drug Coverage for Medic are Enrollees - A Call to Action," New England Journal of Medicine, March 4, (340)(9): 722-728.
Rowe, J.W. 1999. "Geriatrics, Prevention and the Remodeling of Medicare," New England Journal of Medicine, March 4, (340)(9): 720-721.
Gramm, P., A. Rettenmaier, and T. Saving. 1998. "Medicare Policy for Future Generations - A Search for a Permanent Solution," New England Journal of Medicine, April 30, (338)(18): 1307-1310.
Feder, J. and M. Moon. 1999. "Can Medicare Survive Its Saviors?" The American Prospect, May-June, (44): 56-60.
Iglehart, J.K. 1999. "The American Health Care System: Medicaid," New England Journal of Medicine, February 4, (340)(5): 403-408.
Kenney, G., S. Rajan, and S. Soscia. 1998. "State Spending for Medicare and Medicaid Home Care Programs," Health Affairs, January/February, (17)(1): 201-212.
Cohen, M.A. 1998. "Emerging Trends in the Finance and Delivery of Long-Term Care: Public and Private Opportunities and Challenges," The Gerontologist, (38)(1): 80-89.
