home health providers. These developments, many of which are already under way, will add enormous complexity to the ombudsman function because of the large number of diverse and often small sites to monitor.

If present trends in some Medicaid waiver programs continue and the proposals in the 1993 Health Security Act prevail, then more public subsidies for LTC will be given directly to clients to pay self-employed workers of their choice, and payment of family members who give care will increase. These patterns will make the job of an ombudsman more complex, and they will introduce a need to conceptualize the roles and responsibilities of a family member who is also publicly paid. When these family members are also surrogate decision makers for incompetent clients, new abuses may arise; these in turn will pose additional challenges to the ombudsman program.

LTC services and systems will probably employ more strategies to contain costs, such as capitation. Further, under managed acute care (such as already exists in Medicare health maintenance organizations), LTC allocations and individual allocations are more likely to be made by those responsible for managing the resources of comprehensive health care plans. An ombudsman program would necessarily need to be familiar with the incentives that prevail in these markets and the new points of accountability. Such systems are likely to have available elaborate technology to track high-cost consumers, and to predict the likelihood of cost-effective outcomes; ombudsman programs in turn may find a need to work with privacy concerns of consumers.

Stricter rules have recently been enacted to prevent divestiture of assets by persons trying to become eligible for Medicaid LTC. Even more stringent rules have been established to require states to make vigorous attempts to recover assets after the deaths of the person receiving LTC and, when applicable, his or her community-dwelling spouse. Public sentiment in some states and among some state legislators favors pursuit of these measures. At a minimum, these issues introduce a significant concern about which vulnerable older people need information—and perhaps vigorous advocacy—to ensure that their rights are not abridged.

Assisted suicide and withholding or withdrawing of treatment may be legalized, in response to consumer demands, the “Kevorkian” phenomenon, and policymakers’ desire to curb costs. Older people may be encouraged to enact advance directives for no heroic measures, and these may be filed and followed more rigorously than is now the case. The ombudsman may increasingly become involved at the individual and system level in ensuring that these important choices are not made without information or out of a desperate fear on the part of elderly persons about their likely quality of life.



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