Moreover, it is likely that LTC will continue to evolve as demographic and other changes interact with the health care and LTC reform processes.

The following overview briefly reviews the issues of aging, disability, and financing for LTC services. This chapter answers the following questions: What exactly are LTC services? Who uses LTC services? Who pays for them? Finally, issues relating to the quality of LTC services are discussed.


“LTC services” is a broad term used to describe a constellation of services used by people with disabilities. Such services may include health care, housing, transportation, and other social and supportive services. In a 1991 report, the IOM defined disability as “the expression of a physical or mental limitation in a social context—the gap between a person’s capabilities and the demands of the environment”; thus, disabilities may include physical, mental, and cognitive impairments (IOM, 1991a).2 Disability is often measured in terms of “activities of daily living” (ADLs); these include tasks such as eating, getting in or out of a bed or chair, toileting, bathing, and dressing (Katz et al., 1963). A broader view includes “instrumental” ADLs (IADLs); these are activities required for independence, such as preparing meals, grocery shopping, arranging for transportation, managing personal finances, taking medications, telephoning, and housekeeping. Thus, LTC can involve an immense array of services to assist individuals of all ages, and with a wide range of impairments, in achieving a meaningful life according to their own expectations and yardsticks. This is indeed a considerable challenge.

The fact that the current health care system emphasizes acute medical care complicates this picture. Practitioners and systems of care experience great difficulty adapting to the long-term trajectory of chronic health and disability problems (Corbin and Strauss, 1988). The trajectory itself can be quite unpredictable (Verbrugge and Balaban, 1989). Reimbursement mechanisms such as Medicare, aimed specifically at the elderly and disabled, provide financing for medically oriented care related to acute health problems. To date, federal policy response to growing LTC needs has been limited, and private LTC insurance has not provided coverage for the great majority of Americans (Ball and Bethell, 1989; Estes et al., 1993). Thus, most people in this country are not able to avail themselves fully of the complex set of services typically considered to be LTC. This problem might not attract significant attention from the public or from policymakers were it not for the


The Disability in America report focuses chiefly on the prevention of disability (and the consequent gain in quality of life) among the nonelderly.

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