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OVERVIEW
Long-term care in the United States is widely perceived to be
inadequate as to access, choice of setting, quality, and cost e These
inadequacies permeate the entire service structure and affect all
populations dependent upon long-term care: the frail and ill elderly,
ill, the physically disabled, and the
the chronically mentally
developmentally disabled.
Unprecedented numbers
The resulting changes in
. . .
Of Americans are living to a very old age.
the size and structure of the elderly
population wall create a substantial increase in the need for long-term
care. By the year 2000 15 million Americans are expected to need
extensive long-term care services in institutions or home settings;
about 40 percent will be under the age of 65. By 2020 the aging of the
baby boom cohort will swell the numbers of those needing long-term care
to more than 23 million.
Can long-term care services be restructured and improved before the
projected demand creates even more intractable problems of access,
quality, and cost? Can the supportive services and health care that
millions of Americans will need in the years to come be provided
without bankrupting the nation or impoverishing the disabled and their
families? The Institute of Medicine is proposing to undertake a major
study to evaluate public policy options and private initiatives that
. . ~ ~ t . ~ . ~ ~
together might form the basis of a national strategy for responding to
the nation's growth needs for long-term care.
The long-term care problem for the elderly is similar to other
problems that have been dealt with effectively by risk-pooling schemes,
that is, insurance. Almost every American family is at risk of having
an elderly member require substantial long-term care services. For the
relatively few that actually require extensive services, the costs are
huge. Some of these unfortunate families are forced to make poignant
choices: daughters abandon their promising careers and sacrifice their
independence; spouses divorce their lifelong partners to protect their
meager incomes; some individuals are totally impoverished.
Insurance has not been developed in any comprehensive way for
long-term care, notwithstanding a growing number of the very old and a
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growing probability that a greater proportion of families will be faced
with catastrophic costs. Why is this the case? What barriers exist to
establishing the appropriate insurance scheme? What should be done in
its absence? The potential of a pooled-risk approach to financing
long-tenm care justifies a full exploration.
The study proposed here by the Institute of Medicine would explore
how various public and private financing strategies could be employed
to facilitate the development of appropriate, accessible, and
affordable long-term care. In this country, where little central
planning of health care occurs, the structure of health care financing
has an inordinate influence on the shape, content, and quality of the
ultimate product. Although the framework of the proposed study is
options in financing, pooled-risk approaches in particular, the study's
ultimate intent is to contribute to the development of an improved
system of long-term care services. We propose to use the goals and
objectives of an effective and desirable system of long-term care to
determine the design of the financing system.
The Institute of Medicine is well qualified to lead such a project.
Its membership represents the nation's leaders in two areas that must
be brought together to address the nation's future long-term care
needs: clinical experts from many disciplines to evaluate the elements
of the proposed long-term care system and the tradeoffs required by
fiscal realities; and financial experts to evaluate alternative
risk-pooling strategies that can promote the development of a better
system of long-term care. It is our hope that the Institute's national
reputation as an objective, scientific, and policy relevant institution
will confer on the conclusions of the study the credibility necessary
to influence national policy. As an example of this role, the TOM
recently completed a study that sets out a comprehensive blueprint for
reform of the regulation of nursing homes. That report has received
widespread attention and endorsement by both consumer and health
provider groups, and its recommendations are being incorporated in
legislation.
The study will focus on the elderly, but will do so within an
overall perspective that also recognizes the long-term care needs of
those under the age of 65. The likelihood that at least 40 percent of
the nation's long-term care population in the year 2000 will be under
65 makes it imperative that public policies for the chronically
mentally ill, the developmentally disabled, and the nonelderly
physically disabled be formulated and evaluated as soon as possible. A
product of the proposed study will be an examination of the possible
positive and negative impacts on the disabled nonelderly of policy
choices to improve long-term care for the elderly.
The options to be considered will range from incremental to
comprehensive. Attention will be given to strategies to ensure an
orderly and equitable transition between current and proposed
policies. The overall goal of the study is the development of broad
policy recommendations and choices that could lead to practical and
effective responses to the nation's growing needs for a wide range of
long-term care services.
Representative terms from entire chapter:
proposed study
