The Changing Role of Non-Profit Organizations in the U.S. Long Term Care System.

The American long-term care system has changed dramatically over the last several years as the need for care has increased steadily with the aging of the boomer generation. Arguably, the most important change has occurred in the Medicaid-funded part of the system as several states, with strong federal support, have moved toward contracting with large for-profit insurance companies to provide overall administration of Medicaid long-term care services, largely displacing the non-profit organizations that constitute the nation's Aging Network. We are concerned that the displacement of the mission-oriented model of long-term care that is administered by the Aging Network will negatively affect access, quality, and cost in state Medicaid long-term care programs.

Neoliberal Long-Term Care: From Community to Corporate Control.

Publicly (mainly Medicaid) funded long-term care (LTC) services have evolved from a nursing home dominated system of service to a much more balanced system including home- and community-based services (HCBS) programs over the last 30 years. The HCBS programs have been largely administered by the state and local level nonprofit aging networks (ANs) consisting of Area Agencies on Aging and thousands of service providers. Over the last decade, however, for-profit HMOs administered primarily by large insurance companies have begun to displace AN organizations. State policymakers have embraced for-profit privatizations under the rationale that this approach will generate greater savings, efficiencies, and higher quality outcomes than the traditional public or private nonprofit models of program administration. As we show here, there is very little evidence for this rationale; yet, this lack of evidence has not prevented the continuing growth of for-profit managed LTC programs supported more by an ideology of market fundamentalism than empirical evidence. We also describe six possible consequences of the trend toward corporate control of public LTC services in the years ahead.

The neoliberal political economy and erosion of retirement security.

The origins and trajectory of the crisis in the United States retirement security system have slowly become part of the discussion about the social, political, and economic impacts of population aging. Private sources of retirement security have weakened significantly since 1980 as employers have converted defined benefits precisions to defined contribution plans. The Center for Retirement Research (CRR) now estimates that over half of boomer generation retirees will not receive 70-80% of their wages while working. This erosion of the private retirement security system will likely increase reliance on the public system, mainly Social Security and Medicare. These programs, however, have increasingly become the targets of critics who claim that they are not financially sustainable in their current form and must be significantly modified. This article will focus on an analysis of these trends in the erosion of the United States retirement security system and their connection to changes in the United States political economy as neoliberal, promarket ideology, and policies (low taxes, reduced spending, and deregulation) have become dominant in the private and public sectors. The neoliberal priority on reducing labor costs and achieving maximum shareholder value has created an environment inimical to maintain the traditional system of pension and health care benefits in both the private and public sectors. This article explores the implications of these neoliberal trends in the United States economy for the future of retirement security.

The aging network and managed long-term care.

Since the early 1980s, service providers and area agencies on aging, that is, the aging network, have developed a number of strengths as they built a community-based long-term-care system in most states. Many area agencies and providers now have the capacity to assess the needs of older persons, identify appropriate services, and administer cost-effective community programs while operating within fixed, capped budgets. They have also been able to identify and maintain roles for informal caregivers, draw on community resources through donations and the use of volunteers, and create substantial political support. In this article we argue that the aging network should draw on these strengths to develop integrated long-term-care systems designed to shift the balance of state long-term-care systems from institutional to home- and community-based services. We also argue that the nonprofit aging network, because it is made up of area agencies on aging and service providers, provides a potentially more effective framework for the integration of long-term-care resources than do proprietary managed care organizations.

Medicare privatization and the erosion of retirement security.

This paper describes initiatives to privatize the Medicare program over the last 10 years and the implications of these initiatives for the future of retirement security. Our analysis focuses on the privatization provisions of the Medicare Modernization Act, which is largely designed to benefit the corporate health care sector without containing costs or significantly reducing the threat of rising health care costs to the economic security of current and future retirees. In fact, as designed, the Medicare Modernization Act is likely to increase the threat to retirement security in the years ahead. We conclude with a series of policy alternatives to the neoliberal agenda for the privatization of Medicare.

The relative benefits and cost of medicaid home- and community-based services in Florida.

PURPOSE: We compared inpatient days, nursing home days, and total Medicaid claims for five Medicaid-funded home- and community-based services (HCBS) programs for in-home and assisted living services in Florida. DESIGN AND METHODS: We studied a single cohort of Medicaid enrollees in Florida aged 60 and older, who were enrolled for the first time in any of five Medicaid HCBS programs and who had at least one assessment (N=6,014). In this 3-year longitudinal study, we used a two-stage probit regression and ordinary least squares regression in order to test the independent effects of explanatory variables on outcomes and cost. RESULTS: After controlling for differences in frailty, chronic health conditions, presence of dementia, and available caregiver, we found that Medicaid HCBS programs had a differential effect on hospital and nursing home utilization and cost. IMPLICATIONS: Medicaid HCBS programs serve very impaired populations at a wide range of costs to Medicaid. The rates for Medicaid HCBS programs could be adjusted upward or downward in order to better reflect the level of need in each program. At the same time, providers could use titration techniques based on the relative costs of these needs in order to budget for the costs of meeting the needs of particular elders.

Predictors of lawsuit activity against nursing homes in Hillsborough County, Florida.

The objective of this study is to examine the litigation experience of twenty-eight nursing homes in Hillsborough County, Florida. Primary data were collected from Hillsborough County Circuit Court's Clerk's Recording Computer System about lawsuit activity from 1996 to 2000 and linked to the Centers for Medicare and Medicaid Services Online Survey, Certification, and Reporting system. We found that registered nurse levels, size, and being part of a chain or system impacted litigation in Hillsborough County.

The nursing home problem in Florida.

The nursing home problem in Florida was characterized as a debate over quality of care and the rapid increase of lawsuits against nursing homes that led to a decline in the availability of affordable liability insurance. The staff for Florida's Task Force on Availability and Affordability of Long-Term Care analyzed lawsuit and quality-of-care data from one county in Florida and quality-of-care data statewide to understand the relationship between the two sides of the argument. Analyses showed support for both positions and a middle-ground policy position was achieved. The subsequent nursing home reform legislation and implications for the future of long-term care in Florida are discussed.

Utilization across the continuum of long-term care services.

PURPOSE: This study presents an analysis of the influence of consumers' predisposing, enabling, and need characteristics on the utilization of long-term care (LTC) services in nursing facilities (NFs), assisted living facilities, or home- and community-based services (HCBS). DESIGN AND METHODS: Data were gathered through a record review of a cross-sectional sample of 1,968 consumers aged 60 years or older receiving formal LTC services. RESULTS: Need contributes the most to differential LTC use. Those with the most need are more likely to be in a NF or HCBS. Enabling characteristics such as Medicaid eligibility and geopolitical region of the state were associated with higher use of NFs. Predisposing and enabling characteristics had a moderating influence on need. IMPLICATIONS: Although high need predicts care in NFs, some of the most impaired elders are also being cared for at home. Because Medicaid increases the likelihood of NF placement, public financing of LTC should reflect the capacity of the system to serve elders at home.