REVIEWED BY ELSE M. KIEFER
The Future of Long Term Care:
Social and Policy Issues
Robert H. Binstock, Leighton E. Cluff, and Otto von Mering, eds.
Johns Hopkins University Press, Baltimore
1996, 324 pp., $38.50
This wide-ranging book discusses the history, problems, and future prospects of long-term care in America. Inspired by the 1992 National Health Forum held at the University of Florida and edited by an interdisciplinary team from medicine (Cluff), anthropology (von Mering), and social gerontology (Binstock), it contains chapters by 15 authors who represent the diverse fields of history, ethics, social welfare, nursing, health policy, and healthcare administration.
The book's central theme is the fundamental issue that both healthcare and the elderly population are changing in the United States. Planners and providers of long-term care must be aware of these changes and the many obstacles to effective response that currently plague their profession. The baby-boomers will soon be reaching the age of declining health and income, and they are better educated and more sophisticated than their parents. They will also live longer, many with chronic illnesses. As a group they not only will need much more long-term care than our society now can provide but also will demand better care at a time when fewer resources will be available.
Moreover, as the excellent chapter on history by Martha Holstein and Thomas Cole shows, the industry has evolved largely without planning, as evidenced by the inefficiency, varied quality, and biased distribution of current services. Too many elderly people, especially racial minorities, women, the very old, and those living alone, lack the necessary access. A recurrent theme is the care burden carried by women, many in frail health, often poor, and usually underpaid, who are the primary caretakers of most disabled elderly people today. The authors also demonstrate that a large proportion of those needing long-term care services are children, adolescents, and young adults.
The Future of Long Term Care examines a number of proven and promising approaches toward improving this situation. Valuable experience has been gained from demonstration projects throughout the United States, showing how innovative funding and delivery schemes can improve quality and lower cost. The authors provide useful details on many of these, including projects on assisted living, case management, improved integration of acute care and long-term services, and health promotion. Another chapter describes currently underused technologies that promise longer lives with a higher quality of life.
In discussing what needs to be done, the book effectively exposes the irrationalities of current funding. Cost-saving services such as health promotion, case management, and environmental improvements usually are not reimbursable. Separate insurances for separate services (social, acute, and long term) discourage coordination. Current Medicare and Medicaid rules offer few incentives for clients to plan for their futures. In an effort to cut costs, payers often micromanage care, resulting in great administrative waste and poor balance between needs and services. A useful concluding chapter by Dennis Kodner reports the results of a Delphi study of long-term care experts, recommending fairly specific and realistic changes in practices and funding. The experts who participated have a vision of the future and have managed to break away from the traditional thinking that still limits most of us in the field.
The style of The Future of Long Term Care is a major asset. Unlike so much literature in gerontology, the book is clear, straightforward, and well focused on practical issues, while maintaining a high standard of scholarship throughout. Both academics and service professionals will find it extremely useful. My single stylistic quibble involves the index, which should include more entries, especially geographic names.
The content is excellent but necessarily has its shortcomings, given the broad subject matter. Although the book provides essential background on the history, economics, and politics of long-term care, a wider perspective is needed. Anyone seriously dedicated to reforming long-term care must understand the relevance of the far-reaching, persistent problems in American society, of which the book's focus is but one small expression.
For example, the reader is left wondering how the long-term care industry will manage to provide better trained personnel (one of the book's recommendations) when underpaid nursing aides, often from urban ghettos, now perform most of the work. The observation that "tomorrow's elderly will be wealthier" ignores the increasing gap between rich and poor people and the current trend to exclude certain populations from services. It would be more correct to say that "a few of tomorrow's elderly will be enormously wealthy; the sicker majority will be as poor as ever." Many references are made to community-based and home-based care, but none to the problems of crime and environmental degradation, which are among the most serious obstacles to these solutions.
We hope that long-term care, along with many other societal obligations, can be improved without a total overhaul of the society. The broader conditions just mentioned would seem to limit the options, however, and could be an appropriate subject of a supplemental book.
Else M. Kiefer
Consultant
Catholic Healthcare West
San Francisco