I was particularly proud of this chart I assembled from the following article,
Smith DB, Feng Z. The Accumulated Challenges of Long-Term Care, Health Affairs 29(1), January 2010, 29-34.
|
Time Period |
Problem |
Solution |
Effect on the Problem |
Consequences |
|
1910-1930 |
Controlling Indigent Care Costs |
Indoor Relief: Funnel the elderly into poorhouses |
Because it relies of shame and few quality standards were in place, this action was the most cost efficient of the three option (others being cash payments, and auctioning off care) |
Only cost efficient if the “woodwork” effect didn’t occur; shame prevented moral hazard of people flocking to receive aid. Quality was poor. This solution was not well protected if shame could be overcome, which happened in the Great Depression. |
|
Great Depression floods the poorhouses. Too many to care for; too many indigent to punish in penal system. |
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|
1930-1950 |
Eliminating Poorhouses |
Income Security: Title I of the Social Security Act of 1935 |
Shift from punitive poorhouse model to private boarding homes that received payments via Title 1. |
The shift to boarding homes only considered housing and meals. Once medical needs of boarded clients are accounted for, costs escalate. |
|
Universal health care bill fails. Public care models face routing to private models to contain cost. |
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|
1950-1970 |
Assuring Access to Affordable Medical Insurance |
Medicare & Medicaid created in 1965 |
Provision of medical coverage for a limited number of people. |
Philosophical change in handling care from the planned universal social coverage to a private coverage system that seeks to minimize moral hazard rather than seek quality. Nursing homes grow rapidly to cash in on new government Medicaid spending (poor implementation planning during creation due to speed of bill passage). |
|
Nursing home growth overwhelms State’s capacity to provide oversight and quality control. Abuse & fraud runs rampant. |
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|
1970-1990 |
Controlling Provider Abuse |
Strengthening State & Federal Enforcement: 1987 OBRA |
The 1987 OBRA (Omnibus Budget Reconciliation Act) created minimum standards for nursing homes, which helped improve quality and reduce admissions to some sub-par institutions. |
Resulting prospective payment method disincentivizes provision of care. When paired with decreasing nursing homes and a focus on avoiding cost, many elderly are forced to find other arrangements to receive the care they need. (at home, or limited options for private pay) |
|
Nursing home flight leads to the next least-regulated Medicaid funding avenue, assisted living and waiver care. Potential risk of collapse due to baby-boomer pressure. |
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|
1990-2010 |
Providing Long-term Care the People Actually Want. |
Market Reform |
Private residence homes start for able-to-pay. Medicaid wavers for community care provide an alternative. |
Medicaid coverage of non-institutionalized care increases from 10% to over 40%. Privately traded assisted living homes boom related to new 1915(c) waivers which allow community care funding. |
