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Economic concerns and efficiency clearly dominate long-term care. Accordingly, descriptive terms of those receiving care such as "patient" or "client" have been replaced in many contexts by the term "consumer." This term positions the recipient of long-term care as an individual who seeks and uses products and commodities rather than as one to whom services are delivered.
The economic status and productivity of individuals within this economic context are therefore the primary determinants of access to care. For those consumers able to afford private long-term care, access to purchase a host of private options exists. See Box 2.1 for just a few of the on-line sites where an individual can scrutinize and purchase long-term insurance to cover the cost of services and supports under the long-term care rubric. (Please note that no endorsement of these sites is intended. They have been provided here as examples only.)
Box 2.1 - Long-term care Insurance Web sites
Long Term Care Insurance Services has provided education and planning since 1992. Our firm has carefully researched the countries top rated policies. We can help you determine if insurance is appropriate and will provide financial security. http://www.ltcinsuranceservices.com/ LTCinsurance.Com is an an unbiased information source for long term care insurance. Our goal is to be a guide for consumers through the complex levels of information about ltc insurance. http://www.ltcinsurance.com/long_term_care_free_quote.html
Keane Care, Inc. is a leading provider of clinical and financial software information systems to the long-term care industry. http://www.carecomputer.com/
Medical Insurance Information: Here we will post information on medical insurance and help in processing health insurance claims. If you would like to submit information regarding these subjects please e-mail us. http://seniors-site.com/medinsur/index.html
However, for those seeking public services, supports and resources, purchase power is limited and the determination of the worth of an individual and her/his related eligibility for resources are externally imposed by those with economic power. In the case of long-term care, so many systems have emerged that deciphering who is worthy and who is not is confusing because different systems have separate values regarding eligibility (Gleeson, 1997).
Nevertheless, in all systems legitimate worth is directly or indirectly related to economic productivity. Let us consider income replacement programs to illustrate. Of the programs that exist, Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) are the two primary public sources of income for individuals who cannot work. There are many web sites and written resources that provide complex, detailed information about eligibility specifics, application procedures and benefits, so we will cover basic information here. Box 3.2 suggests some web sites where we have found comprehensive and intelligible information about Social Security.
Box 2.2 - Social Security Links
Social Security Online: http://www.ssa.gov/SSA_Home.html SSI Table of Contents: http://www.ssa.gov/OP_Home/rulings/ssi-toc.html
List of related SS programs: http://www.socialsecurity.gov/disability
FAPE: (tip: enter "social security" in search field): http://www.fape.org/search/query.asp
SSDI for Children with Disabilities: http://newfederalism.urban.org/html/anf_a10.html
SSDI information: http://www.ssa.gov/dibplan/
The Social Security Administration defines legitimate disability as any physical or mental problem that prevents an individual from working; the condition must be expected to last at least a year, or result in death. (Social Security Act of 1935) In order for adults to qualify for benefits under SSDI they must meet the legitimate definition of disability and must have contributed to social security through work withholdings. (There are other ways to qualify that are related to family status as well). Actual benefits are based on a credit system that is calculated on income and length of time that an individual has contributed to social security.
In order to receive SSI, an individual must be poor. There are several eligibility criteria for non-disabled individuals but for disabled people to qualify on the basis of disability, the same definition used for SSDI specifies the legitimacy criteria for disability status under SSI. The benefits received from SSI are even more meager than those given by SSDI.
Recipients of SSI and SSDI can receive Medicaid, the health insurance program for those in poverty. Medicare, public health insurance for elders, is given to those who have received SSDI for two consecutive years. Both types of health insurance will cover hospital costs, physician visits, and some other medical needs.
In order to be deemed legitimately disabled, a physician (or other specified professional depending on the explanatory diagnosis for not working) and several other evaluators determine one’s fit with the legitimacy criteria. The process is one in which an individual must prove disability legitimacy. Moreover, the rate of denial is high, after which the appeals process must be invoked if an individual still wants to seek benefits. Furthermore, each step in the process is slowed by bureaucratic processing, so eligibility status often takes months, or even years to achieve (Scotch, 2001).
Until the passage of the Ticket to Work and Work Incentives Improvement Act (PL 106-170) in 1999, an individual who returned to work would loose all benefits including health insurance. However, with this legislation (which has not been implemented in all states), health benefits and some income can continue as people attempt to return to work. Nevertheless, if an individual is supported on Social Security, it is likely that he or she will be poor. Look at the following website to see if TWWIIA has been implemented in your state: http://www.ccer.org/twwiia/States.htm.
Let’s look at Medicaid in more detail since it is the primary long-term care support for individuals with low incomes who are legitimately qualified. In 1965, Medicaid was passed as Title XIX of the Social Security Act (PL 74-271). Medicaid is supported by federal dollars delivered through states. As suggested by Axinn & Stern (2000), the distance of a program from federal administration illustrates its public value. Thus, it is not surprising that Medicaid, a program for the poor, is located as state administered, unlike Medicare, a program for elders, which is directly administered within the federal government.
States have significant leeway in how to structure Medicaid and thus the benefits differ greatly from state to state. However, in general, in order for individuals with atypical activity explained by legitimately qualifying medical diagnostic conditions to receive Medicaid for residential long-term care, they also must meet the eligibility criterion of poverty. Thus families must "spend down" assets, a euphemism for becoming poor. For more detail on Medicaid, you can log on to http://cms.hhs.gov/. This site provides important and comprehensive information about Medicaid eligibility, services and options.
As you can see by the structure of benefits, an individual’s legitimacy for benefits and income support are closely linked to his/her economic productivity. Economic considerations are not however, limited to service recipients.
Long-term care providers, while regularly referred to as "helping professionals"
are not exempt from capitalist influences. Long-term care has become a global
industry with many opportunities for profit (Starr, 1982;
Gill, 1992). Direct services, management and
administration, and products are just a few of the areas that offer profit
potential in the long-term care industry. In
addition, professional education is now big business as schools and professional
organizations vie for market control through licensing and other methods of
professional regulation. Look at these photos as examples:
See photos and descriptions of educational marketing.
Not all economic opportunity is positive for providers and businesses however. As we are reminded by Starr (1982), the financial advantages of exchanging specialized knowledge and technology for capital was also a major limitation. The increasing cost of technology has forced providers to move from delivering service in individual or small practices to joining global corporations which can purchase and maintain costly technology-based research and practice. Thus, the opportunities that used to be available for individual profit are now largely controlled by multi-national corporations and many would-be entrepreneurs are now employees. The loss of provider autonomy to managed care organizations is considered to be a serious issue that affects multiple realms of practice. Listen to this description of the loss of provider autonomy:
At the agency level of economics, the nursing home system for elders was heavily influenced by the following economic factors:
As the awareness of the exorbitant cost of institutional care increased, deinstitutionalization and provision of long-term care in the community increased. While the incentive for community care in large part may have been economic, many other considerations, such as civil rights, for recipients were operative in moving long-term care services from institutions to the community. We discuss these influences in other parts of this module. (Gleeson, 1997) Here we focus on capitalism as a driving force for community-based care.
Beginning in the 1970's and continuing into the 1980's, federal and state-sponsored demonstration projects were developed to explore less expensive, more humane community-based care options. Under HCBS (home and community based services) waivers, Medicaid funds were used to provide LTC services in-home and community settings (ADAPT, 2002). Because states were required to provide services without increasing costs, thorough case management systems and technology were developed to ensure cost containment. Listen to Kane, Kane and Ladd (1998) for a look into the efficacy of this strategy.
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Loss
of Provider Autonomy
