Financing the health care of the aged.

The Medicare and Medicaid programs, which were enacted through the 1965 amendments to the Social Security Act, placed the federal government in the central role of assuring access of the aged and the poor to needed medical care. In this article the trends in the sources of financing medical care services for the aged are examined. The distinction in terms of insurance coverage between acute care services and long-term care services is highlighted. The effect of the programs in terms of reducing the aged's direct financial cost of medical care, increasing their access to medical services, and improving their health status is explored. The unanticipated increase in the cost of these programs has led to a change in emphasis in public policy, from assuring access to mainstream medical care to containing the cost of providing care. The direction of new federal policies is analyzed, and it is concluded that no longer will it follow the private sector's specifications of the conditions and arrangements under which health services are provided to program beneficiaries.     

Introduction

The seemingly disparate aspects of long-term care (LTC) exist in a broader context of concern for the ability of disabled and chronically ill individuals of all ages to function in everyday life. A focus in LTC, therefore, is on the types of services and products needed for an individual to perform basic activities of daily living.

A primary emphasis in LTC is on the individual who is in need of assistance. Related questions include: What impact will the receipt of LTC have on the autonomy of the individual? How will the care, which may extend over a period of years or decades, be funded? How will the various payment mechanisms affect an individual's access to care? What are potential solutions to the problems encountered as the individual and his or her family deal with the fragmentation and other problems of the LTC system? Such questions are addressed in the articles in this symposium, “Issues in Long-Term Care.” This paper provides a context for the symposium.     

THE SOCIAL FUND AS AN EXERCISE IN RESOURCE ALLOCATION

The social fund is the latest attempt to cope with the exceptional needs sometimes experienced by people in receipt of social assistance. It is also the first occasion when resource allocation decisions have been located centre-stage in a policy area that, hitherto, has been primarily demand-led. The social fund, which is eventually to be cash-limited, is allocated between over 400 Department of Social Security ( dss ; formerly Department of Health and Social Security, dhss ) local offices. The article describes how the 1988/9 budget was fixed and allocated between local offices, considers some of the problems that policymakers faced when devising the allocation criteria and examines the territorial redistribution inherent in the chosen strategy and which may or may not have been intended.     

Restructuring,Reconsidering, Reconstructing: Implications for Health Human Resources

Abstract

In the 1990s, many health care organizations adopted restructuring strategies that were inappropriate to an industry in which the effective use of workers' knowledge, skills and social relations was essential to productivity. Workforce cuts and the withdrawal of workplace supports without sufficient consideration of human consequences led to a demoralized and short‐staffed workforce rather than cost containment. This paper uses two neo‐capitalist perspectives to illustrate the impact of restructuring initiatives on nursing, the most numerous health care profession. It describes how reconsideration of strategies adopted during restructuring has led to a search for new approaches to institutional change that make optimum use of human and social capital.     

Health maintenance organizations as Medicaid providers.

Evolution of a one-door, one-class system of medicine for all Americans was the professed goal of the social legislation of the 1960s. The development of health maintenance organizations (HMOs) was seen to be a major mechanism for assuring access to care and at the same time reducing the costs of social health programs. This has currently been reinforced by procompetitive proposals, which predict great efficiency resulting from the envisaged competition among organized systems of care. This article argues that established HMOs have no incentives to enroll Medicaid beneficiaries and that under current arrangements. Medicaid beneficiaries have no incentives to enroll in HMOs. As Medicaid programs across the states are cut, resulting in fewer benefits and more restricted physician payments, beneficiaries may have greater incentives to enroll in organized systems. Private physicians may also face greater incentives to develop HMOs to serve Medicaid beneficiaries. If that happens, however, a two-class system--one for the poor and one for others--will be institutionalized; and to assure minimum standards of care for the poor, more, not less, regulation will be required.     

Case-mix nursing home reimbursement: a technical “fix” for a policy inadequacy?

Most state Medicaid programs, in many cases the largest fundors of long term care, reimburse nursing homes or home health agencies on negotiated flat rates. However, several states have implemented or are planning to use reimbursement methods using case-mix indices to adjust for the different variable costs (e.g., resource utilization groups, RUGs) incurred in caring for different types of patients. Advocates contend that such methods can simultaneously help contain costs and enhance access by motivating the nursing home to keep costs below predetermined rates and mitigating providers’ reluctance to admit “heavy care” residents. The numbers of such residents putatively have increased as a result of incentives in the Prospective Payment System for hospitals to more quickly discharge sicker patients. However, the potentially negative effects of case-mix reimbursement (CMR) on quality of care have not gone unnoticed, and the costs (as yet undetermined) of mechanisms to avert these effects likely are nontrivial.

This paper examines the effects of CMR on cost (to states and nursing homes), access and quality. A preliminary review of the available evidence seems to indicate mixed results; yet, CMR obviously appeals to some Medicaid programs and representatives of the nursing home industry. We suggest that the allure of CMR may be due to a mistaken belief that, to borrow from Brandon (1990), such “tech fixes” obviate irksome negotiation on the part of policy elites.

An alternate reimbursement policy is proposed: a negotiated prepayment, based on a facility's global budget, with periodic allocations and an end of period adjustment to compensate the provider for unanticipated costs.     

Chapter 10. Central American Survivors of Political Violence

Abstract

Despite compelling, well-documented findings on the levels of stress and trauma among Central American refugees, this group continues to be underserved. A host of issues contributes to this underservice, ranging from macro-level imposed obstacles, such as citizenship and health insurance as determining factors for accessing social and health services, to institutional factors that impede service utilization, such as an insufficient number of translators or a cumbersome and confusing bureaucracy. This chapter adopts a human rights framework as a strategy for working with groups of Central Americans who have experienced political violence. The ongoing effects of political violence on Central Americans, as they relate to mental and physical health problems, are reviewed and a case vignette is used to illustrate how political violence affects individuals and how macro-level forces and institutions create barriers to access and use of health care and social services. Treatment approaches for helping survivors of political violence in the context of a human rights framework are suggested.     

PUBLIC RESPONSIBILITY AND INEQUALITY IN HEALTH INSURANCE COVERAGE: AN EXAMINATION OF AMERICAN STATE HEALTH CARE SYSTEMS

This article examines the effect of the three publicness dimensions on inequality in health insurance coverage across 50 American state‐level health care systems. The analysis validates a Gini‐coefficient measure of Americans' unequal distribution of health insurance coverage across nine income groups and compares public ownership, financing, and control of health care systems across all 50 states from 2002 to 2010. There is a significant and negative relationship between public ownership and inequality in health insurance coverage, although the substantive impact of ownership is relatively small. Both public financing and control substantially reduce inequality in health insurance coverage across income groups. However, both of these must be present in order to be effective at reducing inequality. This article expands our understanding of the link between different institutional arrangements and inequality in health insurance coverage in hybrid health care systems.     

Remittances,Banking Status and the Usage of Insurance Schemes

Empirical evidence that migrants send home more remittances after disasters raises the question of whether remittances are used to self-insure, substituting for both formal and informal insurance. We investigate this question using a unique data set on the usage patterns of financial services by households in South Africa. We show that the likelihood that a respondent has a formal funeral cover increases with income and banking status. However, it is lower for individuals receiving remittances, which supports the idea that remittances act as self-insurance. We also show that other risk management strategies influence the purchasing of formal funeral cover. Finally, we find that determinants of informal insurance differ from those of formal insurance.     

Automatic cost-of-living adjustments and the structural federal budget deficit

The mounting budget deficit is both economically and politically in supportable Projections of the unified federal budget deficit and the structural unified federal budget deficit and the structural deficit and the structural deficit converge in the next few years, indicating that nearly all of the deficit is the result of policy choices.

Efforts to significantly reduce the deficit must focus on the largest componenet of federal spending, entitlements such as social security, federal retirements, and medicare. Entitlements account for 45 percent of federal spending. About two-thirds of the growth in these programs arises from automatic cost of living adjustments (COLAs). Each one percent COLA increase adds $23 billion to the deficit over the next two decades.

It is debated whether COLA restraint should be included in deficit reduction efforts. Advocatesargue that COLAs are a major cause of deficits , tha trestraint is fair after a decade in which benefits grewfaster than in flation and wages, and that restraint improves the solvency of major programs. COLA restraint also reduces the deficit quickly, spread s the burden of deficit reduction over a very large group, and allows nominal benefits to remain at current levels, or even to grow, albeit more slowly. Opponents of restraint argue that COLAs are a fundamental program feature, that COLAs are needed to maintain beneficiaries purchasing power, and that recipients would experience economic hardship if COLAS were reduced.

Common approaches to restrain COLAs emphasize either short-term budget savings or long-term program reform. Past successful efforts to restrain COLAs have been related to ensuring program solvency or ensuring equal treatment of individuals in different programs.Proposals to slow COLA growth to achieve budgetary savings haven ot been successful.

Three types of COLA options seem viable under current economic and political conditions: A one-year COLA freeze, a cap on the COLA at two-thirds the rate of

inflation, and a cap on the COLA at two percentage points less than the rate of inflation. The one-year COLA freeze reduces the deficit most quickly, but produces less savings in the long-run than the other options.

A major attraction of formula reductions in the COLA is that the concept may be extended to other areas of the federal budget and greatly reduce the federal deficit. A plan to limit growth to two percentage points less than in flation on COLAs, other entitlements,national defense, discretionary domestic programs, and income tax indexing would reduce the deficit by one-half by 1990. An overall budget reduction plan based on CCLA restraint may be the only approach left for policy-makers who have exhausted other approaches to reducing the deficit.     

Social Protection Policy or a Political Largesse: Disability Fund Efficacy Assessment and Roadblocks to Sustainable Development Goals

ABSTRACT

Social protection policies have been tools for fighting social exclusion, inequality and reducing poverty incidence among vulnerable populations in developing countries. In this regard, the government of Ghana through the institution of the disability fund has demonstrated a commitment to advancing the cause of people with disabilities. In assessing policy efficacy, the realities on the ground, as well as policy challenges, 130 persons with disability (PWDs) and 10 Key Informants (KIs) were recruited from across five regions. In addition to conducting face-to-face interviews with PWDs, the study conducted a number of interviews with key informants (KIs). The study findings concluded amongst other things that, the policy is plagued with challenges such as limited information about the fund, fund access difficulty and disbursement delays. It was also revealed that; the policy is saddled with opacity and partisan politics. To ensure efficiency and expedite the achievement of Sustainable Development Goal (SDG) 1, the research proposed for policy restructuring. In addition to introducing financial literacy and management training for beneficiaries, the study proffers decoupling the fund management from political structures to help meet the objectives for which it was incepted.     

Housing trends of the elderly: emerging policy and implications

Housing and living environment options are both one of the most pressing problem are as for the elderly and an unavoidable policy subject for public administrators. This article analyzes the topic of housing and the elderly so as to high light selected dimensions that might have implications for decision - makers in resource considerations and allocations. An opening section gives the status of how and where the elderly are now living. Six events, or environmental and policy changes, that affect the housing options of the elderly are analyzed. These events are: high mortgage rates; rent controls; condominium conversions; tax relief measures; weatherization programs; and reverse annuity mortgages. The two dominant trends that appear to shape the future housing options of the elderly are examined. The first trend is the provision of a range of alternatives in living arrangements. The creation of alternatives, also known as a continuum of living environments, includes congregate housing, share - a - home, life care or continuing care, geriatric foster care, and single room occupancy hotels. The second major trend is the increasing provision of services in the home setting. The final portion draws together the evident implications about the housing problems of the elderly for policy makers in the public management field. Implications that have community-wide ramifications are clustered as they relate to: increasing the housing supply; regulatory mechanisms; and budgetary references.     

Social Health Insurance and the Use of Formal and Informal Care in Developing Countries: Evidence from Ghana’s National Health Insurance Scheme

This paper studies the relationship between the use of formal and informal health care in a developing country setting by examining the introduction of a social health insurance scheme in Ghana. We estimate the effects of gaining coverage on changes in care seeking behaviour and show how these effects differ by age and wealth status. District-level differences in the implementation of the insurance scheme provide exogenous variation in access to insurance and allow us to address issues with selection into coverage. Results indicate that insurance access strongly increased use of formal care and reduced out-of-pocket expenditures on health services.     

Health care finance in the US: Past,present, and future

Presently the US is the only major industrialized nation that does not insure universal access to health care for all of its citizens. Although the US spends one out of every eight dollars on health care, over one-eighth of all Americans lack basic health insurance coverage. Another concern is health care cost inflation. The quest for comprehensive health care coverage for all Americans began shortly after the turn of the century and has received varying degrees of support since then. Since the historical course of health policy in the US has followed an evolutionary rather than revolutionary course, unless consistent policies are developed to rationalize the incentives facing consumers, providers, and insurers, alike, the future path of American health policy will continue to be characterized by disjointed incrementalism. National health insurance can provide decision makers with a tool to structure and focus the American health care system. In order for cost control measures to be effective they must be coordinated with measures to promote universal access, and vice versa. NHI can be a catalyst to focus attention on the dual goals of access to care and cost containment.     

The oregon plan: Toward a model for the future of health care financing

The State of Oregon has proposed a new method of financing health care services for its citizens. Oregon proposes to fund only the most cost-effective services. But in addition to narrowing the offering of health services funded by the State, Oregon proposes to fund all of the State's poor for services, no matter the family status. This broadened number of poor (everyone at the federal poverty level and below, single or married, children or not) will provide health care for more than 200,000 additional Oregonians. The supplementary legislation, SB 534 and SB 935, combined with broadened health care coverage for the poor (SB 27) will cover an additional 478,000 Oregonians. Nearly 95 % of its citizens will have some form of health insurance in Oregon.     

Formal and informal disability resources for Afghan reconstruction

After 23 years of turbulence the number of disabled Afghans is unknown and formal services are minimal. The great majority live with whatever resources they find in themselves and their families, the normal pattern throughout history. Informal help and some cultural resources of Afghan history and Muslim teaching are noted in this paper, together with some common negative views. UN agencies and NGOs have made efforts to promote an adapted Community Based Rehabilitation in Afghanistan from the 1980s to the present and to transfer rehabilitation knowledge and skills to families with disabled members. Some local resource centres and community disability organisations have developed and can be a useful basis for disability planning in the anticipated national reconstruction. Emphasis should be given to the participation of disabled people as beneficiaries and employees in all reconstruction programmes, which should proceed in consultation with families and disabled individuals.     

The ‘tenure guidelines’ as a tool for democratising land and resource control in Latin America

Abstract

The current configuration of global land politics – who gets what land, how, how much, why and with what implications in urban and rural spaces in the Global South and North – brings disparate social groups, governments and social movements with different sectoral and class interests into the issue of natural resource politics. Governance instruments must be able to capture the ‘political moment’ marked by the increasing intersection of issues and state and social forces that mobilise around these. This paper looks at whether and how the Voluntary Guidelines on Responsible Governance of Tenure of Land, Fisheries and Forests in the Context of National Food Security (also known as the TGs) passed in 2012 in the United Nations Committee for Food Security (CFS) can contribute to democratising resource politics today. This work puts forward some initial ideas about how systematic research into the TGs can be done more meaningfully.     

Constructing Policy Networks: Social Assistance Reform in the Czech Republic

Abstract

Czech social insurance and family transfers experienced fundamental reform in 1995 but Czech social assistance benefits still lack comprehensive change. This article explains the delay in Czech social assistance reform by appling policy network studies in a postcommunist context. Although few organizations perticipate in the Czech social assistance policy network, they are divided: they lack the common interests and exchangable resources necessary to create dialogue and compromise. The organizations of disabled citizens are the only interest group active in the policy network, with the operators of state social care institutions their primary opponents. In the late 1990s, this already fragmented issue network suffered further division when the EU entered as a powerful network actor with another set of policy goals. Until the policy network structure facilitates more dialogue and consensus‐building, hopes for comprehensive social assistance reform will linger unfulfilled.     

NONPROFIT ORGANIZATIONS AND FOR-PROFIT ORGANIZATIONS PROVIDING HOME CARE SERVICES FOR THE ISRAELI FRAIL ELDERLY: A COMPARATIVE ANALYSIS

The article presents a longitudinal study on the behavior and functioning of voluntary nonprofit organizations (VNPOs) and for-profit organizations (FPOs) providing home care services to frail elderly persons in Israel according to the Long Term Care Insurance Law, which was implemented as of 1988. The study examined differences and similarities in the strategic, structural, administrative, and human behavior of VNPOs and FPOs over a 10-year-period. The main findings point to blurring distinctions between organizations in both sectors, which can be attributed to their high dependence on governmental resources, adoption of similar service technologies, and transmission of professional norms. In light of the above, the article seeks to shift the focus of research from the question who provides to how services are provided and what structural and organizational properties may contribute toward improving service effectiveness.     

Multiple Dimensions of Social Assistance: The Case of Peru's ‘Glass of Milk' Programme

Social assistance has attracted renewed interest in countries where economic growth is doing too little on its own to address high levels of income inequality and poverty. Research into the material effects of such programmes is important but can be misleading if it fails to capture their full meaning to intended beneficiaries and other stakeholders. This is illustrated by a case study of Peru's ‘glass of milk’ programme, drawing on mostly qualitative evidence of its material, social and cultural dimensions. The programme is found to be well adapted to diverse contexts, but in a way that enhances its efficacy as a gendered instrument of mass patronage rather than as a means of addressing Peru's structural inequalities. The paper also suggests that a switch to conditional cash transfers is unlikely, on its own, to change this.