Historical Events

Social Security Act (1935)

With a dramatic increase in life expectancy and decreases in mortality rates, many old

People live their later lives with chronic illnesses and disabilities. As a result, long-term care is becoming an important part of service to the elderly population. The US General Accounting

Office (1994) reports that more than 12 million Americans need long-term care and 55% of them

are people aged 65 or older (Binstock, Cluff, & Mering, 1996). Accordingly, the government

spends substantial amounts of money to provide care through nursing homes and community/home based services. In 1994, more than $100 billion was spent on long-term care in the US in 1994, 72% of which went to nursing home care (Binstock, Cluff, & Mering, 1996). It was not until recently, however, that long-term care of the elderly received attention from the government and the health care sector. Throughout most of American history, the long term care of the elderly has been considered a responsibility of family households, especially a daughter of the person, rather than the society and its health system (Holstein & Cole, 1996). Now, public attention has increased due to the growing elderly population and their political influence, the economic and psychological burden of the family and caregiver is still substantial. According to 1994 statistics, it is estimated that individuals and their families pay out of pocket costs equaling 44% of the total amount of long-term care expenses. Private insurance pays 1% and federal, state, local government pay the balance (Binstock, Cluff, & Mering, 1996). Consequently, many elderly who cannot afford care and are also not eligible for public assistance are neglected and suffering chronic illnesses. In this paper, I will examine the history of the development of long-term care services, its current status, its strengths and weaknesses, and the emerging issues in the field.

A response by the government to the problems of the elderly came with the rise of organized interest groups in the 1930s during the Great Depression. With the economic crisis, groups of people asked for minimum pensions from the government. Their demand influenced the government to develop an array of programs for the elderly including the Social Security Act of 1935 (Torres-Gil, 1999). The Social Security Act, however, did not contain provisions for health care, let alone long-term care of the elderly. In addition, hospitals were "biased toward acute care (Holstein, Martha & Cole, 1996: p.20)" and didn't welcome chronically ill patients. As a result, almshouse, originally established to accommodate poor people, was also used as a place to house elderly people with chronic illnesses who either became poor because of illnesses or were poor from the start (Holstein, Martha & Cole, 1996). Although the Social Security Act couldn't fully respond to the needs of chronically ill elderly, the Old Age Assistance funds of the Social Security Act (Title I) authorized federal matching grants for needy older people, and extended grants to any person living in the institution. This provision facilitated development of a commercial nursing home industry (Holstein, Martha & Cole, 1996). In 1965, Medicare and Medicaid were passed to provide health care for older persons and the poor. They were enacted as amendments (Titles XVIII and XIX, respectively) to the Social Security Act (1935) and went into effect in 1966 (Encyclopedia Britannica Online, 1999). The Medicare program covers most of those who are aged 65 or older with a hospital insurance plan (called Part A) and a supplementary medical insurance plan (Part B). The hospital plan is financed through Social Security payroll taxes. It helps pay the cost of inpatient hospital care, skilled nursing home care, and certain home health services. Medicaid is a health insurance program established for low-income persons under age 65 and persons over that age that have exhausted their Medicare benefits. The program is jointly funded by the federal government and the states (Encyclopedia Britannica Online, 1999). Although Medicaid was created to cover mainly the medical needs of poor individuals, it largely serves older persons who cannot afford the high cost of nursing home care (Torees-Gil, 1999). The Medicaid program helped many elderly people getting long-term care through placements in nursing home care. But because of this funding stream, many people actually had to choose to go to a nursing home although they wanted to stay at home. Furthermore, government rarely regulated the quality of care at nursing homes, offering reasons such as fear of escalating costs under higher standards and a vague belief that nursing homes would do better with the regulations.