Restructuring long term care: Past lessons and current opportunities

The current long term care system in the United States, similar to an archeological site, is composed of past layers now jerry-rigged together and on the verge of collapse. The bulk of the nation's nursing home bed stock is reaching the end of its useful life and the boom in private assisted living that began in the last decade now face a wave of bankruptcies in the current financial crisis. This paper explores the lessons from the history of past efforts to design a long term care system and the opportunities they provide for restructuring. The U.S. long term care system was constructed in five phases, in roughly twenty year intervals. Efforts in each of these phases focused on often contradictory organizing principles: (1) indoor welfare relief (1910-1930), (2) outdoor income security (1930-1950), (3) indoor health care support (1950-1970), (4) regulatory control (1970-1990) and (5) market control (1990-2010). The resulting long term care system combines many of the contradictory organizing principles and structures of all five phases, frustrating families, the frail elderly and their providers. The past lessons suggest a restructuring that would synthesize the best of each of these previous periods: (1) support for the family informal care system, (2) an emphasis on outdoor relief through income supports, (3) financing that supports a one class system of care within a fully integrated health system, (4) adequate regulatory oversight and (5) responsiveness to the consumers permitting them, as much as possible, to age in place in their own homes.