Long-Term Care: Priate Markets Or Public Policies?
Mark Schlesinger1990, Health Affairs
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This review discusses the implications of demographic shifts, particularly the aging baby boomer population, on long-term care policies and practices in the United States. It highlights the limitations of existing public and private mechanisms for long-term care funding, emphasizing the need for a more equitable approach to care for not only the elderly but also younger individuals with chronic conditions and disabilities. The critique of the collection of essays edited by Marion Ein Lewin and Sean Sullivan underscores the failure to adequately address intergenerational equity and the complexities of integrating care funding across different populations.
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BOOK REVIEWS
Theexperienceofthekidneydialysisselectioncommitteesinthelate 1960s,which
Callahandiscusses,isinstructive."Thecommitteesliterallyhadtomake life-and-death
decisions,"hewrites."Theyreportedthemselvesunabletomakemeaningful comparisonsand choices
The sameexperience,
nowwritlarge,islikelyifthepoliticalprocess is left to make the decision [about
health care priorities] but given no moral
standards to help guide it." Callahan's visionofthehealth caresystemsuffers from
thesameproblem:itmaybeamoralvision,
197
but it isjust one of an infinite number of
visions,andonwhatbasisdowechoose?
Yet despite this inherent weakness, of
whichtheauthoriswellaware, What Kind of
Lifeisanimportantcontribution.Itlaysbare
the bankrupt assumptions of the current
healthcaresystem,anditservesasa forceful
reminderofthetrade-offs bothwithin our
healthcaresystemandbetweenhealthand
other societal values.Most importantly, it
requiresustoconfront therolethat health
plays in our lives and in our society. The
choicesareourstomake.
Long-Term Care: Private Markets Or Public Policies?
by Mark Schlesinger
The Care of Tomorrow's Elderly
MarionEinLewinandSeanSullivan,
editors
(Lanham,Md.:AmericanEnterprise
Institute,1989),208pp.,$26.50
sociallyvaluedoutcomes.Becausethecosts
and benefits of each potential change are
inextricablylinkedtotheothers,itisdifficult, and almost certainly unwise, to considertheseinisolationfromeachother.
From this perspective, there ismuch to
Whenthebabyboomistransformed into recommend in The Care of Tomorrow's Eltheelder boom over the nextthirtyyears, derly.Although the book is intended to
American society will confront questions focus primarily on issues related to the
aboutavarietyofpublicpoliciesandprivate "long-termneedsoftheelderly,"itseditors,
practicesthat have become established so- MarionEinLewinandSeanSullivan,have
cialinstitutions.These will include the re- assembledasetofpapersthatarestrikingly
distribution of income from working-age wide-ranginginboth their topicsand their
Americanstotheretiredundertheauspices methodologicalapproaches.(Indeed,unless
of Social Security, employer practices that onereadsthe"overview"bytheeditors,the
encourage early retirement, societal norms reader islikely to puzzle through the first
that motivateelderstoremain inthesame half of the book looking for atheme;itis
homesinwhichtheyhaveraisedtheirfam- not until thesecond half that anyrealdisilies, government policies that encourage cussionoflong-termcareactuallyappears.)
private health insurance to be provided Thechaptersrangeincontentfrom internathrough the workplace, and public pro- tionalcomparisonsofhealthcaresystemsto
grams that pay for the costs of long-term trends in retirement by older (increasingly
careonlyafterthoseinneedhaveexhausted middle-aged) workers to the prospects for
their incomeand financial assets.Whether private insurance for nursing home care.
weshouldorcanchangethesearrangements Theyrangeinstylefromthequantitativeto
isa matter of considerable debate. Butwe the philosophical and in focus from those
will inevitably be forced to consider such thatlookbackinhistorytothosethatlook
changesandtotrytopredicttheireffectson forward tothedemographictransition that
willoccuroverthenexthalf-century.
Mark Schlesinger is assistant director of the This breadth is refreshing. It leads the
Center for Social Policy at Harvard Universit's authorstoconsiderissuesthatarenot norJohnE Kennedy School of Government and mallywithin the purview of policy-related
assistant professor of health policy at Harvarddiscussionsoflong-termcare.Ithighlightsa
number of broad societaltensions, includMedical School.
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198
HEALTHAFFAIRS | Fall1990
ingemergingquestionsof intergenerational
equity,whichuntilrecentlyhavebeengiven
too little attention. Though the chapters
varyinquality,eachraisessomeinteresting
andusefulperspectivesonelders'needsand
rolesinAmericansociety.
But though the book benefits in some
waysfromthissortofbreadth,italsocarries
some liabilities. This is a slim volume, so
thatcoveringawiderangeoftopicsnecessitatesleavingsomethingelseout.Thisleads
to at least three serious limitations. First,
thoughthebookdoeswellbysettinglongterm care issues in a broader context, it
reducestheissuesinvolvedinlong-termcare
to almost exclusively financial terms.Second, ifthe book isbroad in methods,itis
extremely narrow in philosophy—most of
the authors take care to toe the relatively
conservativepartylineoftheAmericanEnterpriseInstitute(AEI).Finally,though the
bookisbroadinscope,theindividualchaptersare often lacking in depth, addressing
issueswithoutadequatereferencetotheexistingliteratureandwithoutadequatelyexploringtheissuesthattheyraise.
FinancialQuestions
The first of theselimitations isreflected
by the book's rather inappropriate title.
There isverylittlehereabout "caring" for
tomorrow's elders, in either the sense of
establishingemotionalbondswitheldersor
thesenseofprovidingservicestomeettheir
long-term care needs.Virtually everything
aboutlong-termcareisreducedtofinancial
questions: Can we afford to pay for the
services? Do elders pay their fair share?
Could they pay more themselves or work
longer so that society could pay more?
These are certainly important questions.
Butviewingthemapartfromadiscussionof
service needs or the relationship between
long-term care and housing leads one to
overlook some important interactions betweenfinancingandserviceprovision.
Forexample,theauthorsofseveralofthe
chapters assert that choice isimportant to
individualsandthatthismeansthatprivate
insurance ispreferable to public programs
topayforlong-termcare.Inarguably,choice
isimportanttomanychronicallyillAmericans. But the choice that matters most to
themislikelytobethatamongserviceproviders and settings for care, not in their
insurance coverage. Indeed, private insuranceplans,whichincreasinglyusemanaged
carearrangementsandselectivecontracting
with a limited number of providers, are
more likely to limit choice when enrollees
actually seek services than would a public
insuranceprogramthatcoveredallprovidersnationwide.
PublicAndPrivateResponsibility
Thephilosophicalnarrownessofthisvolumeisperhapstobeexpectedfrom awork
in which, in the editors' words, "many of
these authors are AEI scholars." Not surprisingly,theauthorsplaceastrongemphasison individual choice and favor private
markets over public policies,cash benefits
overservicebenefits, and government programsthatarenarrowlyfocusedonthepoor
overbroaderentitlement programs.A case
canclearlybemadeforeachofthesepoints.
But the counterarguments are also plausible,anditillservesthereadertohavethese
arguments omitted or cast as weak straw
men,astheyarehere.
Such a one-sided political perspective
alsoleadstoanalysisthat islessthan completelyconvincing.Consider severalexamples.Severaloftheauthors"pointtowarda
redefined role for the federal government
with respect to the needs of older Americans"that would replaceentitlementswith
programstargetedtothe"mostneedy."Yet
this is precisely the role that the federal
government has played in financing longterm care over the past twenty-five years.
Thistrackrecordhasbeensufficiently uninspiringthat itseemscurioustohavepolicy
analysts suggest that it be replicated for
otherhealthandincomesupportprograms.
Universal entitlement programs for longtermcare,suchasitsinclusionunderMedicare, are never even seriously considered.
Thistooseemscurious,sincepublicopinion
pollssuggestthatbetween70and80percent
oftheAmericanpeoplewouldfavorsucha
program,andoneversionwasincorporated
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BOOK REVIEWS
intotherecentreportofthebipartisanPepperCommission.
Thisjaundiced viewofthepublicsector
also leads authors to overlook potentially
effectivesolutionstosomeoftheimportant
problems that they identify. One chapter,
forinstance,considersoptionsto"stem the
rising tideofearlyretirement."Thismayin
fact be a legitimate policy goal. But the
authorsconsideronlychangesinpublicprograms,suchaschangingtheearned benefits
test or age of initial benefits under Social
Security,though they admit that theseare
likelytohavelittleeffectonretirementdecisions.Theyentirelyoverlooktheeconomic
incentives to employers that encourage
early retirement because fringe benefits
(health insurance and pension) are much
morecostlyfor olderworkers.The average
healthcarecostsofasixty-five-year-old are
likelytobetentimesthat ofatwenty-oneyear-old. With health insurance representingonaverageabout9percentofemployee
compensation, employing older workers
couldinvolveanaddedcostofasmuchas25
percent per employee for experience-rated
(orself-insured) employer groups.The obviouswayaroundthisistosocializethecost
(or community-rate premiums) of health
insurance, but since this would expand
rather than contract governments role, it
wasneverevenraisedasanoption.
Other Limitations
Perhapsthemostdistressinglimitationof
this volume, however, is the failure of a
number of itsauthors to fully explore the
issues that they quite legitimately raise.
Someomissionsrun throughout the entire
book.Long-termcareisalmostalwaysportrayed as an issue of the elderly. Private
solutionsareseentodependonelders'abilitytopayforinsuranceandservices;public
costs,onthedemandsthattheywillplaceon
thelong-termcaresystem.Virtuallyignored
istheevidencethatsuggeststhat40percent
of thosewith chronic illnessesand impairments in the United States are less than
sixty-five years old. There is little if any
discussion of how methods of paying for
long-term care for elders should be inte-
199
gratedwith,ormadeequitableinterms of,
thewaywecurrentlypayforservicesforthe
chronically mentally ill, the developmentallydisabled,patientswithprogressedcases
of acquired immunodeficiency syndrome
(AIDS),orthephysicallyhandicapped.
Several authors touch on questions of
intergenerational equity—the appropriate
balance between the needs of dependent
childrenandeldersandthedemandsonthe
resourcesofworking-ageAmericans.Thisis
clearlyacriticalissue.Butitisalsoanissue
with a substantial and growing literature.
Readerswouldnotlearnthisfromthematerialpresentedinthisvolume.Thedepthof
theanalysisisaptlycaptured inthe book's
final sentence:"Itisasifweweretosayto
ourselves:Asknotwhatourchildrencando
forus,butwhatwecandoforourchildren."
Thisisacharmingsentimentforapresidentialaddress,butonethatoffersneithergreat
insightnoranymeansforresolvingtheinevitable tensions that willarisearound these
issuesofintergenerationalrelations.
The Care of Tomorrow's Elderly isthus a
book that sacrifices depth and balance for
breadth.Itstandsasauseful positionstatementfromonesideofthepoliticalspectrum
aboutthefinancialaspectsoflong-termcare
policy.But,ironically,itdoesnotgivereaderstherangeofperspectives,evidence,and
argument that would allow them to make
their ownchoices.A previously published
volumebythesameeditors,The Economics
and Ethics of Long-Term Care and Disability,
struck this balance more successfully. The
twovolumesshouldbereadtogether.Even
better, they should be supplemented by
publishedperspectivesthatdonotbearthe
ratherheavyimprintofanAEIpublication.
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