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Health care reform: Implications for seniors introduction
HEALTH CARE REFORM: Implications for Seniors Introduction
NEENA L. CHAPPELL* University of Victoria
The International Sociological Association’s World Congress in Bielefeld, Germany in 1994 included a session on Health Reform in the 90s Implications for Seniors. The articles generated much excitement, partly a result of the striking similarities in the rhetoric of reform and lack of action following from that rhetoric, irrespective of the industrialized country involved. In this special issue of the JournaE ofAging Studies, the same researchers have been asked to provide an analysis of the current situation within their countries. Now, in the second half of the decade, the rhetoric of reform has been translating into action, generating concern that the vision of reform will not become reality. Fundamental criticisms against the state-centred conception of social policy that has been prominent for much of this century were evident by the mid 1970s. With the economic stagflation of the 70s and the economic recession of the 80s and 90s all western industrialized nations were questioning their health care systems. As Hall (1984) notes, the welfare state had been charged as “inefficient and wasteful: a spendthrift state.” Concerns over the escalating costs of health care became central to these critiques. A new paradigm for health care emerged in the 1990s with the central idea that most people, most of the time, will be able to take care of their own needs. In other words, the front line of our social welfare system should be existing informal support, the family, the neighborhood, churches, etc. The new rhetoric of social policy reform is reemphasizing or rediscovering community care and caregiving. The role of government is being reframed from provider to partner, a partner that enables and empowers people to exert greater control over their lives (OECD 1992). In European countries, the term ‘mixed economy of welfare’ aptly describes the new philosophy embracing social policy (Chappell and Prince 1994).
*Direct all correspondence to: Neena L. Chappell, Director of Centre on Aging, Department University of Victoria, Victoria, British Columbia, Canada VSW 2Y2. JOURNAL OF AGING STUDIES, Volume 11, Number 3, pages 171-175 Copyright 0 1997 by JAI Press Inc. All rights of reproduction in any form reserved. ISSN: 0890-4065.
of Sociology,
172
JOURNAL OF AGING STUDIES
Vol. 1 l/No. 311997
In Canada, Mhatre and Deber (1992) examined the various reports, task forces, and commissions on health reform. The themes they identify also apply to the reports that have come out since then in Canada and are generally true for industrialized countries, with the notable exception being the United States. The recurring themes of health reform that characterize the rhetoric virtually around the industrialized world include:
. . . .
broadening the definition of health with the collaboration of multiple sectors; shifting the emphasis from curing illness to promoting health and preventing disease; switching the focus to community-based rather than facility-based care; providing more opportunities for individuals to participate with service providers in making decisions on health choices and policies; decentralization of provincial systems to some form of regional authorities; improved human resources planning, with particular emphasis on alternative methods for remuneration of physicians; enhanced deficiency in the management of services through the establishment of councils, coordinating bodies and secretariats; and increasing funds for health services research, especially in the areas of utilization, technology assessment, program/system evaluation and information systems.
That is, the vision being put forward for health care in the 1990s represents a dramatic change from old health care policies. It offers the promise of a new vision that appeals to governments as less expensive than high tech medical care in hospitals and to the public as more appropriate health care focused on welfare and healthy lifestyles rather than illness. However, the recognition of the importance of a broad definition of health and of the need for an expansion of community care has come at a time of fiscal constraint. The new rhetoric for reform argues that we want our medical and institutional care to be more efficient and to extend our community care to bring this care closer to home. It rests on the assumption that family care, primarily provided by women, is available and that we provide care by professionals when family care is not available. These policies reinforce traditional family value structures and authorities; they do not question why it is women who are primarily the people who provide care and they do not ask whether this is just or equitable (Neysmith 1991; McDaniel and Gee 1993). In addition, policy rhetoric does not make a clear distinction between community care and family care, but this distinction is critical and especially relevant to women. As we reform health care, more of a focus on community care may or may not mean more family care. Even if community care were expanded, this need not necessarily improve the situation for women who currently dominate, both as informal caregivers and as paid health care workers. This special issue contains five articles, one each from the United States, Great Britain, Canada, Australia, and the Netherlands. The first article by Gill and Associates focuses on the United States, the only major industrialized country of the world that does not have universal medicare. It is especially instructive for those of us living in other industrialized countries to be reminded of the arguments for why basic medical services should be granted to all citizens. The ethical principal of distributive justice, in which no one should be barred access to a medical service or procedure that can prevent the onset of a disease or illness, can cure an acute condition, or ameliorate a chronic illness, is the foundation of a universal health care system. Gill and colleagues point out that objective
Introduction
173
criteria (scientific knowledge) can distinguish between effective and ineffective medical intervention, and that an appropriate mechanism for resolving decidedly complex uncertainties would be through a system of public accountability whereby a collectively based panel of judges consisting of some proportion of professional and lay persons sanction or curtail the use of scarce resources for procedures with unpredictable outcomes. However, in the U.S., the domination of the values of a market approach, where competition is assumed to be the most potent force for directing medical care expenditure, will not allow the development of a universal medicare system in the foreseeable future. These authors argue that sufficient grassroots support will, in all likelihood, not be generated from large sections of the American public, and therefore the state will not be forced to act on behalf of the uninsured, under-insured, and tenuously insured. While the U.S. still struggles with the principles of universal access, other industrialized countries, with established universal medicare, are in the process of trying to set limits to the number and type of medical procedures that are covered by their plans. The remainder of the articles analyze the struggle to maintain this system in tough economic times. As Bond notes in his article on the United Kingdom, it is perhaps surprising that it has taken so long for universal medicare programs with unlimited and unrestricted demands from medicine to feel the cash crunch. However, in the 1990s continually escalating costs of these programs has become a major factor driving political forces to reform. In Britain, reform has brought increasing p~vatization, the introduction of business style general management, and the development of a contract culture through the separation of purchasers of health care from providers. Key reforms have included the establishment of the internal market as a mechanism for delivering cost effectiveness. In terms of primary care, the reforms seem to have benefited the position of general practitioners and their professional and political status has increased. There is a greater accountability of their clinical work to their peers and their political masters, but as yet, any accountability to patients or examination of the benefits for patients remains unidentified. Despite the fact that community care is a central plank of government policy for old people, the level of resources provided for community care is so grossly inadequate that only the most disadvantaged can benefit. Bond argues that there is still much middle class support for the national health service in Britain and that, as long as this continues, it is likely a universal, comprehensive, and centrally funded health care system will continue. He forecasts, however, that the broad macro-economic constraints will also continue. A key debate, therefore, around the rationing of scarce health care resources will continue. McDaniel’s paper focuses on Canada, where universal medical insurance has been subject to reform at a variable rate from one province to the next. In the province of Alberta, cost cutting has been p~icuIarly evident. While population aging is seen as driving costs, McDaniel argues that population aging can also be seen as an excuse for cost cutting rather than a cause. Furthermore, while the rhetoric of cost cutting involves a lessening of government involvement, it also reflects a strongly interventionist state policy, taking control over professional and union policies, granting private sector operators untold opportunities, and shrinking the responsibilities of governmental control. In Alberta’s health care res~uctu~ng, there have been massive layoffs of nurses and allied health care personnel, hospital closures, and bed closures, but there has been very little redistribution of funding to home care or community care. While seniors emerge as those most likely to be disadvantaged by health reform, McDaniel argues that, because of this,
174
JOURNAL OF AGING STUDIES
Vol. 1 l/No. 311997
they may also become active participants in a further dismantling of universal medicare, since they may be eager to support private health care in order to avoid the waiting lists and other disadvantages of a cutback universal system. The process of reform has taken place too quickly and without due respect for the values of Canadians. It is seriously dismantling a health care system that the majority of Canadians support. The article by Courtney and associates from Australia describes yet another variation on the universal medicare theme. Australia’s unique funding arrangements demonstrate the many varieties in which universal medicare comes. Nevertheless, the same attempts at cost cutting and the same arguments that the aging of the population will become an increasing and unacceptable burden on the tax base are again evident. Australia has introduced a case mix formula similar to the diagnostic related groups (DRGs) in the United States for hospital care. This article argues for the potential drawbacks of this system for seniors, including less incentive to admit them because they could cost the hospital more, poor discharge planning, and the inadequacy of support services in the community upon discharge, the quicker and sicker discharge phenomenon, and the shift in post-acute care to community health services. The article also discusses the difficulties of ensuring autonomy and dignity within the long-term institutional environment. The article, like others in this special issue, points to the many obstacles encountered in attempting to reform universal medicare. The last article, by van den Heuval, analyzes policy development in the Netherlands. Somewhat unique about this country is the fact that governmental policy explicitly states the importance of societal integration of the elderly and has the opportunity for older people to fully participate and fulfill a worthwhile role in society as an explicit goal. Over the past 25 years, significant and major policy, spanning several government ministries, has been developed for seniors. While the article focuses on policies, it notes that action has resulted in less dramatic change than would be indicated by the policy alone. Nevertheless, over time, a policy focus on only care and containment of costs has shifted to include participation and emancipation of the elderly in society. Like other industrialized countries, the concern with cost cutting is evident and a lessened role for the state is also evident. Notably, the 1990s has seen the formation and election of a new political party for, and consisting of, elderly people. It is expected that the interests of the elderly will increase in the policy process in the Netherlands. In sum, the latter half of the 1990s has been characterized by an overriding concern with health care costs. The rhetoric preaches a broadening of the definition of health; a shift from institutional to community care; efficiency and health outcomes within medical care; an embracing of informal and social care; but also a lack of distinction between formal community care and informal care from family and friends; and a lack of concern over the role of women in health care. However, the action taken around the world demonstrates an overriding concern with cost. Efforts are directed towards changing and decreasing budgets to medical care and institutional care, but without redistribution of those funds to the community and to social care in order to build a broader health care system. Indeed, the transference that is taking place appears to be more a medicalization of community care than an expansion of social care. With earlier hospital discharges, the quicker but sicker discharge from hospitals, home care budgets are being swallowed up by post-acute care, leaving decreased resources and personnel available to fulfill the traditional mandate of long-term chronic care within the community. Health reform, in other words, is leading to change but it is not leading to a more appropriate and accessible health (rather than
175
Introduction
medical) care system. The industrialized world that has universal sliding back towards the non-system evident in the United States.
medicare
seems to be
REFERENCES Chappell, N. L. and M. J. Prince. 1994. Social Support among Today’s Seniors, Centre on Aging, University of Victoria. Hall, S. 1984. “The state in question.” Pp. l-28 in The Idea of the Modem State, edited by G. McLennan, D. Held, and S. Hall. Milton Keynes: Open University Press. McDaniel, S. A. and E. M. Gee. 1993. “Social Policies Regarding Caregiving to Elders: Canadian Contradictions.” Journal of Aging and Social Policy 5(s): 57-72. Mhatre, S. L. and R. B. Deber. 1992. “From Equal Access to Health Care to Equitable Access to Health: A Review of Canadian Provincial Health Commissions and Reports.” International Journal of Health Services 22(4): 64.5-668. Neysmith, S. M. 1991. ‘Closing the Gap between Health Policy and the Home Care Need of Tomorrow’s Elderly.” Canadian Journal of Community Mental Health 8(2): 141-150. Organization for Economic Cooperation and Development (OECD). 1992. Meeting of the Employment, Labour and Social Affairs Committee at Ministerial Level: New Orientations for Social Policy. Paris, France, SC/Press.
NEENA L. CHAPPELL* University of Victoria
The International Sociological Association’s World Congress in Bielefeld, Germany in 1994 included a session on Health Reform in the 90s Implications for Seniors. The articles generated much excitement, partly a result of the striking similarities in the rhetoric of reform and lack of action following from that rhetoric, irrespective of the industrialized country involved. In this special issue of the JournaE ofAging Studies, the same researchers have been asked to provide an analysis of the current situation within their countries. Now, in the second half of the decade, the rhetoric of reform has been translating into action, generating concern that the vision of reform will not become reality. Fundamental criticisms against the state-centred conception of social policy that has been prominent for much of this century were evident by the mid 1970s. With the economic stagflation of the 70s and the economic recession of the 80s and 90s all western industrialized nations were questioning their health care systems. As Hall (1984) notes, the welfare state had been charged as “inefficient and wasteful: a spendthrift state.” Concerns over the escalating costs of health care became central to these critiques. A new paradigm for health care emerged in the 1990s with the central idea that most people, most of the time, will be able to take care of their own needs. In other words, the front line of our social welfare system should be existing informal support, the family, the neighborhood, churches, etc. The new rhetoric of social policy reform is reemphasizing or rediscovering community care and caregiving. The role of government is being reframed from provider to partner, a partner that enables and empowers people to exert greater control over their lives (OECD 1992). In European countries, the term ‘mixed economy of welfare’ aptly describes the new philosophy embracing social policy (Chappell and Prince 1994).
*Direct all correspondence to: Neena L. Chappell, Director of Centre on Aging, Department University of Victoria, Victoria, British Columbia, Canada VSW 2Y2. JOURNAL OF AGING STUDIES, Volume 11, Number 3, pages 171-175 Copyright 0 1997 by JAI Press Inc. All rights of reproduction in any form reserved. ISSN: 0890-4065.
of Sociology,
172
JOURNAL OF AGING STUDIES
Vol. 1 l/No. 311997
In Canada, Mhatre and Deber (1992) examined the various reports, task forces, and commissions on health reform. The themes they identify also apply to the reports that have come out since then in Canada and are generally true for industrialized countries, with the notable exception being the United States. The recurring themes of health reform that characterize the rhetoric virtually around the industrialized world include:
. . . .
broadening the definition of health with the collaboration of multiple sectors; shifting the emphasis from curing illness to promoting health and preventing disease; switching the focus to community-based rather than facility-based care; providing more opportunities for individuals to participate with service providers in making decisions on health choices and policies; decentralization of provincial systems to some form of regional authorities; improved human resources planning, with particular emphasis on alternative methods for remuneration of physicians; enhanced deficiency in the management of services through the establishment of councils, coordinating bodies and secretariats; and increasing funds for health services research, especially in the areas of utilization, technology assessment, program/system evaluation and information systems.
That is, the vision being put forward for health care in the 1990s represents a dramatic change from old health care policies. It offers the promise of a new vision that appeals to governments as less expensive than high tech medical care in hospitals and to the public as more appropriate health care focused on welfare and healthy lifestyles rather than illness. However, the recognition of the importance of a broad definition of health and of the need for an expansion of community care has come at a time of fiscal constraint. The new rhetoric for reform argues that we want our medical and institutional care to be more efficient and to extend our community care to bring this care closer to home. It rests on the assumption that family care, primarily provided by women, is available and that we provide care by professionals when family care is not available. These policies reinforce traditional family value structures and authorities; they do not question why it is women who are primarily the people who provide care and they do not ask whether this is just or equitable (Neysmith 1991; McDaniel and Gee 1993). In addition, policy rhetoric does not make a clear distinction between community care and family care, but this distinction is critical and especially relevant to women. As we reform health care, more of a focus on community care may or may not mean more family care. Even if community care were expanded, this need not necessarily improve the situation for women who currently dominate, both as informal caregivers and as paid health care workers. This special issue contains five articles, one each from the United States, Great Britain, Canada, Australia, and the Netherlands. The first article by Gill and Associates focuses on the United States, the only major industrialized country of the world that does not have universal medicare. It is especially instructive for those of us living in other industrialized countries to be reminded of the arguments for why basic medical services should be granted to all citizens. The ethical principal of distributive justice, in which no one should be barred access to a medical service or procedure that can prevent the onset of a disease or illness, can cure an acute condition, or ameliorate a chronic illness, is the foundation of a universal health care system. Gill and colleagues point out that objective
Introduction
173
criteria (scientific knowledge) can distinguish between effective and ineffective medical intervention, and that an appropriate mechanism for resolving decidedly complex uncertainties would be through a system of public accountability whereby a collectively based panel of judges consisting of some proportion of professional and lay persons sanction or curtail the use of scarce resources for procedures with unpredictable outcomes. However, in the U.S., the domination of the values of a market approach, where competition is assumed to be the most potent force for directing medical care expenditure, will not allow the development of a universal medicare system in the foreseeable future. These authors argue that sufficient grassroots support will, in all likelihood, not be generated from large sections of the American public, and therefore the state will not be forced to act on behalf of the uninsured, under-insured, and tenuously insured. While the U.S. still struggles with the principles of universal access, other industrialized countries, with established universal medicare, are in the process of trying to set limits to the number and type of medical procedures that are covered by their plans. The remainder of the articles analyze the struggle to maintain this system in tough economic times. As Bond notes in his article on the United Kingdom, it is perhaps surprising that it has taken so long for universal medicare programs with unlimited and unrestricted demands from medicine to feel the cash crunch. However, in the 1990s continually escalating costs of these programs has become a major factor driving political forces to reform. In Britain, reform has brought increasing p~vatization, the introduction of business style general management, and the development of a contract culture through the separation of purchasers of health care from providers. Key reforms have included the establishment of the internal market as a mechanism for delivering cost effectiveness. In terms of primary care, the reforms seem to have benefited the position of general practitioners and their professional and political status has increased. There is a greater accountability of their clinical work to their peers and their political masters, but as yet, any accountability to patients or examination of the benefits for patients remains unidentified. Despite the fact that community care is a central plank of government policy for old people, the level of resources provided for community care is so grossly inadequate that only the most disadvantaged can benefit. Bond argues that there is still much middle class support for the national health service in Britain and that, as long as this continues, it is likely a universal, comprehensive, and centrally funded health care system will continue. He forecasts, however, that the broad macro-economic constraints will also continue. A key debate, therefore, around the rationing of scarce health care resources will continue. McDaniel’s paper focuses on Canada, where universal medical insurance has been subject to reform at a variable rate from one province to the next. In the province of Alberta, cost cutting has been p~icuIarly evident. While population aging is seen as driving costs, McDaniel argues that population aging can also be seen as an excuse for cost cutting rather than a cause. Furthermore, while the rhetoric of cost cutting involves a lessening of government involvement, it also reflects a strongly interventionist state policy, taking control over professional and union policies, granting private sector operators untold opportunities, and shrinking the responsibilities of governmental control. In Alberta’s health care res~uctu~ng, there have been massive layoffs of nurses and allied health care personnel, hospital closures, and bed closures, but there has been very little redistribution of funding to home care or community care. While seniors emerge as those most likely to be disadvantaged by health reform, McDaniel argues that, because of this,
174
JOURNAL OF AGING STUDIES
Vol. 1 l/No. 311997
they may also become active participants in a further dismantling of universal medicare, since they may be eager to support private health care in order to avoid the waiting lists and other disadvantages of a cutback universal system. The process of reform has taken place too quickly and without due respect for the values of Canadians. It is seriously dismantling a health care system that the majority of Canadians support. The article by Courtney and associates from Australia describes yet another variation on the universal medicare theme. Australia’s unique funding arrangements demonstrate the many varieties in which universal medicare comes. Nevertheless, the same attempts at cost cutting and the same arguments that the aging of the population will become an increasing and unacceptable burden on the tax base are again evident. Australia has introduced a case mix formula similar to the diagnostic related groups (DRGs) in the United States for hospital care. This article argues for the potential drawbacks of this system for seniors, including less incentive to admit them because they could cost the hospital more, poor discharge planning, and the inadequacy of support services in the community upon discharge, the quicker and sicker discharge phenomenon, and the shift in post-acute care to community health services. The article also discusses the difficulties of ensuring autonomy and dignity within the long-term institutional environment. The article, like others in this special issue, points to the many obstacles encountered in attempting to reform universal medicare. The last article, by van den Heuval, analyzes policy development in the Netherlands. Somewhat unique about this country is the fact that governmental policy explicitly states the importance of societal integration of the elderly and has the opportunity for older people to fully participate and fulfill a worthwhile role in society as an explicit goal. Over the past 25 years, significant and major policy, spanning several government ministries, has been developed for seniors. While the article focuses on policies, it notes that action has resulted in less dramatic change than would be indicated by the policy alone. Nevertheless, over time, a policy focus on only care and containment of costs has shifted to include participation and emancipation of the elderly in society. Like other industrialized countries, the concern with cost cutting is evident and a lessened role for the state is also evident. Notably, the 1990s has seen the formation and election of a new political party for, and consisting of, elderly people. It is expected that the interests of the elderly will increase in the policy process in the Netherlands. In sum, the latter half of the 1990s has been characterized by an overriding concern with health care costs. The rhetoric preaches a broadening of the definition of health; a shift from institutional to community care; efficiency and health outcomes within medical care; an embracing of informal and social care; but also a lack of distinction between formal community care and informal care from family and friends; and a lack of concern over the role of women in health care. However, the action taken around the world demonstrates an overriding concern with cost. Efforts are directed towards changing and decreasing budgets to medical care and institutional care, but without redistribution of those funds to the community and to social care in order to build a broader health care system. Indeed, the transference that is taking place appears to be more a medicalization of community care than an expansion of social care. With earlier hospital discharges, the quicker but sicker discharge from hospitals, home care budgets are being swallowed up by post-acute care, leaving decreased resources and personnel available to fulfill the traditional mandate of long-term chronic care within the community. Health reform, in other words, is leading to change but it is not leading to a more appropriate and accessible health (rather than
175
Introduction
medical) care system. The industrialized world that has universal sliding back towards the non-system evident in the United States.
medicare
seems to be
REFERENCES Chappell, N. L. and M. J. Prince. 1994. Social Support among Today’s Seniors, Centre on Aging, University of Victoria. Hall, S. 1984. “The state in question.” Pp. l-28 in The Idea of the Modem State, edited by G. McLennan, D. Held, and S. Hall. Milton Keynes: Open University Press. McDaniel, S. A. and E. M. Gee. 1993. “Social Policies Regarding Caregiving to Elders: Canadian Contradictions.” Journal of Aging and Social Policy 5(s): 57-72. Mhatre, S. L. and R. B. Deber. 1992. “From Equal Access to Health Care to Equitable Access to Health: A Review of Canadian Provincial Health Commissions and Reports.” International Journal of Health Services 22(4): 64.5-668. Neysmith, S. M. 1991. ‘Closing the Gap between Health Policy and the Home Care Need of Tomorrow’s Elderly.” Canadian Journal of Community Mental Health 8(2): 141-150. Organization for Economic Cooperation and Development (OECD). 1992. Meeting of the Employment, Labour and Social Affairs Committee at Ministerial Level: New Orientations for Social Policy. Paris, France, SC/Press.