Providing long-term care through the market—experience in the USA

Abstract

The US health system operates within a free market ideology, constrained in Rochester, New York, through strong local planning and regulation. Long term care follows the same market ideology, with a safety net of publicly funded Medicaid, skewed heavily towards nursing home use. Nursing homes are now very big business. Rochester attempted to redress this balance by restricting the growth of nursing home beds and directing money instead towards rehabilitation and community based services. Quality is regulated through provider agreements, inspection and consumer rights which are much more strongly backed by advocacy and legal recourse than in the UK. However, the market and federal and state funding systems have produced services which are largely unaffordable by most people, do not enhance choice, and fail to meet important social goals. Where costs have been controlled, greater choice achieved and at least some social goals met, it has been through local planning and regulation proceeding from a strong local value base, as in Rochester. Now, however, these mechanisms are being severely weakened and a market-free-for-all is emerging, with big business in the driving seat. The acknowledged successes of local planning in keeping costs down and ensuring greater rationality and equity in the system look set to be undermined.

Key Words:

• long-term care
• social markets
• planning
• older people
• nursing homes
• USA