Health Care and The Elderly

American Academy of Political and Social Science
Health Care and the Elderly

Author(s): David Mechanic
Source: The Annals of the American Academy of Political and Social Science, Vol. 503, The
Quality of Aging: Strategies for Interventions (May, 1989), pp. 89-98
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ANNALS, AAPSS, 503, May 1989
Health Care and the Elderly
By DAVID MECHANIC
ABSTRACT: Western values have long emphasized an interventionist

approach to problems of health and health care. Yet, as medical technology
becomes increasingly expensive and as the number of older people grows,
proposed changes often are now governed more by considerations of cost
than by quality of services. This tension between cost and quality also affects
public willingness to invest in social components of health care despite their
importance in enhancing quality of life. The tension emerges in sharpest
contrast as scarce resources are allocated by gatekeepers in health main-
tenance organizations and in the arrangements for long-term care. With
respect to financing, what seems to be needed is a creative mix of voluntary
inputs from the community, private initiatives, and new programs of public
entitlements. With respect to quality of care, what has often been overlooked
is the recognition that gains in the quality of life require programs that
encourage older people's continued involvement and participation in social
life and in active and healthy life-styles. This article discusses the evolving
balance between these two types of interventions: the medical and the social.
David Mechanic is director of the Institute for Health, Health Care Policy, and Aging
Research at Rutgers University. He is also University Professor and the Rene Dubos Professor
of Behavioral Sciences. He received his Ph.D. from Stanford in 1959. Among his books are
From Advocacy to Allocation: The Evolving American Health Care System (1986); Mental
Health and Social Policy (third edition, 1989); Medical Sociology (second edition, 1978); and
Future Issues in Health Care: Social Policy and the Rationing of Medical Services (1979).
89
90 THE ANNALS OF THE AMERICAN ACADEMY
HE growing numbers of elderly per- shows little sign of diminishing, has facil-
sons in our population are both itated
a the rapid diffusion of intensive care
challenge and an opportunity for health and new diagnostic and treatment modal-
care institutions. The challenge is to ities. Such technologies as computerized
respond appropriately to the burden of tomography and nuclear magnetic imag-
chronic disorders that occur with increas-ing devices, organ transplantation, coro-
ing prevalence at older ages, causingnary angioplasty and open-heart surgery,
physical and social disability and erodingextracorporeal shock-wave lithotripsy,
the quality of life. The opportunity is tototal hip replacement, and implantation
reshape more completely the pattern of of intraocular lenses are all of recent
medical care services, initially mobilizedvintage but make up a sizable component
largely for the care of short-term acute of biomedical effort. These new tech-
nologies have special relevance to the
illness, to one more closely fitted to the
burdens of illness as experienced at theelderly population, who are more likely
threshold of the twenty-first century.than younger people to have the problems
Planning of care on a longitudinal basisto which these technologies are directed,
and thus the elderly account for an
with attention to quality-of-life issues
represents a need not only of the frail
increasing component of expenditures.
elderly but also of the chronically ill The elderly are, of course, a large and
throughout the life course. heterogeneous population with varying
Patterns of health care organization
types of needs ranging from health pro-
motion and maintenance to long-term
are shaped by history and sociocultural
factors as well as by the imperatives ofcare for irreversible dementias and other
incapacities. Apart from those limited
demography, patterns of disease distribu-
instances where science and technology
tion, and medical science and technology.
have made possible extraordinary ad-
The health care system is, in its most basic
vances extending not only life but also
sense, a cultural institution that implicitly
incorporates the values, aspirations, andeffective function, there are many cir-
goals of those who organize and providecumstances where the challenge for med-
services as well as those they serve. Theicine is to facilitate people's abilities to
development of hospitals in America is cope
a with inevitable and often irreversible
reflection of American society and West- illness and disability in a fashion that
ern values,' and the extent to which protects the quality of life, and in some
hospitals share so many attributes world-instances it does no more than control
wide reflects in part the diffusion of thesepain and provide support. The latter
values. challenge may require different treatment
Western values put great emphasis on contexts, a different mix of personnel,
the ability to shape the environment, and a different philosophy of care. It
promoting an active, interventionist ap- clearly requires a longitudinal point of
proach to disease and, increasingly, to view, attention to the patient's social
ideas of prevention and health promotion. context, and a broad view of sociomedical
The public's faith in technology, which needs. While excellent technical care in a
narrow medical sense must underlie these
efforts, it must be allied with a range of
1. Charles E. Rosenberg, The Care of Strang-
ers: The Rise of America's Hospital System (New social supports and other services facilita-
York: Basic Books, 1987). tive of coping effectiveness.
HEALTH CARE AND THE ELDERLY 91
This article is concerned with both ing home residents have spent down th
assets, stripping many of the disab
types of interventions: medical and social.
It explores the current system of health elderly of their dignity and commonl
services, including such developments as leaving their spouses impoverished
health maintenance organizations (HMOs);well.
it confronts the dilemmas created by the The nation spends enormous sums on
twin requirements of cost effectiveness the medical care of the elderly, but the
and quality of care, as illustrated in the
system of care is highly complex, substan-
case of gatekeepers versus case managers;tially fragmented, and poorly coor-
it faces the challenges of long-term care
dinated. Many elderly undoubtedly benefit
and how yet-to-be-developed programs from the sophisticated technologies avail-
might be financed. Throughout, I take able
an to them for diagnosis and treatment,
but the system of care is excessively
interventionist approach. While recogniz-
ing the medical contributions of such
focused on procedures, with too little
innovations as HMOs or plans forattention to the range of sociomedical
financing long-term care, my approach
issues pertinent to maintaining people in
assigns at least equal emphasis to social
settings they themselves prefer and assist-
ing their coping capacities. Too often,
interventions that, even when they involve
technical medical procedures substitute
only small changes in everyday life, can
encourage continued activity, indepen-for carefully listening to patients, assist-
dence, a sense of personal control, and
ing them to overcome loneliness, isola-
improved health among older people. tion, and depression, and helping to
These two types of intervention combined
strengthen the social supports they require
cannot but enhance the quality of aging.
in the community.
Many of the new initiatives in the
THE EXISTING health care system are motivated more by
HEALTH SERVICES SYSTEM the intent to reduce cost than improve the
quality of service. Efforts for case-man-
That the elderly depend on andaged usehome
farcare were initially organized
more medical and hospital services than
because of the assumption that avoiding
other age groups is inevitable with thecare could more than pay for
institutional
accumulation of chronic problems and
the additional community services. Most
disabilities in older age. The availability
of the demonstrations and evaluations
of Medicare, which cost $76 billionfound,as of
however, that it was extraordi-
1986, has substantially increased access
narily difficult to target specifically those
to necessary services, but, despite the at risk of entering nursing
who were
massiveness of the program, it accounts
homes and that good community pro-
for less than half of the elderly's health
grams attracted new clients with signi-
care expenditures. The largest gap
ficantis in but not those at greatest risk.2
need
the area of long-term care, where Med-
Community care programs were not found
icaid, the $44 billion federal-state program
to be effective in reducing morbidity and
for the poorest poor, has become the or in cost containment, but
mortality
major funding source, accounting for
2. William Weissert, "Some Reasons Why It
approximately half of national nursing-
Is So Difficult to Make Community Based Long-
home-care expenditures. Medicaid cover-
Term Care Cost-Effective," Health Services Re-
age, however, is only available once nurs-
search, 20:423-33 (1985).
services in order to generate income as

they significantly contributed to patient
satisfaction and the perceived quality
oftenof
happens in private fee-for-service
life among patients and their families.3
medicine. Moreover, the elderly are pro-
But is this not, in itself, a meaningful
tected against out-of-pocket payments,
which can constitute a significant cost
outcome, worthy of public commitment?
burden for some of them. For theory to
HEALTH MAINTENANCE work in actuality, however, the HMO
ORGANIZATIONS must be reasonably imaginative in de-
veloping
Cost constraints also motivated efforts appropriate services pertinent
to the needs of older persons and must
under the Tax Equity and Federal Re-
invest cost savings from other areas in
sponsibility Act to enroll more Medicare
these services. Without such investments,
recipients in HMOs, although there was
and a strong primary-care management
considerable skepticism about cost sav-
structure, HMOs may have little to offer
ings if significant social selection could
those elderly who already have excellent
not be prevented. A variety of studies had
accessibility to mainstream care. There is
suggested that HMOs were likely to
also, of course, the risk of underservice in
attract more healthy elderly who utilized
plans that are strongly motivated to
less care than others.4 It seems plausible
reduce cost and be profitable, particularly
that elders who have profound needs for
when physicians' incomes are reduced
care are more likely to have established
when expenditures are high.
regular and trusting relationships with
HMOs, of course, as an alternative to
doctors that they feel dependent on and
the existing care system, fail to address
that they are resistant to leaving. Experi-
the long-term-care issues that concern
ence in this area is very new, however,
many of the elderly and their advocates.
and marketing efforts among the elderly
The demonstrations of the social health
are selective and underdeveloped. The
maintenance organization (SHMO) begin
next several years should give us a better
to address these issues in a modest way
picture of how well the needs and wants
and define a potential strategy that can be
of the elderly could fit the expanding
implemented more broadly as enhanced
HMO sector and how well HMO manage-
financing becomes available.5 Like the
ment can accommodate to the special
HMO, the SHMO offers a wide array of
needs and demands of the elderly.
services within a managed care system,
In theory, HMOs have much to offer
but it expands the range to include
elderly patients by managing care so as to
homemaker, home health, and chore
provide a good mix of medical and
related sociomedical services. Because services. Other services might include
meals, counseling, transportation, and
such practice is prepaid, there is no
home monitoring, among others. The
incentive to provide marginal technical
range of services may be extraordinarily
3. Peter Kemper, Robert Applebaum, and
Margaret Harrigan, "Community Care Demon- 5. Linda Hamm, Thomas Kickman, and
strations: What Have We Learned?" Health Care Dolores Cutter, "Research Demonstrations and
Financing Review, 8:87-100 (1987). Evaluations," in Longterm Care: Perspectivesfrom
4. Paul Eggers and R. Prihoda, "Pre-Enroll- Research and Demonstrations, ed. R. Vogel and H.
ment Reimbursement Patterns of Medicare Bene- Palmer (Washington, DC: Department of Health
ficiaries Enrolled in 'At Risk' HMOs," Health Careand Human Services, Health Care Financing Ad-
Financing Review, 4:55-73 (1982). ministration, 1982), pp. 167-253.
to limits
broad, restricted only by financing more of the population and thei
and organizational capacity to manage
families, government must be prepared
and coordinate services across a range
respondof in a framework that offers mo
service sectors. A SHMO may offer control
thesethan has typically been availab
services directly or may contract with
In the eyes of policymakers, the case m
other service organizations forager
certain
is more gatekeeper than advocate
service components, and the models Asnow
of this point in time, the rush t
take advantage of the opportunities und
being tested have varying organizational
structures. the Tax Equity and Federal Responsibili
Act for the elderly to enroll in HMOs
been less than overwhelming. This refle
CASE MANAGER
OR GATEKEEPER
in part the unwillingness of many elder
to end long-established relationships w
Apart from HMOs, some formphysicians,
of case and the lack of sophisticat
knowledge
management is often needed. It is widely about HMOs and their a
vantages.
recognized that the elderly, given their Indeed, the evidence show
substantial
expected range of chronic illnesses and shifting among elderly joini
such plans,
complaints, could be and often are sub- suggesting the initial choic
made were not adequately informed
jected to very extensive and expensive
medical investigations that havePatients
limited with strong preestablished ph
utility. Moreover, those who aresician
frail butrelationships are more likely
have complex
relate to systems of care in an episodic medical histories, and th
may help
and fragmented way often could benefit explain the evidence suggesti
that HMOs
substantially from social services, al- enroll elders who are youn
though these are not likely to beer, healthier, and who have used few
mobil-
ized. Thus the importance of the role of a previously. Nor should we d
services
count of
primary physician, the desirability the ingenuity of marketing effo
that target populations who are lea
which is recognized in general, is especially
likely
essential for those in later decades of life. to be a financial burden to t
HMO.
Concerns about both the quality ofWhile the point is not well docu
care and the costs of care encourage it appears that those who cou
mented,
benefit most from the economic ad-
developing medical case management as
vantages
a major focus, but, depending upon the of HMO enrollment-the eco-
emphasis, the manager may be nomically
either a vulnerable and disadvantaged
sophisticated broker of care orelderly-are
a gate- precisely those who are least
vigorously
keeper with incentives to protect the recruited.
The notion of gatekeeper, one of grow-
public coffers. Concerns about budgets,
ing gen-
deficits, changing demography, and importance to the health care system
erational equity have encouraged overall,
govern- has special relevance to the el-
derly,
ment to seek ways of capitating thewho might be especially disad-
Medicare population as efforts tovantaged
expand in a system that confuses age
6. David Mechanic, From Advocacy to Alloca-
cost sharing among the elderly increas-
ingly confront strong resistance.tion: The Evolving American Health Care System
More-
(New York: Free Press, 1986).
over, as pressures grow to extend7. the
John K. Iglehart, "Second Thoughts about
range of services in Medicare and HMOs
as long-
for Medicare Patients," New England Jour-
term-care needs become of greater nal
concern
of Medicine, 316:1487-92 (1987).
with morbidity. Very few in theing this need, Callahan defines thre
United
States would tolerate the degree ofaspirations:
ration- first, that we desist fro
ing based on age that characterizesgoalsthe
in which the elderly are primaril
allocation of renal dialysis services in
the beneficiaries, the costs are high, an
gains
England;8 but, as pressures on costs for the entire population are margin
grow,
ally slight;
reputable spokespersons from public of- second, that the old shift the
priorities
ficials to some policy analysts seem to from their own concerns
stress the duty of the elderly tothose
forgoof the young and future generation
and, finally, that we view death as
available and efficacious technologies.
Such technologies are sometimes used of life to be accepted, "if not f
condition
our pru-
with poor judgment and with little own sake, than at least for the sake
others."10
dence, but the jump in logic required to
Callahan's
ask the elderly to forgo opportunities for argument is more subtl
than
benefit simply because they are old is is
a apparent from this quick sum
significant shift in discourse. mary, and he appreciates that, had h
Here it is essential to differentiate aspirations been applied two or thr
potential gain from a crude categorization decades ago, advances now taken for
based on age. It is one thing to argue thatgranted would have never been impl
an individual in a particular state of mented. At the core of his argument is th
assumption of profound scarcity an
health and debility has too little to gain to
justify a heroic intervention. It is quitegrowing acrimony between the genera
another to argue that persons of a par-tions, both highly exaggerated. But th
ticular age, whatever that age may be, by basic flaw in his argument is neither th
definition meet this criterion. While stateassumption of scarcity nor the presume
need to make choices but rather the focus
of health and debility may be correlated
with age, and thus old people may be on age as the criterion. The contenti
that the elderly should die gracefully f
less likely to be appropriate candidates
the sake of others confuses both moral
for specific interventions, the judgment
should be made on the basis of health questions and issues of reasonable public
criteria and not on the basis of age. choice. While appropriate standards
might tend to result in favoring the young
LIMITS ON HEALTH CARE over the elderly, the criteria themselves
FOR THE ELDERLY? should not be discriminatory on the
absolute basis of age or any other ascrip-
Daniel Callahan has argued the need
tive criterion.
to place limits "on the length of individual
lives that a society can sensibly be expected
THE CHALLENGES OF
to maintain at public cost, and invest- LONG-TERM CARE
ments in the kind of research and health-
care delivery that will constantlyThe raise
issue of long-term care exemplifie
the intimate relationships between med
expectations about such a life."9 Underly-
ical care and patterns of culture and
8. Henry J. Aaron and William B. Schwartz,
social relationships. The demand for suc
The Painful Prescription: Rationing Hospital Care
(Washington, DC: Brookings Institution,care
1984).depends not only on levels of mor
bidity
9. Daniel Callahan, "Adequate Health Careand debility but also on househo
and an Aging Society: Are They Morally Com-
patible?" Daedalus, 115:266 (1986). 10. Ibid., p. 262.
structure, norms about family and com-

munity services attract additional clients
munity responsibility, and networks of
who are not of highest risk for institu-
reciprocal obligation." The number of but the evidence also suggests
tional care,
that such services are mostly supple-
nursing home beds needed and the require-
ments for formal services of manymental
kindsto informal care and not replace-
ments.14 There is a high level of need
are related to expectations about housing
arrangements, informal care, and among
com-the frail elderly, who are capable
of avoiding institutional care but still
munity supports. The elderly in Western
nations increasingly seek to maintain
require much assistance in the com-
independent households and avoid de-Public policy that views home-
munity.
pendency on children and other rela-
based care as only an alternative to
nursing home care is unlikely to be
tives.12 Doing so, unfortunately, exacer-
bates the risk of dependency on formal
responsive to important medical and psy-
chosocial
care and contributes to the complexity of needs among sick elders. The
planning for long-term care. nursing home is a source of fear and
The issue of formal versus informal revulsion among many elderly, and most
care is not a simple one. Although patternswill use all their ingenuity and resources
of household structure have substantially to avoid institutionalization. But because
changed over several decades, with the
the idea of nursing homes is a barrier to
elderly commonly maintaining single- long-term care and serves to ration admis-
sion, it is a particularly poor basis for
person households, family members feel
a strong sense of obligation and are defining the threshold for public respon-
willing to assume considerable burden.13 sibility. Available resources set pragmatic
In a society where three or even four limits on how deeply we can respond to
generations may still be alive, where there
need, but the current implication that our
is extensive female participation in the responsibility stops beyond those eligible
work force, where extended periods of for nursing home admission is arbitrary
socialization and education are the norm, and difficult to justify in a society as
affluent as ours.
and where many households are disrupted
by divorce, assumption of daily responsi-
bility for the elderly may pose major THE FINANCING OF
burdens for individuals facing other stress- LONG-TERM CARE
ful life conditions and transitions.
Ultimately, the issue always comes
Policymakers have been extremely
down to money and who pays. In th
wary of extending long-term-care bene-
period 1983-90, the population of those
fits, in fear of replacing informal services
over age 75 is expected to have increased
with costly formal ones. It is well known
per annum at an average rate four time
that programs that extend new com-
higher than that of the population of
11. David Mechanic, "Challenges in Long- those under 65 years.15 This population
Term Care Policy," Health Affairs, 6:22-34 (Sum-
mer 1987). 14. Kemper, Applebaum, and Harrigan, "Com-
12. Stephen Crystal, America's Old Age Crisis: munity Care Demonstrations."
Public Policy and the Two Worlds of Aging (New 15. U.S. Department of Health and Human
York: Basic Books, 1982). Services, Health Care Financing Administration
13. Pamela Doty, "Family Care of the Elderly: Division of National Cost Estimates, "National
The Role of Public Policy," Milbank Quarterly, Health Expenditures, 1986-2000," Health Care Fi
64:34-75 (1986). nancing Review, 8:1-36 (1987).
This is not the context in which to

of 75 or older, which now constitutes
two-fifths of those over 65, will increase
examine the complex benefit structures
to almost half in the next two decades. of Medicare and Medicaid or the gaps
Similarly, the proportion of elders who that currently exist. While Medicaid is
attain age 85 has been increasing especiallycurrently the nation's long-term-care pro-
rapidly, and the composition of ourgram by default, it is unlikely that the
elderly population now includes manystructures of these programs, by them-
more persons who have serious problemsselves, will provide the resources for an
of illness and disability. All of this, ofappropriate response. But expansion of
course, puts increasing pressures on med-federal programs tied to new initiatives in
ical care expenditures independent ofthe private sector and a clearer division of
serious efforts to address needs for long-responsibilities between the elderly and
term care. their families, government, and private
insurance
There is no clear long-term strategy in can provide a framework for
an appropriate
sight, although a growing consensus is long-term program in
emerging on the need to share responsi-
future years.
Because long-term care typically in-
bility. The elderly as a population are no
longer in the disadvantaged position cludes
they skills and services that are inter-
changeable with informal care-such as
were in during the 1950s and early 1960s,
when Medicare was being shaped,meal andpreparation, assistance with chores,
they constitute a heterogeneous popula-
transportation, and so forth-the poten-
tion economically as well as in other tials for shifting responsibility are large.
ways. Our first responsibility must beThisto results in actuarial problems and
care for those who are poor, but we encourages
must cautiousness among insurers.
also do so within a framework meaningful
There is now increased experimentation
to our entire population. Without suchwitha long-term-care insurance policies,'6
framework, it is unlikely that webut
will
the costs are high and benefits restric-
significantly respond to the needs oftive.'7
the It seems reasonable that provision
truly poor. of long-term care will require substantial
The program we seek would provide cost sharing not only to reduce obligations
access to those who are most vulnerable of third-party payers but also to establish
and in greatest need but would alsoa realistic threshold for seeking formal
services that might be met in informal
protect those in the mainstream and their
families from impoverishment resultingways. Deductibles and coinsurance must
not be so large as to provide serious
from long-term-care needs. It would shape
disincentives to using essential services,
incentives for patients, professionals, and
caretakers to seek improved function andbut they must be substantial enough so
rehabilitation within meaningful eco-there is no obvious incentive to shift new
nomic constraints and to reinforce-not
weaken-the informal care and supports 16. Mark Meiners, "Long-Term Care Insur-
that currently exist. In examining ways to ance: Agenda for Further Research and Develop-
insure that those without resources receivement," Generations, 9:39-42 (1986).
17. Marilyn Moon and Timothy Smeeding,
the care they need, we will have to address
Can the Elderly Really Afford Long Term Care?
the responsibilities of the elderly with
(Washington, DC: American Enterprise Institute,
greater resources as well. forthcoming).
thealterna-
responsibilities to formal care. An economic resources to protect them-
selves or of
tive is careful screening for eligibility who play the odds and lose.
Inevitably, government, through Med-
services by a sophisticated case manager,
or gatekeeper, but such screeningicaid
is or some similar program, will have
often
unreliable and can be expensive ifthethe
to be provider of last resort for those
goal is to differentiate accuratelyunable
between
to provide for themselves. What is
the elderly with varying levels of lessneed.'8
clear is how best to structure the
As the judgments become more subtle, role and to coordinate govern-
government
and not simply an issue of whether a
ment entitlements with private sector
nursing home admission is merited, thereand patient copayment. Many
insurance
people
is much need to perfect predictive believe that, while government
cap-
abilities. Judgments must be made
should not
guarantee coverage for the large
only about what people can do long-term
on their catastrophic costs, a mix of
own but also about the strengthsprivateand
insurance with cost sharing by the
capabilities of their families and other
patient should assume the front-end risk
networks. The criteria, then,up areto en-
a significant threshold defined
either
tangled with complex personal and by a large dollar amount or a
social
values and with beliefs about the re- significant proportion of family income.
sponsibilities of family members, friends,
and neighborhoods. This is, thus, an area COMMON GOALS OF
MEDICAL AND SOCIAL
of high discretion and vulnerable to arbi-
INTERVENTIONS
trary and unfair judgments.
Possibilities for extending long-term-Whatever the policies or issues under
care insurance are many, including having
discussion, too much debate about the
such insurance as an employment fringe health care of the elderly is artificially
benefit or as an option within a cafeteria
polarized by advocates of technical and
fringe-benefit program. If payment social
for care, respectively. The elderly have
such care begins early enough, the insur-
gained a great deal through advances in
ance costs can be relatively modest, but it
technology, and they correctly value the
is not yet apparent that younger adultsnew possibilities that medical research
are prepared to pay the necessary makes
in- possible. The issue is less tech-
surance premiums. Moreover, the port-nology and more the goals of the care
ability of such insurance between employ-
encounter and how means are applied to
ers may constitute a difficult technical
solve health problems.
problem until such insurance becomes The appropriate criterion at all ages is
more widespread. Alternatives might call
to maximize people's capacities to perform
for mandatory program participation their valued roles and responsibilities
through Social Security or an approved
Increasingly, we are learning that efforts
private insurance policy. To the extent
to prevent disease and declining function
that insurance is optional, we face are
the as relevant in the later years as in
typical problems of biased selectionearlier
of development and that real gain
risk and how to protect those who lack
are possible by maintaining healthfu
life-styles and by encouraging activity,
18. William G. Weissert, "Hard Choices: Target-
ing Long-Term Care to the 'At Risk' Aged,"
participation, and skill maintenance and
enhancement. A growing body of research
Journal of Health Politics, Policy and Law, 11:463-
81 (1986). suggests that the elderly do better when
they can retain valued roles, when can,

they although in too many settings staff
can continue to exercise control over find it easier and more efficient to do
things for them. But an effective staff
their own lives, and when they can main-
learns to be comfortable with the disorder
tain a reasonable level of activity. All
such desiderata might involve some dailyof having clients take some responsibility
for themselves.
physical exercise consistent with the in-
dividual's potential, engagement in desiredIn even the most excellent health care
activities, some reasonable contact withfacilities, one encounters an indifference
to the most basic amenities of everyday
others, and some direction over the shape
living such as respect for privacy, ap-
of one's day. Among the reasons the el-
propriate forms of addressing elders, and
derly prefer to maintain their own house-
holds, and particularly fear nursing
differing styles and paces of activity.
homes, is the loss of autonomy and pri-
There is little question that maintaining
treatment environments that have diver-
vacy, diminished control over their own
environment and contacts with others,sity, that avoid impersonality, and that
and loss of self-respect associated with
convey a sense of respect and caring is
the dependence characteristic of institu-more difficult than maintaining an orderly
tional residence. People, of course, differ
and efficient atmosphere. But if our goal
and have varying needs and wants, but is to enhance the lives and functioning of
medical institutions tend to err on the the elderly in their later years, we have no
side of excessive structure, bureaucraticalternative but to create more personalized
routine, and client dependence. living environments in both formal and
Institutional care commonly reflects informal care settings.
the management needs of those who On the service side, American society
administer the facility more than the has the professional personnel, facilities,
personal wishes and tastes of those theyand organizational capacity to provide a
serve. The organization designed to main-very decent level of care for older people.
tain order with minimal effort reinforces With our large and growing corps of
docility and passivity among clients and health
a professionals and our strong com-
restricted range of activities. The more mitment to volunteerism, we have the
poorly staffed and managed the institu-essential elements for a creative response
tion, the more frequently patients are to emerging problems. Effective health
care-both long-term and short-term-
oversedated, spend long hours in front of
televisions, or simply sit doing nothing.will require major initiatives in social
But the one thing we have learned exceed- organization and community education
along with the medical and social services
ingly well is that the health and vitality of
people is best enhanced by an active,needed. Through a balance of individual
responsibility between the elderly and
though not overtaxing, regimen that main-
tains involvement and participation in their families, enhanced voluntary efforts,
the affairs of everyday life. The fact thatprivate and nonprofit initiatives, and an
individuals have different needs and ca- appropriate array of public entitlements,
pacities, and different tastes and wants aswe can provide a meaningful framework
well, makes an individualized manage-that gives the later years meaning and
ment plan essential. Clients must be dignity as well as the critical services a
allowed to do for themselves what they decent society requires.

Health Care and The Elderly

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Health Care and The Elderly

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American Academy of Political and Social Science

Health Care and the Elderly

Health Care and the Elderly

ABSTRACT: Western values have long emphasized an interventionist

services in order to generate income as

structure, norms about family and com-

This is not the context in which to

they can retain valued roles, when can,

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