Residential care for the elderly.

Journal of Health Politics, Policy and Law

Residential Care for the Elderly lens Alber University of Konstanz

Abstract This article maps variations in a standardized way in residential care for elderly people in three Western nations. Measured by the number of available places per person aged sixty-five and over and by the number of staff members per bed in nursing homes, the United Kingdom has the most highly developed standards. The United States ranks second, with Germany lagging considerably behind. The variations are explained by four variables: the pressure of the problem, as defined by the percentage of the population aged sixty-five and over; the caretaker potential in the family system, which alleviates this pressure; the structure and financing of the supply of residential care; and decision-makingprocedures in health care policy-making. My analysis emphasizes the last two variables. In the United Kingdom and the United States, the public and private providers who supply care have either political or market incentives to expand their services. Germany’s mix of public and private, by contrast, is dominated by voluntary associations that are neither responsible to an electorate nor allowed to make profits. Thus, their clients do not have opportunities to articulate their needs. Health care decision making in Germany takes place through a collective bargaining process between the sickness funds and the providers. In such a system, the interests of groups who are not represented at the negotiation table-such as the elderly-tend to be neglected. A national health system of the British type links political decision makers via the election mechanism more closely to the concerns of the public. As older people represent growing proportions of the electorate, their needs find more adequate consideration in the policy process. In the United States, politiThis article builds largely on the national reports on residential care for the elderly presented at the conference on “The Division of Labour in the Light of New Challenges,” which was organized by the Max-Planck-Institut fur Gesellschaftsforschung in Cologne in 1990. I am heavily indebted to the three scholars who contributed the reports: Willi Ruckert, Anne Jamieson, and Robert Kane. I also gratefully acknowledge the helpful suggestions for revisions of an earlier draft, made by J. Rogers Hollingsworth, Ellen Immergut, and James Morone. All information regarding Germany pertains to the Federal Republic before unification.

Journal of Health Politics, Policy and Law, Vol. 17, No. 4, Winter 1992. Copyright 0 1992 by Duke University.

Published by Duke University Press


930 Journal of Health Politics, Policy and Law

cal officeholders also have to pay attention to the needs of increasingly organized older people, since the tax-financed and federally regulated Medicaid system is largely responsible for financing long-term care for the elderly.

Since the mid-l970s, state welfare schemes in Western societies have found themselves in stormy waters. As declining economic growth rates combine with public deficits and as governments are taken over by liberalconservative parties, there is mounting pressure to control spending on social programs. Many scholars think that this pressure to limit the welfare state weighs disproportionately on marginal groups with little organizational power. Several authors highlight the development of a new poverty, linked to segmentation or marginalization of groups in Western welfare states, which continue to protect the concerns of productive labor but leave the needs of economically unproductive groups increasingly neglected (Tennstedt and Leibfried 1985; Dahrendorf 1988). My article places residential care for the elderly within this wider theoretical context. Since health has been one of the fastest-growing sectors of the welfare state for several years, all Western governments have been trying to curb the growth of expenditure on health care. The questions then are how extensive the cuts in the health sector are, and whether they have disproportionately hit groups with little bargaining power, leaving them subject to growing gaps in welfare provision. Older people, who are no longer economically active and are frail to a degree that makes them dependent on care. may be considered one of the most prominent of these groups. In this article, I examine the extent to which the needs of the elderly are neglected (or met) in different institutional contexts. I selected three countries for this study-Germany, the United Kingdom, and the United States. All three experienced changes of government from more social-democratic to more conservative parties during the late 1970s or early 1980s, so the effect of political turnover with its attendant policy changes may be held constant, to a certain degree. The countries, moreover, present different institutional types of health care systems, so one can move beyond mere description to address the interesting question of the extent to which different health care systems shape the response to the need for long-term care in aging societies. I will return to this crucial issue in the concluding section of this article. Germany

Germany relies predominantly on a compulsory sickness insurance scheme financed by contributions from employees and employers. In this Published by Duke University Press


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system, corporate actors, steering the health system by means of collective bargaining, play a dominant role. The German health care system is public to the degree that legal provisions passed on the federal level determine the scope of compulsory coverage, the method of financing, and the standard of benefits. However, except for the case of hospital investment, the state does not participate in the financing of the scheme and the implementation of policy is left to self-governed corporate bodies run by representatives of employees and employers, who share in the financing of the system. The statutory sickness insurance scheme is financed from earmarked contributions shared equally by employees and employers. It is administered by autonomous boards composed of elected representatives of these two contributing groups.’ The federal government has no implementing agencies of its own. Most health services are delivered by private providers or by voluntary associations. Details concerning the conditions of service delivery and the price of services are usually settled in negotiations between the provider groups and the insurance funds. Thus, the health system of Germany is steered predominantly by corporate associations, rather than by state bureaucracies or markets. With respect to its benefit structure for older people, the central characteristic of the German health care system is that it draws a sharp dividing line between sickness that needs medical care, on the one hand, and decrepitude or frailty, on the other (behandlungsfiihige Krankheit versus Pjegebediirjtigkeit). Only the former is covered by sickness insurance, while the latter continues to be largely a private risk for which there are almost no public provisions. Once older people become dependent on residential care, they frequently have to turn to a locally administered public welfare (social assistance) scheme to cover the cost. Therefore, a prolongation of the stay in acute hospitals is the only way to prevent older patients from having to foot the bill for delivery into nursing homes, which they can rarely afford. United Kingdom

The United Kingdom has a national health service financed from general taxation, which makes the minister of health responsible to Parliament and the wider public. The British National Health Service (NHS) has covered all the country’s residents since its creation in 1948. It is financed from the central government budget and placed under the direct authority of 1 . Only the substitute funds (Ersurzkussen)are administered exclusively by representatives of the insured persons.




the four ministries of health for England, Wales, Scotland, and Northem Ireland. The minister of health is responsible for planning health care and is accountable to Parliament for the allocation of resources. Under guidelines from the ministry, the service is administered through partly autonomous health authorities at the regional and district levels. These authorities develop regional health plans, which have to follow the policies determined by the government. The consumers of health services are represented in special community health councils at the local level. In contrast to the German system, the British health care system does not draw a clear distinction between medical treatment and long-term care. The NHS provides and finances acute medical services as well as long-term care in hospitals or nursing homes. Geriatric patients are served within special geriatric wards of the general hospitals. There is, however, an important differentiation between short- or long-term health care, on the one side, and social care, on the other. Nursing homes for the elderly are considered to be part of the national health service, while residential care facilities, which basically provide only accommodation, are part of the local social services controlled and financed by local government authorities. The local government services are funded by a mixture of local taxation and central government grants. United States

The United States has a bifurcated health care system, with differentiated provisions for people of working age and older people. For members of the labor force there is a highly pluralistic and organizationally fragmented insurance scheme, which is heavily dominated by private insurers and leaves much room to the market and to private or voluntary activities. While 33 million Americans, or 14 percent of the population, were not covered by any sickness insurance scheme at all in 1987, 181 million or 76 percent were covered by private insurance programs, the bulk of which are related to employment contracts (Statistical Abstract of the United States 1990: Table 152). For people outside the established core of the labor force, two government schemes were adopted in 1965. The Medicare system covers persons aged sixty-five or older as well as disabled persons. Its benefits include institutional services, including the cost of skilled nursing in residential homes for up to 150 days, but exclude custodial and residential-care services for the elderly (Jazwiecki 1989: 301). The program is a federally operated insurance scheme, administered through local fiscal intermediPublished by Duke University Press


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aries, such as insurance companies, and financed from taxes paid by virtually all workers and their employers. The other program, Medicaid, is a federally regulated public welfare scheme for the poor, under which the individual states offer basic health services, including the cost of longterm care, to eligible low-income persons. Apart from these two schemes, there is an almost complete absence of long-term care insurance. While the bulk of acute health services for the elderly is paid by the two public programs, residential care in nursing homes is predominantly financed from private out-of-pocket resources and from the stateadministered Medicaid program. Medicaid is jointly financed by state and federal tax revenues. Basic standards are set by the federal government. Within its guidelines, the state governments determine both benefit and eligibility conditions. Almost all recipients of cash welfare benefits are automatically eligible for medical benefits. In addition, most states have extended the Medicaid program to persons who do not satisfy the income requirements for welfare but who are deemed “medically needy,” as their health bills exceed a certain percentage of their income. Based on this provision, medically indigent older people, many of them in nursing homes, soon became significant items in state budgets (Kane 1990: 3). The question then is how residential care services for the elderly have developed in these different contexts. Before we deal with this question in more detail, some additional factors have to be considered. Services for older people are embedded in a societal context which contains three crucial features: the problem pressure (the pressure caused by a functional problem, which societies have to solve) as defined by the proportion of older people in need of care, the informal network of caretakers in families, which alleviates this pressure; and the availability of home care services, which may substitute for residential care. Most of the care in Western countries is provided by private households and by ambulatory services or respite care. In their policies for older people, most countries have given priority to the expansion of home care services, in order to keep older people for as long as possible in their home environments. Interestingly enough, however, in western Europe there is apparently no substitution effect: countries with underdeveloped residential care services are not marked by a disproportionate expansion of home care services. As home care services are discussed by Jamieson elsewhere in this issue, I will not pursue the subject here. We do need to consider, however, to what extent the problem pressure in the three countries may be considered to be similar. Published by Duke University Press



Table 1 The Number and Percentage of Older People in the Populations of Germany, the United Kingdom, and the United States Aged 65 and Over 1960

Country

1,OOOs

Germany 5,644 U.K. 6,141 16,675 U.S.

Aged 75 and Over

1988

1960

1988

Percent 1,OOOs Percent 1,OOOs Percent 1,OOOs Percent 10.6 11.7 9.2

9,515 8,883 30,867

15.4 15.6 12.5

1,830 2,204 5,622

3.4 4.2 3.1

4,562 3,852 12,470

7.4 6.8 5.1

Source. Calculated from national statistical abstracts.

The Problem Pressure

Demographic Structure

The proportion of older people in the total population is a crude measure of the pressure in health care politics to serve the needs of the elderly. The more older people there are and the faster their numbers are growing, the greater the demand for residential care and other services for the elderly. As Table 1 shows, the proportion of older people is rapidly growing in all three countries. The highest dependency ratio is presently found in Germany, followed closely by the United Kingdom. Although the American population is still comparatively young, the numbers and proportions of older people are growing rapidly. The demand for services for older people is thus rising in all three countries. It is important to note, however, that the elderly are a very heterogeneous group. Nothing would be more misleading than to assume that uZZ older people are frail or in need of special care. Even among very old persons, a majority remain capable of caring for themselves. However, the need for long-term care or nursing sharply increases with age. In the age group above eighty, roughly every third person now needs daily care. Table 2 gives some of the (not strictly comparable) estimates by age group. Up to the present the vast majority of the elderly in need of intensive care are looked after by family members. The question then is to what extent the care potential of the family system as the major functional equivalent of public support has been expanding or shrinking in recent years.



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Table 2 Percentage of Older People with Severe Incapacity Requiring Intensive Care or Living in Residential Care Facilities in Germany, the United Kingdom, and the United States Age Groups (years)

Country

60-69

65-74

70-79

75-84a

80-89

Germany

1.5

3.8

10.6

11.1

29.1

U.K.

4.7

U. S. (in residential care only)

10.0 1.2

80+ 85+

90+

31.4 40.5 38.8

9.6

over 20

a. In U.S.A.,the figures are for people aged seventy-five and older. Source. Germany: Sachverstandigenrat 1990: Abbildung 6; Thiede 1988: 25 I ; United Kingdom: Walker 1991 : 26; U.S. : Statistical Abstract ofthe United Stares 1990, Tables 13, 177; Kane 1990:17.

The Caretaker Potential of the Family System

Statistics of households show that most older persons live by themselves in single-person households. In many cases, they also increasingly live at some distance from their children or other relatives. In addition, declining birthrates make for a shrinking care potential in the family system, as a decreasing number of younger relatives has to provide for a growing number of older people. A body of research has shown that care for the elderly is almost exclusively provided by women, who are themselves frequently over fifty years old (for Germany: Alber 1990; for U.K.: Walker 1991; for U.S.: Jazwiecki 1989). Therefore, the ratio of women aged forty-five to sixty to people over sixty-five may be considered an indicator of the caretaker potential within the family system. This ratio is rapidly shrinking in all three countries (see Table 3).* Caretaker potential has been reduced by one-third in the U.S. and by even wider margins in the two European countries since 1960. Germany had an exceptionally high caretaker potential, by international standards, up to the 1970s. Its 1960 figure represents an informal care potential that the Scandinavian countries had already fallen short of in the 1930s (Ruckert 1989: 122). In recent years, however, the German care potential of families has been rapidly declining. The decline means that traditional forms of support for older people are no longer sufficient. In order to 2. The delimitation of age groups used for this indicator is to some extent arbitrary. It follows conventions applied in earlier internationally comparative studies (see Ruckert 1989: 121).



936 Journal of Health Politics, Policy and Law Table 3 The Shrinking Caretaker Potential within the Family System in Germany, t h e United Kingdom, and t h e United States Number of Women Aged 45-60 per 1 ,OOO People over 65

Country

1960

1988

Germany United Kingdom United States

1,097 892 885

656

Source. Calculated

525 587

Index (1960 = 100)

60 59 66

from national statistical abstracts.

provide functional equivalents for depleting societal care capacities, a growing supply of public provisions for long-term care is indispensable. My task now is to examine to what extent residential facilities meeting this new demand have built up in the institutional settings of each country. In order to map the variations, 1 will distinguish between the delivery structure, the financing structure, and the regulatory structure of services. The Structure of ResidentialCare in Germany, the United Kingdom, and the UnitedStates Germany

Delivery Structure. The paucity of data on services for older people is a notorious characteristic of the fragmented German welfare state (see Alber 1990 for details). Thus the number of facilities offering residential care for the elderly is not known exactly. There are three different types of homes for older people: sheltered housing (Altenwohnheime), residential homes (Altenheirne), and nursing homes (Pcflegeheime).Admission to these different types of homes usually varies with the person’s degree of incapacity, but as there is no clearly drawn institutional borderline, there is much overlap in the actual client groups. Therefore, varying sources frequently give different statistics on the numbers of homes and clients (see, for example, Priester 1989: 142; Schulz-Nieswandt 1990: 26). Government statistics for 1990, based on the distinction of the three types of homes mentioned above, yield the figures given in Table 4. Expressed as a proportion of the elderly population, the total number of beds in residential homes corresponds to 5.3 per 100 people aged sixtyfive and over. In comparison with neighboring European countries, such as the Netherlands, and with the other two countries studied here, this Published by Duke University Press


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Table 4 Residential Facilities for Older People in Germany in 1990

Beds

Homes Number

Facilities

Percent

Number

Percent

Sheltered Housing (Altenwohnheime)

624

9.3

50,409

9.8

Residential Homes (A1tenheime)

2,066

30.9

125,642

24.3

Nursing Homes (Pjlegeheime)

1,392

20.8

9 1,070

17.6

Mixed Homes (Mehrgliedrige Einrichtungen)

2,607

39.0

249,698

48.3

Total

6,689

100.0

516,819

100.0

Source. Bundesministerium fur Familie und Senioren 1991 .

may be considered a relatively low s u ~ p l yViewed .~ from a longitudinal perspective, however, the number of places in residential facilities has been growing faster than the number of older people. Following expert estimates, there were only some 200,000 beds available in 1960 (Riickert 1990: 5 ) . This would mean that the stock of available beds has increased 2.8 times within the last thirty years. The bulk of residential facilities for the elderly is supplied by voluntary nonprofit associations (Verbiinde der freien Wohlfahrtspjege). These are organized into six major associations, which reflect the historical segmentation of German society into denominational and other social groups, including the Catholic and Protestant churches and the labor movement. The voluntary associations control 53 percent of all residential care facilities and 65 percent of all beds. Publicly provided homes account for 14 percent of all homes and 19 percent of all beds. For-profit firms own 33 percent of the homes, but only 17 percent of all beds. This is an indication that the private nursing sector is still a small-scale cottage industry, rather than in the hands of big industrial chains. On average, privately controlled homes tend to be very small, with a mean number of forty beds.4 3. Geriatric day care centers are severely lacking. Throughout the country only 54 day care centers with 801 places were reported for 1988 (Bundesministeriumfur Jugend, Familie, Frauen und Gesundheit 1990: 18). 4. Publicly provided homes are usually larger, offering 100 beds on average. The size of nonprofit homes is in between these two extremes, with an average size of 94 beds (my calculations based on Bundesministerium fur Familie und Senioren 1991).




Beds in special nursing homes for frail people are not only in short supply, but also very expensive. The cost of nursing homes varies between DM 3,000 and 4,000 per month in standard cases, whereas the average monthly income of pensioner households only amounts to DM 1,941, on average. Thus, older people frequently lack sufficient means to pay for nursing homes. As the social insurance scheme does not provide any benefits for residential care, they must resort to the means-tested social assistance system when they need such care. Since the receipt of social assistance still carries a stigma and the local authorities in charge of financing the system seek to discourage the use of expensive residential services ,5 there are demand-side and supply-side impediments against a proliferation of nursing homes. Sound empirical data on the demand for places in nursing homes are very scarce. The information that is currently available shows that even among very old persons a majority remain capable of caring for themselves (Bundesministerium fur Jugend, Familie und Gesundheit 1980: 5, 1984: 3). Three types of information suggest, however, that the demand for residential facilities is growing rapidly: ( I ) a growing proportion of people are of very advanced age, (2) the need for nursing sharply increases with age: (3) the use of residential care also increases with age.’ Thus, the need for long-term care of elderly people in residential facilities can no longer be considered a rare exception. It must be seen as a new standard risk. for which there is currently no adequate public provision. There is a more or less general consensus that Germany needs social security reforms that cover the risk of long-term care in nursing homes and hospices. The 1988 health insurance reform law (Gesundheitsrefurmgesetz) took first steps to alleviate the problem of insufficient ambulatory services for people in need of nursing! but it did not contain any provi5 . This refers to the 1984 amendment to social assistance law which stipulated that ambulatory care should be considered the standard type of provision and that residential care will only be paid for if other forms of help are not available or if the particular circumstances of the individual case make residential care indispensible (for a summary of the law see Schulz 1989: 229). 6. Following the 1988 socioeconomic panel, the proportion of people receiving care was 8.8 percent among persons aged sixty-five and over, but 3.8 percent in the age group sixty-five to seventy-four, 1 1 . I percent aged seventy-five to eighty-four, and 31.4 percent among those aged eighty-five and over (Thiede 1988: 251). 7. Following regional statistics for Bavaria, the percentage of people living in residential irlstitutions is roughly 1 percent of people in the age group sixty-five to seventy, 3 percent in the agc group seventy to seventy-five. but 21 percent among those aged eighty-five and over (Ruckert 1987: 29). From all we know, the average age of residents has been growing rapidly in recent years (Ruckert 1987). 8. The sickness insurance system now covers the expenditure for professional nursing help at home for a period of up to four weeks per year, with a ceiling of DM 1,800. This is designed to enable family members of frail people to take a vacation. Since 1991 the sickness insurance



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sions to cover residential care. Therefore, the nursing emergency (P’egenotstand) has become a central policy issue in the most recent past, for which various reforms have been p r o p ~ s e dThere . ~ still is general consensus among policymakers that home care services that enable frail people to remain integrated in their traditional networks and social environment should have priority over residential care in institutions. Given the shrinking care potential in the family system, however, it is most likely that the supply of nursing homes needs to be further expanded. The current state of information on expenditure and staffing of residential homes in Germany may best be described as disastrous. Concerning expenditure, only a few, widely discrepant estimates are available. The leading expert in the field reckons that some DM 15-20 billion were spent on residential and nursing homes for the elderly in 1986 (Ruckert 1990: 28). More reliable figures are only available for the expenditure of the social assistance scheme on nursing benefits (Hiffe zur P’ege) for people in residential institutions. These outlays roughly doubled from DM 3.7 billion in 1978 to DM 7.9 billion in 1989 (Statistisches Bundesamt 1981: 399; 1991: 474). In the same period the total benefit expenditure of the statutory sickness insurance scheme grew 1.7 times from DM 71.5 billion to DM 123.2 billion (Sachverstandigenrat 1991: Table 461) . It would be tempting to conclude from these figures that expenditures for older people in need of residential care have been growing faster than the sickness insurance outlays for less marginal groups. This would be misleading, however, since the aggregate data do not give any information on the size of benefits per recipient. If we calculate per capita benefits, we realize that the average nursing benefit of the social assistance scheme for residents in homes has increased at the same rate as per capita sickness ~

system also covers the cost of ambulatory nursing services rendered at home, up to a ceiling of twenty-five visits or a cost of DM 750 per month. 9. Basically, three alternative models have been proposed which might be labelled the market solution, the transfer solution, and the social insurance solution. The market solution-which is favored by the state government of Baden-Wurttemberg and at the federal level by the liberal Freie Demokratische Partei-wants to make all citizens beyond a certain age insure themselves privately, following the model of private insurance against car accidents. The transfer model would introduce a tax-financed nursing allowance, following the model of the housing allowance system. The social insurance model, which is championed by the federal government, foresees a new, contribution-based social insurance benefit, which would be affiliated with the sickness insurance scheme. Following this latter concept, all compulsory members of the sickness insurance scheme should pay an additional 1.7 percent of gross wages, which would be financed equally by employees and employers. As the transition from sickness to decrepitude is frequently a gradual process, requiring a ff exible integration of medical services, nursing, and rehabilitation measures, only such an integrated coverage of both risks in a common scheme would guarantee that frail persons would receive continuous services without becoming the victims of quarrels between various financing agencies over the question of who is to cover the cost of care.




insurance benefits between 1978 and 1989 (i.e., 1.8 times-calculated from Statistisches Bundesamt 1981: 391, 1991: 474, and from Sachverstandigenrat 1991: Table 463). Data on the staffing of residential homes for the elderly are as scarce as expenditure data. According to Ruckert ( 1989: 139), 132,000 full-timeequivalent staff members were working in residential and nursing homes in 1987. This would mean that there were about three beds per staff member. From a longitudinal perspective, the staffing of residential homes has been considerably expanded. Following a survey of voluntary institutions, only 44,900 persons were employed in residential homes for the elderly in 1970, as compared to 118,942 in 1987 (Priester 1989: 142). These are crude aggregate figures, which include part-time employees as well as administrative personnel. They yield little information on the amount of care actually received by the clients. That the staffing situation is less favorable than the figures suggest is implied by regional guidelines on staffing ratios used for setting the daily rates of residential homes and nursing homes. In the state of BadenWurttemberg, for example, recommended staffing ratios for the realm of care in residential facilities grew as summarized in Table 5. It appears from these ratios that the situation is improving, albeit at a rather slow pace. The most recent improvement is related to the higher rates of pay for nursing staff that were negotiated in 1989. Judged by international standards, however, the ratio of caretakers to clients remains low in Germany (Riickert 1989: 139).This is especially true if we consider that only 50 percent of the staff consists of qualified personnel with a professional training in nursing (Landtag von Baden-Wurttemberg 1990: 157).

Financing Structure. In contrast to hospital care, there is no legislated public responsibility for the adequate provision of residential care. Private households and the social assistance system bear the lion’s share of the cost. However, state and local governments subsidize homes run by voluntary associations (but not private homes). The degree of subsidization varies by state. In Baden-Wurttemberg, the state government contributes 15 percent of the construction cost of nursing homes considered as necessary by a screening committee and 30 percent of the cost of nursing homes. Local authorities contribute another 10-40 percent of the cost (Landtag von Baden-Wurttemberg 1990: 149, 151). The running costs are covered by user charges, for which daily rates are negotiated between the financing agencies of the public social assistance scheme and the voluntary organizations (Landtag von BadenPublished by Duke University Press


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Table 5 Recommended Staffing Ratios for Residential Homes in Baden-Wurttemberg (beds per nursing staff) Institutions

1989

1990

1991

Residential Homes Nursing Homes

1:15 1:3.5

1:13 1:2.65

1:12 1:2.37

Source. Landtag von Baden-Wurttemberg 1990: 156.

Table 6 The Financing Structure of Residential Care in Germany, 1982 Source of Care

DM Million ~

Private Households (estimate) Social Assistance Various Social Security Schemesa Total

Percent ~~~~

4,000.0 3,671.5 654.7 8,326.2

48.0 44.1 7.9 100.0 ~~

~

a. Kriegsopferversorgung ,Lastenausgleich, Beihiwe, Unfallversicherung. Source. Calculated from Bundesministerium fur Jugend, Familie und Gesundheit 1984.

Wurttemberg 1990: 154). Nationwide data on the financing structure of residential care are deficient. The estimates for 1982, given in a 1984 government report, are summarized in Table 6. More recent regional data for Baden-Wiirttemberg show similar results, with a private share of 65 percent for residential homes and 50 percent for nursing homes (Landtag von Baden-Wurttemberg 1990: 161). Thus the cost of residential care is predominantly financed by private households paying user charges and by the social assistance system.

Regulatory Structure. Residential homes and nursing homes are regulated under the federal Residential Home Acts of 1974 and 1990 (Heimgesetz). Both types of home can only be opened with the approval of public authorities. Only homes run by voluntary associations may be opened without state consent. The act stipulates minimum standards concerning safety, building sizes and structures, and participation rights of residents for all homes, including those in the voluntary sector. These regulations are specified in a number of additional decrees (Schulz 1989: 219-21; Landtag von Baden-Wiirttemberg 1990: 134-41). Staffing ratios are not legally stipulated under the law but are loosely regulated under recommendations that are negotiated between provider and payer organizations. The regulations merely specify minimum standards, which tend to become actual standards in practice, but even these are not respected in all Published by Duke University Press



cases.IOAs paragraph 10 of the Residential Home Act allows voluntary associations and other corporate bodies providing residential care to participate in the inspection process, the German model of home regulation relies more on advice than on strict control from above. United Kingdom

Delivery Structure. In the United Kingdom it is common to distinguish between residential homes controlled by local authorities and nursing homes, which form part of the national health system. In addition, longstay beds in NHS hospitals are available for people in need of care. British statistics on these facilities concentrate on the number of beds rather than the number of homes. In 1989 a total of 497,600 places in institutions for the elderly, chronically ill, and physically handicapped persons were counted." These were distributed, as shown in Table 7, among residential and nursing homes run by various types of agencies. Including the 71,320 places for elderly mentally ill people yields a total number of 568,920 places in residential institutions. Expressed in relation to the population aged sixty-five and over, this number of beds corresponds to about 7 percent of the elderly population. Other sources arrive at a degree of institutionalization of 6 percent among the elderly (Walker 1991: 11). The number of applications and admissions to institutions grows sharply with increasing age. The average age of residents has been rapidly rising over the past years. Even at the highest levels of incapacity, however, there are about three to four times as many people in the community as in residential care (Jamieson 1990: 14). Nonetheless, the sector of residential care has expanded dramatically during the 1980s, as shown by the statistics for England in Table 8. The total number of places in residential or nursing homes has grown faster than the number of older people in the population. The recent growth is heavily concentrated in the private sector. By the end of the 1980s, the private sector had outpaced local authorities as the predominant provider of residential care. In contrast to the German case, the nonprofit voluntary sector is of very modest importance. Private business provides considerably more places in residential care than in nursing 10. Thus it is estimated that one-fifth of the homes run by Catholic associations (Caritas) in a particular region of the state of Baden-Wiirttemberg do not have a council representing the residents as stipulated by law (Landtag von Baden-Wurttemberg 1990: 140). 1 1 . In addition, there were 71,320 beds in nursing homes and residential care for the mentally ill (Jamieson 1990: Appendix Table 3).



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Table 7 Beds in Nursing and Residential Homes in the United Kingdom, 1989

Nursing Homes Agency

Number

Public Voluntary Private Total

Residential Homes

Total

Percent

Number

Percent

Number

Percent

80,100a 10,500 88,600

44.7 5.9 49.4

135,300 39,900 143,200

42.5 12.5 45.0

215,400 50,400 231,800

43.3 10.1 46.6

179,200

100.0

318,400

100.0

497,600

100.0

a. NHS beds for long-stay geriatric patients and for elderly mentally ill persons. Source. Adapted from Jamieson 1990: Appendix Table 1, with my calculations.

Table 8 People Aged 65 and Over in Residential Care in England

1989

1980 Number

Percent

Number

Percent

Local Authority Homes Voluntary Homes Private Homes

102,890 25,449 28,854

65.5 16.2 18.3

95,335 25,801 1 1 1,391

41 .O 11.1 47.9

Total

157,193

100.0

232,527

100.0

~~

Source. Adapted from Walker and Warren 1991: 29, with my calculations.

homes. Although the British nursing industry is still dominated by small business, corporate providers account for an increasing share of the market. In 1989 they owned 19 percent of beds in nursing homes and 4 percent of residential care (Jamieson 1990: 5 ) . As will be shown below, the recent increase in private provision is clearly related to changes in national legislation that modified the financing procedure. Including private fees, the total expenditure on nursing, residential, and long-stay hospital care of elderly, chronically ill, and physically handicapped people amounted to E3.9 billion in 1988 (Jamieson 1990: 11; see also Table 9). Following Walker and Warren (1991: 10) public expenditure on residential and nursing homes increased from &6million in 1978, to &460million in 1988, and to &I .3 billion in 1991. This would indicate that public expenditure on residential care facilities is growing faster than total current expenditure on the National Health Service, which increased roughly threefold from E7.4 billion to E21.8 billion between 1978 and 1989 (Central Statistical Office 1990: 47, 1991: 47). Apart from the stipulation that nursing homes must employ at least one Published by Duke University Press



Table 9 The Financing of Long-Term Care in England and Wales, 1988 Source

f Million

Percent

Private a

1,425

36.3

Public For Public Facilities For Private Facilities

1,729

770

44.1 19.6

2,499

63.7

Total

a. Including f279 million for local authority charges to residents. Source. Adapted from Jamieson 1990: 1 I , with my calculations.

qualified nurse, staffing ratios in residential facilities are not legally regulated. The interpretation of what constitutes adequate staffing is left to individual authorities (Jamieson 1990: 18). The majority of staff in both nursing and residential homes are unqualified and female. Staffing ratios vary from a mean 0.8 patients per staff member in small homes to a mean of 1.7 patients per staff member in large homes (calculated from Jamieson 1990: 17).

Financing Structure. Public financing is by far the most important source of funding for residential facilities. This is due to the fact that public authorities not only provide nursing or residential homes but also grant support to people in homes of the independent (private and voluntary) sector. The private sector derives its funding from charges to residents. Table 9 shows the financing structure for expenditure on nursing, residential, and long-stay hospital care in England and Wales. Residents who are not able to pay the fees of private nursing homes are entitled to transfer payments from the central government. This arrangement dates back to a 1980 social security law that was one of the major innovations of the new Thatcher government. The Department of Health and Social Security (which was split into separate departments of health and of social security in 1988) was charged to meet the cost of care in private nursing homes for those living on income support, and its local officers were allowed to set the amount of allowance deemed appropriate for their area. From the point of view of local authorities, this presented an incentive to offload some of their fiscal burden by shifting older people from local authority residential homes to private nursing homes. As a result of the new legislation the private care industry boomed, and the



Alber

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proportion of older people in private homes receiving all or most of their fees from the social security system rose from 14 percent in 1979 to 56 percent in 1988 (Walker and Warren 1991: 10). Under the new 1990 NHS and Community Care Act, local authorities will receive a single unified budget, paid by central government through the revenue support grant, for the care of older people, whether they are in residential care or living at home. The resources which have so far financed care through social security payments to people in residential or nursing homes will then be transferred to local authorities. These will then be responsible for all public funding of care for older people. Additional social security funding will continue to be given to residents in private nursing and voluntary homes but will not benefit those in public sector homes. The implementation of these new regulations has been deferred until April 1993 (Walker 1991: 30). Regulatory Structure. Nursing homes have been subject to regulation ever since 1927, when the first Nursing Home Registration Act was passed. The category of residential care homes was officially introduced in 1948. Both types of homes are now regulated within the 1984 Registered Homes Act as long as they have at least four residents. This legislation came about as a result of the publicizing of various scandals in private nursing homes. Homes with fewer than four residents, which represent about one-fifth of all homes, are exempted from regulation but will be included when recent reform legislation comes into effect. Publicly provided services remain unregulated but are subject to inspection. Nursing homes are inspected by the Health Advisory Service, created in the 1970s. Local authority residential care homes have since 1985 been inspected by the central government Social Services Inspectorate (Jamieson 1990: 18). Residential care homes in the independent (voluntary and private) sector must register with the local authorities who are also responsible for their inspection. Nursing homes must register with and be inspected by the district health authorities. Homes of a mixed type with clients receiving personal care as well as nursing are registered with both the health service and the social service (Jamieson 1990: 3, 18). The regulations concerning registration and inspection are broadly defined guidelines, rather than strict rules. Neither the criteria for the admission of clients nor the precise quality standards or staffing ratios have been stipulated. Compared with the rule-bound and punitive American deterrence model, the British compliance model of regulation is of a more




persuasive and informal nature, in which public inspection takes the form of advice, of negotiation, and bargaining with the providers (Day and Klein 1987).12

U.S.A.

Delivery Structure. American nursing homes offer widely discrepant levels of care and serve multiple functions with four major types of clients: physically impaired persons with chronic diseases, acutely ill persons recuperating from hospital care, terminally ill persons, and persons with chronic cognitive deficits. The total number of persons institutionalized in long-term care facilities is estimated at I . 8 million (Jazwiecki 1989: 308). This would correspond to roughly 6 percent of the population age 65 and over. As in the other countries studied here, there are more nursing homes than hospitals in the United States. In 1986, 25,646 residential care facilities offering different levels of care were counted. These provided 1.709 million beds with an occupancy rate of 91 percent (Statistical Abstract of the United States 1990: Table 176).13Expressed as a proportion of the population aged sixty-five and over, this aggregate number of places corresponded to 5.6 percent in 1986. Access to residential care varies widely among states, however. The total number of long-term care facilities may be classified into 16,388 fully fledged nursing homes, with 1.5 million beds, and 9,258 residential homes offering personal care or supervisory care, but no nursing services. These had 202,000 beds. About one-half or 13,420 of the homes with roughly 1.4 million beds were certified for participation under the Medicaid or Medicare schemes as either skilled nursing facilities or intermediate care facilities (Statistical Abstract of the United States 1990: Table 176).14 12. Given the imprecise nature of the regulations, the quality of service offered in residential and nursing homes varies widely. On average the more expensive and privately paid homes in the independent sector are able to offer higher-quality service. Following the Wagner Report, published in 1988 by a commission set up to provide a review of residential care, it would be "exceptional to find a local authority home in which most residents can lock their own rooms, or have their own furniture, or get up when they please, or bathe when they want" (Wagner Report, as quoted in Jamieson 1990: 17). 13. These figures do not include hospital-based nursing homes. 14. Since 1983 the Medicare program has made special provisions for the care of persons who are believed to be terminally ill. Persons with a prognosis of six months or less can opt to be treated in a specially designed hospice program. The hospices receive a fixed amount for each day of coverage. The intent of the Medicare hospice program is to promote less use of expensive high-technology care in favor of more humanistic personal services (Kane 1990: 12-13). The



Alber

The Elderly 947

Unlike hospitals , nursing homes are primarily owned by proprietary companies. These account for roughly 75 percent of the homes and 72 percent of the beds. Tax-exempt nonprofit associations account for 20 percent of all homes and 21 percent of the beds. The public sector is almost negligible, providing only 5 percent of the homes and 6 percent of the beds (Statistical Abstract of the United States 1990: Table 176). Almost one-half of the homes are part of chain operations which in many cases are vertically integrated health care corporations which include hospitals and outpatient facilities (Kane 1990: 7). However, most of the industry is still primarily run by single-owner or small-chain organizations, with the biggest ten companies controlling less than 20 percent of the total long-term care capacity (Jazwiecki 1989: 335). Information on the residents of nursing homes was supplied by a 1985 nursing home survey (reported in Jazwiecki 1989). This shows that the rate of nursing home use varies sharply with age (see Table 2, above). Such data on the proportion of elderly people living in institutions at a given point of time tend to conceal the fact that the lifetime risk of institutionalization is much higher than statistical snapshots suggest. For persons above the age of sixty-five it is estimated at some 40 percent (Kane 1990: 17). More than 70 percent of all nursing home residents are over seventy-five (Jazwiecki 1989: 296). Despite this high proportion of very old residents, about half of the persons admitted to a nursing home leave within three months (Kane 1990: 17). Expenditure for nursing home care amounted to $43.1 billion in 1988. This corresponded to about 8 percent of the total health bill of roughly $541 billion (Kane 1990: 7). In comparison to the development of total health expenditure, the cost of nursing homes has been rising disproportionately from 1970 to 1980. Its share rose from 6.3 to 8.2 percent but has since remained more or less stagnant in relative terms (in 1987 it stood at 8.1 percent of total health expenditures; see Statistical Abstract of the United States 1990: Table 136). Expenditure for hospice care under Medicare has grown from $4 million in 1984 to $210 million in 1989 (Kane 1990: 14). The current number of nursing home staff is not known (Statistical Abstract of the United States 1990: Table 175). In 1980, 798,000 full-time employees were counted. This corresponds to 571 employees per 1,000 total number of hospice programs has increased from 1,345 to 1,659 between 1984 and 1989, with the number of programs certified by the National Hospice Organization growing from 176 to 996 (Kane 1990: 14).




resident patients or 1.7 patients per staff member. In 1971, nursing homes were less well staffed, with 568,000 full-time employees or 1.9 patients per staff (Statistical Abstract of the United States 1990: Table 175). The apparently improving staff /patient ratio is remarkable, given that nursing homes are low-prestige work settings whose pay rates are lower than those for comparable jobs in hospitals (Kane 1990: 22).

Financing Structure. In the U.S. roughly one-half (48 percent) of the cost of nursing homes is financed from individual out-of-pocket resources. Another half (49 percent) comes from tax-financed government sources. Paying some 47 percent, Medicaid is the major public payer for nursing home care. Medicare covers only about 2 percent of the cost (Kane 1990: 7). Private insurance pays even less than the small amount covered by Medicare (see also Jazwiecki 1989: 323). The standards adopted by Medicaid thus shape the nursing home industry in America to a large extent. If the monthly costs of a nursing home exceed a person’s income, clients become eligible for Medicaid. In contrast, persons receiving care in their own homes satisfy Medicaid eligibility criteria only after they have depleted all their private funds. Thus, there is an economic incentive for those who have spent down their assets or are close to doing so to resort to nursing homes (Kane 1990: 4). Regulatory Structure. The predominantly privately supplied American nursing homes are highly regulated. In order to be allowed to participate in Medicare or Medicaid programs, the residential care facilities have to meet certified standards. The standard-setting procedure was shaped by two forces, pressure of time and fear of catastrophe, which are easily scandalized in the media. Much regulation occurred in response to disasters such as fires or nursing scandals, which led to federal hearings that uncovered serious neglect of the patients’ concerns (Kane 1990: 21). Under the pressure of time, policymakers then turned to models that were available in the sector of acute care hospitals. Hence, nursing homes were envisioned as miniature hospitals, and the regulations placed strong emphasis on life safety and on staffing requirements modeled on small hospitals, with a strong component of trained nurses. The strong emphasis on standards meant that many of the original nursing homes, which had emerged out of boardinghouses, could no longer operate. In 1971, a new class of facilities, called intermediate care facilities, was established, with less stringent requirements. The strict regulatory system, based on predeterPublished by Duke University Press


Alber

9

The Elderly 949

mined methods of care and negative sanctions of poor performance rather than positive sanctions for achievements, is considered to be an impediment to experimentation and innovation in care (Kane 1990: 21). ComparativeAnalysis and General Lessons

What, then, are the results and the lessons of this attempt to map variations in residential care for the elderly? Table 10 summarizes the major findings and helps to identify what features the three countries have in common and in what respects they differ. In all three countries, the proportion of older people in need of care has risen rapidly, while the caretaker potential within the family system has shrunk. There is, thus, a growing need for alternative long-term care. In response to this need, all three countries have expanded their supply of residential care. The number of places in residential care facilities has risen, as has the number of nursing personnel. As personnel have increased and staffing ratios gradually improved, spending for residential care has grown faster than total health expenditure. The German case suggests that even per capita expenditure has increased at roughly the same rate as per capita sickness insurance benefits. In this sense, the data presented here do not lend support to the idea that Western welfare states are characterized by the segmentation and marginalization of groups outside the core of the labor force, leading to an increasing neglect of their concerns. This may be considered the first substantive lesson to be drawn from this comparative analysis. The question then is how we measure and explain variations in the provisions for people in need of care. The first, and maybe foremost, lesson in this respect is that we need to establish an empirical database for valid comparisons of the social services. So far, comparative welfare state research has been based almost exclusively on information about “social transfers” (cash benefits). This is linked to the fact that international organizations such as the International Labour Office or the Organization for Economic Cooperation and Development have provided readily available comparative data collections on the type and amount of welfare benefits in different countries. Similar collections for the social services are lacking. At present, the information needs to be drawn from a host of national sources with widely discrepant types of data and statistical definitions. The few comparative studies that are available are usually handbook collections compiling various country reports written by authors of the respective nation (see, e.g., the useful pioneer effort by Schwab 1989). Published by Duke University Press

Supply growing faster than elderly population. Number of places grew I .5 fold during the 1980s

Supply growing faster than cldcrly population. Number of places roughly doubled since mid- 1960s

Change

Growing faster than total health expenditure

Growing faster than sickness insurance expenditures on aggregate. Per capita expenditure growing slower

6.8%

7.4%

75 and Over


15.6%

15.4%

65 and Over

Demographic Dependency Ratio

I. Social Structures

Explanatory

5.1%

12.5%

Growing faster than total health expenditure

Gradually improving

Not known

Gradually improving

Change

Expenditure

1:1.7 (in 1980)

About 1:1.5 (mid-1980s)

1:3 (in 1987)

Not known

6% (1986)

U.S.A.

Level

Staffing Ratios in Residential Homes

6-796

( 1989)

United Kingdom

5% (1990)

Germany

Level

Places in Residential Homes per 100 People Aged 65 and over

Dependent

Variables

Table 10 Residential Care for the Elderly in Germany, U.K., and U.S.A.

Mixed private consumer charges and public income support 49%public 48% private about 2% private insurance Strict public regulation with strong emphasis on predetermined standards of care. Public inspection with punitive sanctions. Pluralistic sickness insurance with limited coverage, complemented by Medicare and Medicaid. No clearcut distinction bet ween long-term care in hospitals or nursing homes.

Predominantly public 64%public 36%private

National regulation for homes outside the public sector stipulating loose guidelines. Public inspection in the form of advice. National health services covering both medical treatment and longterm care. Flexible distinction between medical care and social care.

Mixed: private consumer charges plus public income support 48% private 44% social assistance 8% other public

Federal regulation with minimum standards and public inspection. Advice rather than strict control from above.

Statutory sickness insurance scheme with corporate decision making and sharp distinction between medical care and longterm care. Other than social assistance, practically no public provision for residential care.

Financing

Regulatory

Institutional Setting


Predominantly private provision 72% private 2 1% voluntary 6% public

587

Mixed public/private provision with strong private and weak voluntary sectors 47%private 43%public 10%voluntary

525

Predominantly by voluntary sector 64%voluntary 2 1% public 15% private

656

Delivery (% of beds)

11. Institutional Structures

Caretaker Potential (Women Aged 45-60 per 1 ,OOO People Aged 65 and Over)



Helpful as they are, such collections usually provide rather heterogeneous and insufficiently standardized country chapters which do not yet provide a valid basis for truly comparative analyses. In order to facilitate comparisons which go beyond transfers and include the increasingly important social services, genuine basic research is needed. Such empirical groundwork is scarcer than sweeping interpretations of the heterogeneous material that is currently available. In order to move ahead with the task of empirical research on the social services, this article suggested a battery of basic indicators on residential care for the elderly, which should help to provide the ground for comparative analyses: the number of places in residential homes, as a percentage of the population aged sixty-five and over; stafing ratios, showing the number of places per nursing staff the delivery structure, in terms of the percentage of places provided by public, voluntary, and for-profit agencies; and thefinancing structure, showing how the cost of care is distributed among private households and various public agencies. In order to interpret the degree to which needs are satisfied in different countries, these data must be placed into a wider context that describes the two basic functional equivalents to residential care: private care in the family system and home care services for the elderly, which are dealt with in the article by Anne Jamieson in this issue of the Journal of Health Politics, Policy and Law. Once we have sufficiently mapped variations among countries, the question is how to interpret the marked national differences summarized in Table 10. The United Kingdom clearly provides the largest number of places in residential facilities in proportion to the elderly population, and it also has the highest staffing ratios. The United States follows, in second place, with an intermediate supply of places and similar staffing ratios to the United Kingdom. Germany, which has the highest caretaker potential among the three nations, reports not only the lowest supply of nursing homes but also conspicuously poor staffing of its residential facilities for older people. How, then, do we interpret this ranking? A first answer would be that the differences in the caretaker potential sufficiently explain the varying supply of residential care facilities. In fact, the levels of provision-highest in the United Kingdom, intermediate in the U.S.A., and lowest in Germany-vary inversely with the levels of societal resources, as measured by the number of women who could be caretakers. However, aggregate indicators of this kind can hardly be expected to translate immediately into policies. Institutional and organizational factors, which also vary widely among the three countries, Published by Duke University Press


Alber

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are certainly also at work. Among these, the delivery and the financing structure are presumably of foremost importance. In terms of delivery structure, Germany’s residential care is dominated by a host of voluntary nonprofit associations, the most important of which are church-based, i.e., linked to the different denominations (Curitus for Catholics and Diukonie for Protestants). Public and private providers play only marginal roles. The British system, in contrast, is characterized by a public/private mix in which public and private providers control similar shares of the residential care industry, while voluntary agencies are almost negligible. The American sector of residential care, in turn, is clearly dominated by private business. The German delivery structure has two consequences. First, a policy of expansion requires a high degree of cooperation and consensus among policymakers and the various voluntary agencies responsible for policy implementation. As these are neither politically responsible to an electorate nor allowed to make profits, they lack political or market incentives to expand their services. In addition, they are heavily dependent upon the supply of voluntary helpers rendering unpaid or poorly paid services in their leisure time. The potential of church-based agencies shrinks in the context of secularization, however. Second, tlw clients of voluntary nonprofit associations lack effective channels for “interest articulation .” In a system organized largely along denominational lines and group affiliation, they have no voice and no “exit chance” to articulate their concerns. In the British publidprivate mix, in contrast, there are political as well as market incentives to respond to the need of clients who can articulate their interests in the role either of the voter or of the consumer. In the American context, finally, the for-profit providers have an economic incentive to expand their services as long as a growing need for services makes for an expanding market. In this context, however, the quality of service needs to be buttressed by a strong degree of public regulation. The comparatively weak degree of regulation in Germany underlines the autonomy of the voluntary associations, which are subject neither to strong market pressures nor to tight political controls. TheJinuncing structure may be considered a second crucial factor in explaining the cross-country variations. In Germany local authorities are largely responsible for financing residential care from their social assistance budgets. Therefore they tend to shift clients from residential to ambulatory care, because the latter is financed jointly by private households and by the sickness insurance scheme, which bears no responsibility for residential care. In the United Kingdom, in contrast, the local authorities have an incentive to shift people to private residential homes, as Published by Duke University Press



the Department of Social Security meets the resulting cost from the central budget. A similar mechanism is at work in the United States, where people in nursing homes are subject to less stringent eligibility controls under the Medicaid scheme than people receiving ambulatory care. Thus, the British and American incentive structure favors delivery into residential and nursing homes, whereas the German one impedes it. Finally, general features of the health care system are important promotors or inhibitors of the development of residential care, as the two extreme cases, the United Kingdom and Germany, show. The better performance of the British system of residential care may be explained by the following general proposition: If the state functions as the financing and regulating agency of health services, the general interests of consumers have a better chance to win over sector-specific interests of particular powerful interest groups. One major reason for the fact that the British health care system has proved most responsive to the needs of older people in my analysis is that the National Health Service is financed from general taxation and has a minister of health at its top who is accountable to Parliament and to the voters. Since the election mechanism links political elites to the concerns of the public, and since elderly persons represent a growing proportion of the electorate, general consumer interests that are not sectoror group-specific have a better chance to be considered in the policymaking process. In addition, the coordination of various types of services is facilitated if they are united under the common roof of a unified health service. Because access to residential care in various states of the United States varies widely and due to the various levels of care in different institutions, which are only partly certified for participation under Medicaid, the American case lends itself less readily to generalizations. However, the intermediate position of the United States with respect to the aggregate data examined here may be interpreted along similar lines as the British case. Residential services for the elderly could be developed to a larger extent than in Germany because there are not only stronger market incentives for growth but also similar political mechanisms at work as in the United Kingdom. Since it is the federally regulated and tax-financed Medicaid system which pays for residential care to the same extent as private households, political office holders have had to pay attention to the needs of the growing and comparatively well-organized elderly population. In Germany, in contrast, the health care system is dominated by the contribution-based sickness insurance system and its largely autonomous Published by Duke University Press


Alber

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insurance funds, which are administered by corporatist boards composed of employee and employer interests. In this system, the central arena for health care decision making is not the political system but the collective bargaining process between the funds and the providers. This means that there is no institutional coupling with general consumer interests, as in the case of political decision making linked to the election process. In the collective bargaining process between corporate actors, only the interests of the groups represented at the negotiation table are considered. In such a context, the coordination of various types of services is impeded and costs of decisions tend to be shifted or externalized to weakly organized segments of society. Since only economically active contributors (i.e., not pensioners) are represented in the sickness funds, it becomes likely that the interests of older people are neglected and that cost containment interests predominate over interest to satisfy the need for care. This general tendency in a system dominated by employers and employees prevails especially in those sectors of service delivery that are overwhelmingly utilized by economically inactive groups. Thus, German sickness funds have always been hesitant to accept an expansion of benefits for long-term care, which not only would be costly but would also predominantly favor pensioners. An adequate consideration of the health care needs of the elderly requires channels for “interest articulation ,” which a system of the German type does not provide. This may be considered the final and most general lesson to be drawn from this study of residential care in Germany, the U.K., and the U.S.A.

References Alber, Jens. 1990. AusmaB und Ursachen des Pflegenotstands in der Bundesrepublik. Staatswissenschaften und Staatspraxis 3: 335-62. Bundesministerium fur Familie und Senioren. 1991 Heimphtzstatistik. Bonn: Bundesministerium fur Familie und Senioren. . 1984. Bericht der Bundesregierung zu Fragen &r Pfegebediirftigkeit. Bundestagsdrucksache 101 1943. Bonn: Heger. Bundesministerium fur Jugend, Familie, Frauen und Gesundheit. 1990. Tagespfege in der Bundesrepublik Deutschland. Schriftenreihe des Bundesministers Jugend, Familie, Frauen und Gesundheit, Band 249. Stuttgart: Kohlhammer. Bundesministerium fur Jugend, Familie und Gesundheit. 1980. Anzahl und Zahl zu Hause Zebender P$egebedu$tiger. Schriftenreihe des Bundesministers Jugend, Familie und Gesundheit Band 80. Stuttgart: Kohlhammer. Published by Duke University Press



Central Statistical Office. 1990, 1991. Annuul Abstract of Statistics. London: Her Majesty’s Stationery Office. Dahrendorf, Ralf. 1988. The Modern Social Conjlict: An Essay on the Politics of Liberr?,. London: Weidenfeld and Nicolson. Day, Patricia, and Rudolf Klein. 1987. The Regulation of Nursing Homes: A Comparative Perspective. Milbank Quarterly 65 (3):303-47. Jamieson, Anne. 1990. Residential Care and Nursing Homes in the U.K. Paper presented at the conference on “The Division of Labour in the Light of New Challenges ,” Max-Planck-Institut fur Gesellschaftsforschung, Cologne, 19-20 November (mimeo). Jazwiecki, Thomas. 1989. Long-Term Care for the Elderly in the United States. In Caringfor an Aging World, ed. T. Schwab. New York: McGraw-Hill. Kane, Robert L. 1990. “The Nursing Home in America: An Institution for All Reasons.” Paper presented at the conference on “The Division of Labour in the Light of New Challenges,” Max-Planck-Institut fur Gesellschaftsforschung. Cologne, 19-20 November (mimeo). Landtag von Baden-Wurttemberg. 1990. Bericht und Antrng des Untersuchungsausschusses “Menschenwiirde und Selbstbestimmung im Alter” zu dem Antrag der Fraktion der SPD. Drucksache 1014311. Stuttgart: Landtag von Baden-Wurttemberg. Priester, Klaus. 1989. Ambulant oder stationar? Moglichkeiten und Grenzen der Entlastung des Krankenhaussektors durch ambulante sozialpflegerische Dienste und hausliche Pflege. In Das Krankenhaus: Kosten, Technik oder humane Versorgung, ed. H.-U. Deppe, H. Friedrich. and R. Muller. Frankfurt am Main: Campus. Ruckert. Willi. 1987. Der Bedarf an ambulanten Diensten und die vorhandenen Dienste: Eine kritische Bestandsaufnahme. In Gesundheits- und sozialpj7egerische Arbeit im Umbruch: Berujliche Bildung im Schnittpunkt einer veranderten Gesundheits- und Sozialpolitik, ed. B . Meiford. Alsbach-Hahnlein: Leuchtturm Verlag Vevisch. . 1989. Die demographische Entwicklung und deren Auswirkungen auf Pflege-, Hilfs- und Versorgungsbedurftigkeit. In Die demographische Herausforderung: Dns GesundheitssFstem nngesichts einer veranderten Bevolkerungssrruktur, ed. C. von Ferber et al. Beitrage zur Gesundheitsokonomie, Bd. 23 Gerlingen: Bleicher. . 1990. “Nursing Homes and Hospices in Germany.” Paper presented to the conference on “The Division of Labour in the Light of New Challenges,” MaxPlanck-Institut fur Gesellschaftsforschung, Cologne, 19-20 November (mimeo). Sachverstandigenrat fur die Konzertierte Aktion im Gesundheitswesen. 1990. Herausforderungen und Perspektiven der Gesundheitsversorgung. Jahresgutachten 1990. Baden-Baden: Nomos. . 1991 . Das Gesundheitsweserr im vereinten Deutschland: Jahresgutachten 1991. Baden-Baden: Nomos. Schwab, Teresa, ed. 1989. Caringfor an Aging World. New York: McGraw Hill. Schulz, Joachim. 1989. Armut und Sozialhilfe. Stuttgart: Kohlhammer. Schulz-Nieswandt, Frank. 1990. Stationare Altenpflege und “Pjlegenotstand” in der Bundesrepublik Deutschland. Frankfurt am Main Peter Lang .



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Statistical Abstract of the United States. 1990. 110th edition. Washington, DC: U.S. Bureau of the Census. Statistisches Bundesamt. 1981. StatistischesJahrbuchfur die BundesrepublikDeutschland. Wiesbaden: Metzler-Poeschel. . 1991. StatistischesJahrbuchfur die BundesrepublikDeutschland.Wiesbaden: Metzler-Poeschel. Tennstedt, Florian, and Stephan Leibfried, eds. 1985. Politik der Armut und die Spaftung des Sozialstaats. Frankfurt am Main: Suhrkamp. Thiede, Reinhold. 1988. Die besondere Lage der alteren Pflegebedurftigen. Sozialer Fortschritt 37 (1 1 ): 250-55. Walker, Alan. 1991. Sociul and Economic Policies and Older People in the United Kingdom. Report for the European Community Actions on Older People. Brussels: European Community (mimeo). Walker, Alan, and Lorna Warren. 1991. The Care of Frail Older People in BritainCurrent Policies and Future Prospects. In The Graying of the World: Who Will Care for the Frail Elderly? ed. L. K. Olson. Binghamton, NY: Haworth.



HEALTH CARE REFORM Lessons from the Past, Prospects for the Future

Journal of Health Politics, Policy and Law Vol. 18, Nos. 1 and 2 Summer and Fall 1993 A remarkable group of scholars and health policy analysts on what has become the hottest political issue in recent years

Summer Lawrenw Brown on American business and health policy; David McBride on the shim from community heatth care to aisis medicine in Black America; Cathieh Martin on business, government, and the quest for co5f a d ;Rand Rosenblatt on the courts and the reconstruction of American social legion; David M man on the history of health care r e h in America; Mark Peterson on politid influence in the 1990s; Deborah Stone on health insurance; and Kenneth Thorpe on health care spending in the US.and Canada Wnh an introduction by James Morone and mmentariesby Robert Hackyand M i i Sparer.

Fall William Gbser on universal heatth insurance that really works; Lawrence Jacobs on thepuWsambivakm toward government; Nancy Jeckeron employer-based health insurance; Mark Schlesinger on popular support for federal pdtcies; Theda Skocpd on symbols; Bruce Spitz on state governments. Wnh an essay by James Morone and commentaries. From the conference heM in Durham, NC,1-2 May 1992, on k a & h Care R e h : Lessons hum the Past, PIOspeds Ibr the Future

Individual copies $22 each;subscriptions $Wyeaf (institutions) or (individuals), or at speaal introdudory rates using subscnptiin card bound into this issue d JfPR. From: Journals Fulfillment, Duke University Press, Box 90660, Durham, NC 277o84660. $44”


Infection control intervention on meticillin resistant Staphylococcus aureus transmission in residential care homes for the elderly.

Residential care for the destitute elderly: A comparative study of two institutions in Zimbabwe.

Establishing CUTOFF values for the Simplified Barthel Index in elderly adults in residential care homes.

Feasibility and impact of a post-discharge geriatric evaluation and management service for patients from residential care: the Residential Care Intervention Program in the Elderly (RECIPE).

Costs and benefits of home care for the elderly versus residential care: a comparison using propensity scores.

Evaluation of a mobile X-ray service for elderly residents of residential aged care facilities.

Solving the "Personhood Jigsaw Puzzle" in Residential Care Homes for the Elderly in the Hong Kong Chinese Context.

[Medical treatment of the elderly in residential care: a multicenter cross-sectional study].

An evaluation of residential care for tetraplegics.

Dignity, risks and responsibility in residential homes for elderly people.

Care for the infirm elderly.

Iodine Status of New Zealand Elderly Residents in Long-Term Residential Care.

Measuring the quality of residential care.

Assessment of elderly people on entry to residential homes and continuing care arrangements.

Care for the elderly, care by the elderly: The role of elderly women in a changing Tswana society.

Home health care for the elderly.

Letter: Hospital care for the elderly.

Does the Aged Care Funding Instrument provide increased funding in residential care? Comparisons with the Residential Classification Scale.

Coronary care for elderly patients.

Quality of Drinking Water Treated at Point of Use in Residential Healthcare Facilities for the Elderly.

Medical screening of old people accepted for residential care.

Hospital care for the elderly. The need for acute services.

Risks, dignity & responsibility in residential homes for the elderly: freedom or restraint.

Employee influenza vaccination in residential care facilities.