Medical care services for the elderly.

INTRODUCTION The growth and change in the provision of health services in the United States since World War II has been profound. Underlying this change was a national decision to foster a scientific understanding of health and disease. In the post-World War II period the federal government began to support medical research by establishing the National Institutes of Healththe start of 35 years of substantial direct investment in biomedical research. According to Kissick, federal support for the training of health personnel to apply the fruits of this research developed more slowly [ 11. Although support for mental health training began in 1948, broad support for the education of health professionals became substantial nearly 20 years later, when shortages of health manpower became apparent owing to growth of the population, increases in medical knowledge and improved third-party coverage of care. The development of a broad biomedical knowledge base increased the likelihood that the care provided would be beneficial. Application of the knowledge contributed to reductions in mortality among adults, altering the demographic characteristics of the elderly. Importantly, the increased effectiveness of medical care emphasized the inequity of some elderly not having access to care because of its unavailability or cost. As the hospital became the principal site for providing new health care technology, the cost of health care and private insurance for the aged increased. Many elderly could not afford health insurance. In the Great Society, as defined by President Lyndon Johnson in the mid-1960s all who needed health care were to have it. Financial inaccessibility to health care for the aged became unacceptable. Financial access to health care was ensured by Titles XVIII (Medicare) and XIX (Medicaid) amendments to the Social Security Act, implemented in 1966. Medicare provided universal coverage for acute hospital care in Part A and for payment of physician services in the optional Part B, but for no long-term care. Medicaid provided for comprehensive medical service for those categorically needy, as defined by each State. The federal government shared in the cost of services by predetermined formulae, but did not directly control the cost or extent of services reimbursed. Two categories, Old Age Assistance and the Medically Needy, particularly affected the elderly. Medicaid provided for long-term care, specifically nursing home care for those requiring continued personal, as well as nursing care. Unexpectedly, this nursing home care ultimately became the single most expensive Medicaid service, accounting for over half of Medicaid expenditures. In the United States the health care system is often categorized as a nonsystem of care. Care is given by numerous decentralized, pluralistic, entrepreneurial individual providers and institutions. Under such a system innumerable individual decisions are made regarding development of resources and provision of care. Although this makes for uncertain and often unpredictable responses to government policy, the system has the virtue of rapid adaptation to new influences. This is true whether those influences are government regulation, new resources, changes in the financing of care or new health care technology. Government payment for medical care affected provision of services by the health care system. In initiating Medicare and Medicaid, the government promised not to interfere with prevailing patterns of health care service delivery. Nevertheless, as a purchaser of health care, government became concerned with rapid increases in the cost of care for which it had open-ended financial liability. This concern was initially reflected in attempts to modify the health care system indirectly through regional planning, concern for quality, encouragement of alternative delivery systems and reduction in support for new medical resources. Subsequently, the federal govemment more directly affected health care delivery by direct cost controls and by changing traditional means of cost-based reimbursement. This paper presents national statistical reflections of changes in the delivery of health care to the elderly associated with evolving government health policy for the last 20 years. The data will provide a basis for the discussion of changes in service use, current cost problems, and continuing changes in health care delivery to the elderly.