The Evolution of Long-Term Care Services


In the first century of our country’s history there no such things as home care services, nursing homes or assisted living. Society was mostly rural and people lived in their own homes. Families cared for their loved ones at home till death took them. In the latter part of the 1800’s because of an increasingly urban society, many urban families were often unable to care for loved ones due to a lack of space or because all family members including children were employed six days a week, 12 hours a day.

During this period, many unfortunate people needing care were housed in county poor houses or in facilities for the mentally ill. Conditions were deplorable. In the early 1900’s home visiting nurses started reversing this trend of institutionalizing and allowed many care recipients to remain in their homes. Nursing homes or so-called rest homes were also being built with public donations or government funds. With the advent of Social Security in 1936, a nursing home per diem stipend was included in the Social Security retirement income and this government subsidy spurred the construction of nursing homes all across the country.

By the end of the 1950s it was apparent that Social Security beneficiaries were living longer and that the nursing home subsidy could eventually bankrupt Social Security. But in order to protect the thousands and thousands of existing nursing homes, Congress had to find a way to provide a subsidy but remove it as an entitlement under Social Security.

In 1965 Medicare and Medicaid were created through an amendment to the Social Security act. Under Medicare, nursing homes were only reimbursed on behalf of Social Security beneficiaries for short-term rehabilitation. Under Medicaid, nursing homes were reimbursed for impoverished disabled Americans and impoverished aged Americans over the age of 65. The nursing home entitlement for all aged Americans was now gone and replaced by a nursing home subsidy for indigent elderly people.

Over the last 50 years, there has been a gradual change away from the use of nursing homes for long term care towards the use of home care and community living arrangements that also provide in-house care.

We are seeing a trend towards working conditions like those in urban America in the early 1900’s where both husband and wife are working and putting in longer hours. We are also seeing a return of the trend in the early part of the 20th century where outside visitor caregivers are becoming available to replace working caregiver’s and allow the elderly to receive long term care in their homes.

In addition there is a significant trend in the past few years for Medicaid and Medicare to pay for long term care in the home instead of in nursing homes. And as has been mentioned before, given enough money for paid providers or government funding for the same, a person would never have to leave his home to receive long term care. All services could be received in the home. Adequate long term care planning or having substantial income can allow this to happen.

We only need to look at wealthy celebrities to recognize this fact. Christopher Reeve, the movie star, was totally disabled but he had enough money to buy care services and remain in his home. President Ronald Reagan suffered from Alzheimer’s for many years but received care at his California ranch. He was also wealthy enough to pay for care when needed. Or what about Annette Funicello or Richard Pryor? Income from their movie careers allowed them to receive care with their multiple sclerosis at home. We will be willing to bet that Mohammed Ali, who is severely disabled with Parkinson’s disease, will probably never see the inside of a care facility, unless he chooses to go there to die.

With the proper planning and the money it provides, most of us could remain in our homes to receive long term care and we would never have to go to an institution or a hospital.