Healthcare reform in the United States

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Healthcare_reform_in_the_United_States 

Healthcare reform in the United States has a long history. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 (H.R. 4872), which amended the PPACA and became law on March 30, 2010.

Future reforms of the American health care system continue to be proposed, with notable proposals including a single-payer system and a reduction in fee-for-service medical care. The PPACA includes a new agency, the Center for Medicare and Medicaid Innovation (CMS Innovation Center), which is intended to research reform ideas through pilot projects.

History of national reform efforts

The following is a summary of reform achievements at the national level in the United States. For failed efforts, state-based efforts, native tribes services, and more details, see the history of health care reform in the United States article.

• 1965 President Lyndon Johnson enacted legislation that introduced Medicare, covering both hospital (Part A) and supplemental medical (Part B) insurance for senior citizens. The legislation also introduced Medicaid, which permitted the Federal government to partially fund a program for the poor, with the program managed and co-financed by the individual states.
• 1985 The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended the Employee Retirement Income Security Act of 1974 (ERISA) to give some employees the ability to continue health insurance coverage after leaving employment.
• 1996 The Health Insurance Portability and Accountability Act (HIPAA) not only protects health insurance coverage for workers and their families when they change or lose their jobs, it also made health insurance companies cover pre-existing conditions. If such condition had been diagnosed before purchasing insurance, insurance companies are required to cover it after patient has one year of continuous coverage. If such condition was already covered on their current policy, new insurance policies due to changing jobs, etc... have to cover the condition immediately.
• 1997 The Balanced Budget Act of 1997 introduced two new major Federal healthcare insurance programs, Part C of Medicare and the State Children's Health Insurance Program, or SCHIP. Part C formalized longstanding "Managed Medicare" (HMO, etc.) demonstration projects and SCHIP was established to provide health insurance to children in families at or below 200 percent of the federal poverty line. Many other "entitlement" changes and additions were made to Parts A and B of fee for service (FFS) Medicare and to Medicaid within an omnibus law that also made changes to the Food Stamp and other Federal programs.
• 2000 The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) effectively reversed some of the cuts to the three named programs in the Balanced Budget Act of 1997 because of Congressional concern that providers would stop providing services.
• 2003 The Medicare Prescription Drug, Improvement, and Modernization Act (also known as the Medicare Modernization Act or MMA) introduced supplementary optional coverage within Medicare for self-administered prescription drugs and as the name suggests also changed the other three existing Parts of Medicare law.
• 2010 The Patient Protection and Affordable Care Act, called PPACA or ACA but also known as Obamacare, was enacted, including the following provisions:
  • the phased introduction over multiple years of a comprehensive system of mandated health insurance reforms designed to eliminate "some of the worst practices of the insurance companies"—pre-existing condition screening and premium loadings, policy cancellations on technicalities when illness seems imminent, annual and lifetime coverage caps
  • created health insurance marketplaces with three standard insurance coverage levels to enable like-for-like comparisons by consumers, and a web-based health insurance exchange where consumers can compare prices and purchase plans.
  • mandates that insurers fully cover certain preventative services
  • created high-risk pools for uninsureds
  • tax credits for businesses to provide insurance to employees
  • created an insurance company rate review program
  • allowed dependents to remain on their plan until 26
  • It also sets a minimum medical loss ratio of direct health care spending to premium income creates price competition
  • created Patient-Centered Outcomes Research Institute to study comparative effectiveness research funded by a fee on insurers per covered life
  • allowed for approval of generic biologic drugs and specifically allows for 12 years of exclusive use for newly developed biologic drugs
  • many changes to the 1997, 2000, and 2003 laws that had previously changed Medicare and further expanded eligibility for Medicaid (that expansion was later ruled by the Supreme Court to be at the discretion of the states)
  • explores some programs intended to increase incentives to provide quality and collaborative care, such as accountable care organizations. The Center for Medicare and Medicaid Innovation was created to fund pilot programs which may reduce costs; the experiments cover nearly every idea healthcare experts advocate, except malpractice/tort reform.
  • requires for reduced Medicare reimbursements for hospitals with excess readmissions and eventually ties physician Medicare reimbursements to quality of care metrics.
• 2015 The Medicare Access and CHIP Reauthorization Act (MACRA) made significant changes to the process by which many Medicare Part B services are reimbursed and also extended SCHIP
• 2017 Donald Trump is sworn in as President, signs Executive Order 13765 in anticipation of a repeal of the Patient Protection and Affordable Care Act, one of his campaign promises. The American Health Care Act is introduced and passed in the House of Representatives and introduced but not voted upon in the Senate. President Donald Trump signs Executive Order 13813 which allows insurance companies to sell low-cost short-term plans with lesser coverage, enables small business to collectively purchase association health plans, and expands health savings accounts.

Motivation

Main article: Healthcare reform debate in the United States

 

Bar chart comparing healthcare costs as percentage of GDP across OECD countries

 

Medicare and Medicaid Spending as % GDP (data from the CBO)

 

Chart showing life expectancy at birth and health care spending per capita for OECD countries as of 2015. The U.S. is an outlier, with much higher spending but below average life expectancy.

 

Health spending per capita, in US$ PPP-adjusted, compared amongst various first world nations.

International comparisons of healthcare have found that the United States spends more per-capita than other similarly developed nations but falls below similar countries in various health metrics, suggesting inefficiency and waste. In addition, the United States has significant underinsurance and significant impending unfunded liabilities from its aging demographic and its social insurance programs Medicare and Medicaid (Medicaid provides free long-term care to the elderly poor). The fiscal and human impact of these issues have motivated reform proposals.

U.S. healthcare costs were approximately $3.2 trillion or nearly $10,000 per person on average in 2015. Major categories of expense include hospital care (32%), physician and clinical services (20%), and prescription drugs (10%). U.S. costs in 2016 were substantially higher than other OECD countries, at 17.2% GDP versus 12.4% GDP for the next most expensive country (Switzerland). For scale, a 5% GDP difference represents about $1 trillion or $3,000 per person. Some of the many reasons cited for the cost differential with other countries include: Higher administrative costs of a private system with multiple payment processes; higher costs for the same products and services; more expensive volume/mix of services with higher usage of more expensive specialists; aggressive treatment of very sick elderly versus palliative care; less use of government intervention in pricing; and higher income levels driving greater demand for healthcare. Healthcare costs are a fundamental driver of health insurance costs, which leads to coverage affordability challenges for millions of families. There is ongoing debate whether the current law (ACA/Obamacare) and the Republican alternatives (AHCA and BCRA) do enough to address the cost challenge.

According to 2009 World Bank statistics, the U.S. had the highest health care costs relative to the size of the economy (GDP) in the world, even though estimated 50 million citizens (approximately 16% of the September 2011 estimated population of 312 million) lacked insurance. In March 2010, billionaire Warren Buffett commented that the high costs paid by U.S. companies for their employees' health care put them at a competitive disadvantage.

Life expectancy compared to healthcare spending from 1970 to 2008, in the US and the next 19 most wealthy countries by total GDP.

Further, an estimated 77 million Baby Boomers are reaching retirement age, which combined with significant annual increases in healthcare costs per person will place enormous budgetary strain on U.S. state and federal governments, particularly through Medicare and Medicaid spending (Medicaid provides long-term care for the elderly poor). Maintaining the long-term fiscal health of the U.S. federal government is significantly dependent on healthcare costs being controlled.

Insurance cost and availability

In addition, the number of employers who offer health insurance has declined and costs for employer-paid health insurance are rising: from 2001 to 2007, premiums for family coverage increased 78%, while wages rose 19% and prices rose 17%, according to the Kaiser Family Foundation. Even for those who are employed, the private insurance in the US varies greatly in its coverage; one study by the Commonwealth Fund published in Health Affairs estimated that 16 million U.S. adults were underinsured in 2003. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes—73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level. However, a study published by the Kaiser Family Foundation in 2008 found that the typical large employer preferred provider organization (PPO) plan in 2007 was more generous than either Medicare or the Federal Employees Health Benefits Program Standard Option. One indicator of the consequences of Americans' inconsistent health care coverage is a study in Health Affairs that concluded that half of personal bankruptcies involved medical bills, although other sources dispute this.

There are health losses from insufficient health insurance. A 2009 Harvard study published in the American Journal of Public Health found more than 44,800 excess deaths annually in the United States due to Americans lacking health insurance. More broadly, estimates of the total number of people in the United States, whether insured or uninsured, who die because of lack of medical care were estimated in a 1997 analysis to be nearly 100,000 per year. A study of the effects of the Massachusetts universal health care law (which took effect in 2006) found a 3% drop in mortality among people 20–64 years old—1 death per 830 people with insurance. Other studies, just as those examining the randomized distribution of Medicaid insurance to low-income people in Oregon in 2008, found no change in death rate.

The cost of insurance has been a primary motivation in the reform of the US healthcare system, and many different explanations have been proposed in the reasons for high insurance costs and how to remedy them. One critique and motivation for healthcare reform has been the development of the medical–industrial complex. This relates to moral arguments for health care reform, framing healthcare as a social good, one that is fundamentally immoral to deny to people based on economic status. The motivation behind healthcare reform in response to the medical-industrial complex also stems from issues of social inequity, promotion of medicine over preventative care. The medical-industrial complex, defined as a network of health insurance companies, pharmaceutical companies, and the like, plays a role in the complexity of the US insurance market and a fine line between government and industry within it. Likewise, critiques of insurance markets being conducted under a capitalistic, free-market model also include that medical solutions, as opposed to preventative healthcare measures, are promoted to maintain this medical-industrial complex. Arguments for a market-based approach to health insurance include the Grossman model, which is based on an ideal competitive model, but others have critiqued this, arguing that fundamentally, this means that people in higher socioeconomic levels will receive a better quality of healthcare.

Uninsured rate

With the implementation of the ACA, the level of uninsured rates severely decreased in the U.S. This is due to the expansion of qualifications for access to medicaid, subsidizing insurance, prevention of insurance companies from underwriting, as well as enforcing the individual mandate which requires citizens to purchase health insurance or pay a fee. In a research study which was conducted comparing the effects of the ACA before and after it was fully implemented in 2014, it was discovered that racial and ethnic minorities benefited more than whites with many gaining insurance coverage which they lacked before allowing for many to seek treatment improving their overall health. In June 2014, Gallup–Healthways Well–Being conducted a survey and found that the uninsured rate is decreasing with 13 percent of U.S. adults uninsured in 2014 compared to 17 percent in January 2014 and translates to roughly 10 million to 11 million individuals who gained coverage. The survey also looked at the major demographic groups and found each is making progress towards getting health insurance. However, Hispanics, who have the highest uninsured rate of any racial or ethnic group, are lagging in their progress. Under the new health care reform, Latinos were expected to be major beneficiaries of the new health care law. Gallup found that the biggest drop in the uninsured rate (3 percentage points) was among households making less than $36,000 a year.

Waste and fraud

In December 2011 the outgoing Administrator of the Centers for Medicare & Medicaid Services, Donald Berwick, asserted that 20% to 30% of health care spending is waste. He listed five causes for the waste: (1) overtreatment of patients, (2) the failure to coordinate care, (3) the administrative complexity of the health care system, (4) burdensome rules and (5) fraud.

An estimated 3–10% of all health care expenditures in the U.S. are fraudulent. In 2011, Medicare and Medicaid made $65 billion in improper payments (including both error and fraud). Government efforts to reduce fraud include $4 billion in fraudulent payments recovered by the Department of Justice and the FBI in 2012, longer jail sentences specified by the Affordable Care Act, and Senior Medicare Patrols—volunteers trained to identify and report fraud.

In 2007, the Department of Justice and Health and Human Services formed the Medicare Fraud Strike Force to combat fraud through data analysis and increased community policing. As of May 2013, the Strike Force has charged more than 1,500 people for false billings of more than $5 billion. Medicare fraud often takes the form of kickbacks and money-laundering. Fraud schemes often take the form of billing for medically unnecessary services or services not rendered.

Quality of care

There is significant debate regarding the quality of the U.S. healthcare system relative to those of other countries. Although there are advancements in the quality of care in America due to the acknowledgement of various health related topics such as how insurance plans are now mandated to include coverage for those with mental health and substance abuse disorders as well with the inability to deny a person who has preexisting conditions through the ACA, there is still much that needs to be improved. Within the U.S., those who are a racial/ethnic minority along with those who poses a lower income have higher chances of experiencing a lower quality of care at higher cost. Despite the advancements with the ACA, this may discourage a person from seeking medical treatment. Physicians for a National Health Program, a pro-universal single-payer system of health care advocacy group, has claimed that a free market solution to health care provides a lower quality of care, with higher mortality rates, than publicly funded systems. The quality of health maintenance organizations and managed care have also been criticized by this same group.

According to a 2000 study of the World Health Organization, publicly funded systems of industrial nations spend less on health care, both as a percentage of their GDP and per capita, and enjoy superior population-based health care outcomes. However, conservative commentator David Gratzer and the Cato Institute, a libertarian think tank, have both criticized the WHO's comparison method for being biased; the WHO study marked down countries for having private or fee-paying health treatment and rated countries by comparison to their expected health care performance, rather than objectively comparing quality of care.

Some medical researchers say that patient satisfaction surveys are a poor way to evaluate medical care. Researchers at the RAND Corporation and the Department of Veterans Affairs asked 236 elderly patients in two different managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care are easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chang, UCLA, lead author.

Public opinion

The spring 2010 healthcare reform issue of Ms. magazine

Public opinion polls have shown a majority of the public supports various levels of government involvement in health care in the United States, with stated preferences depending on how the question is asked. Polls from Harvard University in 1988, the Los Angeles Times in 1990, and The Wall Street Journal in 1991all showed strong support for a health care system compared to the system in Canada. More recently, however, polling support has declined for that sort of health care system, with a 2007 Yahoo/AP poll showing 54% of respondents considered themselves supporters of "single-payer health care," a majority in favor of a number of reforms according to a joint poll with the Los Angeles Times and Bloomberg, and a plurality of respondents in a 2009 poll for Time Magazine showed support for "a national single-payer plan similar to Medicare for all." Polls by Rasmussen Reports in 2011 and 2012 showed pluralities opposed to single-payer health care. Many other polls show support for various levels of government involvement in health care, including polls from New York Times/CBS News and Washington Post/ABC News, showing favorability for a form of national health insurance. The Kaiser Family Foundation showed 58% in favor of a national health plan such as Medicare-for-all in 2009, with support around the same level from 2017 to April 2019, when 56% said they supported it. A Quinnipiac poll in three states in 2008 found majority support for the government ensuring "that everyone in the United States has adequate health-care" among likely Democratic primary voters.

A 2001 article in the public health journal Health Affairs studied fifty years of American public opinion of various health care plans and concluded that, while there appears to be general support of a "national health care plan," poll respondents "remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan." Politifact rated a 2009 statement by Michael Moore "false" when he stated that "[t]he majority actually want single-payer health care." According to Politifact, responses on these polls largely depend on the wording. For example, people respond more favorably when they are asked if they want a system "like Medicare".

Uninsured Americans, with the numbers shown here from 1987 to 2008, are a major driver for reform efforts

Alternatives and research directions

There are alternatives to the exchange-based market system which was enacted by the Patient Protection and Affordable Care Act which have been proposed in the past and continue to be proposed, such as a single-payer system and allowing health insurance to be regulated at the federal level.

In addition, the Patient Protection and Affordable Health Care Act of 2010 contained provisions which allows the Centers for Medicare and Medicaid Services (CMS) to undertake pilot projects which, if they are successful could be implemented in future.

Single-payer health care

Further information: Single-payer healthcare § United States

A number of proposals have been made for a universal single-payer healthcare system in the United States, most recently the United States National Health Care Act, (popularly known as H.R. 676 or "Medicare for All") but none have achieved more political support than 20% congressional co-sponsorship. Advocates argue that preventative health care expenditures can save several hundreds of billions of dollars per year because publicly funded universal health care would benefit employers and consumers, that employers would benefit from a bigger pool of potential customers and that employers would likely pay less, and would be spared administrative costs of health care benefits. It is also argued that inequities between employers would be reduced. Also, for example, cancer patients are more likely to be diagnosed at Stage I where curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room where treatment can involve years of hospitalization and is often terminal. Others have estimated a long-term savings amounting to 40% of all national health expenditures due to preventative health care, although estimates from the Congressional Budget Office and The New England Journal of Medicine have found that preventative care is more expensive.

Any national system would be paid for in part through taxes replacing insurance premiums, but advocates also believe savings would be realized through preventative care and the elimination of insurance company overhead and hospital billing costs. An analysis of a single-payer bill by the Physicians for a National Health Program estimated the immediate savings at $350 billion per year. The Commonwealth Fund believes that, if the United States adopted a universal health care system, the mortality rate would improve and the country would save approximately $570 billion a year.

Recent enactments of single-payer systems within individual states, such as in Vermont in 2011, may serve as living models supporting federal single-payer coverage. The plan in Vermont, however, has failed.

On June 1, 2017, in light of the recent Trump Administration’s efforts to repeal the Affordable Care Act, California Democratic Senator Ricardo Lara proposed a bill to establish single-payer healthcare within the state of California (SB 562), calling on fellow senators to act quickly in defense of healthcare. The legislation would implement “Medicare for All,” placing all levels of healthcare in the hands of the state. The bill proposed to the California Senate by Senator Lara lacked a method of funding required to finance the $400 billion-dollar policy. Despite this lack of foresight, the bill gained approval from the senate and will move on to await approval by the state assembly.

In wake of the Affordable Care Act, the state of California has experienced the greatest rise in newly insured people compared to other states. Subsequently, the number of physicians under MediCal are not enough to meet the demand, therefore 25% of physicians care for 80% of patients who are covered through MediCal.

In the past, California has struggled to maintain healthcare effectiveness, due in part to its unstable budget and complex regulations. The state has a policy in place known as the Gann Limit, otherwise entitled proposition 98, which ensures that a portion of state funds are directed towards the education system. This limit would be exceeded if California raises taxes to fund the new system which would require $100 billion in tax revenue. In order to avoid legal dispute, voters would be required to amend proposition 98 and exempt healthcare funding from required educational contributions. The state announced on August 1, 2017 that coverage for health insurance will increase by 12.5% in next year, threatening the coverage of 1.5 million people 

Public option

Main article: Public health insurance option

In January 2013, Representative Jan Schakowsky and 44 other U.S. House of Representatives Democrats introduced H.R. 261, the "Public Option Deficit Reduction Act" which would amend the 2010 Affordable Care Act to create a public option. The bill would set up a government-run health insurance plan with premiums 5% to 7% percent lower than private insurance. The Congressional Budget Office estimated it would reduce the United States public debt by $104 billion over 10 years.

Balancing doctor supply and demand

The Medicare Graduate Medical Education program regulates the supply of medical doctors in the U.S. By adjusting the reimbursement rates to establish more income equality among the medical professions, the effective cost of medical care can be lowered.

Bundled payments

A key project is one that could radically change the way the medical profession is paid for services under Medicare and Medicaid. The current system, which is also the prime system used by medical insurers is known as fee-for-service because the medical practitioner is paid only for the performance of medical procedures which, it is argued means that doctors have a financial incentive to do more tests (which generates more income) which may not be in the patients' best long-term interest. The current system encourages medical interventions such as surgeries and prescribed medicines (all of which carry some risk for the patient but increase revenues for the medical care industry) and does not reward other activities such as encouraging behavioral changes such as modifying dietary habits and quitting smoking, or follow-ups regarding prescribed regimes which could have better outcomes for the patient at a lower cost. The current fee-for-service system also rewards bad hospitals for bad service. Some^[who?] have noted that the best hospitals have fewer re-admission rates than others, which benefits patients, but some of the worst hospitals have high re-admission rates which is bad for patients but is perversely rewarded under the fee-for-service system.

Projects at CMS are examining the possibility of rewarding health care providers through a process known as "bundled payments" by which local doctors and hospitals in an area would be paid not on a fee for service basis but on a capitation system linked to outcomes. The areas with the best outcomes would get more. This system, it is argued, makes medical practitioners much more concerned to focus on activities that deliver real health benefits at a lower cost to the system by removing the perversities inherent in the fee-for-service system.

Though aimed as a model for health care funded by CMS, if the project is successful it is thought that the model could be followed by the commercial health insurance industry also.

Centers for Medicare and Medicaid Innovation

With the ACA improving the health of many by increasing the number of people who are insured, this is not the final stage for the ACA due to the push for a medicaid expansion reform. With the Democrats supporting the expansion and the Republicans against it, it was denied in the Supreme Court in the trial of NFIB vs Sebelius. The Court ruled that implementing taxes in order to pay for health insurance for all citizens was an unconstitutional exercise of Congress’s power under Article I. If the expansion eventually succeeds, Medicaid would become a fully federal program with new federal eligibility standards. This would alleviate the responsibility of state governments to fund Medicaid.

In addition to the reform for the medicaid expansion, there are additional reforms focused on addressing social determinants in the healthcare system through various programs and initiatives in order to reduce healthcare expenditures and improve health outcomes.

Programs and initiatives recognizing and addressing non-medical social needs have sprung from various sectors within healthcare, with emerging efforts made by multi-payer federal and state initiatives, medicaid initiatives led by states, or by health plans, as well as provider level actions. State and federal initiatives, primarily sponsored CMMI (Center for Medicare and Medicaid Innovation) a division of CMS, seek to address basic social needs within the context of the healthcare delivery system. CMMI initiatives like the 2016 "Accountable Health Communities" (AHC) model have been created to focus on connecting Medicare and Medicaid beneficiaries with community services to address health-related social needs, while providing funds to organizations so that they can systematically identify and address the health-related social needs of Medicare and Medicaid recipients through screening, referral, and community navigation services. The model was officially implemented in 2017 and will be evaluated for its ability to affect cost of healthcare spending and reduce inpatient/outpatient utilization in 2022. Under the AHC model, funds have been allocated towards developing a 10-item screening tool to identify 5 different patient need domains that can be addressed through community resources (housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety). Increasing bodies of evidence suggest that addressing social needs can help stop their damaging health effects, but screening for social needs is not yet standard clinical practice. Applying this tool in the AHC model will help CMS evaluate the impact of local partnerships between healthcare providers and community organizations in advancing the aims of addressing the cost and quality of health care across all settings. National recommendations around multi-dimension screening for social risk are not yet available since the evidence base to support such recommendations is highly under-developed at present. More research is still needed in this area to be able to demonstrate whether screening for social risk, and especially for multiple domains of social risk, will succeed in meeting the Wilson and Jungner screening criteria.

Health plan specific initiatives

Due to how new CMMI initiatives are, evidence supporting the effectiveness of its various initiatives of reducing healthcare spending and improving health outcomes of patients is relatively small, but is expected to grow within the coming years as many of CMMI's programs and initiatives will be due for their programmatic performance evaluation. However, it remains that there is more evidence of smaller scale initiatives in individual health plans/hospitals/clinics, as several health plans, hospitals, and clinics have sought out to address social determinants of health within their scope of care.^[]

Transportation

Transportation is a key social determinant impacting patient outcomes with approximately 3.6 million individuals unable to receive the necessary medical care due to transportation barrier, according to recent study. In addition, these 3.6 million experience multiple conditions at a much higher rate than those who have stable access to transportation. Many conditions that they face, however, can be managed if appropriate care is made available. For some conditions, this care is cost-effective and results in health care cost savings that outweigh added transportation costs. without access to reliable, affordable, and convenient transportation, patients miss appointments and end up costing clinics money. According to a cross-study analysis, missed appointments and care delays cost the healthcare industry $150 billion each year. Patients without transportation are also less likely to take medications as directed. One study found that 65 percent of patients felt transportation assistance would enable them to fill prescriptions as directed after discharge. According to a recent article published in the Journal of the American Medical Association, ridesharing services such as Lyft and Uber can improve that healthcare disparity and cut down on the $2.7 million the federal government spends each year on non-emergency medical transportation services. To recover revenue and improve care quality, some health systems like MedStar Health and Denver Health Medical Center are teaming up with Uber, Lyft, and other ridesharing companies to connect patients with transportation.

Housing

The University of Illinois Hospital, part of the University of Illinois Hospital & Health Sciences System, identified that large portion of the individuals with high rates of emergency department were also chronically homeless, and that these individuals were in the 10th decile for patient cost, with annual per patient expenses ranging from $51,000 to $533,000. The University of Illinois partnered with a community group called the Center for Housing and Health to initiate the Better Health Through Housing initiative in 2015, an initiative that connected chronically homeless individuals with transitional housing and case managers. In partnering with the Center for Housing and Health, the University of Illinois Hospital saw participant healthcare costs fall 42 percent, and more recent studies have found that costs dropped by 61 percent. The hospital's emergency department reported a 35% reduction in use.

Malnutrition

Some health plans have chosen to address some SDOH within their own means by establishing programs that directly deal with a single risk factor. Studies show that malnutrition can lead to higher costs of care and extended hospital states with the average hospital stay costing nearly $2,000 per day. Advocate Health Care, an accountable care organization in Chicago, Illinois, implemented a nutrition care program at four of its Chicago area hospitals, an initiative that resulted in more than $4.8 million in cost savings within 6 months due to shorter hospital states and lower readmission rates (reduced 30 day readmission rates by 27% and the average hospital stay by nearly two days).

Trump administration efforts

In 2016, Donald Trump was elected president on a platform that included a pledge to "repeal and replace" the Patient Protection and Affordable Care Act (commonly called the Affordable Care Act or Obamacare). Trump proposed the American Health Care Act (AHCA), which was drafted and passed by the House of Representatives in 2017 but did not pass the Senate. Had the AHCA become law, it would have returned insurance and healthcare to the market, leaving around 18 million Americans uninsured.

Incentivizing health reimbursement arrangements is another goal.

Social Security Act

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Social_Security_Act 

Social Security Act of 1935

Other short titles	SSA
Long title	The Social Security Act of 1935
Nicknames	SSA
Enacted by	the 74th United States Congress
Citations
Statutes at Large	Pub.L. 74–271, 49 Stat. 620, enacted August 14, 1935
Codification
U.S.C. sections created	42 U.S.C. ch. 7
Legislative history
Introduced in the House as H.R. 7260 Passed the House on April 19, 1935 (372-33) Passed the Senate on June 19, 1935 (77-6) Signed into law by President Franklin D. Roosevelt on August 14, 1935
Major amendments
Social Security Amendments of 1965 Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999
United States Supreme Court cases
Steward Machine Company v. Davis, Helvering v. Davis

The Social Security Act of 1935 is a law enacted by the 74th United States Congress and signed into law by US President Franklin D. Roosevelt. The law created the Social Security program as well as insurance against unemployment. The law was part of Roosevelt's New Deal domestic program.

By the 1930s, the United States was the only modern industrial country without any national system of social security. In the midst of the Great Depression, the physician Francis Townsend galvanized support behind a proposal to issue direct payments to the elderly. Responding to that movement, Roosevelt organized a committee led by Secretary of Labor Frances Perkins to develop a major social welfare program proposal. Roosevelt presented the plan in early 1935 and signed the Social Security Act into law on August 14, 1935. The act was upheld by the Supreme Court in two major cases decided in 1937.

The law established the Social Security program. The old-age program is funded by payroll taxes, and over the ensuing decades, it contributed to a dramatic decline in poverty among the elderly, and spending on Social Security became a major part of the federal budget. The Social Security Act also established an unemployment insurance program administered by the states and the Aid to Dependent Children program, which provided aid to families headed by single mothers. The law was later amended by acts such as the Social Security Amendments of 1965, which established two major healthcare programs: Medicare and Medicaid.

Further information: History of Social Security in the United States and History of health care reform in the United States

 

President Roosevelt signs the Social Security Act into law on August 14, 1935.

Industrialization and the urbanization in the 20th century created many new social problems and transformed ideas of how society and the government should function together because of them. As industry expanded, cities grew quickly to keep up with demand for labor. Tenement houses were built quickly and poorly, cramming new migrants from farms and Southern and Eastern European immigrants into tight and unhealthy spaces. Work spaces were even more unsafe.

By the 1930s, the United States was the only modern industrial country in which people faced the Depression without any national system of social security though a handful of states had poorly-funded old-age insurance programs. The federal government had provided pensions to veterans in the aftermath of the Civil War and other wars, and some states had established voluntary old-age pension systems, but otherwise, the United States had little experience with social insurance programs. For most American workers, retirement during old age was not a realistic option. In the 1930s, the physician Francis Townsend galvanized support for his pension proposal, which called for the federal government to issue direct $200-a-month payments to the elderly. Roosevelt was attracted to the general thinking behind Townsend's plan because it would provide for those no longer capable of working, stimulate demand in the economy, and decrease the supply of labor. In 1934, Roosevelt charged the Committee on Economic Security, chaired by Secretary of Labor Frances Perkins, with developing an old-age pension program, an unemployment insurance system, and a national health care program. The proposal for a national health care system was dropped, but the committee developed an unemployment insurance program that would be largely administered by the states. The committee also developed an old-age plan; at Roosevelt's insistence, it would be funded by individual contributions from workers.

In January 1935, Roosevelt proposed the Social Security Act, which he presented as a more practical alternative to the Townsend Plan. After a series of congressional hearings, the Social Security Act became law in August 1935. During the congressional debate over Social Security, the program was expanded to provide payments to widows and dependents of Social Security recipients. Job categories that were not covered by the act included workers in agricultural labor, domestic service, government employees, and many teachers, nurses, hospital employees, librarians, and social workers. As a result,

65 percent of the African American workforce was excluded from the initial Social Security program (as well as 27 percent of white workers). Many of these workers were covered only later on, when Social Security was expanded in 1950 and then in 1954.

The program was funded through a newly-established payroll tax, which later became known as the Federal Insurance Contributions Act tax. Social Security taxes would be collected from employers by the states, with employers and employees contributing equally to the tax. Because the Social Security tax was regressive, and Social Security benefits were based on how much each individual had paid into the system, the program would not contribute to income redistribution in the way that some reformers, including Perkins, had hoped. In addition to creating the program, the Social Security Act also established a state-administered unemployment insurance system and the Aid to Dependent Children, which provided aid to families headed by single mothers. Compared with the social security systems in Western Europe, the Social Security Act of 1935 was rather conservative. However, it was the first time that the federal government took responsibility for the economic security of the aged, the temporarily unemployed, dependent children, and the handicapped.

Titles

The Social Security Act has been amended significantly over time. The initial act had ten major titles, with Title XI outlining definitions and regulations. More titles were added as the Social Security Act was amended.

Title I—Old age

Title I is designed to give money to states to provide assistance to aged individuals.

Title II—Federal Reserve account

Title II establishes the Federal Reserve account used to pay for Social Security benefits and gives the Secretary of the Treasury the authority to invest excess reserves from the account.

Title III—Unemployment

Title III concerns unemployment insurance.

Title IV—Child aid

Title IV concerns Aid to Families with Dependent Children.

Title V—Child welfare

Title V concerns maternal and child welfare.

Title VI—Public health

Title VI concerns public health services (investigation of disease and problems of sanitation). It grants the Surgeon General the power to distribute money to the States for that purpose with the approval of the Secretary of the Treasury.

Title VII—Social Security Board

Title VII establishes the Social Security Board and outlines that it is to be composed of three appointees chosen by the President and approved by the Senate and serving for six years.

Title VIII—Taxes with respect to employment

Title VIII establishes a payroll tax used to fund Social Security. In the amendments of 1939, the tax was removed from the Social Security Act, placed in the Internal Revenue Code, and renamed the Federal Insurance Contributions Act. When Medicare was established in 1966, the FICA tax was increased to fund that program as well.

Title IX—Tax on employers of eight or more

Title IX establishes an excise tax to be paid on the first day of every year by employers proportional to the total wages of their employees. It also establishes the first federal unemployment insurance program in the United States.

Title X—Blindness

Title X concerns support for blind people.

Title XI—General Provisions, Peer Review, Progressive Sampling, and Administrative Simplification

Title XII—Advances to State Unemployment Funds

Title XIII—Reconversion Unemployment Benefits for Seamen

Title XIV—Grants to States for Aid to the Permanently and Totally Disabled

Title XV—Unemployment Compensation for Federal Employees

Title XVI—Grants to States for Aid to the Aged, Blind, or Disabled

Title XVI—Supplemental Security Income for the Aged, Blind, and Disabled

Title XVI establishes and concerns Supplemental Security Income (SSI).

Title XVII—Grants for Planning Comprehensive Action to Combat Mental Retardation

Title XVIII—Health Insurance for the Aged and Disabled

Title XVIII establishes and concerns Medicare.

Title XIX—Grants to States for Medical Assistance Programs

Title XIX establishes and concerns Medicaid.

Title XX—Block Grants to States for Social Services

Title XXI—State Children's Health Insurance Program

Title XXI establishes and concerns CHIP.

Amendments

Social Security Act Amendments of 1939

H.R.6635 Approved, August 10, 1939 Public Law 76-379

Expansion of benefits

The original Act provided for only one Federally-administered benefit: Old-Age Insurance, which was paid only to the insured worker. The 1939 Amendments transformed the very nature of the Social Security program. The Amendments created two new benefit categories under §202 of the Act:

• Payments to the spouse and children of a retired worker called dependents or family benefits, a provision of Old-Age Insurance.
• Payments to the family of an insured worker in the event of the premature death of the worker, called survivors benefits, the provision of the then-newly created Survivors Insurance program.

Retirement-aged wives, children under 16 (under 18 if attending school), widowed mothers caring for eligible children, and aged widows were all made eligible for dependents and survivors benefits.

Under select circumstances, parents of deceased insured workers were also made eligible for Survivors Insurance. To be eligible parents must be at least age 65, not entitled to Old-Age Insurance, wholly dependent upon the insured worker for income, and mustn't have married since the death of the insured worker. Furthermore, the parent(s) are not eligible if the deceased insured worker leaves a widow or unmarried surviving child under the age of 18.

The 1939 Amendments also increased benefit amounts and accelerated the start of monthly benefit payments from 1940 to 1942.

Alternation of financing mechanisms

The Old-Age Reserve Account previously established under §201 of the Act was replaced by the Federal Old-Age and Survivors Insurance Trust Fund, administered by a Board of Trustees. The Secretary of the Treasury, Secretary of Labor, and the Chairman of the Social Security Board were all ex-officious members. (The composition of the Board of Trustees has been significantly altered since.)

War Mobilization and Reconversion Act of 1944

S.2051 Approved, October 3, 1944

Public Law 78-458

Title XII

Social Security Act Amendments of 1946

H.R.7037 Approved, August 10, 1946 Public Law 79-719

Title XIII

Social Security Act Amendments of 1950

H.R.6000 Approved August 28, 1950 Public Law 81-734

These amendments raised benefits for the first time and placed the program on the road to the virtually universal coverage it has today. Specifically it is the introduction of the cost-of-living adjustment (COLA).

H.R.6291

Approved June 28, 1952 Public Law 82-420

Social Security Act Amendments of 1952

H.R.7800 Approved, July 18, 1952 Public Law 82-590

Social Security Act Amendments of 1954

H.R.9366 Approved September 1, 1954 Public Law 83-761

H.R.9709

Approved September 1, 1954 Public Law 83-767

Title XV

Maternal and Child Health and Mental Retardation Planning Amendments of 1963

H.R.7544 Approved, October 24, 1963 Public Law 88-156

Title XVII

Social Security Amendments of 1965

Main article: Social Security Amendments of 1965

H.R.6675 Approved, July 30, 1965 Public Law 89-97

Title XVIII Title XIX

Constitutional litigation

In the 1930s, the Supreme Court struck down many pieces of Roosevelt's New Deal legislation, including the Railroad Retirement Act. The Court threw out a centerpiece of the New Deal, the National Industrial Recovery Act, the Agricultural Adjustment Act, and New York State's minimum-wage law. President Roosevelt responded with an attempt to pack the court via the Judicial Procedures Reform Bill of 1937. On February 5, 1937, he sent a special message to Congress proposing legislation granting the President new powers to add additional judges to all federal courts whenever there were sitting judges age 70 or older who refused to retire. The practical effect of this proposal was that the President would get to appoint six new Justices to the Supreme Court (and 44 judges to lower federal courts), thus instantly tipping the political balance on the Court dramatically in his favor. The debate on this proposal lasted over six months. Beginning with a set of decisions in March, April, and May 1937 (including the Social Security Act cases), the Court would sustain a series of New Deal legislation.

Chief Justice Charles Evans Hughes played a leading role in defeating the court-packing by rushing these pieces of New Deal legislation through and ensuring that the court's majority would uphold it. In March 1937, Associate Justice Owen Roberts, who had previously sided with the court's four conservative justices, shocked the American public by siding with Hughes and the court's three liberal justices in striking down the court's previous decision in the 1923 case Adkins v. Children's Hospital, which held that minimum wage laws were a violation of the Fifth Amendment's due process clause and were thus unconstitutional, and upheld the constitutionality of Washington state's minimum wage law in West Coast Hotel Co. v. Parrish. In 1936, Roberts joined the four conservative justices in using the Adkins decision to strike down a similar minimum wage law New York state enforced in Morehead v. New York ex rel. Tipaldo and his decision to reverse his previous vote in the Morehead decision would be known as the switch in time that saved nine. In spite of widespread speculation that Roberts only agreed to join the court's majority in upholding New Deal legislation, such as the Social Security Act, during the spring of 1937 because of the court packing plan, Hughes wrote in his autobiographical notes that Roosevelt's court reform proposal "had not the slightest effect on our [the court's] decision" in the Parrish case and that the delayed announcement of the decision created the false impression that the Court had retreated under fire. Following the vast support that was demonstrated for the New Deal through Roosevelt's re-election in 1936, Hughes persuaded Roberts to no longer base his decisions on political maneuvering and side with him in future cases that involved New Deal legislation.

Records show Roberts had indicated his desire to overturn the Adkins decision two days after oral arguments concluded for the Parrish case on December 19, 1936. During this time, however, the court was divided 4-4 following the initial conference call because Associate Justice Harlan Fiske Stone, one of the three liberal justices who continuously voted to uphold New Deal legislation, was absent due to an illness; with this even division on the Court, the holding of the Washington Supreme Court, finding the minimum wage statute constitutional, would stand. As Hughes desired a clear and strong 5–4 affirmation of the Washington Supreme Court judgment, rather than a 4–4 default affirmation, he convinced the other justices to wait until Stone's return before both deciding and announcing the case.

US Supreme Court cases

Two Supreme Court rulings affirmed the constitutionality of the Social Security Act.

• Steward Machine Company v. Davis, 301 U.S, 548 (1937) held in a 5–4 decision that given the exigencies of the Great Depression, "[It] is too late today for the argument to be heard with tolerance that in a crisis so extreme the use of the moneys of the nation to relieve the unemployed and their dependents is a use for any purpose narrower than the promotion of the general welfare." The arguments opposed to the Social Security Act articulated by justices Butler, McReynolds, and Sutherland in their opinions were that the Social Security Act went beyond the powers that were granted to the federal government in the US Constitution. They argued that by imposing a tax on employers that could be avoided only by contributing to a state unemployment-compensation fund, the federal government was essentially forcing each state to establish an unemployment-compensation fund that would meet its criteria and that the federal government had no power to enact such a program.
• Helvering v. Davis, 301 U.S. 619 (1937), decided on the same day as Steward, upheld the program: "The proceeds of both [employee and employer] taxes are to be paid into the Treasury like internal-revenue taxes generally, and are not earmarked in any way." That is, the Social Security Tax was constitutional as a mere exercise of Congress's general taxation powers.

Other cases

• Flemming v. Nestor, 363 US 603 (1960) upholding §1104, allowing Congress to itself amend and revise the schedule of benefits. Further, however, recipients of benefits had no contractual rights to them.
• Goldberg v. Kelly 397 US 254 (1970) William Brennan, Jr. held there must be an evidentiary hearing before a recipient can be deprived of government benefits under the due process clause of the Fourteenth Amendment.
• Weinberger v. Wiesenfeld (1975) held that a male widower should be entitled to his deceased wife's benefit just as a female widow was entitled to a deceased husband's, under the equal protection and due process clauses of the Fourteenth Amendment.

Impact

In 1940, Social Security benefits paid totaled $35 million and rose to $961 million in 1950, $11.2 billion in 1960, $31.9 billion in 1970, $120.5 billion in 1980, and $247.8 billion in 1990 (all figures in nominal dollars, not adjusted for inflation). In 2004, $492 billion of benefits were paid to 47.5 million beneficiaries. In 2009, nearly 51 million Americans received $650 billion in Social Security benefits.

During the 1950s, those over 65 continued to have the highest poverty rate of any age group in the US with the largest percentage of the nation's wealth concentrated in the hands of Americans under 35. By 2010, that figure had dramatically reversed itself with the largest percentage of wealth being in the hands of Americans 55–75 and those under 45 being among the poorest. Elder poverty, once a normal sight, had thus become rare by the 21st century.

Reflecting the continuing importance of the Social Security Act, biographer Kenneth S. Davis described the Social Security Act "the most important single piece of social legislation in all American history."

Nursing home

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Nursing_home

 

A therapy dog visiting an elderly man in a nursing home

A nursing home is a facility for the residential care of elderly or disabled people. Nursing homes may also be referred to as skilled nursing facility (SNF), long-term care facilities, old people's homes, care homes, rest homes, convalescent homes or convalescent care. Often, these terms have slightly different meanings to indicate whether the institutions are public or private, and whether they provide mostly assisted living, or nursing care and emergency medical care. Nursing homes are used by people who do not need to be in a hospital, but cannot be cared for at home. The nursing home facility nurses have the responsibilities of caring for the patients' medical needs and also the responsibility of being in charge of other employees, depending on their ranks. Most nursing homes have nursing aides and skilled nurses on hand 24 hours a day.

In the United States, while nearly 1 in 10 residents age 75 to 84 stays in a nursing home for five or more years, nearly 3 in 10 residents in that age group stay less than 100 days, the maximum duration covered by Medicare, according to the American Association for Long-Term Care Insurance. Some nursing homes also provide short-term rehabilitative stays following surgery, illness, or injury. Services may include physical therapy, occupational therapy, or speech-language therapy. Nursing homes also offer other services, such as planned activities and daily housekeeping. Nursing homes may offer memory care services, often called dementia care.

History

Mennonites visiting a nursing home in 1961

 

Poorhouses/workhouses were the first implemented national framework to provide a basic level of care to the old and infirm. Pictured, is "The workroom at St James's workhouse" from The Microcosm of London (1808).

From before the 17th century to modern day, many families care for their elders in the family's home. While this is still common practice for many communities and families around the world, this has become increasingly more difficult over time as life expectancy increases, family size decreases, and increased expertise in caring for a person with a chronic disease. In the 21st century, nursing homes have become a standard form of care for most aged and incapacitated persons to account for those complexities. Nearly 6 percent of older adults are sheltered in residential facilities that provide a wide range of care. Yet such institutions have not always existed; rather, their history and development reflect relatively recent demographic and political realities that shape the experience of growing old.

In the 17th century, poorhouses (also referred to as almshouses) originated in England as municipalities were expected to care for their poor. Orphans, people determined to be mentally ill, and elderly people were often placed into these living commons while able-bodied individuals were expected to work and could be imprisoned if they refused. This model was brought to North America by English settlers. Before the 19th century, no age-restricted institutions existed for long-term care; elderly individuals, who needed shelter because of incapacity, impoverishment, or family isolation, often ended their days in an almshouse. Placed alongside people deemed insane, people who were inebriated, or people who were homeless, they were simply categorized as part of the community's most needy recipients. Poorhouses gave a place where they could be given shelter and daily meals.

In the 1800s in the US, women's and church groups began to establish special homes for the elderly persons. Often concerned that individuals of their own ethnic or religious communities might die alongside the most despised society. This lead to the creation of private care facilities for the elderly in these communities. Poorhouses continued to exist into the early 20th century, despite the criticism of the poor conditions of the poorhouses. In the US, the Great Depression overwhelmed the poorhouses, but not enough space and funding. Due to muckraking in the 1930s, the less-than-favorable living conditions of the poorhouses were exposed to the public. This lead to the provision of the Social Security Act (1935) to only give people their pension if they did not live in poorhouses, but could live in private institutions.

In the US, poorhouses were then replaced with residential living home, known as board-and-care homes or convalescent homes. These board-and-care homes provided basic levels of care and meals in a private setting for a specific fee. Board-and-care homes proved to be a success and by World War II, the new way of nursing homes began to take shape. As the times continued to change, the government identified the issue of people spending extensive amounts of time in hospitals. To combat these long stays in short-term settings, board-and-care homes began to convert into something more public and permanent that was state and federally funded. From this, by 1965 nursing homes were a solid fixture. Nursing homes were a permanent residence where the elderly and disabled could receive any necessary medical care and receive daily meals. These nursing homes showed improvement in maintaining care and cleanliness standards in comparison to almshouses and poorhouses. From the 1950s through the 1970s, the dynamics of nursing homes began changing significantly. In the United States, Medicare and Medicaid began to make up much of the money that would filter through the homes and the 1965 amendment laws enforced nursing homes to comply with safety codes and required registered nurses to be on hand at all times. Additionally, nursing homes may sue children for the costs of caring for their parents in jurisdictions which have filial responsibility laws. Later in 1987, in the U.S. the Nursing Reform Act was introduced to begin defining the different types of nursing home services and later added the Residents' Bill of Rights.

In the UK, after World War II many soldiers and civilians needing hospital care due to casualties during the war were planced in the hospital along with the many elderly patients present there, leading to overcrowding. The implementation of the NHS in 1948 and the abolishment of the Old Poor Law allowed for the creation of what would become modern day, public nursing homes. In the 1950s, Professor Peter Townsend brought to light the discrepancies the standard of care between the publicly and privately funded cares homes, leading to health policy reforms that assured the standard care practices for the elderly living in NHS funded care homes. The 1980s and 1990s saw care homes becoming a large industry in the UK. Thus, policies ensuring that private care homes are regulated (Registered Homes Act 1984) and patient needs are met (Care Standards Act of 2000) were established. 

Today, nursing homes are varied. Some nursing homes still resemble a hospital while others look more like a home. Nursing home residents can pay for their care out of pocket or with government assistance. In the U.S., others may receive Medicare for a short time, while in other countries, public assistance may be available, and some may use long-term insurance plans. Across the spectrum, most nursing homes in the U.S. will accept Medicaid as a source of payment.

Considerations

Below are a few reasons to consider a nursing home

• managing a worsening and progressive disease such as Alzheimers
• after a recent hospital admission and not ready to transition to independently caring for oneself at home
• when medical needs at home become unmanageable by the primary caregiver at home. 

When looking into nursing homes, consider what activities and/or medical needs patients one would need from the nursing home. Also consider finances, such as medical insurance and personal funds. Ensure the nursing home is properly licensed and has qualified staff. If time allows, visit the nursing home in person to receive a walk through of the facility and if given the opportunity to speak with a guest or family member of guest, ask about their experience thus far.

Staff

All of the nursing homes employees are all required to be licensed or uphold a certificate in the state of which they work. In most facilities, nursing homes are required to provide enough staff to adequately care for residents. In the U.S., for instance, nursing homes must have at least one registered nurse (RN) available for at least 8 straight hours a day throughout the week, and at least one licensed practical nurse (LPN) on duty 24 hours a day. Direct care nursing home employees usually include registered nurses, licensed practical nurses, social workers, certified nursing assistants, and physical therapists, amongst others.

Medical Staff

Nurses

Main article: Nursing

Nursing homes require assessment and monitoring of residents by a registered nurse (RN) who is typically required to have between two and six years of education. The RN's job duties include implementing care plans, administering medications, recording and maintaining accurate reports for each resident, monitoring and recording medical changes, and providing direction to the nursing assistants and licensed practical nurses (LPN). RNs are not required to choose a specialization. To gain recognition as a specialized nurse professional, RNs typically need education in their specialized field, and further experience through clinical practices. LPNs are typically required to have a year of training before working with any patients. The LPN monitors residents' well-being and administers treatments and medications, such as dressing wounds and dispensing prescribed drugs. LPNs are responsible for patients' direct bed care and carry out a daily routine.

Nursing assistants

A nursing assistant provides basic care to patients while working directly under a LPN or RN. These basic care activities, also referred to as activities of daily living, can include assisting with bathing and dressing residents, helping residents with meals, either serving them or with feeding, transferring to and from the bed or wheelchair, making and cleaning beds, assisting with toileting, and answering call lights. Nursing assistants' official titles can vary between jurisdictions and facilities. They can include Certified Nursing Assistants (CNAs), nursing aides, caregivers, patient care associates, patient care technicians, personal care attendants (PCAs), and care assistants.

Physicians

At skilled nursing facilities, in addition to required 24 hour skilled nursing, a licensed physician supervises individual patients. At nursing homes other than skilled nursing facilities, patients receive care from physicians not affiliated with the nursing home. These physicians are typically employed by a private agency that sends physicians to nursing homes per the request of the patient, nursing home, or patient's family. The majority of these physicians are family medicine doctors or internist; however, some specialists such as cardiologist, nephrologist, etc may also make independent visits to supplement their care.

Non-medical Staff

Administration

Depending on the size of the nursing home, a nursing home may have either a nursing home administrator or an executive director. Some nursing homes may have both, but their job duties are similar and can include overseeing staff, supplying medical supplies, and financial matters. Some nursing homes also have human resources personnel, who are in charge of all aspects of hiring new employees. Human resources job duties vary but can also include coordinating payroll, organizing orientation programs for new employees, interviewing, disciplinary actions, and ensuring compliance with federal and state laws. Nursing homes are usually licensed and heavily regulated under governing legislation. Compliance with the federal and state legislatures are reviewed regularly for adherence to strict standards of building codes, care plans, behavior and altercations between residents, nutrition and dietary services, medical services, nursing and personal care, religious and spiritual practices, pets, and recreational programs.

Housekeeping

Housekeepers perform everyday cleaning and upkeep in nursing homes. They play a huge part in ensuring that nursing homes are kept clean and free of disease causing agents. Housekeepers have a long list of duties which include cleaning floors, changing linens, disinfecting bathrooms, changing towels, washing clothes, emptying trashcans, sanitizing rooms, replenishing supplies, dusting, vacuuming, and keeping windows and woodwork clean. These duties can vary from facility to facility but it will overall include basic cleaning. Housekeeping does not require any licensure or schooling, but some jobs may prefer experienced housekeepers.

Recreational staff

Recreational staff usually include an activity director and possibly activity assistants depending on the size of the nursing home. Activities aim to meet each residents' emotional, intellectual, physical, social, spiritual, and vocational needs. The transition from being independent to having to depend on others and be away from home is oftentimes very difficult, which is why activities are important to combat depression and anxiety. Some of the different activities that may be offered include hosting birthday parties, celebrating holidays, book clubs, musical events, outdoor activities, discussion and social groups, exercise, arts and crafts, pet therapy, religious services and community outings. Volunteer involvement is also an important part of nursing home activities given that volunteers can act as a link between the nursing home and the outside community.

Therapy

Occupational therapy

One of the many services offered in a nursing home is occupational therapy. Occupational therapy may be necessary following an injury or illness in order to regain skills and to receive support during any physical or cognitive changes. Occupational therapy will focus on activities of daily living such as bathing, dressing, grooming. Occupational therapy also assists with instrumental activities of daily living which include home and financial management, rest and sleep, education, work, play, leisure, and social participation. Occupational therapists work to allow the person to safely and comfortably reintegrate into society by practicing public dining, transferring to different surfaces (chairs, beds, couches etc.), and will assess the need for any home modifications or safety equipment to ensure a proper and safe transition. When a cognitive and/or perceptual deficit is presented, therapists will work with the person by teaching strategies to maximize memory, sequencing and attention span length.

Physical therapy

Another important service found in a nursing home is physical therapy. Physical therapy may be necessary following an injury, illness or surgery. Physical therapy works with the person to help them regain strength, endurance, flexibility, balance and range of motion. Physical therapy is also used as a way of preventing injuries and accidents by focusing on restoring mobility, increasing fitness levels, reducing pain and overall reaching a certain point of independence. There are many conditions that can benefit from receiving physical therapy in a nursing home, these conditions include arthritis, pain associated with cancer, dementia, Alzheimer's, stroke and incontinence.

Speech language therapy

Speech-language pathology is another service found in a nursing home. Speech language pathologists specialize in working with those who have a difficult time with language and/or speech, usually following an injury or an underlying diagnoses. The SLP will evaluate the persons speech. If the person is having trouble with speech, this points to an issue with coordinating the movements and muscles used to produce speech. While trouble with language points to the person having difficulty with understanding what they are hearing and seeing. The SLP will also look at difficulty with swallowing food and will evaluate the person in order to figure out which part of the swallowing process is not working. Some of the many speech disorders worked with by the SLP are:

• phonology meaning the speech patterns used,
• apraxia meaning difficulty with coordinating the movements needed to make sounds,
• receptive language meaning difficulty understanding language,
• fluency meaning stuttering,
• expressive language meaning difficulty using language, and many other disorders.^{[citation needed]}

Criticism

Elder abuse

Elder abuse is more prevalent in hospitalized settings including nursing homes than in the general community. There are three major types of abuses reported in nursing homes: physical, emotional, and sexual abuse.

Physical abuse is the intention or action to hurt an elderly person resulting in scars and bruising.

Emotional abuse occurs when an employee makes verbal threats and continuously degrades the patient, resulting in the patient experiencing mood swings, anxiety, and depression.

Sexual abuse is when an elderly patient is being forced into unwanted sexual activity by an employee, resident or visitor, usually attempted and reported when the patient is sleeping, sick, or weak. Nursing home neglect is similar to elder abuse. It is when employees begin to repeatedly ignore and leave a patient alone, neglect the patient's personal hygiene like bathing and brushing of teeth, provide the patient with an inadequate amount of food and water, or neglect to provide the patient with the correct amount of medication they require. One factor unique to elder abuse in nursing homes is that many nursing home contracts require residents to sign delegation clauses, giving up their right to trial by jury and instead using an Arbitrator to settle disputes.

By country

Canada

Main article: Nursing home care in Canada

Long-term care facilities exist under three major types: privately owned, non-profit/charitable, and municipal. Regardless of their ownership, aspects of funding, admission criteria, and cost to the individuals are all regulated by their respective provincial governments. As medical care is publicly funded in Canada, all long-term care facilities receive funding from provincial governments for the health care component of the residence – the nurses and personal support workers. Residents pay daily rates for 'room and board' (accommodation and food) that are determined by the type of room chosen, either shared or private. Provincial governments manage waiting lists for long-term care facilities. People who cannot afford to pay the monthly fees receive subsidies, and no one is refused due to inability to pay.

United Kingdom

Main article: Nursing home care in the United Kingdom

In the United Kingdom, care homes and care homes with nursing are regulated by different organisations in England, Scotland, Wales and Northern Ireland. To enter a care home, a candidate patient needs an assessment of needs and of their financial condition from their local council. The candidate may also have an assessment by a nurse, should the patient require nursing care. The cost of a care home is means tested in England.

Care homes for adults in the UK are regulated by Care Quality Commission, which replaced the Commission for Social Care Inspection, and each care home is inspected at least every three years. In Wales the Care Standards Inspectorate for Wales has responsibility for oversight, In Scotland Social Care and Social Work Improvement Scotland otherwise known as the Care Inspectorate, and in Northern Ireland the Regulation and Quality Improvement Authority in Northern Ireland.

In 2002, nursing homes became known as care homes with nursing, and residential homes became known as care homes.

As of April 2009, the lower capital limit is £13,500. At this level, all income from pensions, savings, benefits and other sources, except a "personal expenses allowance" (currently £21.90), goes towards paying the care home fees. The local council pays the remaining contribution provided the room occupied is not more expensive than the local council's normal rate. The NHS has full responsibility for funding the whole placement if the resident is in a care home with nursing that meets the criteria for NHS continuing Health Care. This is identified by a multidisciplinary assessment process.

In May 2010, a coalition government announced the formation of an independent commission on the funding of long-term care, which was due to report within a 12-month time frame on the financing of care for an ageing population. It delivered its recommendations on Monday 4 July 2011. The Care Quality Commission have themselves implemented a re-registration process, completed in October 2010, which will result in a new form of regulation being outlined in April 2011.

In 2020 it emerged that some UK care home residents had blanket Do Not Attempt Resuscitation (DNACPR) orders applied during the COVID-19 pandemic. These decisions were made without discussion with the patients involved, and the practice is being investigated by the Care Quality Commission.

United States

Main article: Nursing home care in the United States

In the United States, there are three main types of nursing facilities (NFs).

An intermediate care facility (ICF) is a health care facility for individuals who are disabled, elderly, or non-acutely ill, usually providing less intensive care than that offered at a hospital or skilled nursing facility. Typically an ICF is privately paid by the individual or by the individual's family. An individual's private health insurance and/or a third party service like a hospice company may cover the cost. Board and Care Homes are special facilities designed to provide those who require assisted living services both living quarters and proper care. Often referred to as residential care homes, these facilities can either be located in a small residential home or a large modern facility. In fact, a large majority of board and care homes are designed to accommodate fewer than 6 people. Board and care homes are typically staffed by licensed professionals, including nurses, doctors and other medical professionals. These facilities are highly regulated in order to ensure that the best possible care is being provided for the residents. Board and care homes offer residents 24-hour assistance, making them a highly popular choice for those in need of regular assistance.

Assisted living residences or assisted living facilities (ALFs) are housing facilities for people with disabilities. These facilities provide supervision or assistance with activities of daily living (ADLs); ALFs are an eldercare alternative on the continuum of care for people, for whom independent living is not appropriate but who do not need the 24-hour medical care provided by a nursing home and are too young to live in a retirement home. Assisted living is a philosophy of care and services promoting independence and dignity.

A skilled nursing facility (SNF) is a nursing home certified to participate in, and be reimbursed by Medicare. Medicare is the federal program primarily for the aged (65+) who contributed to Social Security and Medicare while they were employed. Medicaid is the federal program implemented with each state to provide health care and related services to those who are below the poverty line. Each state defines poverty and therefore Medicaid eligibility. Those eligible for Medicaid may be low-income parents, children (including those in State Children's Health Insurance Programs (SCHIPs) and maternal-child wellness and food programs), seniors, and people with disabilities.

The Centers for Medicare and Medicaid Services is the component of the U.S. Department of Health and Human Services (DHHS) that oversees Medicare and Medicaid. A large portion of Medicare and Medicaid dollars is used each year to cover nursing home care and services for the elderly and disabled. State governments oversee the licensing of nursing homes. In addition, states have a contract with CMS to monitor those nursing homes that want to be eligible to provide care to Medicare and Medicaid beneficiaries. Congress established minimum requirements for nursing homes that want to provide services under Medicare and Medicaid. These requirements are broadly outlined in the Social Security Act, which also entrusts the Secretary of Health and Human Services with the responsibility of monitoring and enforcing these requirements. CMS is also charged with the responsibility of working out the details of the law and how it will be implemented, which it does by writing regulations and manuals.

See also

• American Medical Directors Association
• Care Quality Commission
• Elderly care
• Home care
• International Association of Homes and Services for the Aging
• List of companies operating nursing homes
• Retirement community
• Caring for people with dementia