GOVERNMENT'S ROLE.

There really is no long-term care history before the middle of this century. The population we serve in long-term care didn't exist in sizable enough numbers to call what we had a long-term care system. The almshouses and poor houses were forebears, but they were a small social phenomenon. The growth of long-term care institutional providers began with the Social Security Amendments of 1950.

The amendments allowed the first government vendor payments to providers in public institutions. This was followed in 1954 by amendments to the Hill-Burton Act--the hospital construction legislation--that permitted government grants to nonprofit and public providers to construct nursing homes. Government funding for proprietary construction followed in 1959.

Medicare and then Medicaid, implemented in 1966, served as the basis for today's financing. But nursing homes were never a priority consideration, and the history of the field since then can be characterized as a series of false starts and stops, and enormous growth without any sort of plan.

Among the highlights and lowlights of this period, I would include among the highlights: the 1972 Social Security amendments, which permitted reasonable cost-based Medicaid reimbursement for nursing homes and Medicare coverage for the disabled; OBRA '87 and subsequent survey and enforcement regulations; and the Balanced Budget Act of 1997 (BBA). I nominate BBA because this was the first statutory recognition that Medicare does cover long-term care. BBA also modernized and rationalized payment for post-acute services and, although some might call BBA a lowlight in its implementation, many windfalls were eliminated and many ripoffs were stopped.

The lowlights included the nursing home scandals and investigations of the late 1960s and '70s in New York, Ohio, California and other states, best symbolized in the reports on New York's Moreland Act Commission. Another lowlight, for me, was the 1995 legislation repealing OBRA '87 and providing for Medicaid block grants that, fortunately, President Clinton vetoed.

I found that, during my tenure as HCFA Administrator, my perspective on long-term care changed in a couple of ways. First, I developed a greater appreciation of how varied healthcare programs and service provision are throughout the country. There are enormous differences in state policies for nursing home care. Second, I learned how complicated and unsatisfying the relationships are between the federal and state governments, particularly with regard to Medicaid and long-term care. Neither side gets what it wants, the outcomes are not very good, and there is frustration, mistrust and miscommunication on both sides. I know that the current state of affairs isn't working very well.

I've also been surprised by how little real change we've seen in the nursing home field over the past 25 years. True, there have been the secular trends of an aging and increasingly disabled older population, and a gradual trend toward home- and community-based care. But, in many ways, there has been less change than one might have predicted 20 years ago. There has been a lot of stability, even stasis, here, and I'm not quite sure where this comes from.

That's why I don't join those who predict the obsolescence of nursing homes. Yes, there has been a decline in the proportion of the elderly in nursing homes, but total census has not declined, and utilization of services has intensified. The most one can say about nursing home "obsolescence' is that these facilities occupy a shrinking place in a rapidly growing field.

I don't think the past 20 years gives any empirical basis for optimism about our ability to change this system dramatically. The system is so dependent on public money and public policy, it is difficult to imagine any significant change occurring without a kind of public policymaking of which we, as a nation, no longer seem capable. We need a transformation of our political process--an ability to address complex public problems substantively rather than symbolically. It's been a long time since we've been able to do that.

Bruce Vladeck, is director of the institute for Medicare Practice of the Mount Sinai School of Medicine. The Institute was founded in September with a mission to "bridge the two worlds of health policy and practice by bringing together and working callaboratively with researchers, practitioners, educators and consumers to improve Medicare and the services provided to Medicare beneficiaries."

Dr. Vladeck was administrator of the Health Care Financing Administration from 1993 to 1997, and authored the 1980 book, Unloving Care: The Nursing Home Tragedy.