HIGHLIGHTS AND LOWLIGHTS.

In brief outline, nursing homes grew out of the almshouses and poorhouses of the past. In the late l9th and early 20th centuries, various sectarian groups founded "old age homes" to take care of their own. Old Age Assistance under the Social Security Act of 1935 enabled people to pay for more services at home. The proliferation of facilities as we know them began with Medicare and Medicaid in 1965.

Perhaps the next major milestone in the development of long-term care came with the liberalizing of Medicare's home healthcare rules in the late 1980s; physicians were able to reauthorize a continuation of Medicare-funded services indefinitely. As a result, Medicare home healthcare expenditures grew from $1.9 billion in 1988 to $16.8 billion in 1996--a 762% growth. Adoption of the Balanced Budget Act of 1997 reversed that growth, though; home healthcare expenditures have since dropped by 31%, and more than 10% of home health agencies have closed.

For nursing homes, the establishment of federal payment for post-hospital stays in their facilities was a highlight of their recent history. A lowlight, however, is that much of the industry provided a minimal quality of care, and there still are tremendous problems in that area, despite OBRA '87--witness the reports on the violations in California nursing homes that had not been followed up.

There's a sense that the better quality of care has been provided by the not-for-profit sector. Aside from the fact that they are trying to breakeven, rather than make a profit, there is also the fact that they are more directly responsible to their communities. It would be tough to be a board member and have your neighbors say that they would never send their mothers to your facility.

For-profit nursing homes do make the point that declining reimbursements and increasing regulatory demands have placed them in a financial bind. We have had a real problem, though, in understanding the "cost-of-quality curve"--i.e., at what point do either decreases or increases in revenues truly impact quality of care? I would venture that if a nursing facility is receiving $50,000 to $60,000 a year private pay, going much above that will not buy you that much more for your dollar. How far under that you can go without impacting quality we don't know, and there is no research that I know of being devoted to that question. I do note, however, that there are far fewer nursing homes going out of business these days than home health agencies.

As for the future, the system is constantly evolving, and older people today can reside in many different settings, including assisted living, board and care, congregate living and CCRCs. I suspect that in 20 to 30 years, the term "nursing home" will be obsolete, just as the terms "almshouse" and "poorhouse" are today. I also wonder if tomorrow's long-term care won't be much less staff-intensive, with technology, used in a humane way, taking over many of the functions of staff. This is something that continues to develop in acute care but not, as yet, in long-term care. I wouldn't be surprised if that became a focus, especially with today's ongoing problems with staffing.

Robert H. Binstock, PhD, is professor of Aging, Health, and Society at Case Western Reserve University, Cleveland, Ohio, with a primary appointment in the Department of Epidemiology & Biostatistics in the School of Medicine, and secondary appointments as professor in the departments of Medicine, Political Science, Sociology, the Center for Biomedical Ethics and the School of Nursing. A former president of the Gerontological Society of America, Dr. Binstock also served as director of a White House Task Force on Older Americans for President Lyndon B. Johnson and on several advisory panels for foundations and state, local and federal governments. His books include The Future of Long-Term Care and the Handbook on Aging and the Social Sciences.