Time to rethink.

One of life's more fascinating experiences is having one's horizons broadened. One tends to focus on one's own daily life and work to the point that it seems to be The Main Event; certainly nothing seems to rival the importance of the problems we face and the solutions we try. Then, one suddenly realizes that we are only a small part of a very big picture - a realization both painful and helpful.

Nursing home executives are experiencing this - at least those who are hearing the message that long-term care is more broadly defined than ever these days. They're confronting markets and business concepts never before relevant to nursing homes, such as those associated with assisted living or subacute care. It's a kind of shock that provides a new perspective.

Yours truly has undergone this, too, recently. A health care journalist for over 25 years, I have developed some familiarity with the classic issues of health care: financing options, patient access, quality of care, professional standards, the realities of "doing business". It's been easy of late to think of these as the principal domestic issues of the day, a feeling that Washington's recent battling over Medicare and Medicaid has done little to dispel. Thanks, however, to this magazine's recent work with the American Association of Homes and Services for the Aging in developing a special section on issues of interest to AAHSA members, I've had my own consciousness-raising. At first it all sounds familiar: Big government programs, major budgetary shortfalls, proposed cutbacks, imperilled access - but we're talking here about the world of low-income supportive housing.

This issue's "Not-For-Profit Report" (p. 27) includes an item on funding by the Federal Department of Housing and Urban Development (HUD) for supportive housing for low-income elderly. One of its key facets, Section 8 - a rent subsidy program established in the mid-1970s - has thrust the Feds on the horns of a cruel dilemma: either to adhere to the program's built-in 20-year expiration dates and risk seeing new legions of homeless hit the streets as affordable housing evaporates, or to extend the subsidies and face the possibility of spending $200 billion over the next 25 years (10 times HUD's current annual budget) simply to subsidize rents.

How is that for perspective on the Medicare/Medicaid squeeze? It doesn't take a fire-breathing "freshman Republican" to drive home the point that government programs need major rethinking. That doesn't necessarily mean jumping to the conclusion that "Big Government" should simply throw in the towel. Though that might sound good, in the abstract, that can hurt - a lot - when the savings are taken out of your pocketbook. Let's face it, those well-intentioned government programs of the 1960s and '70s are so woven into our lives - not just health care and housing, but environmental protection, educational support, agricultural production and more - that serious cutbacks will be both painful and personal. (Those howls of outrage that one hears almost daily on C-Span aren't coming just from" the politicians," they're coming from us!) Yet continuing to meet these needs by using borrowed money makes no sense. Big Government deficits have their uses, but not in perpetuity.

The central question, therefore, is: how does one provide vital supports to Americans who cannot personally afford them? None of the apparent options is at all attractive: borrow more; raise taxes; walk away. But what about a fourth option: to work smarter?

Maybe there's a way for health care providers and researchers to focus more on illness prevention, so that long-term need for expensive health care services will decline. Maybe there are alternative, "high-tech" materials and designs to use to enhance housing affordability (after all, "weird" housing is better than none). There may be countless other economies we can affect in protecting the environment, supporting agriculture, teaching our kids, etc., etc., that will place lighter demands upon our common funding pool. And maybe, while we're at it, we can streamline red tape enforcement to home in on the really bad guys.

Easier said than done, obviously, but as a serious goal deserving of a common commitment, why not "working smarter"? In fact, in my new state of wild surmise, I've even thought of a slogan to use. It's one that's as old as America: "Can do."