Carroll L. Estes & Karen W. Linkins. Handbook of Social Studies in Health and Medicine. Editor: Gary L Albrecht, Ray Fitzpatrick, Susan C Scrimshaw. Sage Publications, 2000.
Introduction: What is the Field of Critical Health and Aging?
Critical approaches to health and aging employ a variety of theoretical perspectives including political economy, feminist theories, and humanistic gerontology (Minkler and Estes 1998; Phillipson 1996). These perspectives examine social issues in ways that challenge dominant or mainstream thinking, and reveal underlying ideological justifications of existing structural arrangements and resource distributions that affect health and aging. As such, these perspectives are open to multiple and alternative accounts of social processes, such as current concerns and debates regarding the aging population and the impact this will have on societies around the world.
As social and health policy interests regarding the aging of the population have intensified in Europe and the United States over the last decade, aging and old age have been constructed and regarded as a problem of the welfare state. Thus, much of the policy focus in many countries has centered on the role of the welfare state in the financing of care and support for the elderly. The field of critical health and aging is concerned with the cause and effect of this policy focus that reduces the experience of aging in all societies to a problem of dependency of the elderly and overlooks other issues associated with aging. As such, many issues of import and consequence to research and policy regarding the condition of aging in societies are under-explored. These issues are at the heart of critical health and aging, and include the meaning and lived experience of aging, the heterogeneity of (differences in race, class, and gender) and inequalities within the aging population, and how the state and the economy influence health and aging.
Major Theoretical Perspectives Constituting the Field
The critical approach is founded on an array of intellectual traditions, including Marx, Weber, Gramsci, the Frankfurt School, and more recently Habermas, state theorists such as Offe and O’Connor, psychoanalytic perspectives (Biggs 1997), and the contemporary work of Giddens. Building on these theoretical seeds, the field of critical health and aging has coalesced over the past decade with work in the United States and Europe. In general, three major theoretical areas constitute and inform the field: political economy, feminist theories, and humanistic gerontology.
A central and unifying tenet among these theories is the notion that aging and the problems faced by the elderly are socially constructed and result from societal conceptions of aging and the aged (Estes 1979a). This process occurs at both the macro- and microlevel. The state and economy can be seen as influencing the experience and condition of aging, while individuals also actively construct their worlds through their interactions with their social worlds and society.
Political Economy
The political economy approach offers an important approach to understanding the condition of health and aging in society. Beginning with the work of Estes (1979a,b), Guillemard (1983), Phillipson (1982), and Walker (1981), these theorists initiated the task of describing the role of ideology in systems of domination and marginalization of the aged. The political economy perspective can be distinguished from pluralist and other political approaches in that it gives greater importance to social structures and social forces other than the government as shaping and reproducing the prevailing power structure of society. Social policies pertaining to issues such as income, health, and social service benefits and entitlements are seen as resulting from economic, political, and sociocultural processes and forces interacting at any given sociohistorical period (Estes et al. 1995). As such, policy is considered an outcome of the social struggles, conflicts, and dominant power relations of the period. Policy represents the structure and culture of advantage and disadvantage as reflected in class, race, gender, and age relations. Concurrently, policy stimulates these struggles, and as such, social policy is a powerful determinant of the life chances and conditions of population groups such as the elderly.
A central assumption of the political economy perspective is that aging and old age are directly related to the nature of the society in which they are situated, and therefore cannot be considered or analyzed in isolation from other societal forces and characteristics. The power of the state, business, and labor, and the role of the economy, are central concerns. The operating framework of this approach comprises at least four conceptual levels that facilitate an understanding of the various ideological views and stakes regarding perspectives on aging and the structure and organization of health and aging services: (1) the global level of financial and industrial capital (e.g., multinational corporations with financial stakes in health, medical care, insurance, pharmaceuticals); (2) the activities of the capitalist state within and among countries; (3) the level of the ‘aging enterprise’ (Estes 1979a) and the health-care industry; (4) the public level (McKinlay 1984). Explicitly recognized in this framework are the structural influences on the aging experience and the role of societal institutions and social relations in understanding how aging and old age are defined and treated in society. The major problems facing the elderly, such as dependency, are understood as socially constructed as a result of societal conceptions of aging and the aged (Estes 1979b).
Feminist Theories
Another set of theories constituting the critical approach to health and aging are feminist theories. Feminist theories, which are complementary and often related to or included in the political economy perspective, emphasize the importance of gender by examining the gender biases in social science research on health and aging and within social policy. Gender is seen as an organizing element of social life throughout the life course that influences and shapes the experience of aging (Calasanti 1993; Diamond 1992; Estes 1998b; Ginn and Arber 1995) and the distribution of resources in old age to men and women.
Feminist approaches to aging offer an important angle for addressing differences in the health and aging experiences of the population, as well as how social, cultural, and structural factors influence and shape social conditions (Calasanti 1993). Gender is a crucial organizing principle in economic and power relations and societal institutions. This perspective builds a more robust picture of the aging population (which is mainly female) by identifying and challenging the dominant, male-centered biases in society (Arber and Ginn 1991; Calasanti 1996). When integrated into the political economy perspective, feminist approaches argue that there are fundamental, gender-based differences in the accessibility of material (e.g., income), health, and caring resources that influence the aging experience for men and women.
Humanistic Gerontology
Humanistic gerontology adds still another dimension to critical approaches to health and aging, especially insofar as it seeks to critique existing theories and to construct positive models of aging based on research by historians, ethicists, and other social scientists (Bengtson and Allen 1993; Cole 1992; Cole et al. 1993). Moody (1993) identifies several goals for the critical humanistic perspective in gerontology. These include: (1) developing theories that emphasize and reveal the subjective and interpretive dimensions of aging, (2) committing to praxis and social change, and (3) producing emancipating knowledge. Consistent with and complementary to both the political economy and feminist theories, this approach centers on the concepts and relations of power, social action, and social meanings as they pertain to aging. Central to this approach is concern regarding the absence of meaning in the lives of the elderly, and the sense of doubt and uncertainty that is thought to permeate and influence their day-to-day lives and social relations (Moody 1992).
Prevailing Gerontological Theories and their Limitations
Since its inception in 1945, the field of gerontology has evolved into a formal interdisciplinary science involving biology, clinical medicine, and the behavioral and social sciences. While researchers, practitioners, policy makers, and the lay population agree that aging is a part of the life course, there is substantial disagreement among and within these groups regarding the definition of old age, the perception of what constitutes normal and successful aging, and the extent and scope of public/private responsibility in the promotion of ‘successful’ aging. This disparity in perspectives is reflected in the broad and fragmented body of theory that constitutes the field of gerontology, where ‘… there is no common thread or tie to a common core of disciplinary knowledge to unify the field’ (Estes et al. 1991: 50). Another aspect of this fragmented body of work on aging stems from the larger social science debate of micro versus macro, in which the leading theories of aging are seen as emphasizing either the individual actor or the structure of society as the primary object of study. A small group of theoretical strands attempt to bridge both micro and macro perspectives (Bengtson et al. 1997).
Many of the leading theories of aging, especially those that approach the study of aging from the perspectives of biology and social psychology, focus on the individual as the primary unit of analysis. As such, the aging process is viewed and assessed in terms of the biological breakdown of the individual, or in terms of the individual personality and process, and the presumed concomitant dependency, loss, and requisite adjustment to these states of being.
Two examples of aging theories developed by social psychologists that focus on the individual are disengagement theory and activity theory. Disengagement theory (Cumming and Henry 1961) holds that old age is a period in which the aging person and society engage in mutual separation (e.g., retirement). The process of disengagement is treated as a natural, biologically based, and normal part of the life course. This assertion also fits into the broader functionalist paradigm that was dominant at the time of its development insofar as disengagement is presumed to be ‘functional’ from the standpoints of both the individual and society. Although disengagement theory is no longer widely accepted among researchers in aging, its influence is still apparent in the policy arena (e.g., Social Security and Medicare) as well as in the retirement policies of corporations. In fact, this theory can be seen as a basis for the trend in implementing incentives for early retirement evident in corporations, universities, and public sector institutions over the past decade.
Activity theory developed in opposition to the assumptions of disengagement theory, asserting that people in old age continue the roles and activities they developed over the course of life, including maintaining the same needs and values present at earlier points in their lives. The basic assumption of this theory is that the more active people are, the more likely they are to be satisfied with their lives. Activity theory stimulated the development of a whole host of social psychological theories of aging, including continuity theory (Costa and McCrae 1980) and successful aging (Abeles et al. 1994; Baltes and Baltes 1990; Rowe and Kahn 1987). Continuity theory asserts that aging persons have the tendency and need to maintain the same personalities, habits, and perspectives on life that they developed over their life course. As such, decreases in activity or social interaction are viewed as related more to changes in health and physical function than to an inherent need for a shift in, or relinquishment of, previous roles.
More recently developed theories of successful aging expand the basic framework of activity and continuity theory to three fundamental components: low probability of disease and disease-related disability, high cognitive and physical functional capacity, and active engagement with life (Rowe and Kahn 1997). Successful aging is seen as involving more than the absence of disease and more than the maintenance of functional capacities. Rather, these two components combine and interact with the active engagement with life.
On the surface, activity theory and its later derivations promote the eradication of ageist stereotypes of the elderly and create opportunities for individual empowerment and quality of life in later years. Nevertheless, these theories rarely account for the influence of structural factors on individual outcomes; nor do they examine or treat race, gender, and class as individual attributes or social mediators of the aging experience. In addition, they provide little insight into understanding the broader (and unequal) division of labor and allocation of resources in society. Therefore, policies and programs developed from these theories frequently do not account for or address the diversity and heterogeneity of the aging experience. As such, these policies and programs do not hold much promise for remedying social inequalities or promoting social change.
From the early days of development, a major focus of inquiry for gerontology concerned not only the adaptation of aging persons in society, but also the consideration of health, economic, and social problems related to aging. With regard to elders’ health, there has been a strong emphasis on the biomedical aspects of aging (Estes and Binney 1989), with early work treating aging as a disease and the prescription of medical services as the primary intervention. Aging, defined and treated largely by physicians and biologists, was described as decremental, and both unidirectional (inevitable loss of function and adaptability) and negative in terms of outcome.
While the early social and behavioral work focused on individual aging and the factors in ‘successful aging,’ life satisfaction, adaptation, disengagement, and adjustment with advancing years, more recent studies focus on understanding the process of aging from the perspective of the life course and its relationship to coping, social support, personal control, self efficacy, and the behavioral dimensions of aging. This work acknowledges the malleability and reversibility of various biological and behavioral phenomena previously thought to be inevitable (Rowe and Kahn 1987, 1998) and increasingly recognizes the influence of social, behavioral, and environmental factors in the explanation of the processes of aging and of health in old age (House et al. 1990). This work is consistent with a substantial body of literature affirming the importance of social, behavioral, and environmental factors in both individual and population health (Adler et al. 1993; Hahn and Kaplan 1985; Navarro 1990; Syme and Berkman 1976). In particular, the work of Rowe and Kahn and Bortz and Bortz (1996) suggests a declining significance of medical and biological factors in health with advancing age. Attention to the interplay of social structures (structural opportunities in schools, offices, families, communities, social networks, and society at large) and structural change in explaining healthy and successful aging is highlighted by Riley and Riley (1994, 1998). Other recent work calculates the proportion of health (mortality and morbidity) that may be accounted for by biological in contrast to social, environmental, and behavioral factors. The latter factors are seen as carrying the most weight (ranging from 50 per cent or more of the explanations for health outcomes).
More recently, aging has been viewed from the life-course perspective, which situates aging of individuals and cohorts as one phase of the entire lifetime and is shaped by factors (historical, social, economic, and environmental) that occur at earlier ages (Bengtson and Allen 1993; George 1993). An important contribution of life-course theory is the commitment to bridging the macro-micro levels of analysis. Nevertheless, there is a tendency within this perspective to focus more on the micro, with an emphasis on how macrolevel phenomena influence individuals.
Another macrolevel approach is the age stratification perspective, which analyzes the role and influence of social structures on the process of individual aging and the stratification of age in society (Riley and Riley 1994, 1988). This perspective looks at the differential experiences of age cohorts across time, as well as what Riley and Riley (1994) call the interdependence of changes in lives and changes in social structures. A more recent dimension of this theory is the concept of structural lag, wherein social structures (e.g., policies of retirement at age 65) do not keep pace with changes in population dynamic and individual lives (such as increasing life expectancy). One of the major limitations of the age-stratification approach is its relative inattention to issues of power and social class relationships, especially insofar as these factors influence the social structure and the policies constituted by it.
Critical perspectives on aging and health emerged in response to the limitations of traditional theorizing in aging. Critical analysis of traditional aging theories reveals how these theories avoid questioning the very social problems and conditions facing the elderly (Estes 1979a) and therefore have the tendency to reproduce rather than change the conditions of the elderly. At a basic level, theories such as disengagement and activity can be seen as reinforcing ageist attitudes about the elderly and legitimating policies that reinforce dependency at the expense of empowerment. In addition, the association of age with disease and inevitable decline can be reframed such that aging is seen as a social, rather than a biological process. This alternative view, which is central to the critical perspective, reveals that many experiences related to aging result from socioeconomic conditions and inequalities experienced over the life course.
In attempting to bridge some of the issues of concern about many of the aforementioned aging theories—namely fragmentation and the macro-micro problem—the critical approach to aging considers the multilevel relationships among social structure, social processes, and the population. Within this frame, the recursive relationship among levels of analysis are emphasized (Giddens 1984), which provides an avenue for extending and further synthesizing this micro-macro linkage. As such, issues of aging are not perceived as beginning with the individual, the generation, institutions or organizations, or society. Instead, all levels are viewed in terms of mutual dependency, rather than in opposition.
Although the field of critical approaches to health and aging has grown over the past decade, the promise of the field—namely its incorporation of a variety of disciplinary perspectives—also contributes to the difficulty that the field faces in realizing its potential. For one, as both Baars (1991) and Phillipson (1999) note, critical health and aging is a very broad field concerned primarily with questions and analyses that fall outside the mainstream of gerontology and other disciplines in the social sciences. These questions and analyses range from understanding the role of the state and capital in managing the aging process (e.g., Estes 1979a, The Aging Enterprise) to questions regarding the meaning and purpose of aging in the context of postmodern societies (Cole 1992).
The Changing Context of Health and Aging
Two major elements of the larger context of health and aging are the ongoing market-driven restructuring of the delivery system and changes in the welfare state.
Delivery System Restructuring, Privatization, and Devolution
A critical perspective on health and aging addresses health policy developments in terms of the changing roles and resources of the state and corporate enterprise, respectively, with a particular interest in the consequences for society and the public’s needs and access to care and the distribution of inequalities therein. Attention is also given to the uses of ideology (e.g., the superiority of the market) in advancing the interests of dominant economic and political forces. The critical framework points to power struggles and social conflicts as central processes through which resources are distributed that either maintain the status quo or alter disparities in health status and health care by race, class, gender, and age. The medical industrial complex and the aging enterprise are seen as ‘products’ of the relations of the state, capital, the sex/gender system, and the public (Estes 1998b). Simultaneously, these entities and the businesses that comprise them influence, reflect, and benefit from the definition and treatment of old age and the aging as a medical-techno rather than a social problem (Estes 1979a).
Since the 1930s, the federal government has played an influential role in the development of health and long-term care through policies supporting an expansion of the federal welfare state, such as Social Security, Old Age Assistance, the Hill-Burton statute, the Kerr-Mills program, Medicare and Medicaid, and other policies and regulations.
In the United States, the state’s role has been and continues to be one of complementing and subsidizing, rather than competing with the private sector. The passage of Medicare for the elderly in 1965 was the first major public health insurance program for the nation aimed at citizens aged 65 and older. Medicare supported private fees for service physician care and hospital payments based on retrospective billing—both of which provided incentives for doctors and hospitals to bill more and often. Barbara and John Ehrenreich aptly described this as the beginning of the ‘American Health Empire.’ Furthering the process that began with the passage of Medicare and Medicaid in 1965, Reagan Administration policies in the 1980s fueled the growth in the for-profit service sector and health care costs (Fuchs 1990). Although 40 per cent of the cost of US health care is financed by a largely private sector medical-industrial complex, the state has limited its own activities in the public health and social services arena to those that maintain and assist the development of the private market through limited public financing programs of health insurance. These programs are primarily for the aged (Medicare) and the poor, who cannot afford to pay for private insurance (Medicaid) (Estes 1991).
State policy also provides opportunities for private capital through civil law and regulation by protecting the market and encouraging the participation of proprietary health entities (e.g., the Omnibus Reconciliation Act of 1980), including more than $30 billion in federal tax subsidies for the purchase of private health insurance. Over time, government tax cuts for business, combined with the promotion of for-profit medical care, have acted in a contradictory fashion to exacerbate the fiscal problems of the state (Estes 1991).
Direct attacks on the welfare state, including Social Security and Medicare, surfaced early in the 1980s as part of President Reagan’s first term of office. Subsequently, Reagan, with the support of a rattled but democratically controlled Congress, produced both a recession and a major federal deficit due to increased military expenditure and deep tax cuts for the wealthy. The financing of the deficit then generated major interest payments by the federal government, which further increased the deficit. In the late 1980s and early 1990s there was grave political concern and exhortation over the size of the federal deficit. President Clinton was elected on the mantra of ‘It’s the economy stupid’ and the promotion of deficit reduction as a major policy, which has contributed to intensified power struggles over the commitments and jurisdiction of the Federal government. These concerns have prompted the passage of multiple policies aimed at (1) reducing the federal deficit, (2) stimulating market competition and containing costs in the health-care sector (e.g., legislation promoting managed care and prospective payment), (3) transferring a greater cost burden and risks of out-of-pocket medical payments to patients (e.g., the 1997 Balanced Budget Amendment for Medicare), and (4) re-directing responsibility to the state and local levels (e.g., the 1996 Welfare Reform Act) and the private sector.
Between the time that President Reagan took office and the present, there has been more than a threefold increase in US health expenditure, which now exceeds one trillion dollars annually. The Reagan administration created a watershed in promoting state policies that would increase market involvement in medical care, accompanied by ideologically laden rhetoric extolling the superiority of the market and excoriating the inferiority of government. As a result, a series of developments over the past two decades have converged to shape and transform the health and long-term care industries in the United States (Estes 1986; Estes et al. 1984 1993; Relman 1980; Starr 1982).
The magnitude and profundity of this restructuring have been described as the medical equivalent of the industrial revolution, in which health-care entities moved from small entrepreneurial operations to large, powerful, and increasingly concentrated capital enterprises. Three key characteristics of these changes are: (1) the overpowering strength of the ideology of the market, (2) the expansion and near-domination (in influence if not dollars) of proprietary organizations into every aspect of health care, and (3) an increasingly contested but continuing role of government as a major revenue source supporting the growth of the medical industrial complex and as a payer of care for the elderly, the disabled, and the poor. While the roles of federal and state governments in the health-care system are challenged, there has been a shift away from the federal government and an increase in the responsibility and discretion given to the states. Such a shift is particularly consequential for the elderly, given that the federal-state Medicaid program is the largest public funding source for long-term care for the elderly.
Beginning with the passage of the 1983 Medicare Prospective Payment System (PPS), which gives hospitals financial incentives to discharge patients earlier, and the dramatic reductions in hospital lengths of stay (LOS), the sector of postacute and ambulatory care services increasingly assumed an important role in the health-care delivery system (Estes 1986, 1988; Estes and Binney 1988; Estes et al. 1993). For the elderly who have been discharged from hospitals ‘quicker and sicker’ (with millions of days of the caregiver time formerly provided via hospital care transferred to the home and community), the demand for skilled nursing and home health care increased (Heinz 1986). New forms of care emerged, such as hospitals branching into home health services, inpatient posthospital services, and hospice and hospital swing beds (Guterman et al. 1988). Access to nursing home care became more limited as the illness acuity levels of patients discharged earlier from hospitals increased, thus requiring more complex treatment from highly trained health-care professionals (Hing 1987; Shaughnessy et al. 1990). In addition, regulatory policies, such as the 1987 Omnibus Budget Reconciliation Act (OBRA), introduced a number of changes to organizations that provide community-based long-term care (CBLTC). These include new training and reporting requirements, more strict reimbursement standards, and other forms of oversight and utilization review.
One significant change that occurred during the Reagan administration was the initiation of what has become a sustained attack on the nonprofit sector in health (Estes and Alford 1990). President Reagan’s approach reversed the prior state policy (in effect from the mid-1960s to the 1980s) in which preference had been given to nonprofit health and social service agencies as President Johnson intentionally supported the development of the nonprofit service sector. The attack on nonprofits occurred through the deregulation and encouragement, as well as the direct financing, of for-profit providers of medical care and social services. In this way, state policy under Reagan clearly augmented and stimulated market investment opportunities for private capital in areas that had been traditionally the domain of nonprofit health entities (Marmor et al. 1987). The medical market has advanced in areas that promised the greatest likelihood of profit (e.g., managed care, hospital, and home health services).
With all of the state financing and the high and growing government and private sector costs for health care, there has been (1) a deepening of divisions in the defacto rationing system of US health care based on ability to pay (Darling 1986), and (2) a largely unchecked rise in federal health-care costs (Estes et al. 1995: 354; Reinhardt 1988). Beginning in the early 1980s and continuing to the present, the state intensified funding constraints for social and community care services, which was of great concern to the elderly (Abramson and Salomon 1986; Estes and Linkins 1997; Salomon 1987). These services are among the most needed by the elderly because they are not funded by Medicare and are provided largely in nonprofit service organizations that have had a high degree of dependency on government funding. These social and supportive services experienced the most severe cuts by the Reagan administration (and are underdeveloped today). Also, these services tend to be less attractive for business investment because there is less certainty of profitability due to the bias in reimbursements in favor of medical and skilled care and against the social and supportive services needed for the chronically ill and for the elderly. Additional impediments to for-profit investments in social services concern their relative labor intensity, lower technological content, and their unpredictability in terms of demand and scope (Estes 1986; Estes et al. 1993).
All of the government’s promotion of market forces and competition from the 1980s to the present has failed to realize either the goal of containing the rising costs of health and long-term care services or the goal of increasing access to care. Based on research by Himmelstein, Woolhandler, and Carrasquillo, the nation’s uninsured exceeded one in six, or 43.2 million in 1997 (PCHRG 1998: 11-12), while an even higher number of Americans are underinsured for health care. The failure of President Clinton’s national health insurance reform efforts shifted the initiative for health policy reform to the discretion (and direction) of the market. The resulting structural changes have further accelerated the privatization and rationalization (Weber 1946) of medical care through the growth of large, complex, multi-facility systems (Fennell and Alexander 1993; Shortell et al. 1990). State tax subsidies, the lure of high profit margins, and state policies to promote competitive bidding practices have continued to encourage and stimulate proprietary sector involvement of ever larger and more complex organizational health-care entities, conglomerates, and subsidiaries that may have few community ties. The continuing consolidations, mergers, and conversions of nonprofit health entities to for-profits have greatly strengthened and emboldened the hand of the insurance and managed care industries (Bergthold et al. 1990; Berliner 1987; Estes et al. 1993) Institute of Medicine 1986; Light 1986; Salomon 1987).
Regarding public financing of health care, compared with other developed countries, the United States spends significantly more on health care in absolute dollars and as a percentage of gross domestic product (approximately 14 per cent of the GDP in 1998, which is two to three times the expenditure of other comparable nations). Yet the United States remains the only Western industrialized nation without national health insurance. Historically, US health costs rise well above general inflation. In terms of health care for the elderly, the United States lags behind other Western industrial nations in the provision of long-term care.
Medicare
Medicare, the US program of health insurance for the elderly, covers nearly all nonworking persons over age 65. Although Medicare is a program primarily for the elderly, 13 per cent of its beneficiaries are younger than 65 and disabled; 300000 are covered for kidney dialysis. In 1994, Medicare represented 12 per cent of the federal budget, with growth projections to 16 per cent by 2002 (Feder 1995/1996). In 1996, Medicare spent about 169billion for elderly beneficiaries, or 4875 per elderly person. By 1998, Medicare expenditures exceeded 217 billion (5600 per person). In the early years of the program, Medicare represented 11 per cent of total health-care expenditure. By 1993 and continuing to the present, Medicare has accounted for about 20 per cent of total health-care expenditure (Davis and Burner 1995; Kaiser Family Foundation 1998). In 1998, Medicare accounted for 2.6 per cent of the economy, and it is expected to more than double to 5.9 per cent in 2030. The Medicare Trust Fund faces a shortfall in the next decade, which is being addressed by 1997 legislation that promotes HMOs and increases the costs of care to beneficiaries. In addition, a federal Medicare commission is debating options that are expected to augment elements of privatization and rationalization of the Medicare program for the elderly through additional means of market stimulation and proposals to privatize Medicare through vouchers and/or medical savings accounts.
Medicare barely covers half of the total health-care expenditures incurred by people over age 65. The bulk of Medicare payments (79 per cent of 1998 benefit payments) are for hospital (inpatient and outpatient), physician, and managed care costs (CBO in Kaiser Family Foundation 1998: 4). The most significant exclusions from Medicare coverage are long-term care and prescription drug coverage (44 per cent and 18 per cent of out-of-pocket costs, respectively).
Medicaid
For two distinct groups of elders that comprise about 15 per cent of the total Medicare population (Kaiser Family Foundation 1998), Medicaid augments Medicare coverage. The first group includes the below-poverty-level elderly. The second group includes elders who ‘spend down’ to Medicaid eligibility later in life, typically as a result of expenditure on medical and long-term care services not covered by Medicare. Some of these services include custodial nursing home care, prescription medications, and nonskilled home health services. Medicaid typically covers a wide range of uncovered services for both groups of eligible elderly. Medicaid’s most important coverage for the elderly is nursing home coverage.
Privatization and Devolution
Two social processes are strongly linked with struggles over labor and the economic fortunes of increasingly large (now global) capital enterprises. During the 1970s and 1980s, the United States was joined by other industrial societies in pursuing policies to promote the sale of public goods at an escalating rate (Esping-Andersen 1996). Privatization, or the administrative transfer of public goods and services to the private sector, became an acceptable approach for governments to fend off fiscal crises and to delegate down (devolve) or even outright to divest their responsibilities to their citizenry (Estes and Linkins 1997).
The process of privatization in health and long-term care is the subject of a great deal of debate and controversy, and raises major questions about the proper role of government and the existence of citizenship rights and entitlements. Nevertheless, there is limited empirical data about the human and social costs and consequences of the multiple ways in which governments are privatizing health services.
A number of scholars working from the critical perspective view privatization in terms of a new form of class war (Piven and Cloward 1997), where privatization and globalization are both seen more as ideological weapons in the struggle of workers and citizens against big business, rather than as economic requisites. Privatization is not seen as an inevitable response to the fiscal crisis of the state, nor does it inevitably stem from some conspiracy to roll back the welfare state. Instead ‘health services privatization depends on the specific nature of conflict among the state, the private sector, health care consumers, and capital’ (Scarpaci 1989: 2).
Current interest in privatization intersects with a climate increasingly disposed toward market solutions and devolution. The dominant and deep-seated view in the United States is that the market and business sectors can administer programs more efficiently than politicians and bureaucrats. Public opinion polls indicate that the public believes the market system is fairer than the political system. ‘They prefer the market’s criteria of earned desserts to the polity’s criteria of equality and need, and believe that market procedures are more fair than political procedures’ (Lane 1986: 386).
The market-generated discourse of cost-effectiveness, downsizing and rightsizing, and fiscal restraint now permeate the government and virtually all elements of the welfare state, health care, and even the social services. However, the application of these principles in welfare state and health and social service activities reveals the contradictions of capitalism with regard to how two value structures conflict or blend together—the market forces of postindustrial capitalism and the more socialistic traditions of industrial capitalism (Nelson 1995). Although the welfare state is currently incurring formidable attacks, it is unlikely that it will be eliminated entirely (O’Connor 1973; Piven and Cloward 1997). ‘Health, welfare, education, security—these are considered to be “rights” and are not easily dismissed’ (Nelson 1995: 137).
What is emerging through the processes of privatization is an altered form of the welfare state in which the context is shifted from the public sector to a sector coordinating public-private linkages. The private sector, including a gigantic trillion-dollar medical industrial complex, represents major stakeholders in this emerging new form. Social welfare expenditure, broadly defined with Social Security included, are relatively large expenditures at all levels of government. Privatization breaks the constraints on the use of public resources and puts them to multiple ends: to provide welfare and secure profits (Nelson 1995). The fundamental principle driving the development of the welfare state was for economic development to feed social development and, in so doing, to minimize inequality. Privatization is an example of an economic development strategy that potentially escalates inequality, as has occurred in the United States. The altered resources associated with privatization result in a new principle of economic growth.
For the elderly, a fundamental question is whether privatization will lower (or increase) costs (and efficiency) in health care and long-term care in accord with the prevailing rationale undergirding the drive toward more privatization. The high costs associated with health and long-term care reflect the pluralistic financing, complexity, and fragmentation of these domains of service delivery. The political and economic stakes render cost-cutting procedures difficult. From a pluralistic perspective, the costs associated with health and long-term care stem less from the inefficiencies and lack of competitiveness of government than from (1) expenses associated with health-care professionals, (2) the difficulty and extensive use of diagnosis for problem evaluation, (3) costly technology at the edge of innovation, and (4) the growth of care needs associated with the aging population. There is little evidence that for-profit institutions and mechanisms will lead to lower costs associated with the delivery of health care and long-term care. Instead, as Brad Gray asserts:
Studies of hospitals provide no evidence to support the common belief that investor-owned organizations are less costly or more efficient than are not-for-profit organizations … [Available] studies that have controlled for many confounding factors including distinguishing investor-owned from independent proprietary hospitals show the opposite to be true. (Gray 1994: 1525)
From a critical perspective, the rising costs associated with health and long-term care are attributed primarily to the waste and excess resources squandered in the drive for profits, the costs of marketing, and the extraordinary costs of administration and regulation of the highly varied corporate activities and entities. Such entities continually seek to avoid the risks of a sick population and to dump those who cannot be profitably treated on the state or the nonprofit sector. The fact that the United States continues to pursue its current course, in view of very high costs (which are variously estimated at 40 per cent or more of the health-care dollars spent), signals the power of corporations in health (Navarro 1993), particularly when contrasted with the consistent positive evidence that the alternative publicly administered single-payer system has higher administrative efficiency and lower cost (Himmelstein and Woolhandler 1992). An additional and very high price is the inability of the current US health-care system to provide health insurance coverage for more than 43 million persons. Vicente Navarro notes:
… the popular demand for allocating health care resources according to need has always conflicted with the capital logic of putting profits first and people’s needs second. Every inch of human space in the capitalist order has been won after enormous struggle carried out by working people against the powerful and rich. (Navarro 1993: 98)
The Welfare State and Aging: A Critical Perspective
According to Gosta Esping-Andersen (1996: 27), the ‘welfare state has been a mechanism of attaining the goals of social integration, the eradication of class differences, and nation building including solidarity and citizenship.’ From the late 1970s to the present, the politics of aging have been fought in the political context of ‘crisis’ (Estes 1979a). Esping-Andersen (1996) confirms that the phenomenon of demographic aging is part of the present welfare state debate. He identifies three categories of contemporary theorizing about the welfare state ‘crisis’ in which scholars alternatively attribute the problems of the welfare state to (1) distortions of the market, (2) the cataclysmic effects of population aging, or (3) the consequences of the new global economy, which is punishing governments that spend and those that are not economically competitive.
Indeed, the social construction of, and the political uses of, crisis definitions have been—and remain—central to the struggles over social policy for the aging (Estes 1991). Today the question is whether it is possible for the United States to continue to afford to support such bedrock social programs for the elderly as Social Security and Medicare. Beginning with the Reagan administration, increasing attention has been given to the elderly as the source of problems in larger US society and the economy, particularly in creating the necessity for great ‘tradeoffs’ for the society. Actual and projected demographic changes associated with population aging have been ballyhooed as a major crisis. The elderly have been widely and negatively portrayed by the media as ‘greedy geezers’ getting rich at the expense of their children. The media is also reporting that US welfare policy will have to be changed due to the inability of the nation to afford the growing number of elders as the baby boomers reach age 65 and older.
The construction of population aging as a crisis reflects ideological dimensions of the larger sociopolitical struggle in US society (Estes 1979a 1996), which is of particular import for older women, people of color, and those who earn low incomes. The concept of the ‘demographic imperative’ is a rallying point for those who argue that the elderly are living too long, consuming too many societal resources, and robbing the young, which is an argument used to justify rollbacks of state benefits for the aged. It is an inescapable fact that the majority of these elders are female, and the majority who are most dependent upon the welfare state are female, low income, and members of racial and ethnic minority groups.
Some of the most persuasive critical approaches to understanding national health policy have focused on social class and the status cleavages that have split the power of workers by ‘granting … different levels of benefits to different types of workers and the use of means tests [by which] the capitalist class sought to break working-class solidarity’ (Navarro 1993: 86). For health policy, Navarro’s point would be the crucial import of retaining universality of coverage and provision as contained in the social insurance principles underlying US retirement (Social Security) and health (Medicare) programs for the aging. Navarro (1993: 86-87) identifies eight conditions on which working-class power depends, including degree and type of unionization, unity of the labor movement, links between labor and political parties, alliances with other classes, and the unity of the capitalist class.
Welfare state theories seek to explain the patterns of social provision adopted by different nations. Research attends to the relations of the state, corporate interests, and labor in producing different types of welfare state programs (Esping-Andersen 1996). Work on the state and the life course focuses on the ‘impact of the state on the structuring of the life course’ (Mayer and Schoepfin 1989), highlighting Overarching and integrative mechanisms for institutionalizing the life course’ including old age, childhood, public employment, education, military service, and wars. Applied to aging, welfare state theories have acknowledged the importance of both the demographic aging and social class (particularly the strength of labor) in producing more rather than less generous welfare state programs (e.g., Social Security for the elderly) (Pampel 1994; Street and Quadagno 1993). These theories have been successfully used to illuminate the varying health and welfare spending patterns for the elderly in different nations. Particularly important developments for understanding the welfare state and aging are in the incorporation of gender into theories of state-market relations. Two additional dimensions are proposed to capture the effects of state social provision on gender relations: access to paid work and capacity to form and maintain an autonomous household (Orloff 1993: 303).
Major Issues Raised by a Critical Perspective
A critical perspective on health and aging draws attention to the importance of social inequality and gender in understanding the life chances and life experience of older persons. Key individual and structurally linked attributes that explain the experience of aging are one’s social location according to race, ethnicity, social class, and gender.
Social Inequality, Health, and Aging
Over the life course, a variety of social and economic factors interact to shape the trajectory of disease development, treatment, and health outcomes. The critical approach to health and aging considers social class, broadly defined to include wealth, status, and power, as one of the most significant factors influencing the experience of aging in all societies. The inequality of wealth, status, and power evident between racial and gender groups has an impact of health status, and in old age this effect is seen as an issue of accumulated advantage or disadvantage experienced over the life course. Crystal and Waehrer (1996) show that inequalities among groups depend upon and intensify with age. These and other findings (Burkhauser and Smeeding 1994) highlight the ineffectiveness of state policy in compensating for the discrimination (e.g., wage) and disadvantage that one may experience earlier in the life course. Retirement income from all sources is appreciably less for older women than older men (averaging 75 per cent or less the retirement income of men, see Hartman 1998), while nearly three-quarters of the elderly below the poverty level are women. Women are much more dependent on Social Security for their subsistence than are men. Half of older unmarried women rely on Social Security for 80 per cent or more of their income, while one-fifth (20 per cent) of all women rely on it for 90 per cent or more of their income. Fifty-five per cent of women aged 75 and older and 45 per cent of those 65-74 years old are below the poverty line (Stone and Griffith 1998).
The concept and measurement of social class has been addressed and measured in a variety of ways. A frequently used proxy for social class is socioeconomic status (SES), which is widely recognized as a strong predictor of morbidity and premature mortality, and a linear mortality gradient has been demonstrated at all socioeconomic levels with a variety of diseases (Adler et al. 1993). Recent research demonstrates that SES, measured in terms of education or income, is a major predictor of health status because persons with lower SES are at greater risk of exposure to a range of psychosocial risk factors to health, primarily in middle and early old age (House et al. 1994).
With regard to race and health status, data consistently show the African-American elderly to be disadvantaged compared with whites in life expectancy, chronic illness rates, and levels of disability. While the health disparity between blacks and whites declines with advancing age on some health indicators, including mortality rates, African-American elderly as a group are less healthy and more disabled than white elderly. Some suggest that the health gap between white and black elderly will widen due to increased rates of diabetes and hypertension (Wallace et al. 1998: 331). Older African-Americans and Latinos have two to three times the poverty rate of white elderly, and many do not have health insurance. Thus, access to care is a serious problem to many minority elders. Because minority elderly are ‘projected to comprise over one-third of all persons age sixty-five and older’ (Wallace et al. 1998: 331) in 2050, racial disparities in health status and access to care will be a serious concern. Although it is often assumed that access to health care is a major determinant of health status, international comparative research on SES and health reveals that correction of data for access to health care (e.g., through the availability of universal health insurance) does not eliminate SES as a risk factor (Adler et al. 1993). Therefore, social and environmental factors have persistent and direct effects on health outcomes and on the health status and life expectancy of elderly individuals.
Differences and disparities in life expectancy by race and gender offer another window into the issue of inequality in health and aging. Overall, elders of color experience more health problems than whites because of problems accessing adequate medical care, high poverty rates, and relatively low participation rates in Social Security. These factors contribute to morbidity and mortality differences across populations. For example, research shows that the most important factor contributing to the widening gap in life expectancy between whites and African-Americans is the slower decline in heart disease mortality experienced in the African-American population in recent decades (American Health Line 1998; Papas 1994).
In the United States, population trends reveal a ‘female advantage’ in terms of overall life expectancy; however, this trend is offset by the disability rates occurring among older women. Women at age 65 can expect to live approximately 10 years free of disability and 7 years with disability. In contrast, older men can expect to live 8 disability-free years and 7 years with disability. Therefore, the proportion of disability-free remaining years at age 65 is greater for men, while the absolute number of years of life is less than that for women. Women are also much more likely to be the primary long-term caregivers, to live alone, and to need caregiving assistance themselves.
Inequality related to social class, gender, race, and ethnicity also tend to be related to and reinforce each other, creating a situation that many call double or multiple jeopardy (Bengtson and Dowd 1980-81; Dressel et al. 1998; Minkler and Stone 1985).
Gender, Health, and Aging
Based on demographics alone, with older women outliving and outnumbering older men 3 to 2 (and with the gap growing larger with advancing age), aging is appropriately defined as a gender issue. In important respects, aging is a women’s issue. Corroborating this view, Dr Robert Butler, former director of the National Institute on Aging (NIA), recently described the US health programs for the elderly, Medicare and Medicaid, as ‘women’s programs’ for the very old (Butler 1996).
Gender dependence on the state and the consequences of state policy for older persons in general, and older women in particular, are essential elements of a critical analysis of public policy and health and aging (Estes 1998a). A pivotal element in the critical analysis of health and aging from a gender perspective is an examination of the ‘interlocking systems of oppression’ and inequality (Collins 1990) that are contained within, and result from, the social relations of gender, social class, and racial and ethnic status. Social class, race, and gender are directly related to the health resources (e.g., Medicare policy, private insurance, and access) upon which older men and women may draw through systems of public and private sector provision. There is an important life-course dimension to these intertwined systems of inequality and oppression (gender, race and class), resulting in multiple and triple jeopardies in old age. Feminist analysis, race, and class must not simply be used in an ‘add and stir’ approach, but one that recognizes the compounding and interacting effects of the relative disadvantages and advantages of these three attributes of stratification (Dressel et al. 1998).
Women and Health Insurance over the Life Course
Public and private sector policy discriminates against women in terms of health insurance. It also rewards the traditional nuclear family in which married women do not live alone and economically depend on a working male spouse. This is in spite of societal trends of increasing divorce, single motherhood, and attenuated work careers.
Mature women are more likely to be insured as wives than as workers, but that safety net is only available to married women. Unmarried women are 2 to 3 times as likely to be uninsured or to rely on public programs such as Medicaid, and because they are significantly less likely to be married to a covered worker, black women are 2 to 3 times more likely to be uninsured or to rely on public programs. Given rising instability in both employment and marital status across the life course, stable health insurance coverage can only be attained by universal rather than employment-based or family-based schemes (Meyer 1990: 553). Women comprise a significant proportion (18 per cent) of the ‘near elderly’ (those aged 55-64) who are not insured for health care.
Women, Social Policy, Health, and Aging
Analysis of the role of the state in social provision for the aging, issues of gender dependence on the state, and the consequences of state action are significant elements of the study of the political economy of aging. A feminist critical perspective seeks to understand how state policy actually ‘constructs’ the experience of older women, including their economic status and/or dependency (e.g., through Social Security policy) (Estes 1979a). In the United States, both health and retirement policy contribute to the dependency of older persons and women. Older women’s dependency is produced as a result of women’s roles in the family, the labor market, and the state (Estes et al. 1984). Multiple sources of older women’s dependency include:
- wage inequality and sex discrimination that exists throughout the life course, with cumulated results in old age;
- Social Security policy predicated on the traditional nuclear family and a wife’s dependency on her husband for economic security;
- women’s informal caregiving labor that is not compensated or counted toward retirement income credits;
- age discrimination in employment and early retirement necessitated by caregiving work;
- health policy (e.g., the provision of private health insurance through employment) and retirement policy (e.g., Social Security) that rewards married women and penalizes unmarried women;
- the projected cumulative negative economic effects for women over the life course of the 1996 Welfare Reform for single mothers.
Women, the State, and Long-Term Care
The treatment of older women by state policies is particularly important because women are more dependent on the welfare state than are men (Butler 1996; Estes 1998b). Older women are particularly vulnerable as a result of the absence of government financing for long-term care.
- Medicare (the nation’s universal elder health policy) does not cover long-term care (LTC), necessitating women to provide these services, largely without assistance.
- Reimbursement incentives through public policy (e.g., Medicare) have widened the gap between medical and social services. Acute care services are paid for under Medicare, while long-term chronic care services are not. This is one form of the ‘medicalization’ of aging (Estes and Binney 1989), with negative social and financial cost shifts to older women.
- The effects of the government’s refusal to adopt a publicly financed universal LTC policy are borne unequally by gender. As the majority of care providers, women do most of the LTC work, and they are also more likely to outlive anyone to care for them (thus, to need formal LTC assistance). Women are more likely than men to have to ‘spend down’ all of their resources to poverty in order to qualify for public assistance for nursing home care through Medicaid.
- A higher number of risk factors for both health and economic insecurity exist for older women than for men (e.g., living alone, chronic illness, low income). Also a higher proportion of income is required for older women to pay for LTC services.
- Devolution and increased state responsibility place long-term care policy (and the women who need it) at the effect of 50 state governors and legislatures, which are increasingly conservative (more than 30 with Republican governors). The result is the continuation and deepening of a fragmented and unequal policy for similar women across different states.
Arguments against a universal long-term care policy reside in the unfounded contention that it would encourage the abdication of family (i.e., women’s) responsibility for providing care to the aging and cost the state. The debate is whether the public provision of social services will diminish private care services by family members (Sharlach and Kaye 1997). Such reasoning legitimates the state’s refusal to either provide or pay for long-term care beyond that for the poor under Medicaid. Thus, the state reinforces the ideology that such care is, and must continue to be, the responsibility of women and their ‘free’ labor.
A reasonable question is whether the continuing denial of responsibility for long-term care by government, with the support of business, is attributable to the unnamed gender content of aging—female.
Critical Health and Aging: Three Debates
Two basic organizing principles on which public (state) policy may be based are (1) citizenship and entitlement, and (2) the market. The first principle accords formal recognition in the national community of social rights of citizenship, while the second principle recognizes individual responsibility and the rights of private property. They refer, respectively, to citizen-based or state-based rights versus class-based or property-based rights. A key question concerns the basic organizing principle for a society and state policy and how it affects age relations, and within these, class, race, and gender relations.
As we approach the new millennium, macro-or policy-level issues surrounding the topic of health and aging command attention not only of scholars but also of the media, the public, and policy makers. It is a time of hotly debated controversies that are both highly politicized and polemic. Three significant examples are: (1) the challenge to entitlements and the potential privatization of Social Security and Medicare; (2) the debate surrounding long-term care policy as a universal program versus one provided through commercial private insurance; (3) the pros and cons of Medicare managed care for the elderly.
Understood from a critical perspective, each of these issues involves enormous economic and political stakes, with struggles over profits and control of financial resources and the organization and delivery of medical care in the private sector that have profound consequences for the elderly and their health and well-being. To the extent that steps toward privatization and the curtailment of public programs are realized, the consequences will be most severe for those who are least powerful in society and most economically vulnerable. The media emphasis on the viability of (and preference for) the privatization of entitlements reflects the strength of the market ideology and the reality of the threat of transforming social policy from a communal and universal basis to a class basis that is simultaneously gender- and race-biased. Similar stratified and deleterious consequences are associated with commercial health insurance for long-term care in lieu of a public plan.
The Challenge to Citizen Entitlements: Privatizing Social Security and Medicare
Social policy debate concerning the elderly has, for almost two decades, been permeated by the rhetoric of crisis and increasing attacks on the entitlement and social insurance programs that are the backbone of support for older persons in the United States. These social struggles are profoundly important in health policy and in the provision of health care to the elderly.
The ‘model of citizenship entitlements,’ in which ‘benefits accrue to individuals independently of need or labor force participation’ (Myles 1996: 126) is rare in the United States, but the near-universal coverage of Medicare for those over age 65 (regardless of need or labor market contributions) and to a lesser extent Social Security retirement programs, reflect such a principle.
The late 1990s are characterized by an increasingly divisive contest between corporate and conservative political forces aimed at privatization and those moderates and citizen activists seeking to preserve the existing entitlement-based provisions under Medicare and Social Security.
The privatization of Medicare could be accomplished through the replacement of this federal insurance program with private commercial health insurance. Capitated managed care plans will effectively eradicate the defined benefits of the current Medicare system and replace them with defined contributions and tax subsidies that encourage the purchase of private plans. This would shift the financial risk from the Medicare program to individual elders. Included among privatization strategies are policies to promote private savings to pay for the costs of medical care through medical retirement accounts (MRAs) and vouchers for the purchase of medical care insurance.
The means testing of Medicare is another means of eliminating the universal entitlement to the program, while simultaneously eliminating the universal broad base across all social strata of public support for the program. With means testing, Medicare would become a poor people’s welfare program (and with all the liabilities of diminished public support of welfare programs). The large majority of elders whose incomes exceed Medicare means-tested eligibility levels would be forced to purchase private insurance to cover their medical care.
From a critical perspective, pressures for the privatization of health care for the elderly inhere in the private profits to be made and the corporate control that can be imposed via such policy change. Privatization proponents argue that the rising costs of health care and the Medicare program mean that government (i.e., taxpayers) cannot afford it with the demographic expansion of the aging. Further, the market ideology holds that the private insurance market is more efficient. Opponents of privatization contend that privatizing Medicare does not address the factors that increase the costs of medical care (the fragmented, highly inefficient, and expensive for-profit system that promotes provider- and technology-induced cost increases and service demand). In addition, policies of privatization are class-based policies that disadvantage the already vulnerable (women, minorities, the poor and near poor, and the oldest old).
Commercial Private Insurance versus Universal Public Insurance for Long-Term Care
Given the state’s reluctance to pay for long-term care (LTC) costs under Medicare and its existing and limited LTC coverage, the primary public coverage for LTC is available under Medicaid only for those who are poor or near poor (depending on the state in which a person lives). Advocates for commercial private LTC insurance argue that public insurance is too costly and that LTC should be insured privately, with some subsidy by the government. Opponents of private insurance for LTC argue that only a small percentage of the elderly are ever likely to be able to afford private LTC insurance (10-20 per cent), and that lower cost LTC insurance products do not provide enough benefits or inflation protection to make them attractive even to those who could afford them (Estes and Bodenheimer 1994; Wiener 1997).
With the limited ability of most elders to afford private insurance and the design of LTC insurance policies themselves, less than 10 per cent of the costs of LTC will ever be covered (or saved) by private insurance. Private LTC insurance will still leave the major financing responsibility of paying for LTC to the individual and to the government for those who ‘spend down’ to the poverty level and have Medicaid eligibility for LTC. Wiener (1997) notes that,
virtually no one argues that the sick or … terminally ill should use all of their income and assets to pay for hospital or physician care, yet doing so is routine in long term care. (Wiener 1997: 51)
Universal health care advocates contend that the public financing of LTC is a reasonable extension of the already universal Medicare program. Such a
social insurance approach explicitly recognizes LTC as a normal risk of growing old. There is no cogent reason why LTC should be financed primarily through a welfare program [Medicaid], whereas acute care and income support for the elderly are financed through the non-means-tested programs of Medicare and Social Security. (Wiener 1997: 54)
Universal social insurance programs have the political advantage of
including more middle and upper income beneficiaries as part of their constituency… [and] to be more politically stable than programs for the poor. (Wiener 1997: 54)
Managed Care for the Elderly
Lynch and Estes (1997), Feder and Moon (1998), and others have raised a number of issues concerning the benefits of managed care for the elderly. First, HMOs provide ‘managed money, not managed care’ and at a higher cost than does Medicare (Feder and Moon 1998). HMOs have administrative costs of 12-20 per cent off the top before paying providers, compared to the 2-3 per cent costs to administer Medicare. Second, certain groups of elderly and disabled fare worse in HMOs compared to fee-for-service (FFS) medical care. Research on Medicare HMOs show that they enroll a more healthy population than the average, and although research is sparse on how elders with chronic diseases and disabilities fare in HMOs, the studies that do exist point to problematic results. Access to home health care and chronic care services is more limited in HMOs. For example, elders in Medicare HMOs receive 50 per cent less home health care (Brown et al. 1993). Other access problems identified include that for Alzheimer’s diagnostic and treatment centers and comprehensive services (Safran et al. 1994).
As Medicare shifts billions of public dollars to for-profit HMOs with few strings attached, the following items fuel the managed care debate.
- The potential and real tradeoffs between (lower) out-of-pocket costs (in HMOs) for (higher) quality and satisfaction (with fee-for-service non-HMO plans). As health care restructuring and competition squeezes the easy profits out, consumers face rising HMO rates and curtailed benefits—elevating questions about the possible loss of the HMO advantage in providing more benefits than Medicare fee-for-service options.
- The lack of incentives (contrary to rhetoric) to provide preventive care because of annually generated plan redesign and enrollment changes (e.g., disenrollments).
- The public accountability and consumer involvement issues attendant to for-profit insurance companies that comprise the large majority of HMOs.
The Future
From a critical health and aging perspective, some of the most important issues for future empirical and theoretical work are given below.
- Tracking the origins and consequences of the dramatic acceleration in social inequality (e.g., the gap between rich and poor) in society between Americans of all ages and its rise within the older generation. Particular attention needs to be given to the consequences of the high social inequality for the health and quality of lives of older women, minorities, and poor and middle-class people, and the effects of social inequality on health inequality between generations and within the older generation, by race, class, and gender.
- The effects of devolution and privatization on the elderly, including changes in social policy that trade off federal universal social provision for decentralized state and locally determined policy and provision. Attention needs be given to the effects on the health and health care of the aging, particularly of those most vulnerable (women, minorities, the poor, the oldest old, and the unmarried).
- Whether devolution promotes a ‘race to the bottom’ in which states compete to reach the lowest common denominator.
- The changing role of the welfare state and its effects on the economic and health security of the elderly under conditions of postindustrial capitalism and globalization. One issue is whether in health and retirement programs for the elderly, the United States will become part of a solely market-determined ‘class state’ or a citizen rights-based ‘universal state’—and with what effects on older persons of color, and by gender and social class.
- The future of Medicare and Medicaid in the short and long term, and the consequences for program beneficiaries in subgroups of elders of policies to promote cost containment, managed care, and privatization initiatives.
- The success of different stakeholders (capital, the state, labor, women, minorities) in advancing policy and/or pro-entitlement and pro-privatization social movements.
Conclusion
To address the pressing research questions facing the field, there is a need for both the development of new and the reconceptualization of existing methodologies. There is a clear need for more research and theory development that is informed by the social, political, and economic factors that converge and interact to produce significant differences among the elderly. As a field, gerontology and studies of health and aging need to acknowledge the value of multiple methodological and theoretical approaches. There is a great need for systematic meta-analytic and retrospective work in the field, particularly that which addresses the meso- and macro-level of explanation in the critical examination of health and aging. To address the need for research that accounts for the differential effects of phenomena occurring at different levels of analysis, there are several analytic methods, such as hierarchical linear modeling, that would allow this type of assessment. Finally, the debate and resultant false dichotomy between quantitative and qualitative methods needs to be put to rest in favor of studies that incorporate both.
In addition to the need for alternative and creative methods, there is also an ever-present need for data, and particularly projects in the tradition of the Frankfurt School that are multidisciplinary and that attend to the structural factors and institutional forces and processes that are important in any critical examination of health and aging in society and globally. Attention must be given to rebalancing studies of the individual aspects of health and aging with the ‘social’, including the examination of the political, economic, and cultural processes underlying public policy and the social provision that materially affects the health of the different elements of the population in significantly and unequal ways. The historic and relative disciplinary funding advantage of psychology, biology, and economics over sociology has diminished the prevalence of more critical studies while reproducing the knowledge structure of the field through the funding of positivistic research approaches that are perceived as more ‘scientific.’