Government Must Call For Stable Long-Term Care

A defining issue for our generation is how the U.S. will address the needs of their aging populations and provide adequate care for the dependent elderly.  Indeed, as Americans live longer, the need for long-term care and long-term caregivers will continue to grow. From 2000 to 2050, the U.S. population age 65-74 will grow from 18 million to 35 million, the population age 75-85 will grow from 12 million to 26 million, and most dramatically, the population age 85 + will grow from 4 million to 18 million. The number of people using nursing facilities, alternative residential care, or home care services is expected to almost double from close to 15 million to 27 million in 2050.

As things stand, the United States is ill-equipped to handle the current demand for long-term care, and the burgeoning elderly population will only exacerbate these strains.  A newly released report by Lisa Eckenwiler at the Center for American Progress lays out an ethical framework for discussing and understanding long-term care, and most important, establishing standards by which policies, programs, and practices concerning caregiving should be evaluated.

An ecological ethic calls for seeing caregivers and the elderly as interdependent and profoundly affected by policies on the economy, health care, labor, and even immigration. Just as ecologists study of patterns in nature, how those patterns came to be, how they change, and why some are more fragile than others, policy makers should see caregivers and the elderly as interdependent; affected in patterned ways by shifting social, economic, health care, labor, and even immigration policy choices; and above all, vulnerable to varying degrees.

An ecologically-minded ethic aims to address fragility and to promote sustainability in the policies and systems surrounding the elderly and caregivers. It aims to ensure that caregiving is organized in a way that secures integrated, quality care for some elderly and supports and advances the well-being of those who care for them. This principle encourages us to ask such questions as: How can labor policies promote quality care for the elderly? How can we design employee leave policies that support women’s long-term health and economic security? How can cost cutting in health care and increased support for the elderly and caregivers co-exist? And how can we coordinate labor, health and immigration policy choices to better manage the migration of nurses, while supporting the native workforce?

Respect for human dignity requires supporting people’s ability to make free and informed choices and for promoting the ability of individuals—of all ages, abilities, genders, income levels, nationalities, races, and ethnicities—to achieve a sense of their unique worth and pursue their vision of a good life at all stages.  This calls for policies that support accessible, high quality information and options for the elderly and families with a wide variety of needs.  At the same time the principle highlights systemic concerns like the inadequate staffing for institutional or home care that can threaten the dignity of the elderly and those working to care for them.  It also directs attention to the plight of family caregivers who often abandon their own aspirations for the sake of loved ones and to paid care workers who lack opportunities for professional development.

The principle of beneficence compels us to maximize benefits, including health and security for the dependent elderly and their caregivers and minimize harms done by existing and absent policies and practices and strive to address them.

Beneficence highlights the physical, emotional, and financial strain that long-term care often puts on the elderly and their caregivers. The strain of managing a full-time job and full-time care for unpaid caregivers, and the lack of training and adequate compensation for paid caregivers often causes financial hardship, stress, and illness.  Beneficence can also highlight the way in which the fragmentation of health care – a particular concern for the elderly who often have multiple conditions that demand care – and the emphasis on acute care rather than chronic care can cause harm to the health and well-being of the elderly and their family members.

Beneficence requires investment into the education and training of long-term care specialists so that they can provide care that offers more benefit to the elderly. Re-organizing the health care system around the goals of long-term care is also essential.  Employee leave policies that provide meaningful supports to workers who are caregivers as well as health care and retirement policies that provide for those who leave the paid labor force to work as caregivers are important areas for policy intervention.  Paid caregivers need labor policies aimed at improving wages, health insurance coverage, and working conditions.

Compassion refers to showing concern for the well-being of others, especially the vulnerable.  Compassion can highlight the often substandard care that the elderly receive, the lower standing and thus poor treatment of health care workers in geriatric care, and the dearth of corporate policies to help those providing long-term care to a family member.

Policies designed with compassion in mind would support adequate staffing levels in institutions for the dependent elderly and sufficient training for direct care workers. Another, already mentioned, would be stronger leave policies for employees tailored to the demands of elder care. These would encourage employers to treat workers who serve as family caregivers with compassion.

Reciprocity recognizes that those who serve society deserve adequate recognition and benefits. The elderly have put in years of service and therefore deserve to be taken care of in their last years of life. And those that serve the dependent elderly—whether they are taking traditionally less-valued jobs in long-term care or whether they are contributing to the over $300 billion given each year in unpaid care—should be rewarded rather than taken for granted.

Policy makers should ensure that sufficient economic and social resources are available for caregiving.  Creating policies that acknowledge the condition of unpaid caregivers by adequately compensating them for the important work they do is also central to reciprocity. This could take many forms: tax credits, direct subsidies or stipends, or perhaps credit time for Social Security—all options that merit further exploration.

Given that the U.S. increasingly relies on caregivers from other countries where health care systems may be more fragile and understaffed we should also consider ways to reciprocate.

Temperance calls for taking a long view rather than looking for short term fixes. This principle underscores the problems with shorter-term solutions like recruiting caregivers from overseas by considering longer-term issues such as health infrastructure in the developing nations where those workers are coming from and the need for greater self-sufficiency in supporting a stronger native non-migrant workforce. It can help to envision the long-range consequences for the elderly and their caregivers of cost-cutting in health care. It also recognizes that with the diminishing number of young people compared to the elderly, policies must provide guidance for American businesses striving to cope with a growing number of workers who also serve as caregivers.

Social justice calls for treating people fairly and giving them their due, and it demands that society’s institutions reflect and promote justice. This means, most fundamentally, that resources are equitably distributed and that social norms, economic structures, and decision-making processes enable people—particularly the most vulnerable—to exercise self-determination and live under conditions of equality.

Social justice, like some other principles, calls on us to ensure that sufficient resources are allocated for the care of the elderly and the support of paid and unpaid caregivers. It also demands that we respond to problems such as ageism, the gendered and unequal distribution of caregiving labor, the unequal treatment of paid care workers, especially those who are immigrants, and the notion that caregiving does not constitute a meaningful social or economic contribution. Social justice also requires us to listen to the voices of the elderly and caregivers at all levels of the policy making process. Considered in a global context, the principle calls for ensuring a fair distribution of caregiving resources around the world so that we avoid perpetuating inequalities in global health.

The seven ethical principles of caregiving require the government to take a central leadership role in ensuring that fair and sustainable practices are developed in the coming years. Yet employers, professional associations, advocacy organizations, international lending institutions, and trade unions, also have particular contributions to make according to their scope of action, their skills, resources, and powers. And indeed, not only our values, but our desire for a socially and economically vibrant America call for nothing less.