The Evolution of Long Term Care in the United States

In the first century of our country's history there was no such thing as nursing homes or assisted living. Society was mostly rural and people lived in their own homes. Families cared for their loved ones at home till death took them.

In the latter part of the 1800's because of an increasingly urban society, many urban families were often unable to care for loved ones because of lack of space or because all family members including children were employed six days a week, 12 hours a day. During this period many unfortunate people needing care were housed in County poor houses or in facilities for the mentally ill. Conditions were deplorable.

In the early 1900's home visiting nurses started reversing this trend of institutionalizing and allowed many care recipients to remain in their homes. Nursing homes or so-called rest homes were also being built with public donations or government funds. With the advent of Social Security in 1936, a nursing home per diem stipend was included in the Social Security retirement income and this government subsidy spurred the construction of nursing homes all across the country.

By the end of the 1950s it was apparent that Social Security beneficiaries were living longer and that the nursing home subsidy could eventually bankrupt Social Security. But in order to protect the thousands and thousands of existing nursing homes Congress had to find a way to provide a subsidy but remove it as an entitlement under Social Security.

In 1965, Medicare and Medicaid were created through an amendment to the Social Security act. Under Medicare, nursing homes were only reimbursed on behalf of Social Security beneficiaries for short-term rehabilitation. Under Medicaid, nursing homes were reimbursed for impoverished disabled Americans and impoverished aged Americans over the age of 65.  Since 1965 it has not been the intent of Congress to pay for nursing h

ome care for all Americans.  With the passage of the Older Americans Act, nursing home entitlement for all aged Americans was now gone.

Over the last 40 years, there has been a gradual change away from the use of nursing homes for long term care towards the use of home care and community living arrangements.

We are currently seeing a trend towards working conditions like those in urban America in the early 1900's where both husband and wife are working and putting in longer hours. We are also seeing a return of the trend in the early part of the 20th century where outside visitor caregivers are available to replace working caregivers and allow the elderly to receive long term care in their homes. In addition there is a significant trend in the past few years for Medicaid and Medicare to pay for long term care in the home instead of in nursing homes.

The return to an emphasis on the home care is encouraging because as a general rule most people do want to remain in their homes as long as possible.  With continued government support and with the proper planning and the money it provides, most of us could remain in our homes to receive long term care and we would never have to go to a nursing home.