One of the principles that help explain the logic—or lack of logic—in the health care system is this: financing drives the organization of services. This principle is especially important for frail or physically disabled people who depend largely on government to finance their health care. Two distinct financing—and, therefore, delivery—systems that do not coordinate with each other have developed: the first system, Medicare, the federal government program for people over 65 and severely disabled individuals, pays for acute medical care. Except for stays immediately following hospitalization, it does not pay for nursing home care; nor does it cover supportive services, such as help in cleaning and cooking. The second system, Medicaid, a federal and state program for poor people, does pay for nursing home care and, in some states, supportive services. The two systems are cumbersome and difficult to navigate, particularly for poor, elderly people who are eligible for both Medicare and Medicaid.
A challenge for those trying to improve the care of poor older people is making the financing and delivery of services more rational and understandable. The challenge has been picked up by the Robert Wood Johnson Foundation, whose interest flows naturally from one of its three goals: to improve care and support for people with chronic health conditions. The Foundation's grantmaking has focused on improving acute, chronic and supportive care for people with chronic conditions. However, improvements can happen only when financial incentives for providers are changed and when new models of organizing care emerge.
This chapter of the Anthology by Joseph Alper and Rosemary Gibson chronicles the Foundation's efforts to develop and support programs that integrate the financing and delivery of long-term care services for poor elderly and disabled people. The Foundation's grantees have devised strategies—many of them based on managed care—from which a number of creative models have emerged. But many older people, when given a choice, have rejected managed care approaches and the loss of independence they imply. The goal of developing coordinated services accessible to the majority of those with disabling conditions remains unmet.