Rethinking the Welfare State: The prospects for ... - e-Library

Rethinking the selfare state 116
and Disability has found it impossible to develop a specific list of priorities in treatment.
As a result, significant discretion has been left in the hands of the Regional Health
Authorities who have largely resorted to maintaining pre-existing service patterns. The
question of what services should be covered and which should not is indeed a difficult
challenge and requires recurrent revisitation in response to technological developments
and new evidence of health service costs and benefits, raising institutional issues of who
should decide these questions, on what criteria, and following what kind of decisionmaking
process.
With the aging of the population in many countries, the provision of long-term care
(LTC) raises the issue of scope of coverage in one of its most acute forms. LTC
comprises a wide range of services including medical care, assistance with activities of
daily living (ADLs), which includes assistance with mobility, using the restroom and
eating, and assistance with instrumental activities of daily living (IADLs), which includes
assistance with household chores, taking medication and money management. LTC can
involve institutionalization in a hospital or nursing home, the use of adult day care
facilities, or home visits. While the medical components of LTC are often treated as
health care benefits, non-medical components are generally viewed as “social” benefits,
hence not attracting the same level of government support.
The policy rationalization for this distinction seems to be that LTC services that are
not “medically necessary” fall outside the ambit of the Rawlsian justification for
universal access to health care. In our view, a comprehensive and efficient system of
health care should include many LTC services. First, most non-medical LTC services are
required as a direct consequence of medical conditions. For example, an elderly person
with severe arthritis may require help with household chores because of her medical
condition. The distinction between a “medical” service and a non-medical service that is
required as a direct consequence of a medical condition is tenuous, and the denial of a
benefit to a person requiring the latter conflicts with values of distributive justice and
personal autonomy.
In many countries, only those with extremely low levels of assets are eligible for
government funding of non-medical LTC services. 103 This means-testing is often
normatively justified on the basis that these services are akin to welfare benefits, and thus
should only be provided to those who are seriously impoverished. However, it fails to
recognize that the costs of LTC are often prohibitive, even for those people with
moderate income/asset levels. In many countries, individuals are required to “spend
down” their assets in order to meet eligibility requirements for state-funded LTC, 104 at
which point they will then be eligible for state-financing but will then find themselves in
a state of poverty
Another concern is that the strict separation of medical and non-medical services
serves as a source of inefficiency in the health care system. Hospitals may simply
discharge patients requiring chronic care to nursing homes or to the community, thereby
divesting themselves of the costs. Alternatively, hospitals may be under pressure to keep
patients in high-cost, publicly financed chronic care units even when a more efficient but
unfunded alternative exists.
Finally, there does not seem to be a coherent theoretical reason for the reluctance to
finance LTC primarily through a public insurance system. Feder and colleagues argue
that, “we typically rely on insurance to deal with costs that are potentially catastrophic