LTC Bullet:  The History of Long-Term Care

Monday, July 8, 2002


*** Update on Hawaii's CarePlus program which we critiqued in our LTC Bullet published Friday, June 28, 2002,  Source:  "LTC Daily Analysis Briefs," July 2, 2002, prepared by for members of  "Hawaii Governor Signs Landmark LTC Bill.  HONOLULU, HI, July 3 (Eli Digital)  Hawaii will break new ground with the establishment of the first ever state-run long-term care program.  Gov. Ben Cayetano this week signed legislation establishing the preliminary framework for a state-run long-term care system, the Associated Press reports.  The bill instructs the Executive Office on Aging to convene a summit to present a comprehensive and affordable long-term care system to next year's legislature and sets up a board of trustees to oversee a state fund.  Hawaii's first lady had pushed for a $10 a month tax on all workers, but that proposal was not included in the final bill.  Some opponents of the proposal argue that it will undermine President Bush's efforts to reform Medicare and Medicaid, while others assert that long-term care should be paid for through private insurance, the AP says."  Despite the spin in this coverage, not much remains of the original Hawaii proposal.  According to "National Underwriter" at  "The final version of the bill passed 38-13 in the House and 21-3 in the Senate.  The text of the bill is on the Web at" ***

*** Donor Zone bonanza.  Here's some fresh content just posted.  Be sure to take your one-a-day mental vitamins in The Zone.  Call or email Amy Marohn at 425-377-9500 or to Zone In.  Or simply contribute $100 or more per year to the Center (tax-deductible) at and let Amy know your preferred user name and password (up to 10 characters each).  If you sponsor an LTC Bullet for $500, we'll throw in one year's individual membership in The Zone.  For information on how to qualify your whole company or organization for The Zone, jump to

LTC Week in Review July 1 - 5, 2002:  LTC E-Alerts #167-#170

LTC E-Alert #167--WSJ on LTCI

LTC E-Alert #168--Progress on Parkinson's

LTC E-Alert #169--High Cholesterol Risks Alzheimer's

LTC E-Alert #170--Drugs, LTC, and Reverse Mortgages

LTC Week in Review June 24 - 28, 2002:  LTC E-Alerts #162-#166

LTC E-Alert #162--NH Quality in Bankrupt Facilities

LTC E-Alert #163--Online Gerontology Certification

LTC E-Alert #164--Vitamins for Seniors

LTC E-Alert #165--Shellenbarger on Paying Family Caregivers

LTC E-Alert #166--Are Seniors Over-Medicated?

The LTC Reader:

The LTC Reader #22-- Medicare Savvy Pays

The LTC Reader #23--VA Nursing Home and Domiciliary Care

The LTC Reader #24--GAO or Pollyanna:  Who's Right about Social Security, Medicare and Medicaid?

The LTC Data Base:

The Data Base #22--Could Home Equity Conversion Fund LTC and LTCI Premiums? 

The Data Base #23--Global Aging

The Data Base #24--Doctor Visits and Costs Rising with Aging

Spend 5 or 10 minutes per day in The Zone to stay on top of developments throughout long-term care. ***


As we've recounted many times before, America's long-term care system is a mess:  nursing home bankruptcies, slow assisted living fills, collapsed stocks, scarce capital, institutional bias, doubtful quality, high cost, staff shortages, low government reimbursements, little private LTC insurance, skyrocketing liability premiums, etc. 

Lincoln said:  "If we could first know where we are and whither we are tending, we could then better judge what to do and how to do it."  (House Divided Speech, 1858)  Before we can look forward to a solution successfully, we should look backwards and ask "How did long-term care come to be the way it is today?"

Author and publisher Karen Stevenson Brown has undertaken to write the history of long-term care service delivery and financing.  She's posting the work in progress at  The results so far are fascinating.  Here's an article by Ms. Brown introducing the project and a few excerpts to spur your interest. 

"History of Long Term Care" by Karen Stevenson Brown;

This new section of ElderWeb is a comprehensive overview of how our long term care system has evolved by examining the events and decisions that changed the way that we have provided and paid for the care of our elderly over the years.

My goal in this project is not to create a simple chronology of events, but to identify causes and effects - why did things turn out the way they did?  For instance, back in Colonial times, older people were generally cared for by their families.  That changed when children started moving away from the family home in the 19th century as they went into the cities and out to the West.  Urbanization had a big impact, too.  City families were smaller (there were fewer children who could eventually provide care), city homes were smaller, especially the tenements, and there was no way to maintain gardens or livestock in the city, and city jobs were different (it was harder for an older person to find work in order to be self-supporting). 

My approach has been to investigate events that happened in each time period, but also to work backwards to try to identify the catalyst for changes in the type of care we provide or the way we pay for it.  Why did CCRC's emerge in the 1960's and assisted living in the 1980's and 1990's?  Why did the nursing home industry end up dominated by for-profit companies?  Why did we end up with 70% of nursing home residents on Medicaid?  Why doesn't Medicare cover nursing home care?  Why were the poor farms created, and why did they disappear?

I believe that understanding what has happened in the past, and why, is critical to understanding why our system works the way it does, and planning for its future.  Certain themes re-appear over and over.  The government creates a new source of funding, everyone piles in to take advantage of it at the expense of programs the government does not pay for, costs explode to levels far beyond initial projections, we try to find the "culprit" for the cost over-runs, the program is scaled back or saddled with burdensome restrictions that start to deny service to even the most deserving, then we have to find a new way to help the under-served.  We'll keep making the same mistakes if we don't stop and look back from time to time to try to understand what went wrong and what went right.  [LTC Comment:  Right on!]

It is an enormously interesting project.  I've spent nearly 20 years in this field, including 9 years working with the ElderWeb web site and newsletter, 9 years as the CFO of a nursing home chain, 6 years doing finance and technology consulting to providers, and personal experience helping family members and friends with their own problems, and I never knew many of the things I've discovered in the last few weeks.

Some tidbits from the information posted so far:

- In colonial days, "old age security" meant having children and/or property.  Old men and women who had no children to care for them and no money had few good options available.

- The first "institution" for the poor elderly was the poorhouse, where "inmates" had to give up all their rights.  It was like a prison, inmates couldn't leave or have guests without permission.  They were even forbidden to wear their own clothes -- they had to wear a uniform.  Many of the elderly shared space with the mentally-ill, who were sometimes chained and kept in pens or stalls.

- "Benevolent Societies" created one of the first organized old-age assistance programs.  Members paid monthly dues to the Society while they were young and healthy, then received help when they were elderly, infirm, or in need.

- "Old age homes" were developed during the 1800's to protect "respectable" people from the "indignity" of the poorhouse.  Some of them required the recipient to pay an up-front fee and turn over whatever income and assets they had in exchange for a guarantee that they would have a home as long as they liked -- an early version of what we now call "lifecare".

- Early retirement communities were also developed during the 1800's.  One had "convenient two-story brick cottages", a community center, a hospital, and its own water system.

- While fewer people lived to age 65 or age 85 in 1900, those that did had nearly as many years ahead of them as people of those ages do today.  There were reports of hundreds of people who lived past 100.

- Urbanization and the migration to the west in the 18th and 19th centuries reduced family sizes and disbursed families so that older people could not count on having a family member available to care for them, increasing the need to develop alternative solutions.

You'll want to read the story online so you can see the photographs of poorhouses and old age homes of the time.  You'll also want to take a look at dozens of interesting pictures, narratives, graphs, and charts collected in the appendix, many from the wonderful Library of Congress American Memories collection.

The author's contact information is as follows:

Karen Stevenson Brown, Publisher; ElderWeb; 1305 Chadwick Drive, Normal, IL 61761; Phone: 309-451-3319; Fax: 866-422-8995;;

Regarding the content on her website, Ms. Brown states:  "Feel free to link to this material or let others know it exists, however these pages include copyrighted material that took a long time to create, so please do not copy it without permission!"