The subject of nursing homes is not popular. It is not pretty. Dr. Bruce Vladeck's thoughtful and probing analysis of the nursing-home industry is timely, necessary and an outstanding contribution toward a better understanding of this most difficult and emotion-laden subject. Like Mary Mendelson's Tender Loving Greed and Senator Frank Moss' and Val Halamandaris' Too Old, Too Sick, Too Bad. It again serves as a painful reminder of the job that remains to de done in improving the quality of nursing-home care in this country.
Most importantly, it raises the specter of a failure in public policy when it comes to the development of long-term care for the elderly. As Vladeck so forthrightly states: "If conditions in the nation's nursing homes are scandalous, then there has been a scandalous failure of government."
Unloving Care: The Nursing Home Tragedy traces the history of nursing-home programs through the federal executive and legislative processes. What emerges is not the development of a coherent policy, but instead the byproduct of other health and welfare policy decisions. This piecemeal approach -- or "incrementalism," as Vladeck terms it -- has resulted in our present-day pattern of programs and benefits that are riddled with gaps. Vladeck makes it painfully obvious that this approach has not been successful to date, and he points to the serious consequences if we do not correct our present course.
Any discussion of nursing-home care and certainly any discussion of a midcourse change ultimately gets down to the proverbial "bottom line" of money. As Vladeck points out, in Fiscal Year 1977, $12.6 billion was spent on nursing-home care, which is alarming.
However, what is even more alarming is that recent statistics show for every $1 billion spent on health and social services to help maintain the elderly in more community-like environments, $30 billion is spent on medically oriented, long-term acute-care services. This simply underscores the need to develop a comprehensive policy for long-term care encompassing the entire spectrum of services to the elderly. We must move to develop the alternatives to nursing-home care that have been demonstrated to be effective and feasible in various experiments across the country. As Vladeck puts it, "If something does not begin to substitute for nursing-home care now, nothing ever will. There exists an opportunity that will last for five to, at most, 10 years for policymakers to seize control of the future of long-term care. Thereafter, it will be lost."
In contrasting to Vladeck's treatment of "the nursing-home tragedy" as a failure in public policy, David J. Rothman approaches the issues of criminal justice, juvenile justice and mental health from a broader perspective. Rothman's basic premise in Conscience and Convenience: The Asylum and Its Alternatives in Progressive America is that the evolution of the juvenile, criminal and mental institutions has all taken place in the name of "reform," and he goes into great detail to document this evolutionary process. This historic detail is necessary, Rothman believes, because of the absence of any substantive historical account of programs for the criminal, the deliquent and the insane.
Much attention is given to the historical accounts of the various reform movements in these areas in order to understand the rationale or impetus for these efforts and to better understand how we arrived where we are. The central theme of the book, as the title states, is the push/pull, or as Rothman put it, the "dynamic and tension" of conscience vs. convenience and the part these concepts have played in the development of programs to serve these populations. I found this approach to be an interesting way of analyzing the reform movements. The essence of this analysis simply put is that the "conscience" of movements was "the invention of benevolent and philanthropic-minded men and women and their ideological formulations were essential to promoting change." The "convenience" factor comes into play when the reforms being advocated by these reformers were modified and sometimes compromised by the administrators, wardens and superintendents (and in the 20th century, the special-interest groups) who would eventually have the responsibility for carrying out the reforms.
I found Rothman's analysis to be penetrating and extremely timely in this day of reexamination of many of the policies that have come into being as a result of these reform efforts. Is the indeterminant sentence effective? Do community alternatives work? Are outpatient clinics and community mental-health centers effective in reducing mental-hospital populations?
Rothman believes and hopes that many of the answers to these and other policy questions lie in the history of the reform movements of the past century. Can the same institutions guard and help, protect and rehabilitate, maintain custody and deliver treatment? These are the questions of conscience and convenience that were asked by the reformers of today.
The essence of Rothman's analysis that is of profound importance for us in the future is that just as surely as the reformers of yesterday thought they had "the answer," so do the reformers of today. One hopes that, through analyses such as Rothman's, we will better understand that one decade's "reforms" are another decade's problems and that the history of these reforms can teach us some valuable lessons for the future.