Geog 331 AC

1125417

Affordable Elder Care:

A Discussion of Long-Term Care Options for Low-Income Elderly
Alison Leonard
1125417
GEOG 331 AC, Victoria Lawson
March 13, 2012

Geog 331 AC
1125417
Introduction
As working citizens examine their finances and chart the course of
their lives, special consideration must be paid how they will support
themselves in retirement. At a certain age, everyone declines in health to
the point that they can no longer work to take care of themselves and must
rely on other means of supporting themselves, whether drawing on life
savings, collecting social security checks, relying on other types of public
benefits such as Medicare or Medicaid, or depending on the generosity of
family and friends. Paying for end of life care is expensive, and many elderly
citizens are unable to save enough money over the course of their lifetimes
to be able to afford to live in a costly retirement home. Throughout this
quarter, I have been volunteering at Full Life Care, an organization that seeks
to provide an alternative option to live-in retirement homes that allows
clients to continue living in their own homes and engaging in their
communities. Full Life Care operates several adult day health centers that
offer a wide variety of services designed to promote better health and quality
of life among older adults, many of whom are terminally or chronically ill or
disabled, including many clients who suffer from Alzheimers disease or other
forms of dementia. As a volunteer at Full Lifes adult day health center in
Ravenna, I assisted clients during morning exercises, including stretching,
movement, and gentle weightlifting, played modified sports and target
games designed to improve strength and coordination, helped facilitate
gardening and craft activities, and served lunch.

Geog 331 AC
1125417
The ancestor of Full Life Care in Seattle, the Northwest Day Center for
Adults, was created in 1976 after funding was approved during the White
House Conference on Aging (Full Life 2011). While living at home is an
attractive option for some elderly citizens who are unwilling to enter
institutionalized care centers, the main block of clients at Full Life are lowincome clients who come to Full Life because they cant afford other health
and wellness services. As a non-profit organization, Full Life receives most of
its funding from service-reimbursement sources such as Medicaid, which is
the state-run health care program that covers low-income applicants who are
over the age of 65, disabled, or need nursing home care (US Gov. 2008), and
the Seattle/King County Division on Aging, which covers the health services
of qualifying low-income clients (Full Life 2011). These types of publically
funded services are at the center of the debate over who should be
responsible for providing and funding elder care. I will now conduct a brief
literature review to situate Full Life Care in the broader scope of elder care
literature and case studies.

Literature Review
As people age, the likelihood that they will need help preforming daily
tasks increases. While only 5% of men and women ages 65-69 need help to
live independently, this figure rises to 33% for women and 26% for men ages
85 and above (Scharlach 1991). This trend is also reflected in nursing home
dependency, which increases from 1% for adults between ages 65-69 to 15%

Geog 331 AC
1125417
for men and 25% for women ages 85 and above (Scharlach 2011). These
statistics are slightly lower compared to those reported in another source,
which stats that 16.6% of adults of 65 are dependent on some form of care,
and that 29% of those over 65 and over one third of those over 85 live in
some form of institutionalized care (Jamshidi 1992). Many of these patients
need assistance in preforming activities of daily living, such as bathing and
dressing themselves, due to chronic illness or age-dependent disorders such
as dementia, stroke, or Parkinsons disease (Scharlach 1991, Jamshidi 1992).
An estimated 80-85% of adults over the age of 65 have at least one chronic
illness (Jamshidi 1992). As this population ages, they become less able to
support themselves and require greater assistance in preforming activities of
daily living, which leads to a dependency on some sort of care work. In this
context, care work is defined as any tasks done to promote the physical
health of the patient or maintain the home environment he or she lives in,
which can include anything from helping a patient to dress him or herself,
taking baths, changing bedpans and cleaning, to cooking meals and driving
to doctors appointments (Tronto 2001).
Traditionally, families have provided this care work in the home
(Scharlach 1991, Dwyer 1992, Jamshidi 1992). Family members provide 80%
of all in-home care received by elderly people over the age of 75, and for
every person living in a nursing home it is estimated that there are at least
two others who are equally disabled living at home in the community thanks
to the assistance and support of their families, friends, and neighbors

Geog 331 AC
1125417
(Scharlach 1991). All authors also acknowledge that this care work is
overwhelmingly preformed by women; including wives, daughters, and
sisters, although hired help is also predominantly female (Scharlach 1991,
Dwyer 1992, Jamshidi 1992, Tronto 2001, Flores 2009).
There has long been a debate on how to best address the need for
long-term elder care in society, and as American family patterns change and
life expectancy increases, the elderly population is facing a new demand for
care (Scharlach 1991, Dwyer 1992, Jamshidi 1992). Long-term care includes
the health care, personal care, and social services provided over a long
period of time to those who lack a certain degree of functioning ability, and
may be given informally by families and friends in the home, or in formal
settings such as nursing homes, adult day health centers, hospices, or by
paid home health care works (Scharlach 1991). Although informal family
care still dominates the type of long-term care provided, social trends have
led to an increased need for alternative types of care. Children are moving
further away from their parents, divorces leave children with less time and
resources to care for their parents, and parents having fewer children to
share the burden of care have led to a decrease in family members available
to shoulder long-term care responsibilities, while increases in life expectancy
and the retirement of the baby boom generation have left more elders than
ever needing some for of care (Scharlach 1991, Dwyer 1992, Jamshidi 1992).
Families that must seek formal care options for their elderly have
several choices, and the overarching debate centers around who should be

Geog 331 AC
1125417
paying for care. While there is a general consensus that there is a rising
need for care, there are several different angles advocated to address the
problem. The first approach advocated are retirement plans, often offered as
part of a benefits package through the employer doing the adult working
years, that help workers to save enough to pay for retirement. These
programs may include offering long-term care insurance for purchase or
flexible-spending savings accounts that direct a certain percent of the
workers earned salary towards a savings account, and they share the
common principle of helping workers save for their future retirement rather
than providing handouts (Friedman 1988, Scharlach 1991). These retirement
programs supplement federal and state mandated health benefits for
workers and their families (Friedman 1988). While there are some programs
in which employers will subsidize direct care for a workers disabled or
elderly dependent living in the home, such as Dependent Care Assistance
Programs (Scharlach 1991), employer-sponsored programs are in general
reluctant to provide cash benefits for elderly retirees because of the belief
that the corporation should not take on the role of a welfare system
(Friedman 1988, Scharlach 1991).
Workers who have been unable to save enough money to pay for their
retirement expenses, even with the help of employer-sponsored retirement
plans and health benefits, often turn to state and federal programs for
assistance. In addition to social security payments to retirees, the two
programs most often used to subsidized long-term care are Medicare and

Geog 331 AC
1125417
Medicaid, which respectively are federally-run and state-run (Scharlach 1991,
Sherrid 2002). While some elderly patients may qualify for both Medicare
and Medicaid, Medicaid is specifically designed to cover those who are lowincome, and has grown into the largest publically-funded nursing home
program (Scharlach 1991), Jamshidi 1992). The Medicaid roles are saturated
for a variety of reasons, including the high costs of long-term care that force
middle class retirees onto welfare after several years of paying their own
way, employers forcing workers into early retirement before they have saved
enough money to live off, and wealthier retirees diverting assets toward their
children to create the illusion that they qualify for Medicaid once they require
nursing home care (Friedman 1988, Sherrid 2002, Young 2002).
Nursing homes are become a center of controversy over how public
assistance is delivered for those who need it because Medicare payments
from the federal government tend to overestimate the cost of care while
Medicaid pays just under the cost of caring for patients (Sherrid 2002). This
is particularly controversial because many nursing home chains are for-profit
corporations, which raises the question of how much should federal and state
tax dollars be subsidizing these industries (Lamm 1996). Richard Lamm
argues that America is providing too many costly services to the elderly, and
that the retirement age must be raised and benefits rationed in order to
sustain the system (Lamm 1996). Other authors argue instead that
payments into social security and Medicare should be increased, as well as
the minimum wage, to better allow retirees to purchase the care they need

Geog 331 AC
1125417
and insure that federal retirement benefits will be available for them to draw
on in the future (Catchen 2002). However, neither of these reforms address
what level of basic care should be provided to all and how to best meet the
care needs of the elderly.
Other formal care options exist for those who do not wish to live in the
institutionalized setting of a nursing home, such as adult day health care
centers and in-home care. These services allow frail elderly who would
otherwise require nursing home care to continue living in the community
(Friedman 1988, Scharlach 1991, Jamshidi 1992, Tronto 2002). Adult day
health centers are different from general day centers because they also
provide medical supervision, nursing care, and rehabilitation services
(Scharlach 1991, Jamshidi 1992, Tronto 2002). Like most nursing homes and
retirement centers, adult day health centers accept full-paying clients,
Medicare patients, and Medicaid patients, as adult day health care qualifies
for Medicaid subsidies under the Medicaid home and community service
waiver program of 1982 (Scharlach 1991). While many adult day health
clients have their care subsidized by Medicaid and may choose to live at
home in part to avoid the costs of living in a retirement community, there is
some debate over whether or not adult day health centers are any less
expensive than a traditional nursing home. Jamshidi argues that, while this
type of community care is less expensive than hospital stays, the costs of
community care such as adult day health centers are beginning to outstrip
nursing home care as more individuals utilized the community-based

Geog 331 AC
1125417
services. Regardless of the unsuspected costs of community care, care work
done in the home and community is still preferential for many elderly
individuals because living at home allows them to feel less sick and
dependent than living in a nursing home, which improves their quality of life
(Holstein 2002). Without access to either nursing home or community care
subsidized by Medicaid, many elderly individuals would not have the
resources to support themselves, and so would either have no one to turn to
for end of life care or would be left as a time and financial burden to their
families, which is a point has been overlooked in the majority of published
work dealing with who should provide elder care.

Analysis of Full Life Care

Full Life Care serves an important role in society by providing low-cost,
subsidized long-term care to those who would otherwise not afford the
healthcare and assistance they need, but it is difficult to understand Full
Lifes the need for Full Lifes services without considering the context of the
system that leaves people vulnerable and makes subsidized care options
necessary. At the local and personal level, those on Medicaid seeking
subsidized care are in this position because they are low-income and cant
afford to pay full price for long-term care. Regardless of why they are lowincome, long-term care options for the elderly have risen in cost as care has
moved out of the home and public sector and into the private marketplace.
This shift places a greater burden on individuals and families to care for

Geog 331 AC
1125417
themselves and is part of a broader trend of Neoliberal reforms emphasizing
personal responsibility. Neoliberalism is defined as a political and social
philosophy that stresses the importance of autonomous individuals
maximizing their own happiness and assumes that everyone is responsible
for their own success, or lack of it (Harvey 2005). As a guiding political
ideology, neoliberal reforms limit the role of government, deregulate
business and the marketplace, enforce private property laws, and scale back
public assistance and welfare (Harvey 2005). By squeezing the amount of
public assistance offered and simultaneously driving up the cost of crucial
care, neoliberal reforms leave those whose savings do not keep pace with
rising costs unable support themselves. As public benefits are reduced
further and further, the minimal safety-net programs that still exist take
extra stress to accommodate the consolidation, and so remaining programs
like Medicaid-subsidized long-term care become an increasingly important
asset to those low-income families.
How we define these families as low-income is directly tied to the
poverty discourse discussed in class. In neoliberal thinking, reducing the
available welfare safety net is desirable because those who draw on its
resources to survive have some sort of defect of character that has caused
them to fall behind the rest of society. Reducing benefits will give them the
incentive to work harder and catch up (Hickey 2009). In this residual view
of poverty, the poor are a category that draws upon public assistance
because they didnt work hard enough during their professional lives, or who

Geog 331 AC
1125417
squandered their savings making bad decisions. These are the types of
dependents that neoliberal reforms hope to eliminate because they are
considered undeserving of assistance, since they are the ones at fault for
their predicament (Fraser and Gordon 1994). However, in reality this doesnt
quite hold up. From talking to clients at Full Life, no one comes across as
having made poor choices, or been lazy earlier in life. In fact, I wouldnt
have known that 98% of clients are considered low-income if I hadnt been
told. This suggests instead that there must be an alternate version of why
these people are poor. Contrary to residual views of poverty, a relational
view considers how poverty is produced as a function of prosperity, instead
of as a fault of the poor (Hickey 2009). In relational poverty terms, Medicaid
patients are poor and depend on that service because they have not been
afforded the same access to educational or career opportunities as other
segments of society. An employer may also have forced them into early
retirement, or a spouse became sick and they have already used all of their
assets on previous care. In these situations, reducing public assistance will
actually increase their level of poverty instead spurring them to work harder.
Judging from my experiences working in the community, I think that this is a
more accurate representation of how poverty is formed and how the poor are
affected by cuts to public assistance and other forms for welfare because few
people would choose to rely on handouts when given presented with other
options.

Geog 331 AC
1125417
The main societal force that impacts how we view those who are
labeled poor is the stigma attached to receiving welfare. This stigma is well
traced in Fraser and Gordons Genealogy of Dependency, which discusses
how during the New Deal welfare was split into a two-track system: one to
distribute unemployment benefits and social security checks to the
deserving poor and the other to hand out Aid to Dependent Children checks
to poor single mothers. Social security was depicted as the natural reward of
a hard lifes work, while aid for poor families was written off as shameful and
made increasingly hard to collect (Fraser and Gordon 1994). The differences
in societal acceptance between Medicare and Medicaid can be viewed as an
extension of this dichotomy. While potential recipients must be over 65 to
receive either benefit, Medicaids distinction as being designed specifically
for low-income seniors changes it from being viewed as a right of retirement
to a handout to those who are disabled or cant afford to pay their own way,
or worse as a catch for those trying to game the system and cheat the
government, as was discussed briefly in the literature review (Sherrid 2002,
Young 2002). This split is reflected in how much money each pays out to
cover the costs of care. In 2002, Parkway Pavilion, a nursing home in
Connecticut, received $300 a day for each Medicare patient but only $128 a
day per Medicaid patient (Sherrid 2002). By underfunding the cost of care
for the poor and sick based on the perception that they should have been
able to take care of themselves, federal and state budgets reinforce the idea
that receiving public assistance is to be avoided and set the precedence that

Geog 331 AC
1125417
care is not worth receiving its fair share of tax dollars. In this way, the view
of the elderly poor as needing assistance through their own fault and poor
planning leads to the devaluing of the care work done to aid them and
disguises our own responsibility to act by passing off the blame for their
situation onto the poor themselves.
While Full Life Care is a sheltered and accepting environment inside its
doors, I still noticed among clients this dislike of being pegged as a welfare
recipient. One day several weeks into my time volunteering, I walked into
the center and was immediately greeted by a favorite client mine, who we
will call Marie. Marie was bursting to tell me the exciting news that she was
soon going to be moving into a retirement home, and that she would only
have two more weeks at the day center. Marie was thrilled to tell me that
new home was on the water by the beach, but she also mentioned that
someone in her family had said that part of why she was moving was that he
didnt want her coming here (to Full Life Care) anymore. Even though
clients and their families appreciate the services they get at Full Life and
wonder at how they would get along without them, I think that there is still a
feeling that using public assistance in the form of Medicaid to pay for care is
less desirable than living in a well-to-do retirement community where it is
less obvious that you are poor. By stating that the care she got coming to
Full Lifes adult day health center was less desirable than what she would get
at a retirement home, Marie devalued the care work done by Full Life and

Geog 331 AC
1125417
implied that this subsidized care option was worth less than privately
purchased care.

Does Full Life Care Operate in a Care Ethical Way?

To evaluate the effectiveness of the care delivered at Full Life, I will
build a care ethical analysis based on Joan Trontos care ethics. Trontos care
ethics is a process of 4 phases of caring: caring about, caring for, caregiving,
and care receiving (Tronto 2001). The first step, caring about, requires
genuinely caring about others and recognizing that there is a need for care in
a certain population (Tronto 2001). In the second phase, caring for, the
concerned individual or organization assumes responsibility for meeting the
needs they identified, which they then do in a competent way in the third
phase of caregiving (Tronto 2001). The final phase of care receiving involves
the participation and responsiveness of those who receive the care, ensuring
that their needs have been fully and competently meet (Tronto 2001).
To investigate more closely whether or not Full Life follows all four
phases of care in a care-ethical model, I interviewed the northern regional
manager of Full Life Cares facilities, Kristin Ott. The interview was
conducted through email because Kristin works at the Everett branch and
was unable to meet with me and the other service learning volunteer placed
there in person. While many of Kristins responses to our questions were
brief, they help to paint of clearer picture of how Full Life Care operates and
how it fits as an organization into the broader context of elder care work.

Geog 331 AC
1125417
In our initial email interview, we asked for her to explain the role in
society that Full Life Care fills and what other organizations also fill that
need. Kristin explained that Full Life Cares adult day health program served
families and individuals needing a long term care option that would allow
them to remain in their own homes for as long as possible. The adult day
health program stresses each individuals ability to preform their own
activities of daily living, and so provides nursing services, occupational
therapy, and exercise programs to maintain their health and physical fitness.
Full Life Care is one of several adult day health programs run in the Seattle
metropolitan area, including both non-profit and two for-profit programs, but
is the only organization in Washington that offers adult day health, mental
counseling, care consultation, and memory home care from the same
organization. Their adult day health program participants are also served by
Senior Services, which runs meals on wheels, Senior Information and
Assistance, and case management services, as well as the City of Seattle
Human Department program Aging Disability Services, which provides case
management services for people on Medicaid funded programs.
To evaluate the effectiveness of their programs, Full Life facilitates an
annual survey of all participants and caregivers, although the survey appears
somewhat limited in scope. Some questions asked of clients are what
changes they would like to see, whether or not they like the food, what other
programs they are interested in, and if they know who their Full Life case
manager is. Kristin said that their feedback is overwhelmingly positive, but

Geog 331 AC
1125417
did not mention how they evaluate or implement changes in their
programming based on the surveys. Staff members must be certified in their
fields to work at the facilities, with nurses all holding either a LPN or RN level
certification, social workers holding either a bachelors or a masters degree in
social work, and occupational therapists and Certified Occupational Therapist
Assistants having their own training and certification requirements. Kristin
said that having enough staff to run day-to-day programing can be
challenging, and the organization relies heavily on volunteers to assist with
programing.
The issue of Medicaid funding is particularly crucial for Full Life Care.
According to Kristin, most of their clients use Medicaid or other forms of
assistance such as SCSA, Respite, or Veterans Affairs to pay for their
services, so Full Life Cares ability to provide quality care is tied to amount of
tax revenue collected by the state. This money all goes into a general fund
that covers both K-12 education and a wide range of other social services,
and when funds are low their programs risk losing funding. While they worry
about threats to their stability of funding, Kristin emphasized that they try to
never compromise the quality of care for clients, instead redoubling
fundraising efforts and focusing their attention on fewer programs to
maintain their quality. Kristin said that regardless of their allotted budget
from the state they are mandated to provide certain services to their clients,
so while Full Life might be forced to streamline their programing to reduce
costs they cant refuse to provide care to clients based on cost. Kristin

Geog 331 AC
1125417
believes that Full Life Care is doing a good job of meeting their clients needs
given their limited budget. Other programs that Kristin would like to offer if
they had more available resources are speech therapy, Tai Chi, and physical
therapy, and she would also like to be able to purchase modified exercise
equipment for the clients to use.
Based on Kirstins interview and my experience volunteering at Full
Life, I believe that Full Life has meet the first criterion of providing ethical
care by identifying the population needing assistance and recognizing that
there is in fact a need. Full Life understands that there is a need for health
and support services that allow frail elderly to continue living at home,
especially those who are low-income. By stepping up to provide this service
with the help of Medicaid payments and partners around the Seattle area,
Full Life also fulfills the second phase of assuming responsibility. While these
two first pieces are fairly easy to address, the analysis becomes more
difficult when evaluating the third and fourth phases of care ethics. They
main question I reached is, what constitutes competent care? Does having
all of your hands-on care provided by certified staff make your organization
competent, or is there another element? While Full Life provides meaningful
care to many needy clients, budget cuts at the state level have resulted in
less Medicaid money available to support programs and have compromised
Full Lifes ability to provide all of the services they would like to fully meet
their clients needs, such as speech therapy. However, I think that the area
in which Full Life could improve most is in ensuring that the care is

Geog 331 AC
1125417
adequately received. It is inherently challenging to evaluate the
effectiveness of care when most of your clients have dementia and cant
speak their own minds, but even with their annual survey it didnt appear to
me that Full Life did a very effective job of altering their programing based
on clients feedback of what worked and what didnt. Because they dont
fully meet the requirements for competently caregiving and care receiving, I
do not think that Full Life Care is operating in a fully care ethical way, but I
still believe that they are a meaningful organization doing their best to meet
the needs of an underserved community with the limited resources they
have been allotted.
Conclusion
As a non-profit organization, Full Life Care is dedicated to meeting the
needs of frail low-income Seattle residents who wish to grow old in their own
homes. There mission is not an easy one because the devaluation of care
has lead to a curtailing of public funds being directed toward low-income
elder care programs as federal and state governments must trim their
budgets. This underfunding of crucial care programs for some of the most
vulnerable in society are accepted by the public because they play on the
established view that poverty is caused by failings of individuals, and that all
hard working men and women should be able to provide their own end of life
care as independent Americans. As long as this rhetoric exists, there will
always be limits to how effectively we can care for those labeled as poor and
undeserving because as a society we are unwilling to spend our own hard-

Geog 331 AC
1125417
earned resources to help those who we see as capable of helping
themselves.
Several days ago, I read a column in the Seattle Times by Jerry Large
called Paying For Old Age at a Premium, dated March 8th, in which he
discussed Medicaid and paying for retirement care. Large ended the opinion
piece by saying, We Americans are ruggedly independent, right up to the
point where its our turn to need help. Reflecting on this quote and own my
experience this quarter in service learning, I think that I now have a better
understanding of how the American ideal of independence has shaped the
fabric of our society, and but also how we can maybe take better care of
ourselves as a whole by combining this value of personal responsibility with
a little more caring and sensitivity to others needs.

Bibliography
Catchen, Harvey. 2002. Debating the Future of Social Security Policy. In Elder
care and

service learning: a handbook, ed. Susanne Bleiberg Seperson and

Carol R. Hegeman,

205-213. Westport, Conn: Auburn House.

Dwyer, Jeffrey W., and Raymond T. Coward. 1992. Gender, families, and elder
care. Newbury

Park, Calif: Sage Publications.

Flores Y.G., Hinton L., Barker J.C., Franz C.E., and Velasquez A. 2009. "Beyond
familism: A case study of the ethics of care of a Latina caregiver of an elderly

Geog 331 AC
1125417
parent with dementia". Health Care for Women International. 30 (12): 10551072.
Fraser, Nancy and Linda Gordon. "A Genealogy of 'Dependency': Tracing a
Keyword

of theUS Welfare State." Signs, Vol. 19, No. 2 (1994).

Friedman, Dana E. 1988. Issues for an aging America: elder care: highlights
of a conference. New York, N.Y.: Conference Board.
Harvey, David. 2005. A brief history of neoliberalism. Oxford: Oxford
University Press.
Hickey, Samuel. 2009. Rethinking Poverty Analysis from the Margins:
Insights from

Northern Uganda. Afiche e Orienti.

Holstein, Martha B. and Phyllis Mitzen. 2002. Elders in the Community: Moral
Lives, MoralQuandaries. In Ethics in community-based elder care, ed. by
Martha Holstein and

Phyllis Mitzen, 3-16. New York: Springer.

Jamshidi, Roxanne et al. Aging in America: Limits to Life Span and Elderly
Care Options.

Population Research and Policy Review, Vol. 11, No. 2

(1992), pp. 169-190

Lamm, Richard D. and Heather E. Lamm. 1996. The Challenge of an Aging
Society. In Elder

care and service learning: a handbook, ed. Susanne

Bleiberg Seperson and Carol R.

Hegeman, 195-200. Westport, Conn:

Auburn House.
Scharlach, Andrew E., Beverly F. Lowe, and Edward L. Schneider. 1991. Elder
care and the
Books.

work force: blueprint for action. Lexington, Mass: Lexington

Geog 331 AC
1125417
Sherrid, Pamela. 2002. Long-Term Blues. In Health Care, ed. Jennifer Peloso,
123-126. New

York: H.W. Wilson.

Tronto, Joan. 2001. An Ethic of Care. In Ethics in community-based elder care,

ed. by Martha

Holstein and Phyllis Mitzen, 60-68. New York: Springer.

US Government. Frequently Asked Questions about Medicare. Medicare.

https://questions.medicare.gov/app/answers/list.
Young, Carl S. 2002. Long-Term Care in New York: A Failure of Policy. In Elder
care and

service learning: a handbook, ed. Susanne Bleiberg Seperson and

Carol R. Hegeman,

214-216. Westport, Conn: Auburn House.