Conclusion

There is little mystery about what an effective, consumer-preferred long-term care system would look like. For years, if not decades, advocates have described a continuum of care that would provide freedom of choice and the least-restrictive type of assistance as a person moves from independence to assisted living to total dependence. A variety of barriers have kept such a system from evolving:

• Conceptual: The health care system is designed to diagnose, treat and sometimes cure acute illnesses. Long-term care for chronic illnesses has always been an add-on function to health systems. In a country that is youth-focused and that has reached no consensus about universal health care, there has been scant discussion about how best to meet the needs of people who need long-term care.
  
  

• Structural: Programs and funding streams are spread across three levels of government -- federal, state and local. While the State has statutes and a federally required State Plan on Aging that should provide focus for a long-term care system, the State's efforts are fragmented across multiple departments. There is neither the bureaucratic leadership nor the policy-making will to institute broad-scale reform.
  
  

• Funding: In an era of limited resources, policy makers at both the federal and state levels are fearful of creating new programs or making new commitments to meet people's needs. Many worry that attempting to provide government assistance in this area will lead to families abandoning their involvement in the care for elderly relatives. Policies that hold the potential for curbing high-cost government support inevitably save funds in future years or in some other program's budget, so fiscal imperatives create little pressure for reform. As a result, any change is limited in scope and incremental in effect.

Many on the front lines of advocacy would argue that reform is vitally needed today because thousands of Californians live impaired lives and deteriorate prematurely to the point of institutionalization. Adding weight to their push for change is the State's demographic destiny: The population of elderly people needing assistance is expected to soar as the Baby Boomer generation ages and medical advances continue to stave off diseases that once were a death sentence.

This report lays out a series of recommendations for policy makers that will reshape the State's long-term care approach. The key recommendations are:

• Overhauling the State's structure for overseeing long-term care services so there is a single voice and point of leadership.
  
  

• Recasting policies that favor institutionalization so that home- and community-based care are broadened and supported by government actions.
  
  

• Addressing long-identified problems that are specific to the skilled nursing facility and residential care facility industries.

The Little Hoover Commission recognizes that many of the ideas advanced in this report are not ground-breaking. But the Commission believes the timing of this report -- which synthesizes the best-practices trends across the nation -- should enhance the opportunities for reform. The State has already taken good-faith steps toward a home- and community-based ethic of long-term care by creating an integrated services pilot project for five areas of the state and revising the Older Californians Act. The State can continue down this path by providing the oversight structure and leadership to nurture these initial steps.