Carroll L. Estes

Dominant and Competing Paradigms in Gerontology: Towards a Political Economy of Ageing

The origins and influence of social science perspectives have conditioned theoretical and empirical developments in the field of gerontology. Yet little systematic examination has been afforded to the role of social science in the production of gerontological knowledge in providing the underlying rationale for American social policy for the aged. This paper examines the dominant U.S. social science perspectives or paradigms and discusses the reasons for their centrality in American gerontological thought. The paper concludes with a proposal for an alternative line of inquiry — a political economy of ageing — which takes as problematic the effects of social history, the world economy, capitalism and social class on the ageing process and the aged and the policy interventions designed for them.

The globalization of capital, the welfare state, and old age policy.

A new political economy is shaping the lives of present and future generations of older people. The key change has been the move from the mass institutions that defined growing old in the period from 1945 through the late 1970s to the more individualized structures—privatized pensions, privatized health and social care—that increasingly inform the current period. The authors examine the role of international governmental organizations in promoting this trend, with examples drawn from the work of the World Bank, World Trade Organization, and Organization for Economic Cooperation and Development, and the relationship between international governmental organizations and the state. The article concludes with an assessment of the changes to citizenship that accompany globalization and the implications for political organization among older people themselves.

Integrated specialty mental health care among older minorities improves access but not outcomes: results of the PRISMe study.

In this secondary data analysis of Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRIMSe) study, we hypothesized that older minorities who receive mental health services integrated in primary care settings would have greater service use and better mental health outcomes than older minorities referred to community services.

The Retreat of the State and its Transfer of Responsibility: The Intergenerational War

In this article, the socially constructed nature of the conflict between the generations, or the “intergenerational war,” is explored, with a description of the two major fronts of this battle: a health care financing axis and a caregiving axis. Basic to the health care financing axis is the assumption that certain individuals and populations represent an increasing and unreasonable social burden; the caregiving axis gives ideological support to familial and filial responsibility. The politics of mystification perpetuates the idea that these two axes are unrelated and that generational transfers are independent rather than interdependent. Both permit abdication of the state from social responsibility for human needs and massive budgetary reallocations to defense and tax cuts for the wealthy. An alternative approach derives from the principle of universal life-course entitlement to basic human needs.

The Politics of Ageing in America

This paper discusses the politics of ageing in the US within a political economy framework. Four forces are shaping US policy: austerity, federalism, deregulation, and the medical-industrial complex. Two major trends in the development of policy are the commodification of the aged and their needs and a class basis for the distribution of benefits, differentiating the deserving elderly from the undeserving elderly. Ideologies of individualism, self-help, privatisation, and procompetition are being used to delegitimate public programmes and to reduce expectations about what government can and should do to ameliorate social problems. Recent policy is characterised not only by a reduction of federal funds for domestic social spending, but also a restructuring of the community care delivery system as it operates in the private, non-profit sector of the economy. The emergent processes of this restructuring, e.g., targeting of services based on ability to pay and individual characteristics, medicalisation, and absorption of non-profit agencies by for-profits are discussed. These policies and the consequences that flow from them are viewed in light of the search for new sources of capital investment in the domestic markets. This analysis raises important political questions concerning the transformation of relations between the state and the non-profit sector.

What Happened to Long-Term Care in the Health Reform Debate of 1993-1994? Lessons for the Future

During 1993 and 1994, the United States debated but did not enact major health care reform. Although the reform efforts focused on providing health coverage for the uninsured and controlling acute care costs, many proposals included substantial long-term care initiatives. President Clinton proposed creating a large home-care program for severely disabled people of all ages and all income groups, among several other initiatives. By stressing non-means-tested public programs, the presidents plan was a major departure from the Medicaid-dominated financing system for long-term care. In designing the long-term care component, the Clinton administration addressed many of the basic policy choices that must be decided in all reform efforts, including whether initiatives should be limited to older people or cover people of any age, how to balance institutional and noninstitutional care, whether to rely on government programs or on the private sector, and how to control costs. Analyzing the political and intellectual history of long-term care during the health reform debate provides lessons for future reform.

Medicalization, public policy and the elderly: Social services in jeopardy?

This paper examines the medicalization of community-based services for the elderly; a process of restructuring to provide more highly medical services to a frail older population at the expense of providing a broader range of social and supportive services to older persons with varying levels of need. Medicalization is tied to changes in government policy (particularly Medicare reimbursement) which have led to increased competition within the health and social service sector. The paper utilizes data on services, policy impact and staffing from the DRG Impact Study conducted at the Institute for Health and Aging (UCSF), a 3-year study of the impacts of federal policy on 7 types of community providers of services to the elderly. Data are presented from telephone interviews conducted at two points in time (1986 and 1987) with directors of a representative sample of home health agencies (HHAs). Findings include: HHAs were more likely to report adding highly medical services and cited social/supportive services (as opposed to highly medical and/or highly technical services) as the most commonly requested services they cannot provide. Policy effects and societal implications of the medicalization of home care are considered.

Austerity and Aging in the United States: 1980 and beyond

This paper presents a critical examination of the past and future direction of social policies for the aged in the United States. The definitions of the social problem of old age and of the appropriate policy solutions for this problem have reflected the ups and downs of the U.S. economy and the shifting bases of political power during the past thirty years. In the 1980s, three dominant definitions of reality are shaping public policy for the elderly: (a) the perception of fiscal crisis and the necessity for reduced federal expenditures; (b) the perception that national policies should give way to decentralization and block grants; and (c) the perception of old age as an individual problem. It is argued that old age policy in the United States reflects a two-class system of welfare in which benefits are distributed on the basis of legitimacy rather than on the basis of need.

Women and the economics of aging.

Economic and policy arrangements assure the maintenance of gender-based inequities throughout the life cycle. To understand the economics of aging requires consideration of the problems of women of all ages, commencing early in the adult life cycle when the different social roles and opportunity structures available to men and women take effect. Because the economic inequities suffered by women in old age derive principally from inequities suffered earlier as wives and workers, public policy focused on redressing income in old age does nothing to alter the structural basis of inequity. This article examines factors underlying the economics of aging for older women in the United States; delineates the relation between womens roles, social policy, and income; and raises salient policy questions for younger and older women.

Devolution and Aging Policy: Racing to the Bottom in Long-Term Care

For two decades, New Federalism, devolution, and other challenges to the federal role in domestic health and human services policy have fundamentally shaped the structure and delivery of long-term care in the United States. Devolution evokes crucial questions concerning the future of universal entitlement programs such as Social Security and Medicare and, with them, the future of aging and long-term care policy. This article examines the implications of the “devolution revolution” for long-term care in the context of the sociodemographics of aging and the managed care movement. Central issues are the extent to which state-level discretionary policy options (1) alter priorities, services, and benefits for the elderly and disabled; (2) foster a race to the bottom in long-term care; (3) promote generational, gender, racial and ethnic, and social class trade-offs; and (4) fundamentally alter the role and capacity of nonprofit sector services that comprise a significant part of the long-term care continuum.