Health care reform from the view of a geriatrician

In an ideal world, all citizens would receive high-quality health care, all services which are appropriate and necessary, in the setting that can best meet the patients' needs and preferences. The frail, dependent, chronically ill person has been considered an outlier by third party payment systems, including Medicare, the health care system designed for the elderly. Physician payment systems have penalized those who care for the frail, resulting in an inadequate medical workforce to care for the elderly. Medicare and state-financed long-term care systems, by attempting to limit expenditures of public funds on long-term care, have become biased toward institutional care. Although the frail and disabled represent a minority (approximately 12%) of those aged 65 or older, their numbers are large and growing. The health care system of today and the system proposed for tomorrow by the Clinton Administration is not prepared to care for large numbers of people with chronic, disabling illness. Only when the health care system or new health alliances share responsibility for all care provided to every citizen will the looming problems of large numbers of persons with chronic illness and functional dependency be faced. Care must be driven by patient needs and preferences, not by reimbursement regulations and financial incentives. The Clinton plan institutionalizes the segregation of chronic long-term care from hospital and outpatient care. Responsibility for these services is relegated to states. This political compromise, as disappointing as it may be to geriatricians, may offer opportunity for experimentation. Fifty new state-regulated systems may serve as health services experiments.(ABSTRACT TRUNCATED AT 250 WORDS)