How can we best support our ageing populations? Healthcare provided in the homes of older people is a common way to support those in the final years of their lives; and research from Dr Chiara Orsini found sudden funding cuts for this service in the US had serious consequences for many seniors.
Although the U.S. has never created a universal public healthcare service, US citizens aged 65 and older are eligible for Medicare, a publicly funded healthcare programme. Medicare provides access to doctors, hospital treatment and medicine. However, funding for home visits was severely restricted in 1997 when the U.S. congress deemed them too expensive.
The policy change caused an immediate 30 per cent decline in Medicare expenditures for home healthcare visits.
Dr Orsini, an economist who is visiting fellow in the Department of Health Policy, wanted to understand how this cut affected older people. She says: “Ageing populations in many societies mean it’s important to know if we cut services solely to reduce costs, what does this mean for the individual and their families?"
“Almost overnight, when Medicare funding was cut, many older people stopped receiving a service that in most cases was vital. As well as providing basic healthcare, home healthcare visitors also spotted patients’ health problems earlier, helped track of their medicine intake or doctors’ appointments, and advised them on healthy living.”
The analysis showed that cutting home healthcare visits for one group in particular - men aged between 65 and 74 - increased their mortality by 0.6 per cent. This was the equivalent of 4,685 additional deaths in 1999 compared to 1996. Older age groups and women were not significantly affected by the ceasing of home visits.
Why were men of that age particularly vulnerable? “Women tend to live longer than men, and the analysis here suggests that they are probably more able to survive reductions in home healthcare.”
“Home healthcare helps up to a point, but as people get older death is unavoidable. The average life expectancy is around 79 years in the U.S., and older people in this range are likely to have serious health problems which means home visits start to become less effective.”
Dr Orsini adds that the change to Medicare had wider consequences for the relatives of older people. “The people who were most affected by cutting the service were less wealthy.
"Their families took on more responsibility after the change, as many poor elderly had to give up independent living and went to live with their adult children. And it’s usually women who provide this type of care to elderly relatives, so the cuts may disproportionally affect the amount of time women spend caregiving.”
In 2019, Medicare still covers some care given to older people’s homes, but not as generously as pre-1997. How to care efficiently and compassionately for the U.S.’s ageing population is a pressing concern; between 2018 and 2060, the 65-and-older age group’s share of the total US population is expected to rise from 16 to 23 per cent.
Reviewing documents from the US Congress' deliberations over cutting Medicare’s funding for home healthcare, Dr Orsini noticed that it was purely considered in financial terms. “Reading the records of how this was decided, there wasn’t any obvious attempt to look at the wider implications of this change.”
But as the research shows, cuts affected mortality for a group of men. Dr Orsini sayd: "Cuts also affected living arrangements of the extended family of poor individuals, which was not factored in when deciding to limit public service provision for home healthcare."