RESIDENTIAL CARE FOR THE ELDERLY

This article maps variations in a standardized way in residential care for elderly people in three Western nations. Measured by the number of available places per person aged sixty-five and over and by the number of staff members per bed in nursing homes, the United Kingdom has the most highly developed standards. The United States ranks second, with Germany lagging considerably behind. The variations are explained by four variables: the pressure of the problem, as defined by the percentage of the population aged sixty-five and over; the caretaker potential in the family system, which alleviates this pressure; the structure and financing of the supply of residential care; and decision-making procedures in health care policy-making. My analysis emphasizes the last two variables. In the United Kingdom and the United States, the public and private providers who supply care have either political or market incentives to expand their services. Germany's mix of public and private, by contrast, is dominated by voluntary associations that are neither responsible to an electorate nor allowed to make profits. Thus, their clients do not have opportunities to articulate their needs. Health care decision making in Germany takes place through a collective bargaining process between the sickness funds and the providers. In such a system, the interests of groups who are not represented at the negotiation table-such as the elderly-tend to be neglected. A national health system of the British type links political decision makers via the election mechanism more closely to the concerns of the public. As older people represent growing proportions of the electorate, their needs find more adequate consideration in the policy process. In the United States, political officeholders also have to pay attention to the needs of increasingly organized older people, since the tax-financed and federally regulated Medicaid system is largely responsible for financing long-term care for the elderly.