Abstract

This exploratory study aims to examine the present neoliberal context of the Medicaid system in the United States. The neoliberal principals of individualism, privatization, and profit are inappropriate within a public entitlement program. The effects of such an ideology changes spending priorities, service allocation, and policy reform often to the detriment of vulnerable populations. One such population, young residents (<65 years of age) of nursing homes, is specifically at risk in the current neoliberal Medicaid climate. Underrepresented in literature, policy, professional education, and service provision, young residents in nursing homes require a specific level of healthcare that is presently not provided. With the expected growth of young nursing home residents, in coming years, every level of society must act to reform healthcare priorities and advocate for this hidden and very vulnerable community.

Introduction

When imagining a typical nursing home resident, images of a frail and elderly individual often come to mind. Nursing homes are intended to provide specialty care for the older population at the final stage of life. Recent statistics estimate that in 2008, approximately 3.2 million Americans will spend some time in nursing homes (Comarrow, 2011; United States Department of Health and Human Services, 2009). While much research is dedicated to those nursing home residents, there is a new and growing population of individuals living in nursing homes who are often left out of policy, budget discussions and research efforts (Pear, 2011). Those individuals may have different reasons for being in a nursing home but they have two things in common: they are all under the age of 65 and they are all covered by the United States Medicaid program (Persson & Ostwald, 2009; Weingarden, & Graham, 1992; Winkler, Farnworth, & Sloan, 2006).

Due to the lack of rigorous study, estimates are varied but researchers approximate that 10-23%, or about 175,000 United States nursing home residents are younger than 65 years of age and on Medicaid (Fries, Wodchis, Blaum, Buttar, Drabek & Morris, 2005; Persson & Ostwald, 2009; United States Department of Human Services and Centers for Disease Control, 2004). While those numbers may not provide enough motivation to change spending priorities, it is predicted that over time a rapid increase in young nursing home residents will occur (Fries, et. al, 2005; O'Reilly & Pryor, 2002; Persson & Ostwald, 2009; Winkler, Sloan & Callaway, 2010). The presence of personal, respite and therapeutic services required to care for those residents is inappropriate given the age, health and emotional-social development of young residents (Boldy & Silfo, 2006; Chemali, Withall & Daffner, 2010; Cornwell, Flemming, Fisher, Kendall, Ownsworth & Turner, 2009). Part of the reason for this reportedly insufficient care is due to the overriding neoliberal ethic in the United States healthcare system. These young individuals herein called "young nursing home residents" are frequently covered by Medicaid, which scholars have found is guided by the principals of individualism, cost containment, efficiency over effectiveness, and most recently privatization (Boehm, 2005; Hiranandani, 2011). It is posited here that these principals are in direct contradiction with what is in the best interests of the resident for their long-term health and overall quality of life.

It is the purpose of this present inquiry to explain the tenants of neoliberalism and its intersection in the United Stated Medicaid system through the examination of a highly vulnerable group: young residents in nursing homes. To enhance the comprehension and readability of such a detailed subject, this paper has been divided into two portions. The first portion begins by discussing neoliberalism in its history, initial meeting with Medicaid, as well as the present tension between state and federal governments about healthcare policy. This first section also discusses Medicaid, in its original intent, present state, and predictably dismal future. The second section describes young nursing home residents and how their extraordinary set of biomedical characteristics and health needs are negatively influenced by neoliberal Medicaid policy. Ultimately, neoliberal ideals place young nursing home residents at a disproportionately increased risk for extreme health disparity and inequality. In this exploratory examination between young nursing home residents and neoliberal healthcare systems, recommendations for reform, community action, and policy development are also discussed.

Economics of The Neoliberal Welfare State: A Historical Orientation and Recommended Policy Reforms

Medicaid as an entitlement and social security program: Theory versus application

Medicaid was enacted in 1965 as part of the Social Security Act, which intended to provide health care for those who met specific eligibility criteria (Holahan, 2009; Perkins, 2002; United States Department of Health and Human Services, 2010). Medicaid, while a voluntary program for states, provides federal matching dollars for those states that wish to participate. Additionally, should a state choose to participate it is mandated that they implement programming "consistent with minimum federal requirements" (Perkins, 2002, p. 7). Theoretically speaking, it would appear that Medicaid would provide infrastructure for stable health care coverage. In application, however, the states have a lot of discretion as to the actual management of programs, specific eligibility standards, and services covered. A recent study using government databases to identify contradictions and implications of Medicaid policy, found that since the Bush Administration's Deficit Reduction Act of 2005 states have been given increasing flexibility in the application of Medicaid (Coughlin & Zuckerman, 2008). This has led to states changing enrollment guidelines; some states have expanded enrollment while others have capped it completely (Coughlin & Zuckerman, 2008). Additionally, this increase in state flexibility is tied to increased privatization as well as overall cuts to program funding (Coughlin & Zuckerman, 2008).

Divided into multiple parts, Medicare pays for general health services, some long term care, and very rarely home bound respite aid for those with few personal assets or inability to pay (Matthews, 2011). Eye care, hearing tests/aid, dental care, preventative care, physical therapy, chiropractic care, transportation for medical services that are non-emergency, as well as some prescription drugs may not be covered by this system (Matthews, 2011).

Ultimately, there are vast differences not just in the quality of care but also in the coverage of needed services (Perkins, 2002). Ethically speaking, Medicaid was created to provide a high level of quality health services for those who could not otherwise afford them (Mullay, 2007; Segal & Brzuzy, 1997). In doing so, Medicaid was deemed an "entitlement program" in that it universally grants a basic human right: access to the care needed in order to maintain a constant level of health and wellness (Segal & Brzuzy, 1997; United States Department of Health and Human Services, 2009). Medicaid, with all of its applied inconsistencies and differing eligibility guidelines is the program that is responsible for providing health care coverage for young residents of nursing homes. It is argued here that Medicaid is not providing the healthcare coverage, quality of services and breadth of care that young residents of nursing homes need and that those spending priorities stem directly from the rise of Reagan-era neoliberalism politics.

The welfare state: The invasion of neoliberalism into social policy

As scholar Dale Tweetie has so poetically stated: "Economics is fundamentally an advice giving discipline. In all its various forms, it is orientated towards the social world, and is concerned with defending, re-shaping or rejecting existing social orders" (n.d., p. 1). This is the sentiment to keep in mind when trying to understand and apply economic concepts to social policy. Economic principles act to make judgments and as such are primarily concerned with monitoring social indicators while adjusting the service delivery system and dominant paradigmatic views. This is the case with neoliberalism, which in part, seeks to simultaneously maximize effectiveness with profit margin and return on investment (Mullaly, 2007; Wanniski, 1978; Weintraub, 2007). In this way neoliberalism outlines both an ideological and service delivery framework that maintains the status quo and the prevailing wealth distribution.

Neoclassical economic theory, of which neoliberalism is a result of, posits that hard work leads to success, and values individual wants over community needs. Bluntly put, neoliberalism theorizes that both the economy and the state function best with the least amount of intervention from governments, regulatory bodies, and financial markets (Larner, 2000; Snyder, 2001). There are the five main tenants of neoliberalism: the discouragement of economic market regulation, the eradication of public funding for social services, the complete deregulation of government oversight if impeding private profit, the privatization of all government and public services, as well as the elimination of a universal public good (Larner, 2000; Snyder, 2001). Historically, neoliberalism in the public service sector found its footing by framing universal healthcare plans as against the 'state', 'socialist' or 'un-American' (Quadagno, 2005). This political culture has, in part, weakened trade unions that traditionally have had a strong role in shaping welfare policy and social attitudes towards public services (Quadagno, 2005). As a result, the power of special interest groups and their lobbying efforts greatly strengthened (Quadagno, 2005). Over time, this has produced a managed care system that values private profit over public good. The important duty of resolving public needs and problems is increasingly becoming the job of the private sector (Quadagno, 2005). Placing this private sector in this role of public advocate leads to even further incentives to cut spending and increase personal profit; the public interest is defined then in terms of private revenue.

Success, as defined by neoliberalism, is then predicated on individual achievement while discouraging regulation or government involvement. Consequently, when social welfare policies are created, neoliberal minded proponents advocate for small government with an influence on free market economics that promote profit generation. In a complete reversal of the intent of the Social Security Act, social welfare spending priorities have become dictated by powerful private sector entities and not the consumers themselves (Maskovsky, 2000; Mullaly, 2007; Nelson, 2008). Arguably, the rise of corporate America in the late 1970s was the start of this unraveling of public programs with vested profit interests that changed the way public services were provided (Quadagno, 2005). Concretely, these neoliberal attitudes have led to reduced public health spending and increased corporate sector privatization among the social welfare and Medicaid systems in the United States. This has resulted in a loop of profit-controlled rhetoric where private corporations are now able to disproportionately influence politicians and their legislative priorities:

As healthcare has become more corporatized, politicians, policy experts, and media pundits have adopted neoliberal rhetoric, bemoaning the waste and mismanagement associated with nonprofit and public health programs and extolling the virtues of cost containment, competition, and the restructuring of the delivery system to favor for-profit firms and commercial insurers. Not coincidentally, many of these firms exert great influence on politicians…. (Maskovsky, 2000, p. 125)

Clearly, this outlook could lead to deplorable levels of healthcare and reduced quality of life for individuals. This is especially true for vulnerable groups such as young nursing home residents. When a neoliberal free market economy dominates the agenda and aims of the healthcare system inevitably that system ends up "managing inequality rather than providing care" (Rylko- Bauer & Edwards, 1988, p. 476). Milward and Provan (2000, p 362) call this neoliberal spread of a private third party in public services that of a "hollow state", one in which accountability is not closely monitored with quality and consistency of service delivery greatly suffering. Further, it is argued by scholars that neoliberalism has reframed and distorted the idea of a public healthcare system by changing what we think of as a "public good"; no longer something that everyone has access to but something that individuals must work for and earn (Nelson, 2008, p.107). "[P]ublic attitudes toward the welfare state are not only individual-level phenomena, but also collective phenomena" indicating that these ethics are further emphasized by elected officials who may discuss and stereotype people that likely benefit from entitlement programs (Blekesaune & Quadango, 2003, p 2). Health care, Medicaid and welfare have now become individualized commodities within a national entitlement program (Nelson, 2008).

Aside from actions of the government, this same sentiment towards personal work, individualism, and the role of limited government has seeped into the social norms of culture.

"Today, economic policy is driven by what is known as 'neo-liberalism,' which reverses the welfare state model and makes everything subservient to an absolutely free market—free of government regulation, labor unions, social welfare, environmental laws and ethical imperatives—as the best way to secure human prosperity, health and happiness. (Progler, 2000, para. 2).

Evidently, neoliberal ideals have even become engrained into the ways that people determine their self-worth and happiness; this attitude, if perpetuated, will have drastic consequences for the future of social policy and for the quality of care for young nursing home residents (Progler, 2000).

The Rise of the Modern Neoliberalism in the Reagan-Era

The rise of the United States neoliberal paradigm is often given credit to former President Ronald Reagan. Elected in 1981, President Reagan entered an economy that averaged 12.5% inflation and over 9% unemployment nationally (United States Bureau of Labor Statistics, 2011). In order to reduce these numbers, President Reagan employed supply side economics, which aimed to stimulate economic growth by putting money into hands of consumers with the most purchasing power (Clark, 1998; Cohen, 2007). This approach, which became known as "trickle down economics," provided immediate tax breaks to the wealthiest while promising later benefits to the poorest (Segal & Brzuzy, 1997, p. 83). This "…redistribution of wealth clearly did not work. Instead, we have seen a steady upward shift of income and wealth for those at the top, leaving those who were poor worse off than before" (Segal & Brzuzy, 1997, p 83). Among the many programs that suffered from this trickle down philosophy were most notably food stamps, welfare benefits, and Medicaid (Congressional Quarterly Inc., 2004; Segal & Brzuzy, 1997).

While in office, President Reagan also emphasized the neoliberal ideals of competition, efficiency, and privatization as the answer to social problems and as a way to increase individual profit. This devolved and decentralized notion of society seemingly became less important instead favoring the individual (Bakan, 2011; Harvey, 2005). The freedom that came with neoliberal policies also came with great sacrifice (Bakan, 2011; Harvey, 2005). Karl Polanyi summarized this sacrifice by stating that the independence promoted under neoliberalism also promotes the "freedom to exploit one's fellows [and] to make inordinate gains without commensurable services to the community" (Harvey, 2005 pg. 38). These attitudes greatly influenced social welfare policies in the United States, and in 1981 President Reagan drastically slashed healthcare budgets making Medicaid unable to function and thus fundamentally ineffective (Rowland, Lyons & Edwards, 1998). This, it is argued here, may have been the president's intent prior to even entering office as he was quoted in 1965 saying that Medicaid recipients were "[a] faceless mass, waiting for handouts" (Jarecki, 2011.). These Reagan inspired spending priorities as well as cultural values have seemingly become embedded in modern day United States policy and American society. Recent research examining the trend of privatizing public services has found that although public entitlement spending is one of the best ways to stimulate the economy and promote community stability, funding cuts along with increased social taboos in asking for help have continued to persist (Benen, 2011; Congressional Budget Office, 2010, 2011). Understanding the effect of neoliberalism on national priorities helps to set the stage for the future of Medicaid policy and the difficult task of reform post-recession.

Present day Medicaid: Continued effects of neoliberal priorities

In 2007, the United States entered into a recession and as a result, many major industries went bankrupt (Rampell, 2010). Subsequently, the federal government provided financial aid packages to those industries with the hopes of maintaining business operations (Rampell, 2010). Many people were unemployed and had no way to provide health care for themselves and their families. As a result, the federal government decided to overhaul and retool the healthcare system. President Obama signed both the Patient Protection and Affordable Care Act (PPACA) and Health Care and Education Reconciliation Act into law in March 2010. Both of these were intended to work together to provide continuity of care for all individuals by making health insurance available, affordable and unbiased (Elmendorf, 2010). In 2009, President Obama also pledged to renew national commitments in reinforcing healthcare and civil rights for disabled citizens (United States Department of Health and Human Services, 2009, 2010). Those promises however have yet to come to fruition (United States Department of Health and Human Services, 2009, 2010). It is expected such programs may not see additional funding at best until 2012 or 2014 (United States Department of Health and Human Services, 2009, 2010). Many neoliberal Republicans were against these new commitments of expanded government and since, there have been several filed lawsuits challenging the constitutionality of the law itself. It is expected that the final ruling will be determined by the Supreme Court in the next year or so (Central News Network, 2011; The White House Washington, 2010).

Due to the recession, Medicaid applications sky-rocked with 2009 estimates finding a 15% increase in program enrollment (Sack, 2010). Despite the additional strain on already skeletal budgets, 2010 healthcare legislation promised that Medicaid eligibility would expand to cover those living at 133% of the poverty level while providing a sliding scale payment structure for those on Medicare already living at 400% the poverty level (United States Department of Health and Human Services, 2010). If instituted, these actions would have restored some of the original intent of social welfare entitlement programming back to Medicaid. Recall however, while national priorities outline a broad set of goals, the state can micromanage actual program implantation, and funding disbursement. Indeed, there may be a need for expanded coverage, yet there has been no action indicating that such changes are to occur (United States Department of Health and Human Services, 2009). Appreciating the tension that results between the state and federal governments is vital in understanding why the federal healthcare plan may dictate some actions that may never become actualized. Thus, the states are again able to legitimately fulfill their neoliberal economic agendas while also complying with federal policy.

The Congressional Budget Office (CBO) estimates that the United States budget deficit is going to reach 1.5 trillion dollars this year and that by 2016 " interest payments on the federal deficit are projected to exceed the Pentagon's share of total spending" (Martin, 2011, para. 3). This means that 40% of all money spent (or 40 cents of every dollar) by the United States government is borrowed (Kadish, 2011; Martin, 2011). In a 2010 report released by the CBO, it was noted that several states including Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Louisiana, Maine, Maryland, Missouri, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Wisconsin, Wyoming, and Utah all made cuts in Medicaid spending. Worse yet, California, Michigan, Nevada, and Utah completely "dropped coverage" to many people who previously received covered dental and vision care on Medicaid (Johnson, Oliff & Williams, 2010, p.10). Many of these proposed cuts caused distress among providers while also harshly affecting the quality and breadth of needed services for young nursing home residents.

Some states, such as Arizona, have employed Reagan-esque attitudes of privatization by allowing private contractors to provide specific services and programs to Medicaid recipients. Efforts such as these further encourage privatization that is concerned primarily with efficiency and profit, not quality of care. Moreover, privatization of Medicaid includes additional changes to eligibility rules and could result in the denial of needed coverage (United States Department of Health and Human Services, 2010). Accompanying the predicted rise in the number of young residents in nursing homes is the forecasted strain on the United States economy when the aging baby boomer generation files for Medicare. Between 2020 and 2040 baby boomers will reach their peak retirement age and will enter the Social Security system in record rates. This adds further stress to the system that is already very taxed (United States Department of Health and Human Services, 2009, 2010).

In 2002 it was eerily predicted by a scholar that:

…despite its importance, Medicaid faces serious threats. After a period of slow growth, Medicaid spending is expected to increase in the coming years, particularly for people with disabilities and the elderly. These demands could be compounded by recession-drives increases in eligibility. To complicate matters, Medicaid does not have a wealth of political support behind it. Tied at its inception to the receipt of public benefits, the program has never shaken its stigma as a welfare program. Medicaid may become a target of legislative and judicial decision-makers who are seeking to curb program spending and others who see the Medicaid entitlement as antithetical to their concepts of states' rights and a reduced federal role. (Perkins, 2002, p.8)

What the above quote suggests is that not only does Medicaid face a shaky economic future but also an even weaker support network. Perkins (2002) alludes to the fact that politicians may be purposely focusing away from Medicaid in favor of their neoliberal ideals centering on private sector profit, individualism, and small government (Alegria, Frank & McGuire, 2005). Additionally, with the inclusion of the global economy into United States politics there will be a continued importance placed on productivity, efficiency, and profit increasing the demand for private sector contracts (Karger, 1993). Quadagno (1999, p.1) defined this "capital investment welfare state" as the combination of a globalization trend along with an increase in neoliberal ethic. In this capital welfare investment state the "objective is to increase savings and investment" while framing welfare policies as "impediment[s] to the free market" (Quadagno, 1999, p 1). Deeply harrowing, the potential for increased inequality for many vulnerable people is again troublingly clear. The struggle and inequity that young residents of nursing homes already face would increase in a truly unjust way. In 1944, Karl Polanyi concisely said "[t]o allow the market mechanism to be the sole director of the fate of human beings and their natural environment… would result in the demolition of society" (George, 1999, para. 5). While almost 70 years has passed since Polanyi's statements it appears that the sentiment of United States health care policy has remained unchanged.

Understanding the original intent of Medicaid as an entitlement program (to provide long term care for those who could not otherwise afford), and the potential for states to make neoliberally guided changes (by incorporating the free market and private sector into welfare policy), along with the possibility for legislator bias, under the overall trend of predicted increases in young nursing home residents results in an urgent picture calling for national attention. It is clear that the potential for severe economic inequality and undue human suffering of young residents in nursing homes is a likely outcome. Very vulnerable and increasing in number, young residents of nursing homes are in need of intensive care and attention; with nowhere else to go, what are these individuals, their families, and their communities supposed to do? The entitlement program is in fact not doing its job.

The effects of Neoliberalism as understood through the eyes of young residents in nursing homes

Current research findings

In reviewing the literature, there are many gaps with what is actually known about this population. Information about young residents of nursing homes, originate from the United Kingdom and Australia with those scholars acknowledging a general lack of information (Cameron, Pirozzo & Tooth, 2001; Persson & Ostwald, 2009; Senate Community Affairs References Committee, 2005; Smith, 2004; Weingarden & Graham, 1992; Winkler, Farnworth & Sloan, 2006; Winkler, et. al, 2010). However, what is known provides strong encouragement for further research, clinical development and policy analysis. Recently, research has contrasted older nursing home residents with younger nursing home residents and it is now understood just how different the two really are (Persson & Ostwald, 2009; Sedensky, 2011; Stringer, 1999; Weingarden & Graham, 1992; Winkler, Farnworth & Sloan, 2006; Winkler, et. al, 2010). In the research, "young" often refers to residents under 65 years of age, although some studies have defined "young" as those under the age of 50 (Person & Oswald, 2009; Smith, 2004; Winkler, Farnworth & Sloan, 2006). For the purposes of this study, the term "young" denotes individuals under the age of 65, who without disability would otherwise be able to function independent of residential care.

One of the most notable differences between younger and older nursing home residents is their gender: younger residents are overwhelmingly male whereas older residents are often female (Person & Oswald, 2009; Weingarden & Graham, 1992; Winkler, Sloan & Callaway, 2007). Additionally, younger residents are at a much higher risk for developmental disabilities or mental impairments such as retardation when compared older residents (Fries, et. al, 2005; Persson & Ostwald, 2009). In 2009, this higher risk of developmental delay was found in a study detailing young male residents of nursing homes who with severe mental impairments, spent much of their time alone watching television (Persson & Oswald, 2009). In a complimentary 2005 study utilizing data gathered from the assessment of 750,000 nursing home residents representing all demographic categories, it was found that younger residents appeared to have much higher rates of hemiplegia and quadriplegia whereas older residents were prone to neurological illnesses such as Parkinson's and Alzheimer's disease (Fries, et. Al, 2005). Together, these two studies strongly suggest that the overall reason for entering into residential care is quite different for younger individuals (Fries, et. Al, 2005; Persson & Ostwald, 2009). Scholars and literature both agree: young residents in nursing homes often have unique and severe forms of brain injury or rare types of dementia that greatly limit functioning and require high levels of specialized skilled care ((Fries, et. Al, 2005; Persson & Ostwald, 2009; Sedensky, 2011; Stringer, 1999; Weingarden & Graham, 1992; Winkler, Farnworth & Sloan, 2006; Winkler, et. al, 2010).

Level of support needed

Many young residents require intense levels of support and Winkler, Sloan & Callaway, estimate about 26% of those individuals "could not be left alone" for prolonged periods of time (2010, p.299). By using qualitative interviewing along with a specialized assessment tool, Winkler, Sloan & Callaway (2010) were able to obtain a very intimate perspective from 105 young residents in the Australian nursing home system. Common results indicated that residents were:

highly physically dependent, with 33% requiring assistance with moving in bed and 51% needing assistance with mobility …Sixty-eight per cent of the sample required assistance to get in and out of the place they live and 73% required assistance to get around in their local community…80% required specialized or customized equipment such as hoists, wheelchairs and pressure care overlays. (Winkler 2010, p306).

Additionally "[f]orty-two per cent of people with ABI [acquired brain injury] had problems swallowing, increasing their risk of aspiration and chest infections. Many people (48%) had difficulty communicating their basic needs" (Winkler 2010, p. 306).

This sudden inability to function independently is a major shock to one's physical system and can lead to many side effects both psychological and social. Researchers found that initially, family members may attempt to care for the individual on their own but over time, the stress becomes too great (Stringer, 1999; Winkler, Sloan & Callaway, 2010). Studies have noted that families may feel as though they have no other option but to place their loved ones in a nursing home as doctors, hospitals, and therapists cannot provide the necessary supportive or respite services (Winkler, Sloan & Callaway, 2010). This emotional and financial stress can tax any relationship and about 7 out of 10 relationships that include full time, long term care of a young person in a nursing home, result in divorce (Cummings, Hughes, Tomyn, Gibson, Woerner, & Lai, 2007). In a 2007 longitudinal study of about 2,000 adults who are familial caregivers, 56% were moderately depressed and 40% were severely or extremely depressed (Cummings, Hughes, Tomyn, Gibson, Woerner, & Lai). Furthermore, caregivers themselves have the lowest overall level of wellbeing of any group in society (Cummings, Hughes, Tomyn, Gibson, Woerner, & Lai 2007).

Specifically, with regard to dementia, there may be an eventual need for round the clock monitoring and dedicated care (Chemali, Withall & Daffner, 2010). Research suggests that this may be best done at home with the help of a nurse or in a specialized facility trained in providing for the unique needs of younger groups (Chemali, Withall & Daffner, 2010; Winkler, Sloan & Callaway, 2010). Intensive care is often required that involves the health care provider, community, family, volunteers, and home respite aids (Chemali, Withall & Daffner, 2010; Winkler, Sloan & Callaway, 2010). It is also suggested that the family have access to counseling and supportive resources to cope with the changes and demands associated with this level of care (National Center for Biotechnology Information, 2011; National Institute of Neurological Disorders and Stroke, 2011; Winkler, Sloan & Callaway, 2010).

Increases in young nursing home residents

Present studies have noted the trend of increasing young residents of nursing homes and have offered two main explanations. According to Winkler, Sloan, & Callaway (2010) the primary reason for this increase can be attributed to advances in medical care. Historically, most people would not have survived such severe brain trauma and in the past these young residents in nursing homes did not exist (Winkler, Sloan & Callaway, 2010). Previously, young individuals were often left to the care of their families, communities, and churches with most of caregiving up to women (Winkler, Sloan & Callaway, 2010). "This [increase of young residents of nursing homes] has led to a new population of people with catastrophic brain injury that challenge the disability service system, which is ill-equipped to cope with this increasingly numerous group" (Winkler, Sloan & Callaway, 2010, p. 300).

For young residents of nursing homes, severe traumatic brain injuries (TBI) are most often caused by vehicle and transportation accidents (National Institute of Neurological Disorders and Stroke, 2011, Persson & Oswald, 2009). This level of brain injury associated with long term nursing home care is also repeatedly found in those who have been in war (Okie, 2005). Calling it a "distinctive" and "ominous" threat, Dreher found in an exploratory secondary data analysis of census findings that traumatic brain damage is a predominant form of injury for young war veterans (2009, p. 84). "Physicians and scientists are calling TBI the 'signature wound' of the Iraq war because of its increasing prevalence among troops" (Dreher, 2009, p. 84). Considering that the United States invaded Afghanistan in 2001 and Iraq in 2003 and recent governmental reports project soldiers will return home in the next few years, an increase in young individuals with traumatic brain injury is expected (Peskind, Petrie, Corss, Pagulayan, mcCraw, Hoff, Hart, Yu, Rasking, Cook & Minoshima, 2011; United States Department of Health and Human Services, 2009). It is thought that some of these soldiers may end up in nursing homes where they may not be getting the level of care needed (Dreher, 2009). Undoubtedly, the rapid availability of emergency medical care has allowed people to recover from horrible injuries while also placing them at an increased risk for potential residential nursing home care.

The second main reason explaining the increase for young residents in nursing homes is dementia. While the causes of dementia in the young population are largely unknown, the number of nursing home residents with this diagnosis is also increasing (Brain Injury Association of NSW 200; National Institute of Neurological Disorders and Stroke, 2011, Persson & Oswald, 2009). The research has not been explicit as to why this is so and this author suspects that changes in family structure (due to divorce, moving, etc) combined with the lack of respite and supportive services for the familial caregivers has resulted in individuals with dementia being placed in nursing homes out of convenience or last resort (Buchanan, Wang & Huang, 2003; Fries, et. Al, 2005; Persson & Ostwald, 2009; Sedensky, 2011; Stringer, 1999; Weingarden & Graham, 1992; Winkler, Farnworth & Sloan, 2006).

Inequalities and health decline upon entering a nursing home

Upon entering a nursing home, things do not suddenly become easier for the young person and their loved ones. Out of place with the rest of the residents, young individuals in nursing homes are resolved to what little activity can be worked into their day and more often than not, hours upon hours are spent sitting alone in front of the television (Persson & Ostwald, 2009). Often, the nursing homes themselves are either unable or ill equipped to offer younger residents social, community, and recreational enrichment (Bigby, Webber, Bowers, & McKenzie-Green, 2008; Persson & Ostwald, 2009). Bigby, Weber, Bowers & McKenzie-Green (2008) confirmed this in a survey of over 800 nursing home facilities in Victoria, Australia when it was discovered that most young residents did not fit into the nursing home community, did not participate in social activities and often failed to create meaningful relationships. Likewise, Winkler, Farnworth, & Sloan (2006) in a similar study, found that after entering into a nursing home 34% of young residents never went into the community and 21% did not leave the facility except once a month. Shockingly, 44% of residents' friends visit them less than once a year (Winkler, Farnworth, & Sloan, 2006). As friends and even family of the resident fade away, another person must assist them in the normal tasks of eating, bathing, and communication (O'Rilley & Pryor, 2002).

Most individuals in this situation end up in nursing homes as Medicaid does not cover anything else; they literally have nowhere else to go (Sedensky, 2011; Shapiro, 2010). Lapane and Resnik (2005) studied over 1600 nursing home facilities in the United States and found that as a result of this inappropriate nursing home environment about 30% of the obese residents in nursing homes are young residents: a highly disproportionate statistic considering that young residents comprise a much smaller percentage of total nursing home residents. In a qualitative examination Winkler, Farnworth & Sloan noted that young residents in nursing homes live "impoverished lives, characterized by loneliness and boredom…socially isolated from peers and effectively excluded from community life" (2006, p.300).

Furthermore, almost 20 years ago researchers Weingarden and Graham (1992) noted that young nursing home residents with trauma to the brain had increased rates of rehospitalization accompanied by extreme psychosocial stress. A more recent study found very high levels of "unmet psychosocial needs" in young residents of nursing homes (Persson & Ostwald, 2009, p. 24). Over two decades have passed and little has changed for young residents of nursing homes. After already enduring horrible traumas, these young individuals are removed from their entire life, community, family, and home only to be placed in a setting where they are lonely and without stimulation.

In 1999, others had this same concern and the case Olmstead v. L.C. Decision was brought to the Supreme Court. The case dealt with the unnecessary separation and placement of disabled individuals living in isolated institutions stating that it is equal to that of discrimination and is moreover unjust (Perlin, 2000; Williams, 2000) The final decision in July of that same year, required:

…states to administer services, programs, and activities 'in the most integrated setting appropriate to the needs of qualified individuals with disabilities.' This decision interpreted Title II of the Americans with Disabilities Act (ADA), which gives civil rights and protections to individuals with disabilities and guarantees equal opportunity for individuals with disabilities in public accommodations, employment, transportation, State and local government services, and telecommunications" (United States Department of Health and Human Services, 2011, para.1).

Researchers have begun to question this gap in services as well as the poor health status of individuals in relation to the political promises of high quality and consistent healthcare. Several studies have discovered that younger nursing home residents are not receiving the same treatment as older residents (McMillan & Laurie, 2004; Macdonald, Carpenter, Box, Roberts, and Sahu 2002). A recent study out of the United Kingdom noted that "proactive, routine reviews of medical, rehabilitation, and medication needs were rare" for young residents of nursing homes (Persson & Ostwald, 2009, p. 24). Other research teams have called into question the training of staff members as to the unique, pressing and relational aspect of the residents' needs (Gething, 2001; Macdonald, et. al, 2002). The isolation, health disparity, as well as biophysical health decline are direct consequences of an inadequate service system directed by neoliberal Medicaid policy. Neoliberal ideals of profit, individualism and private control over public goods are not working to provide the level of care and quality of life that young residents in nursing homes deserve.

Potential barriers to improving quality of care

Chemali, Withall & Daffner (2010) in an intensive case study of a 39 year old frontotemporal dementia resident identified barriers in improving quality of care for young residents of a nursing homes as well as ways to counteract those challenges through directed initiatives. Of those cited barriers to improving care, three are especially worth mentioning here: lack of community support, lack of public funding as well as lack of advocacy for the individuals themselves (Chemali, Withall & Daffner, 2010). Due to the neoliberal ethic of individualism there is a lack of community support and empowerment for young residents in nursing homes and their support systems (Maskovsky, 2000). As a result, families are often left without treatment options and must resort to whatever aid is available even when it is the least appropriate (Maskovsky, 2000). Lack of public monies and educational funding are also an obstacle in improving the quality of care for young residents of nursing homes. This ideal of profit and privatization over public investment compounds when there is very little advocacy and lobbying for the residents themselves.

Each of these challenges ties directly back to the neoliberal tenants of investing in private corporations over community as well as policy aimed at maintaining the status quo instead of progressive reform putting the individuals' needs first. Several recent studies have also come to this same conclusion about the inability of a neoliberal market to truly provide for a vulnerable population. Scourfield noted, in a study examining 2005 to 2006 market data from England, that over time the trend towards "privatization, marketization and commodification of [the] residential and nursing care" service system are increasing and are tied directly to the vested interests of those parties who stand to profit (2007, p. 155).

Currently, local authorities in England alone spend an estimated £3 billion per annum on residential provision. Most of this is now paid to profit-making providers… it is proposed that, if the current trends continue, it is highly likely that the market could become cartelized or, at least, have strong cartel-like characteristics. (Scourfield, 2007, p. 157)

Similarly, Randall and Williams examined 49 residents in an Ontario, Canada nursing home facility and concurred that structural barriers and overriding neoliberal ethics created an environment of "managed competition" which led to increased costs along with reduced quality for residents (2006, p 1956). Randall and Williams, advocating for overall reform, also concluded that healthcare services are not best delivered through market-based economies (2006). A 1991 study out of the United States discussed concerns about the increase of the private corporation into the human and social services sector (Stoesz & Karger, 1991). This "corporatization" of the welfare state, will eventually lead to overall standardization and commodification of services while increasing cost and reducing overall quality (Stoesz & Karger, 1991, p 157). What is needed for the care and quality of life of young residents in nursing homes is not part of the present individual and private profit focused framework. Identified challenges must be addressed at all levels of society and government. Changes to the macrosystem must occur through policymakers, government bodies, educational institutions, and professional organizations; the mesosystem through community agencies, local governments, and health care providers, and the microsystem through advocacy groups, family, and friends (Chemali, Withall & Daffner, 2010).

What is really needed? An exploratory research study with the patient first

In the late 2000s Australia realized the projected increase of those who are young living in nursing homes and as such proactively decided to investigate and make suggestions for health policy reform (Australian Government Department of Families Housing Community Services and Indigenous Affairs, 2008; Australian Institute of Health and Welfare, 2001; Winkler, Sloan & Callaway, 2010). In 2006, the government, in cooperation with local municipalities spent $244 million dollars and developed the "Young People in Residential Aged Care (YPIRAC) 5-year Initiative" (Australian Government Department of Families Housing Community Services and Indigenous Affairs, 2008; Australian Institute of Health and Welfare, 2001; Winkler, Sloan & Callaway, 2010, p.300). According to researchers this strategic plan was the largest on record to address this vulnerable and unique population (Australian Government Department of Families Housing Community Services and Indigenous Affairs, 2008; Foster, Fleming & Tilse, 2007; Winkler, Sloan & Callaway, 2010).

After analyzing collected data, researchers discovered that most residents had serious persistent health problems and ongoing behaviors associated with prescription drug side effects as well as from the brain injuries themselves (Winkler, Sloan & Callaway, 2010). For example, infections and urinary tract infections were common while "46% [of residents] had an admission to an acute hospital in the past 12 months" only 22% of which actually elected to enter that hospital (Winkler, Sloan & Callaway, 2010, p. 304). Additionally, about 60% of individuals showed signs of depression and 20% appeared to be moderate or severe (Winkler, Sloan & Callaway, 2010). About 90% of residents were assessed at being at least partially aware of their surroundings (Winkler, Sloan & Callaway, 2010). Other prominent mental health issues identified were hallucinations, delusions, anxiety and panic attacks (Persson & Ostwald, 2009; Winkler, Sloan & Callaway, 2010).

It was found that the consequences implemented by nursing home staff for such behaviors were demeaning and inappropriate including time outs, sedation, and physical restraint (Kelly & Winkler, 2007; Winker, Sloan & Callaway, 2010). Kelly & Winkler described this behavior management with the following conclusion:

The consequences of challenging behaviours are immense for the individual as they contribute to the depletion of natural support networks and the loss of access to valued activities… Injury to the areas of the brain that control and regulate behavioural responses is the primary reason people display challenging behaviours. (2007, p. 308)

Clearly, the services delivered at a nursing home are not appropriate for young residents and worse yet individual health is likely to decline upon entering such a facility. (Kelly & Winkler, 2007; Winker, Sloan & Callaway, 2010) A holistic understanding of the environment and how that environment may aggravate the resident's unique condition is pivotal to providing ethical care. Recommendations and policy improvements which came as a result of the Initiative suggested that aside from increased involvement of the resident directly in their care, increasing community inclusion, staff training, and facility budgets were the best long term, cost effective strategies available (Australian Government Department of Families Housing Community Services and Indigenous Affairs, 2008; Foster, Cleming & Tilse, 2007; Winkler, Sloan & Callaway, 2010). These aforementioned strategies are not guided by neoliberal ideals yet are thought to provide the highest long-term benefit with the least overall public expense; reform that benefits both the resident and the government is possible.

Routes to change

If numbers of young residents in nursing homes increase as predicted, an economic and social disaster for the United States could easily result. It is reasonable to ask then: "What is there to do?" Budget cuts and programming pullbacks are unavoidable, yet it is imperative to minimize the effects of those cuts on the most vulnerable populations without resorting to a profit-minded agendas. Neoliberalism removes the public from the private, civic from government, and economic from political, now is the time to move forward and create a system of cooperation, communication, and healthcare for all people (Naples and Desai, 2002).

Considering the financial crisis that the United States is in, it makes sense to explore options that allow individuals to get their needs met while also conserving government funds. Among the often-cited reforms is the removal of long-term care from Medicaid and the subsequent inclusion into Medicare (Congressional Quarterly Inc., 2004). Proponents of this reform argue that this would allow the long-term care consumers a larger share of consistent, earmarked healthcare monies. A second frequently discussed reform includes decreasing the overall cost of healthcare services provided by reducing the profit that insurance companies, drug companies, and other entities make through public policy creation, higher corporate taxes, and transparent bookkeeping (Congressional Quarterly Inc., 2004). In addition to formal and likely slow political changes, there are many ways that the public can bring attention to the issue both nationally and worldwide (Kelly, 1993).

The first and foremost act that the United States can take is for the federal government to freeze all state level Medicaid funding cutbacks for this population. This may need some creativity to enact as this is against neoliberal ideals of small government. The media can have a large role in publicizing the plight of young residents of nursing homes via public service announcements, online publications, as well as newspaper articles. Efforts to emphasize the role of community support and public provision in social services are desperately needed. Additionally, it is vital to focus on a long term approach: cutting funds now may help with the immediate deficit but residents' conditions may get worse which in fact create more expense in the end. Appealing to neoliberal politicians in this manner may have merit in that it is tied directly to profit. Lobbyist groups, nonprofits, and consumer interest groups can be of great assistance in this further spreading information.

Another level to assist in Medicaid reforms are the higher education institutions themselves. It is explicit in the Codes of Ethics of all the helping professions including Social Work, Counseling, Medicine as well as Nursing that the best interests of the individual come first (American Nurses Association, 2001; American Medical Association, 2006; National Association of Social Workers, 2008; National Board for Certified Counselors, 2005). Curriculum committees and accrediting bodies can work together with professional advocacy organizations to lobby legislation, write grants, and educate the public. Along with formal educational systems is the role of the academic researchers. Privileged professionals with the resources, knowledge, and network to produce studies and then disseminate them have the obligation to do so.

Finally, the public and the residents themselves are another place to help enact reform. This is especially salient during times of election when voters have the ability to impact the people that are put in positions to make decisions and represent citizens. Again, the media and special interest groups intersect in their campaigns and visual representations in determining what national priority and government spending are. The business community becomes very important in helping to lead grassroots campaigns and fundraising efforts. Documentaries featuring young residents of nursing homes can provide the knowledge to the general public while also encouraging well-informed voting decisions and charitable contributions.

In direct contradiction to neoliberal ideals, provision of funding along with freezing cutbacks by the government backed by public awareness through academic and media outlets would help promote service providers, nonprofits, family members, and healthcare workers to act in improving the lives of young nursing home residents. This two pronged approach which supports services and research stays true to overall goal: to gain a better understanding of the needs, qualities and characteristics of young nursing home residents while also providing access to high quality and proper health care, respite care, and caregiver support. This may sound 'out of the question' but really it is not; this is a realistic goal that with support could become a reality.

Concluding thoughts

Oppression, unfairness and inequality are the results of a neoliberal healthcare system as evidenced by the community of individuals discussed here who are young, on Medicaid, and reside in nursing homes. Young residents of nursing homes have complex and unique service needs that are not appropriately met under the neoliberal Medicaid program. Profit, individual interest, and privatization are not the principles that best serve the community and while the United States is in the middle of an economic crisis, such stark maltreatment and disparity is the exact opposite of the purpose of entitlement programming. Potentially deleterious economic and social costs could occur should present programming agendas continue. The long term effects of neoliberal cutbacks to programs for those who have no other alternative is a topic that requires much further research, debate, and publication. Understanding the effect of such cutbacks in respect to the groups they affect is essential to changing and reforming outdated ways of thinking with the ultimate betterment of society as a whole.

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