| For decades the U.S. welfare state has been undergoing major economic restructuring due in large part to the influence of policies of decentralization, devolution, and privatization. These changes create an environment of uncertainty for the community-based long term care delivery system (CBLTC). Amidst these changes, access to services is an on-going concern for the elderly. Access to health and long term care can be seen as an historically created product or condition that is inherently class-based, both for individuals and institutions and organizations interacting in the health care delivery system.; This study examines factors influencing access issues in CBLTC using a political economy approach and organizational fields theory by assessing, from the bottom-up (i.e., from the perspective of CBLTC organizations), how political, economic and policy changes shape the nature of access to CBLTC. Data for the study included telephone surveys, conducted in 1991-92 of 956 providers representing the service delivery sector of the CBLTC organizational field (discharge planners, nursing homes, certified home care, uncertified home care, and adult day care).; The findings of the study indicate that, in 1991-92, the effects of the Medicare Prospective Payment System were still present and affecting access to care, with respondents indicating that clients require more hours of care, have more acute care needs, and require multiple services. The majority of the field reported that clients had unmet needs for social services resulting from policies and regulations that emphasize coverage for medical services. This finding is evidence that policy and regulation continue to affect access to services and contribute to the medicalization of CBLTC in terms of the types of services eligible for reimbursement.; Logistic regression results for five models of access (refusing clients for financial reasons, unmet need for medical services, unmet need for social services, increasing fees, and a service limitation index) indicate that tax status, perceptions regarding competition, and reliance on private pay sources for revenue are significant predictors of access problems in CBLTC organizations. The implications of these findings for CBLTC policy and for organizational fields theory are presented. |
