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Intent vs. Reality in Long-Term CarePolicyRam A Cnaan PhD a & Felice D. Perlmutter PhD ba University of Pennsylvania, Philadelphiab Temple University, Philadelphia, PAPublished online: 18 Oct 2008.

To cite this article: Ram A Cnaan PhD & Felice D. Perlmutter PhD (1990) Intent vs. Realityin Long-Term Care Policy, Journal of Aging & Social Policy, 2:2, 107-124, DOI: 10.1300/J031v02n02_09

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INTERNATIONAL WEW

Intent vs. Reality in Long-Term Care Policy:

A Case Study Ram A. Cnaan, PhD University of Pennsylvania

Philadelphia

Felice Davidson Perlmutter, PhD Temple University

Philadelphia, Pennsylvania

ABSTRACT. Care for the frail elderly in the community was the focus of a national debate in Israel between 1980 and 1986. This paper presents a case study of this social policy process as follows: first, it identifies the elements of a uniquely progressive social pol- icy in the field of long-term care; second, it describes a political process that vitiated what could have scrved as model legislation for the field; and third, it traces the link between the policy and imple- mentation, with attention paid to the consequences for the frail el-

Ram A. Cnaan is an associate professor, School of Social Work at the Univer- sity of Pennsylvania. Felice Davidson Perlmutter is a professor in the School of Social Administration, Temple University, Philadelphia, PA.

Journal of Aging & Social Policy, Vol. 2(2) 1990 O 1990 by The Haworth Press, Inc. All rights reserved. 107

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derly. The original intent of this policy, as well as its transforma- tion, should serve to assist policymakers in various countries in their consideration of long-term care policy and programs for the frail elderly.

Demographic studies in industrial societies indicate not only that longevity has risen, but that the fastest growing group are those people over 75 years (Davies, 1984; Kop, 1980; Rosenwaike, 1985). In the United States there are an estimated 5.2 million per- sons over age 65 who in 1985 were mildly to severely disabled and in need of assistance to perform normal activities of daily living (Senate Special Committee on Aging, 1985). This age group with special needs is expected to live longer in a context of deinstitu- tionalized care (Brody, 1982; Luce, Liu, & Manton, 1984; Waer- ness, 1987), thus placing an emotional and financial burden on fam- ilies while also taxing the insurance support system. All modem societies are challenged to provide for the frail elderly in a way that will both be financially feasible and humane to all groups involved: the elderly, their caring relatives, and society in general (Callahan & Wayack, 1981; Morginstin & Werner, 1982).

This paper presents a case study of a debate over long-term care policy, the formulation of a policy, and its subsequent implementa- tion, which took place in one industrialized society, Israel. The primary aim of this policy was to formally define the state's statu- tory responsibility to provide long-term care benefits and services to all frail elderly persons on the basis of personal entitlement pro- vided by national insurance, for example, social security. It was also meant to strengthen the bond of responsibility between families (informal caretakers) and the state -(formal caretaker) in caring for the frail elderly.

The case is important because a first step was taken, albeit aborted, to raise for legitimate public debate a most advanced social policy in long-term care. This should be useful to legislators, social

.. planners, and social administrators in developed societies that are seeking to either advance their existing programs or design new ones.

This article first presents the key policy and implementation con- cepts that underpin the case study; second, it highlights the compo-

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Ram A. Cnaon and Felice Davidson Perlmutter 109

nents of the original version of the long-term care policy (1983); third, it describes the political process that ensued and the modifica- tions that were enacted in the final legislation; and, finally it reports on the demonstration phase (1986-88). The article focuses on the Israeli long-term care legislation from the standpoint of its expected impact on the quality of life of the frail elderly.

ISSUES IN SOCIAL POLICY

There are major debates in the policy literature regarding ap- proaches to caring for frail elderly. The relevant issues for this dis- cussion are as follows: (1) whether institutional (skilled nursing homes) care or community care, including home-based care, should be optimized; (2) whether help should be in the form of services or in cash; (3) whether there should be public provision of benefits, as opposed to private insurance; and (4) if the program is public, whether the program should be a universal or a means-tested one. Although these issues are interwoven, for purposes of clarity we will deal with each separately.

The ambivalence concerning long-term care programs in the United States can be characterized by the recent attention paid to this issue in the media. The Philadelphia Inquirer (1988) reported that a Harris poll showed that "voters of all ages and political be- liefs" favor long-term health care, and yet the House of Represen- tatives is not ready to consider a new entitlement program proposed by Claude Pepper to provide long-term-care nursing and house- keeping assistance at home for those unable to care for themselves. According to the Investors Daily (1988), the small business lobby strongly opposes the legislation because it claims that the bill: would not raise enough revenues to cover its costs; might set a precedent for raising Social Security taxes; would apply to those who already can afford coverage as well as to the poor; and would not cover nursing home stays, the most expensive kind of care for the elderly.

The policy issues identified earlier are clearly reflected in the concerns of the business community; consequently, the coverage will most probably remain in the hands of private insurance com- panies. Currently in the United States, the debate continues to cen-

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110 JOURNAL OF AGING & SOClAL POLICY

ter on how to regulate long-term care insurance (LTCI) provided by private insurance companies rather than on the provision of pyblic LTCI (Goldberg-Alberts, 1986; Kane & Kane, 1985). Meiners (1984) found only 16 LTCI policies in the United States, most of which paid some form of daily indemnity benefit. The majority were limited in coverage to nursing home care, restrictions were numerous, and marketing areas were geographically limited. Al- though this field is currently witnessing a vast proliferation of new companies and new types of policies, the focus is solely on private responsibility, with state and federal involvement being limited to regulating the responsibilities of private insurers toward the insured old persons (Consumer Union, 1988; Sabatino, 1986; Common- wealth of Massachusetts, 1988). Abramovice (1988) notes that thus far custodial care (i.e., help with activities of daily living) and so- cial support services have not been configured in the scope of cur- rent insurance coverage.

It should be noted that one of the most advanced terms of LTCI was instituted in Canada in the 1970s as part of the national health system. Most of the Canadian provinces provide universal long- term care services. Eligibility is based on functional impairment withcmt regard to the individual's income; copayments, if levied, are designed to leave even the poorest pensioner with a small dis- posable income. Thus Canada maintains the principle of universal service to all those in need, irrespective of economic status (Kane & Kane, 1985).

And yet, in two important respects, the Canadian long-term care is rather traditional: first, it is primarily oriented to institutional care with only minor resources for home-based assistance; second, there is relatively little debate about the provision of cash benefits as part of the LTCI.

ISSUES IN IMPLEMENTATION

Pressman and Wildavsky (1973) call attention to several critical elements in the policymaking process. While they emphasize the interrelationship between policy and implementation, they note that policy precedes and sets the conditions for implementation.

A program consists of governmental action initiated in order to

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Ram A. Cnaan and Felice Davidron Perlmutter 111

secure objectives whose attainment is problematic. The word "pro- gram" signifies the conversion of a hypothesis into governmental action. Implementation may be viewed as a process of interaction between the setting of goals and actions geared to achieving them. While the authors separate the analysis of policy and implementa- tion, they are keenly aware of their interdependence, and the pur- pose of the discussion is to bring them into closer correspondence.

The process of implementation includes all actors in the system, lower- as well as upper-level participants; consequently, one must not examine only one sphere of an organization to see whether im- plementation took place. Furthermore, implementation is a sequen- tial process of events that "depend on complex chains of reciprocal interaction." Pressman and Wildavsky suggest two sets of actions to achieve the necessary correspondence between policy and pro- gram: first, it is essential to take into account the complexity and length of the interactions required for implementation; second, it is important to attend to the organizational machinery necessary not only to implement a program but also to launch it. Pressman and Wildavsky also advocate simplicity, as "the fewer the steps in- volved in carrying out the program the fewer the opportunities for a disaster" (p. 147).

One final practice must be noted in relation to implementation, directly related to the policy process. In some nations policy is promulgated at the national level as a "framework law." A frame- work law defines the policy intent in the broadest terms from the perspective of the national legislative body, but leaves the specific- ity of the policy process, as well as the implementation mecha- nisms, to local governmental units (as in Israel) or regional govern- mental units (as in Italy). This approach runs counter to Pressman and Wildavsky's notions of simplicity and parsimony and, in real- ity, can violate the intent of the framework law.

CASE STUDY: THE'ZSRAELI LONG-TERM CARE LAW

A unique policy formulation process regarding the LTCI was be- gun in Israel under the aegis of Dr. Israel Katz, Minister of Labor and Social Affairs from 1978 to 1982. The minister considered two

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I12 JOURNAL OF AGING & SOClAL POLICY

basic options: (1) to place LTCI within the Department of Social Affairs and thus encourage the best allocation of resources; or (2) to place it within the Israeli National Insurance Institute and thus en- hance cash benefits and insurance principles. Dr. Katz opted for the latter position, as put forth in the 1980 framework law.

As a member of a small party, the Democratic Party, which was essential for the ruling national coalition, Dr. Katz was able to gen- erate the support of sufficient Knesset members to pass the LTCI Law in August 1980. However, as is quite common in Israel, in order to avoid fierce opposition it was passed only as a conceptual framework, or declaration of intent. The actual content of the law was left to be fleshed out at a later time. Indeed, the final version was voted finally in the Knesset in 1986 (Cohen, 1987; Kalderon, 1987).

Dr. Katz appointed a 23-member select committee to study the issue of LTCI and to make recommendations that would flesh out this model, or framework, law. The committee was chaired by Kalman J. Mann, MD, the former director of the Hadassah Hospital in Jerusalem and a universally respected professional. The other 22 members of the committee were either experts in gerontology, or goveriimental officials from various branches and ministries.

Because of the complexity of the issue at hand, the committee was active from 1980 to 1983. It reviewed various studies, some of which were carried out specifically for this policy formulation (Fac- tor, Guttman, & Shmueli, 1982; Morginstin, 1982; Shuval, Fleis- man, & Shmueli, 1982; Silberstein et al., 1981). It interviewed experts, and it gathered international material as a means to achieve a rational consensual proposal that all could accept.

In late 1983 the committee provided the minister with its recom- mendations which favored (1) universal (2) community-based ser- vices, (3) cash benefits, and (4) a publicly supported and adminis- tered LTCI. This majority position was endorsed by 17 members; the minority position, which favored an in-kind approach and selec- tive services, was endorsed by six members (Ben-Zvi, 1987; Co- hen, 1987; Mann, 1983). However, it must be noted that the six minority members were representatives of the government branches, with the exception of the National Insurance Institute, a fact that turned out later to be crucial to the final version of the law.

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Ram A. Cnaan and Felice Davidson Perlmutter 113

The Policy Intent: The Mann Committee Report

Both Dr. Katz and the majority of the Mann committee intended a highly advanced reform. The committee recommendations, de- signed to assist old people who suffer difficulties in daily function- ing, dealt with the four policy issues discussed earlier as follows:

1. The program would be designed to assist old people who suf- fer difficulties in daily functioning in their own homes. It would be a community-based program.

2. The program would be in the public sector, with benefits viewed as entitlements, not charity. The benefits would be based on contributions to the National Insurance Institute. In order to assure adequate resources for the program, there would be equal contribu- tions from three partners: employees, employers, and the govern- ment. The amount to be taxed would be equal to .25% of the em- ployee's income which is legally taxable in social security. Since the three parties expected to contribute in equal proportions, the funds designated for this insurance program would be equal to .75% of the taxable income of all employees.

3. The major form of provision would be cash benefits to be utilized by the consumer and his or her family according to their discretion. Thus, the family would have the option of caring for the old person directly or purchasing services. Only in special cases, when cash benefits would not be appropriate, would in-kind ser- vices (e.g., home help) be provided directly. The decision to use cash benefits stemmed from the experience, both in the United States and Europe, where it was found that cost spiraled due to increased demands for expensive services (Morginstin & Shamai, 1987). Since the provisions would be clearly defined by law, and not based on professional discretion, the phenomenon of street- level bureaucracy, common in the social services, would be mini- mized by the strictly regulated cash benefits.

4. LTCI would be a universal, not a means-tested, program. The 1983 report clearly stated that a person's eligibility should not be based on available resources but only on a demonstrated need. If the program were to deplete the available funds, services would still be provided to all eligible persons, but the government would update the contribution formula in order to generate necessary funds.

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In addition to these four critical policy issues, there were the following provisions:

5. Since the local authorities provide an array of services to the elderly (e.g., meals on wheels, friendly visitors), the report speci- fied that LTCI beneficiaries should continue to receive existing ser- vices even if they could purchase additional services with their LTCI cash benefits. The program was not designed to replace exist- ing services but to add new services to what was already in exis- tence.

6. The majority of the resources would go directly to the target population; only a small portion would be allocated to the develop- ment of local social services to serve disabled old persons.

7. The total responsibility for taxing, determining eligibility, and providing benefits would rest with the National Insurance Institute. However, local committees composed of representatives of local service providers would be established to monitor the actual care provided to the elderly and to carry out periodical needs assessment studies. The local committee would be composed of a nurse, a rep- resentative of the National Insurance Institute, and a social worker.

8. The volume of LTCI, both in terms of eligibility and scope of the be'nefits, would be updated periodically based on ongoing eval- uation and needs assessment. The relevant data would be generated from the local committees and from large-scale studies initiated by the National Insurance Institute.

There is no doubt that the Mann committee's proposed law em- bodied the most advanced social welfare perspectives. Further- more, the policy intent was both coherent and uniform, as it ensured equity and self-determination for the target population.

The Implementation Reality

As discussed earlier, Pressman and Wildavsky address the inter- relationship between policy and implementation, and highlight the conditions that are necessary to make them correspond. Accord- ingly, they emphasize the importance of involving all actors in the system, lower- as well as upper-level practitioners; they focus on the complexity and length of the interactions required for imple- mentation; they identify the importance of the machinery necessary

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Ram A. Cnaan and Felice Davidson Perlmutter 115

to launch a program; and finally, they suggest that simplicity, like parsimony, is to be sought.

The 1983 majority report created the possibility of meeting the conditions necessary for implementation in several critical respects. The provision of cash benefits, through the mechanism of the Na- tional Insurance Institute, would indeed have reduced the complex- ity and length of the interactions required for implementation, espe- cially since the machinery was in place to launch the program. Furthermore, the cash benefit provision was the simplest possible one: Not only was it based on a clearly specified formula, but it also located the responsibility for obtaining the services within the fam- ily unit.

While these conditions were necessary for implementation, they are obviously not sufficient. The necessary involvement of critical actors at all levels in the system was not achieved. This single factor can most parsimoniously explain the transformation that took place between policy intent and implementation.

The Political Pfocess

In'spite of the fact that an overwhelming number of the Mann committee members (N = 17) supported the majority report, with universal cash benefits, the position that finally prevailed was the minority one which supported means-tested,' direct services. This can be attributed to several factors.

First and foremost, the ruling party in the ministry changed while the debate was still in progress. Israel Katz of the Democratic Party was no longer the minister; his Likud Party successor did not sup- port, or accept, the majority report. Second, the Ministry of Fi- nance put forth a powerful position which argued (in spite of the international data) that a services strategy would be far less costly than a cash option. Third, the country's economy had shifted from prosperity to austerity. Fourth, the traditional governmental minis- tries involved with care for the elderly, health, and social affairs resisted the entry of what they perceived as a competitor, the Na- tional Insurance Institute, into their domain. Finally, the majority of the Mann committee, in order to salvage elements of the model law, was more willing to compromise than the minority members.

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It took the various officials and politicians another two years to arrive at a compromise. Throughout these two years, 1984-86, at least two Knesset members proposed their own individual legisla- tion in an attempt to rescue the law from the hands of the embattled bureaucrats. In April 1986 the new version of the law was intro- duced in the Knesset and received final approval (Cohen, 1987; Kalderon, 1987; Mann, 1987).

As a consequence of the political process, many of the advanced principles put forth by the majority report were now violated. The final LTCI provisions are detailed in the following section.

The Principles of the 1986 LTCI Law

Whereas the final version of LTCI is still unique among social security systems in the Western world in the provision of long-term care as part of a national insurance program (Schnitt, 1987), the original model could have served as a cornerstone in Israel's social security program, and as a model for other countries. The final version deviates from the original plan in the following manner:

1. The universal approach has been replaced by a selective one: The eligible persons are asked not only to demonstrate physical need but also to satisfy a means test. Furthermore, the entitlement is conditioned not only on a personal test of income, but also on a test of income of the relatives with whom the old person resides.

2. The major mode of assistance is in-kind services, provided by local committees of service providers; only in extreme cases where services do not exist will a person be entitled to cash benefits. Thus the program clearly favors service providers and limits the choice and self-determination of the disabled elderly and their relatives.

3. A refusal on the part of the consumer to accept available home-care services that have been designated by the local commit- tee may be considered unreasonable by the local committee and could affect the right to any future service.

4. The law enables various governmental agencies to finance ex- isting services with the resources of the LTCI; thus there is no real assurance that additional services will be created. It must be noted that in the demonstration phase of the law from 1986 to 1988, most of the allocated resources were in fact diverted to cover the cost of

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Ram A. Cnaan and Felice Davidson Perlrnurfer 117

existing services for the elderly, and not for community-based long- term-care needs, a serious distortion of the intent of the law (Kalderon, 1987; State of Israel, 1986).

5. The tax to cover the cost of this program is not limited to employee and employer contributions; the government contribution has been dropped. Furthermore the contribution of employees and employers is limited each to 0.1% of the employees' taxable in- come. Thus the total of 0.2% of employees' taxed income amounts is significantly less than originally intended by the Mann committee and prevents the program from fulfilling its obligations.

6 . In each local authority a committee is to be established to coordinate and enhance services for the eligible elderly. This committee will be in charge of evaluating needs, designing help', providing help, monitoring, and collecting data. Thus a new and somewhat extensive bureaucratic apparatus is being created and supported by the already scarce resources of LTCI.

7. Various ministries can use the resources of the LTCI for insti- tutional care. The law states that:

If in any fiscal year, the Ministry of Labor and Social Affairs or the Ministry of Health increased the number of persons cared for in nursing homes, the Institute shall finance the cur- rent maintenance of the number of persons added in that fiscal year in the said homes, provided that the total allocation in any fiscal year for each of those ministries not exceed 15% of the annual estimate of the collection of long term care insurance contributions for that year. (State of Israel, 1986)

It is clear that 'an innovative and progressive approach to long- term care for infirm old persons in the community was transformed into a minimal one, limited by the existing bureaucratic structures. Abramovice (1988) states that in long-term care a decision should be made as to whether services are to be client-oriented or self- serving for the professional network. It is our assessment that the 1986 law favors the latter position. However, there is a major re- deeming feature: the national public responsibility for long-term care based on social security has been established. It is hoped it will

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be extended in the future to include some of the features recom- mended by the Mann committee.

The Demonstration Phase

The 1986 LTCI Law established a demonstration mechanism prior to implementation. A two-year period, from 1986 to 1988, was to be devoted to demonstration; during this time four localities would provide the testing ground for carrying out all the procedures necessary for implementation, including the designation of the local committees, client assessment (both for eligibility and services), service provision, and evaluation.

The demonstration phase was designed to provide the local com- munities with adequate time and resources to determine how best to provide services to the eligible population (Cohen, 1987; Morgin- stin & Shamai, 1987). Numerous problems were encountered dur- ing this first phase. First, the four sites selected for the demonstra- tion were chosen for reasons of expediency; The local welfare departments were well orginized and could potentially deliver the product. Unfortunately the sites were not representative of localities throughout the nation. Second, the demonstrations were slow in getting started and consequently there was inadequate time to fully operationalize the program. Third, the late start prevented a mean- ingful evaluation from taking place.

The end result is that at the time full implementation on a national level was to begin there were no available demonstration findings upon which to base the full implementation strategy. Consequently, the program would be developed on a trial and error basis, with the frail elderly as the "guinea pigs."

Additional Dilemmas and Obstacles

This section will be devoted to a discussion of several other ma- jor obstacles related to the pending implementation of the Israeli LTCI law. The discussion will focus on administrative issues, legal accountability, and service and financial resource availability.

First, in the implementation of new social policies, it is important that there be an efficient, effective, and simple administrative struc- ture, as highlighted by Pressman and Wildavsky. Whereas the orig-

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Ram A. Cnaan and Felice Davidson Perlmutter 119

inal version of the law limited the bureaucratic apparatus to local ad hoc committees that were designed primarily to assess the level of functioning of the applicant, the final version added a larger, com- plex, and costly administrative structure consisting of both national and local committees (Cohen, 1987). The functions of the newly added national committees are to coordinate activities and set poli- cies; they are to be composed of representatives of all national agen- cies that provide services to the frail elderly, as well as representa- tives of the public at large.

The local committees' functions have been greatly expanded. Whereas the original intent was to have them deal primarily with eligibility determination, they now will have a variety of responsi- bilities including: reviewing requests, assessing level of function- ing, channeling care, supervising care, studying new needs, train- ing paraprofessionals, recruiting helpers, and coordinating with the National Insurance Institute (Cohen, 1987). Not only has the origi- nal three-person team been expanded to include a physician as a consultant, but other local agencies may also send their representa- tives to assist.

A second critical problem is that this new complex administration is not legally responsible for problems of implementation; accord- ing to the LTCI law, responsibility is lodged in the National Insur- ance Institute. Thus participation and cooperation at the local level is voluntary. However, the minister has established some adminis- trative regulations that are less powerful than the law, but are en- forceable. Of greatest importance is the regulation that if services are not made available to the eligible individual within a 60-day period, the National Insurance Institute will implement its ultimate responsibility through the provision of cash benefits. But there are no sanctions in case of delays by the local committees and it is the responsibility of the'beneficiary, or the local representative of the National Insurance Institute, to initiate cash benefits as a substitute for actual services.

Third, it is necessary to ensure some level of uniformity across localities in order to ensure equity of services as well as to be able to collect data for comparative evaluation. Since the core service will be in the hands of local committees, and since the law does not specify the structure or function of these local committees, all

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120 JOURNAL OF AGING & SOCL4L POLICY

will depend on each locality; variations will occur in response to the availability of local services (Morginstin & Shamai, 1987). Whether the actual organization will be tuned to the needs of the local frail elderly is yet to be seen. Past experience with such un- structured implementation of national policy in the social services has yielded an uneven, inefficient, and counterproductive service, unable to meet clients' needs (Cnaan, Kurazim, Meller, & Rosen- feld, in press). There is no reason to assume in this case that the results will be different.

Fourth, and of great importance, is the match between the con- sumer's needs and the services to be provided. Whereas cash bene- fits provide flexibility in service consumption, the final version of the law leaves the decision of what to provide in the hands of pro- fessionals. While professionals may be equipped to assess the needs and available services, the structure of the local committee creates a problem in that its members may have a vested interest in offering those services that their agencies provide at the expense of con- sumer preference and needs.

~ i f t h , since LTCI depends on the existence of adequate home- help and personal-care services in the community, a shortage of services will vitiate the intent of the law. Thus the insured person may be deprived of entitlement because of a lack of service avail- ability (Schnitt, 1987). Laor (1987) asserts that in order to cover the needs for home help alone there will be a need to expand services by 500%. This will clearly require an extensive effort in recruiting, training, and maintaining a pool of caregivers, not feasible in the Israeli context unless relatives will be paid for their support as in the United Kingdom. Consequently, many disabled old persons will not benefit from this law.

Finally, in implementing new social policies, securing adequate resources is crucial. The final version of LTCI not only excludes the government as a financial contributor to the program but also has lowered the contribution of employees and employers to less than half of the amount recommended by the Mann committee. Conse- quently, the money available for the program will be minimal. Mann (1987) concludes that the help that may be provided, based on the current minimal rate of contribution, will be severely limited

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Ram A. Cnoon and Felice Davidson Perlmutter 121

and will not cover even basic needs. Thus, while the intention is progressive, the actual impact of the law will at best be marginal.

It is clear that not only has the original policy intent articulated by the Mann committee been violated, but also the implementation of the final 1986 legislation has been distorted, as suggested by Press- man and Wildavsky, as follows: first, the complexity and length of the interactions is excessive; second, the organizational machinery necessary both to launch and to implement the program is inade- quate; and third, simplicity has been ignored "at the peril of break- down."

CONCLUSION

Marriane Weber said of her husband Max that "he was moved above all by the fact that on its earthly course an idea always and everywhere operates in opposition to its original meaning and thereby destroys itself" (Weber, 1975, p. 337). This statement can summarize the policy formulation process of LTCI in Israel. The LTCI in its original form was radical and hence bound to encounter political and administrative opposition.

The traditional approach to care for the frail elderly in the com- munity is to wait for the family to do all that it can; only when the family can no longer bear the burden does the public sector enter the picture (Shanas, 1976; Waerness, 1987). The alternative approach i s to assume societal responsibility for all disabled elderly and to help them regardless of their informal supports. While the latter approach may be costly and require massive outreach, it is also more equitable and more suitable for an insurance-based social pol- icy. Although in this case study this approach was postponed in favor of the more traditional one, the concept is now part of the legitimate public debate and can be resurfaced at any time in the future.

Israel's LTCI program merits further study in several critical areas: first, to what extent does the limited LTCI program actually help the disabled elderly; second, how effective, and efficient, is the actual administration of LTCI; third, to what extent has Israel's original and progressive LTCI policy been disseminated to other countries; and finally, what contributory arrangement should be re-

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quired, both in terms of the contributions as well as the amounts, to make the optimal LTCI social policy economically feasible?

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