From elderly care institutions to long-term care policy: Evolution of nursing homes in the United States and China

Background. This study investigates the evolution of nursing homes in the U.S. and China. Nursing homes are currently the sole type of institutions providing long-term care (LTC) for elderly in the both countries. With global population aging today, governments worldwide have begun to realize the severity of problems in their LTC system, particularly concerning nursing home access, cost and quality, which has become a salient public policy issue. Theory. Multiple theoretical frameworks have been applied---historical institutional theory, rational choice and organization theory. Together, it bases on the premise that institutions structure the distribution of power and resources in society and thus influence the strategies that various social groups adopt to pursue their interests, shape their goals and expectations, which helps to explain the LTC policy decisions. Research questions. (1) How were nursing homes created and transformed in the U.S. and China? (2) Why do nursing homes in both the U.S. and China generally perform ineffectively? (3) Do organizational structures affect nursing homes' effectiveness? Methodology. Both quantitative and qualitative research methods are employed---multiple regression analysis, cross-nation historical comparative analysis, survey, case study, and non-participant observation. Findings. (1) In both the studied countries, nursing homes were not originated from the social institutions providing services to elderly. The early U.S. nursing homes were created for housing poor, while the early Chinese nursing homes were created for serving privileged cadres. (2) Nursing home ineffectiveness is caused at least partially by lack of citizen participation---nursing home residents have not directly played any critical roles in decision-making process. (3) Based on the data of this study, nonprofit nursing homes in both the U.S. and China are performing more effectively than for-profit and/or government-owned counterparties. Conclusion. The creation of elderly nursing homes was stimulated by presented interests, needs and goals of active social groups. These groups are critical forces in shaping the LTC institutions and related policies. Thus, the key policy implication is that the efforts of improving LTC institution effectiveness that lacks institution member involvement will end up being ineffective, if not completely in vain.