Skip to main content Accessibility help

The Limits of Consumer Directed Care as Public Policy in an Aging Society*

  • Sharon M. Keigher (a1)


This paper overviews the emergence of a philosophy of “consumer-direction” in personal, home, and community care for the disabled elderly in North America and Europe. Consumer direction is associated with direct payment schemes and other mechanisms that support user choices in the purchase of care, user empowerment and independence. To illustrate the strengths and limitations of consumer direction in practice, the paper analyses interview data collected from users and providers of existing care arrangements where elders and families choose and/or hire, supervise, and manage their “own” homecare workers who are self-employed. Interviews conducted separately with care users and providers illustrate how structural and interpersonal power related to financial, social and geographic proximity affect the way independent care arrangements are established, and maintained. Power issues embedded in marketized arrangements suggest the need for caution against wholesale adoption of market principles in social provisions for serving elders.

Cette communication porte sur l'émergence d'une philosophie «d'orientation du consommateur» dans les soins personnels, à domicile et communautaires offerts aux personnes âgées dépendantes en Amérique du Nord et en Europe. L'orientation du consommateur est associée au paiement direct et autres mécanismes qui appuient l'usager dans ses choix d'achat de soins, de prise en charge personnelle et d'indépendance. Pour illustrer les forces et les faiblesses de l'orientation du consommateur dans la pratique, les auteurs analysent des données d'entrevues menées auprès d'utilisateurs et de fournisseurs de soins dans lesquels les aîné(e)s et leurs familles ont choisi et/ou retenu, supervisé et géré leurs «propres» soignants à domicile, qui sont des travailleurs autonomes. Les entrevues, menées séparément avec les bénéficiaires et les fournisseurs de soins illustrent l'effet des pouvoirs structurels et interpersonnels reliés aux facteurs financiers, sociaux et géographiques sur la façon dont les arrangements de soins indépendants sont négociés et gérés. Les questions de pouvoir incluses dans les arrangements proposés suggèrent qu'il faut faire preuve de prudence devant l'adoption globale des principes du marché dans la provision de services de soins aux aînés.



Hide All
Adamek, M. (1991). Caregivers' views of disability allowances as a support for in-home care. Journal of Gerontological Social Work, 17(2/2), 121137.
Barnes, M. (1997). Care, communities, and citizens. Essex, England: Addison Wesley Longman Ltd.
Barnes, M., & Walker, A. (1996). Consumer vs. empowerment: a principled approach to the involvement of older service users. Policy & Politics, 24(4), 375393.
Barrows, R., & Loader, B. (Ed.) (1994). Towards a post-Fordist welfare state? London: Routledge.
Cranswick, K. (1997, winter). Canada's caregivers, Canadian Social Trends, #47.
Doty, P. (1986). Family care of the elderly: the role of public policy. The Milbank Quarterly, 64(64), 175.
Doty, P., Kasper, J., & Litvak, S. (1996). Consumer-directed models of personal care: Lessons from Medicaid. Milbank Quarterly, 74(3), 377409.
Doty, P., Stone, R., & Jackson, B. (1997). Beyond alternatives to institutionaliza-tion: “Negotiated choices.” Home Care Research Initiative, Robert Wood Johnson Foundation (Author).
Estes, C. & Swan, J., & Assoc. (1993). The long-term care crisis: Elders trapped in the no-care zone. Newberry Park, CA: Sage.
Evers, A. (1998). The new long-term care insurance program in Germany. Journal of Aging and Social Policy, 10(1), 7790.
Evers, A., & Leichsenring, K. (1994). Paying for informal care: An issue of growing importance. Aging International, 21(1), 2940.
Evers, A., Leichsenring, K., & Pruckner, B. (1994). Payments for care: the case of Austria. In Evers, A., Pijl, M., & Ungerson, C. (Eds.), Payment for care: A comparative overview (pp. 191214).
Evers, A., Pijl, M., & Ungerson, C. (1994). Payment for care: A comparative overview. Aldershot, England: Avebury.
Glendinning, C. (1997). Personal correspondence.
Grana, J., & Yamashiro, S.M. (1987). An evaluation of the VA housebound and Aid and Attendance Allowance Program. Millwood, VA: Center for Health Affairs, Project HOPE.
Hoch, C., & Slayton, R.A. (1989). New homeless and old: Community and the skid row hotel. Philadelphia: Temple University Press.
Hooyman, N., & Gonyea, J. (1995). Feminist perspectives on caregiving: Policies forgender justice. Thousand Oaks, CA: Sage.
Keefe, J. (1993). Direct payments to family care in Nova Scotia. Paper presented at Canadian Association on Aging, November, Montreal.
Keefe, J., & Fancey, P. (1997). Financial compensation or home help services: Examining differences among program recipients. Canadian Journal on Aging, 16(2), 254278.
Keefe, J.M., & Fancey, P.J. (1998). Financial compensation vs. community supports: An analysis of effects on caregivers and care receivers. Final Report to the Director of Research & Knowledge Synthesis, March 31. Health Canada, Ottowa.
Keigher, S. (1997, November). Austria's new attendance allowance: Prototype for a consumer choice model of care for the frail and disabled. International Journal of Health Services, 27(4), 753765.
Keigher, S., & Luz, C. (1997). Common stakes in homecare of the elderly: A pilot study of Milwaukee's gray market in independent care. The Helen Bader Foundation and the University of Wisconsin-Milwaukee School of Social Welfare. November.
Keigher, S., & Murphy, C. (1992, summer). A consumer view of a family care compensation program. Social Service Review, 66(2), 256277.
Keigher, S., Simon-Rusinowitz, L., Linsk, N., & Osterbusch. (1988). Payments to informal service providers: Policy divergence affecting the elderly and their families in Michigan and Illinois. Journal of Applied Gerontology, 7, 456473.
Linsk, N., Keigher, S., & Osterbusch, S. (1986) States policies regarding paid family caregiving. The Gerontologist, 28, 204212.
Linsk, N., Keigher, S., Simon-Rusinowitz, L., & England, S. (1992) Wages for caring: Compensating family care of the elderly. New York: Praeger.
Morris, J. (1993). Independent lives'? Community care and disabled people. London: Macmillan.
Morris, J. (1997). Care or empowerment? A disability rights perspective. Social Policy and Administration, 31(1), 5468.
National Center for Health Statistics (NCHS). (1994, June). Healthy people 2000 review 1993. Washington, DC: U.S. Department of Health & Human Services, Centers for Disease Control and Prevention.
NCOA. (1996, October). Survey of states shows consensus on consumer direction. Consumer Choice News, 1(3), 1, 6.
NCOA. (1997). California's public authorities: An emerging model from consumer-directed personal assistance services. Consumer Choice News, 2(2), 1, 6.
Ritzer, G. (1993). The McDonaldization of society. Thousand Oaks: Pine Forge Press.
Roeher Institute. (1997). Self-managed attendant services in Ontario: Direct funding pilot project. Final Evaluation Report, March. Toronto: Centre for Independent Living, Inc.
Stack, C. (1974). All our kin: Strategies for survival in a black community. New York: Harper & Row.
Statistics Canada. (1997, Aug. 19). Who cares? Caregiving in 1990s, 1996. The Daily, Statistics Canada, 56.
Stone, R., & Keigher, S. (1994). Toward an equitable, universal caregiver policy: The potential of financial supports for family caregivers. Journal of Aging and Social Policy, 6(1/2), 5775.
Strychman, J., & Nahmiash, D. (1994). Payments for care: The case of Canada. In Evers, A., Pijl, M., & Ungerson, C. (Eds.), Payments for care: A comparative overview (pp. 207319).
Twigg, J. (1997) Bathing and the politics of care. Social Policy and Administration, 31(1), 6172.
Ungerson, C. (1997a). Social politics & the commodification of care. Social Politics, 4(4), 3381.
Ungerson, C. (1997b). ‘Give them the money’: Is cash a route to empowerment? Social Policy and Administration, 31(1), 4553.
Vinton, L., & Kim, Y. (1996). Paying family members to provide home care: an evaluation of one program. Journal of Case Management, 5(3), 99105.


The Limits of Consumer Directed Care as Public Policy in an Aging Society*

  • Sharon M. Keigher (a1)


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed