This chapter examines the history of long-term services and supports (LTSS) programs to document their racially and ethnically disparate impact, and explain the current research on the access and quality of LTSS used by older adults in communities of color. LTSS are a set of health and social services delivered over a sustained period to people who have lost or never acquired some capacity for personal care. The high costs of LTSS have led a smaller number of low-income older adults to consume a large share of Medicaid expenditures. Cultural beliefs about family responsibility to care for older adults as well as attitudes toward the use of formal and/or public health and long-term care services can shape older adults’ use of LTSS. The coming sociodemographic shift of older minority adults calls attention to other structural and cultural issues that facilitate or inhibit the appropriate use of LTSS.

Rehabilitation counseling has evolved from its inception in federal legislation in the early 1900s to its current recognition as a specialization of the counseling profession. An initial focus on case management served a constructive purpose during the early years, given the historic link of rehabilitation counseling to the state-federal vocational rehabilitation (VR) system. A psychiatric disability is when an individual with a serious mental illness is unable to perform major life activities in particular life contexts, such as community participation, and independent living. Credentialing has defined and regulated the professional practice of rehabilitation counseling in recent years. The professional identity of a rehabilitation counselor (RC) as a counselor has had wide formal endorsement by the major professional organizations and leaders in the field. Counselor licensure laws emerged because of regulations by Medicare and Medicaid as well as private health insurance that required licensure for the reimbursement of mental health services.

Public policy bearing the labels of elder rights and elder justice is scant and only recently appeared on the scene. The terms “elder rights” and “elder justice” have been largely appropriated by the field of elder abuse, which has applied them narrowly to policies and programs that address elder and dependent adult abuse and mistreatment. But “aging policy” in the United States is grounded in social justice principles and goals. This explains how Social Security, Medicare, Medicaid, Supplemental Security, the Older Americans Act, and the Elder Justice Act have advanced individual rights and social justice. It also explores how discrimination against older people has been addressed, explicitly, through measures like the Age Discrimination in Employment Act, and by policies that protect older people as members of other groups. This includes laws and regulations that protect people with disabilities, residents of institutions, consumers, crime victims, prison inmates, and others.

Health promotion, exercise, and the need to focus on these to enhance a healthy long life are discussed. Identification of significant areas of health promotion and barriers to achieving good health are presented. Next, disease prevention along with primary, secondary, tertiary, and quaternary preventive measures are listed. Healthy People 2030, the fifth national health initiative, and its objectives are outlined along with the Patient Protection and Affordable Care Act. Exercise, its meaning, and value in modifying age-related changes are briefed. Types of exercise programs; isometric, isotonic, and aerobic and their recommended use by older adults are listed.

The older adults most at risk for poverty are those who have experienced cumulative disadvantage as a result of low education attainment, entering the workforce for the first time during an economic recession, health problems that limit their ability to work over long periods of time, and involve extraordinary expenses for either themselves or family members and other vagaries of life. This chapter reviews the social insurance programs that support older Americans, poverty rates, modern retirement compared to “old-fashioned retirement”, gender differences, income equality, and the broad reach of Social Security. It also covers the mechanics of Medicare and Medicaid. There are three Voices in the chapter. One addresses the “comfortable retirement” and its differential meaning and possibility, another focuses on women 50 and over, and the final Perspective piece covers the broad reach of Social Security and its importance to families of all ages.

Medicare and Medicaid are often confused with each other, likely due to their similar names. Older adults can benefit from both Medicare and Medicaid, if they meet the respective eligibility requirements of each program, in which case they are deemed dual-eligible beneficiaries. Although both programs relate to healthcare services, they are distinct programs. Medications play an essential role in the health of older adults. “Geriatric health care professionals and their patients rely heavily on pharmacotherapy to cure or manage diseases, palliate symptoms, improve functional status and quality of life, and potentially prolong survival.” This chapter outlines the various components of the Medicare and Medicaid programs. It describes some of the medication-related problems older adults experience and offers insights into how to avoid them. Managing multiple medications is particularly challenging for older adults; it is, therefore, the focus of the Practical Application presented at the end of the chapter.

Long-term care involves the financing and delivery of an array of health and social services to the aged and disabled. In contrast to acute care, which is disease based and curative in orientation, the orientation of long-term care is inherently holistic and function based. The scope of long-term care policies and services thus encompasses the aged, the developmentally disabled, the chronically ill, and persons disabled by trauma. Although both the biological and demographic realities of an aging population and principles of intergenerational justice should propel us toward a feasible approach to the long-term care insurance (whether in the form of social insurance, a normative shift toward the broadscale investments in private long-term care insurance that will reduce the growth of Medicaid long-term care expenditures), the political path to a coherent and effective national long-term care financing strategy remains elusive.

There is no paradox that equals that found in the system of health care finance in the United States. The purpose of this chapter is to provide the reader with a general understanding of the dynamics of this paradox, its origins, and the ways in which it is sustained. To accomplish this, the chapter reviews the system of health care finance in the United States, both in terms of its current organization and in the evolvement of its unique structure. The topics include the magnitude and distribution of health care expenditures in the United States, the relative contributions of government and private sector forms of insurance, the fundamentals of risk and insurance, alternative models of health insurance finance and provider structures, and a detailed description of Medicare, Medicaid, and more recent policy initiatives in the public financing of health care.

The focus of all good care is to determine need. Long-term care (LTC) is not an extension of acute care—it is distinctive in its very nature. Because LTC continues for prolonged periods, it becomes enmeshed in the very fabric of people’s lives. Screening for LTC is one way in which the federal government and, in particular, a state attempts to eliminate unnecessary or premature placement of older or disabled individuals in nursing homes. There are two types of screening: those for a level of care (LOC) involving just medical need and those that address additional factors of care need, which assess issues such as mental illness, development disabilities, and intellectual disabilities. The determination of LOC addresses whether the individual’s care needs meet criteria for a stay in a nursing facility long term. This chapter provides an overview of long-term care screenings and how the Omnibus Budget Reconciliation Act (OBRA) has and continues to impact this process.