Large numbers of baby boomers and a shift towards home-based long-term care designate a need for a greater understanding of caregiver attitudes surrounding the financing of long-term home-based care. This study examined more fully the types of home-based long-term care services that family caregivers were utilizing for their parents. In addition, the willingness and ability of caregivers to privately fund these services for aging parents were explored. The study utilized a preexisting data set of qualitative interviews that were conducted with 30 family caregivers helping to provide long-term care for an elderly parent or older-generation relative. Participants in the sample used many home- and community-based services such as home health aides and nurses, physical therapists, cleaning services and adult day centers. Often these services were funded via Medicare, Medicaid, care recipient funds, state programs, and caregiver funds. In addition, caregivers were often willing, but unable to pay for long-term parent care on their own. Many caregivers in the study found paying for long-term parent care unnecessary. Family expectations, moral and religious responsibility, and a high aversion to nursing home care were cited as reasons for willingness to fund long-term care at home. Similarly, lack of family support and other personal obstacles were noted as reasons for inability to pay for care. Those who found payment for care unnecessary noted that care recipients had sufficient funds for their own long-term care.

This thesis seeks to contribute to the knowledge base about social policy in the United States, using long-term care (LTC) financing policy reform as an illustrative example. Specifically, this thesis explores LTC financing reform efforts during three U.S. Presidential administrations: Bill Clinton (1993-2001), George W. Bush (2001-2009), and Barack Obama (2009-2010). Within this historical framework, the LTC provisions of the Health Security Act of 1993, the development of the Community Living Assistant Services and Supports or 'CLASS' Act during the Bush Administration, and the legislative success of the CLASS Act as a part of the Patient Protection and Affordable Care Act of 2010 provide comparable cases to compare the drivers of social policy. Drawing on the explanatory frameworks of the welfare state such as ideology, historical institutionalism, and an actor-centered approach to policy analysis, this thesis argues that successful path-departing legislation is difficult to achieve due, in part, to the presumed high costs of social programs and the complex institutional framework of the American political system. Policy outcomes result from the interaction between the complex processes and dynamics of the political system through which policy change (or the failure to change) actually occurs. The fact that the CLASS Act was politically successful, yet administratively inoperable as designed, reinforces the argument that social policy outcomes in the United States are reflective of a complex, enduring struggle of competing ideologies. This continual struggle, coupled with a heightened concern over cost control and fiscal austerity, helps to ensure that policies which are legislatively successful within the institutional architecture of the American political system are unlikely to produce major expansions of the welfare state. Social change is therefore highly difficult to achieve, even in the face of significant unmet social needs. Comprehensive reform of U.S. LTC financing arrangements will remain an elusive goal for the foreseeable future. Instead, incremental, highly pro-market solutions are likely to be the types of policies promoted in the years of ahead.