The limits of consumer directed care as public policy in an aging society

This paper overviews the emergence of a philosophy of "consumer-direction" in personal, home, and community care for the disabled elderly in North Ame rica and Europe. Consumer direction is associated with direct payment schem es and other mechanisms that support user choices in the purchase of care, user empowerment and independence. To illustrate the strengths and limitati ons of consumer direction in practice, the paper analyses interview data co llected from users and providers of existing care arrangements where elders and families choose and/or hire, supervise, and manage their "own" homecar e workers who are self-employed. Interviews conducted separately with care users and providers illustrate how structural and interpersonal power relat ed to financial, social and geographic proximity affect the way independent care arrangements are established, and maintained. Power issues embedded i n marketized arrangements suggest the need for caution against wholesale ad option of market principles in social provisions for serving elders.