Aged care financing is a vexed problem for the Australian government. It is already underfunded for the quality the community expects, and costs will increase dramatically. There are also significant concerns about the complexity of the system.

In 2021–22 the federal government spent A$25 billion on aged services for around 1.2 million people aged 65 and over. Around 60% went to residential care (190,000 people) and one-third to home care (one million people).

The final report from the government’s Aged Care Taskforce, which has been reviewing funding options, estimates the number of people who will need services is likely to grow to more than two million over the next 20 years. Costs are therefore likely to more than double.

The taskforce has considered what aged care services are reasonable and necessary and made recommendations to the government about how they can be paid for. This includes getting aged care users to pay for more of their care.

But rather than recommending an alternative financing arrangement that will safeguard Australians’ aged care services into the future, the taskforce largely recommends tidying up existing arrangements and keeping the status quo.

No Medicare-style levy

The taskforce rejected the aged care royal commission’s recommendation to introduce a levy to meet aged care cost increases. A 1% levy, similar to the Medicare levy, could have raised around $8 billion a year.

The taskforce failed to consider the mix of taxation, personal contributions and social insurance which are commonly used to fund aged care systems internationally. The Japanese system, for example, is financed by long-term insurance paid by those aged 40 and over, plus general taxation and a small copayment.

Instead, the taskforce puts forward a simple, pragmatic argument that older people are becoming wealthier through superannuation, there is a cost of living crisis for younger people and therefore older people should be required to pay more of their aged care costs.

Separating care from other services

In deciding what older people should pay more for, the taskforce divided services into care, everyday living and accommodation.

The taskforce thought the most important services were clinical services (including nursing and allied health) and these should be the main responsibility of government funding. Personal care, including showering and dressing were seen as a middle tier that is likely to attract some co-payment, despite these services often being necessary to maintain independence.

The task force recommended the costs for everyday living (such as food and utilities) and accommodation expenses (such as rent) should increasingly be a personal responsibility.

Making the system fairer

The taskforce thought it was unfair people in residential care were making substantial contributions for their everyday living expenses (about 25%) and those receiving home care weren’t (about 5%). This is, in part, because home care has always had a muddled set of rules about user co-payments.

But the taskforce provided no analysis of accommodation costs (such as utilities and maintenance) people meet at home compared with residential care.

To address the inefficiencies of upfront daily fees for packages, the taskforce recommends means testing co-payments for home care packages and basing them on the actual level of service users receive for everyday support (for food, cleaning, and so on) and to a lesser extent for support to maintain independence.

It is unclear whether clinical and personal care costs and user contributions will be treated the same for residential and home care.

Making residential aged care sustainable

The taskforce was concerned residential care operators were losing $4 per resident day on “hotel” (accommodation services) and everyday living costs.

The taskforce recommends means tested user contributions for room services and everyday living costs be increased.

It also recommends that wealthier older people be given more choice by allowing them to pay more (per resident day) for better amenities. This would allow providers to fully meet the cost of these services.

Effectively, this means daily living charges for residents are too low and inflexible and that fees would go up, although the taskforce was clear that low-income residents should be protected.

Moving from buying to renting rooms

Currently older people who need residential care have a choice of making a refundable up-front payment for their room or to pay rent to offset the loans providers take out to build facilities. Providers raise capital to build aged care facilities through equity or loan financing.

However, the taskforce did not consider the overall efficiency of the private capital market for financing aged care or alternative solutions.

Instead, it recommended capital contributions be streamlined and simplified by phasing out up-front payments and focusing on rental contributions. This echoes the royal commission, which found rent to be a more efficient and less risky method of financing capital for aged care in private capital markets.

It’s likely that in a decade or so, once the new home care arrangements are in place, there will be proportionally fewer older people in residential aged care. Those who do go are likely to be more disabled and have greater care needs. And those with more money will pay more for their accommodation and everyday living arrangements. But they may have more choice too.

Although the federal government has ruled out an aged care levy and changes to assets test on the family home, it has yet to respond to the majority of the recommendations. But given the aged care minister chaired the taskforce, it’s likely to provide a good indication of current thinking.

Hal Swerissen, Emeritus Professor, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

We’ve come a long way in terms of understanding that everyone thinks, interacts and experiences the world differently. In the past, autistic people, people with attention deficit hyperactive disorder (ADHD) and other profiles were categorised by what they struggled with or couldn’t do.

The concept of neurodiversity, developed by autistic activists in the 1990s, is an emerging area. It promotes the idea that different brains (“neurotypes”) are part of the natural variation of being human – just like “biodiversity” – and they are vital for our survival.

This idea is now being applied to research and to care. At the heart of the National Autism Strategy, currently in development, is neurodiversity-affirming (neuroaffirming) care and practice. But what does this look like?

Reframing differences

Neurodiversity challenges the traditional medical model of disability, which views neurological differences solely through a lens of deficits and disorders to be treated or cured.

Instead, it reframes it as a different, and equally valuable, way of experiencing and navigating the world. It emphasises the need for brains that are different from what society considers “neurotypical”, based on averages and expectations. The term “neurodivergent” is applied to Autistic people, those with ADHD, dyslexia and other profiles.

Neuroaffirming care can take many forms depending on each person’s needs and context. It involves accepting and valuing different ways of thinking, learning and experiencing the world. Rather than trying to “fix” or change neurodivergent people to fit into a narrow idea of what’s considered “normal” or “better”, neuroaffirming care takes a person-centered, strengths-based approach. It aims to empower and support unique needs and strengths.

Adaptation and strengths

Drawing on the social model of disability, neuroaffirming care acknowledges there is often disability associated with being different, especially in a world not designed for neurodivergent people. This shift focuses away from the person having to adapt towards improving the person-environment fit.

This can include providing accommodations and adapting environments to make them more accessible. More importantly, it promotes “thriving” through greater participation in society and meaningful activities.

At school, at work, in clinic

In educational settings, this might involve using universal design for learning that benefits all learners.

For example, using systematic synthetic phonics to teach reading and spelling for students with dyslexia can benefit all students. It also could mean incorporating augmentative and alternative communication, such as speech-generating devices, into the classroom.

Teachers might allow extra time for tasks, or allow stimming (repetitive movements or noises) for self-regulation and breaks when needed.

In therapy settings, neuroaffirming care may mean a therapist grows their understanding of autistic culture and learns about how positive social identity can impact self-esteem and wellbeing.

They may make efforts to bridge the gap in communication between different neurotypes, known as the double empathy problem. For example, the therapist may avoid relying on body language or facial expressions (often different in autistic people) to interpret how a client is feeling, instead of listening carefully to what the client says.

Affirming therapy approaches with children involve “tuning into” their preferred way of communicating, playing and engaging. This can bring meaningful connection rather than compliance to “neurotypical” ways of playing and relating.

In workplaces, it can involve flexible working arrangements (hours, patterns and locations), allowing different modes of communication (such as written rather than phone calls) and low-sensory workspaces (for example, low-lighting, low-noise office spaces).

In public spaces, it can look like providing a “sensory space”, such as at large concerts, where neurodivergent people can take a break and self-regulate if needed. And staff can be trained to recognise, better understand and assist with hidden disabilities.

Combining lived experience and good practice

Care is neuroaffirmative when it centres “lived experience” in its design and delivery, and positions people with disability as experts.

As a result of being “different”, people in the neurodivergent community experience high rates of bullying and abuse. So neuroaffirming care should be combined with a trauma-informed approach, which acknowledges the need to understand a person’s life experiences to provide effective care.

Culturally responsive care acknowledges limited access to support for culturally and racially marginalised Autistic people and higher rates of LGBTQIA+ identification in the neurodivergent community.

Authentic selves

The draft National Autism Strategy promotes awareness that our population is neurodiverse. It hopes to foster a more inclusive and understanding society.

It emphasises the societal and public health responsibilities for supporting neurodivergent people via public education, training, policy and legislation. By providing spaces and places where neurodivergent people can be their authentic, unmasked selves, we are laying the foundations for feeling seen, valued, safe and, ultimately, happy and thriving.

The author would like to acknowledge the assistance of psychologist Victoria Gottliebsen in drafting this article. Victoria is a member of the Oversight Council for the National Autism Strategy.

Josephine Barbaro, Associate Professor, Principal Research Fellow, Psychologist, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.