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New York, London, Paris, and Tokyo are the four largest cities among the wealthiest, most developed nations of the world. The essays commissioned for this volume compare what it is like to grow older in these cities with respect to health care, quality of life, housing, and long-term care. The contributors look beyond aggregate national data to highlight the importance of how local authorities implement policies.

A comparative analysis of both formal and informal long-term care in ten of the world’s wealthiest countries.

Nations throughout the world are in the midst of an enormous demographic transition, with life expectancy increasing and fertility falling, leading to a rapidly aging population and critical implications for long-term care around the world. This volume documents and compares long-term care programs in ten wealthy countries.

Analyses of survey data and government statistics show that the costs of long-term care are beyond the financial means of a large fraction of the elderly population in most countries, particularly the oldest and most disabled. As a result, public systems bear most of the cost of formal long-term care, such as care in an institution or paid home care. Most countries spend more on nursing homes than on home care, but this relationship varies widely as does the mix of care needs and resources used to define eligibility for public funding. At the same time, most care is provided informally through family or unpaid caregivers. The costs of informal care, including the foregone earnings of caregivers, are estimated to account for at least one-third of all long-term care spending in every country. Thus, any estimate of the social costs of long-term care must account for the implicit costs of informal care.

In Reinventing Care, David Barton Smith offers brilliant insights into those questions by examining the realities of assisted living in New York City. Encompassing the largest, most concentrated population of elderly in the United States, New York spends more per person caring for its seniors than any other urban center. Yet, while the size of the city's care system boggles the mind, it nevertheless contains the same elements that exist in other metropolitan areas and thus provides valuable lessons for the nation as a whole.

Smith's study draws on twenty-five years of research, including hundreds of interviews and visits to representative facilities. He provides a succinct overview of how care is presently organized for New York's aging population and traces the history of the system up to the present. Among the key issues he addresses are the role of market forces and government regulation, the impact of class differences on access to quality care, and the ways in which perceptions of community affect the creation and management of assisted living programs. At the heart of the book are ten fascinating case studies, half of them focused on private-pay facilities and the other half on public-pay institutions.

While finding that the actualities of assisted living rarely match the rhetoric of its proponents, Smith sees much to admire in its goals. He suggests tactics and strategies--such as promoting family- and community-based models of assisted living and adopting a standard of licensure for certain facilities--that could point the way to a better future.