A discussion between Generations Journal Guest Editor Rich Browdie, Robert Blancato, president of Matz, Blancato and Associates in Washington, DC, and Meredith Ponder Whitmire, vice president of Matz, Blancato, on how advocacy challenges around the Older Americans Act are evolving.
Aging Network, Medicare, Medicaid, nutrition, elder justice
Many people involved in services to older adults see the Older Americans Act (OAA) as something of a sideshow, perhaps no longer relevant. Others with longer experience as a part of the Aging Network believe that the OAA has been allowed to languish, as national organizations representing various provider and consumer interests chase the money.
A pair of experienced advocates—Robert Blancato and Meredith Ponder Whitmire—well-known for their effectiveness across a range of issues impacting older Americans beyond the OAA, agreed to a brief round of questions with Winter Generations Guest Editor Rich Browdie on how the advocacy challenges are evolving.
Rich Browdie (RB): Among other things, the OAA was intended to establish the Aging Network. Despite the many differences one sees state-to-state and community-to-community, the OAA has been pretty successful in establishing a national support system for older Americans. And the Network, with all of its variety, enjoys popular support among older Americans who have contact with it. At the same time, money to provide services under Medicaid and now Medicare is expanding rapidly, and specialized policy issues get pursued under other legislative arenas. Nutrition and Elder Justice come to mind.
RB: How does an advocate for serving older Americans in the community approach this multitracked requirement? Do you have to sacrifice one issue for another?
Meredith Ponder Whitmire (MPW): I don’t think it’s about sacrificing one issue for another. The broadening of avenues and means to serve older adults in the community, such as through Elder Justice Act funding, Medicaid home- and community-based services, and Medicare Advantage benefits, is really to our advantage as advocates. OAA funding has effectively shrunk over time due to inflation and increased demand on systems; any additional funding for providers that we can advocate for is appreciated!
Communication between the provider sector and the Aging Network needs to continue to improve.
The real issue is ensuring that connections are made for policymakers as to how all of these programs intertwine to serve older adults in their homes and communities. This plethora of programming has quickly become necessary and desired by older adults. Our other main challenge is ensuring that coordination continues to happen among providers receiving various (and often multiple) funding streams.
Robert (Bob) Blancato (BB): I generally agree. It is also about the Aging Network becoming better at business acumen to be able to compete for different contracts. Communication between the provider sector and the Aging Network needs to continue to improve. The network and its services are a built-in and established entity, and they also have the key benefit of having the trust of older adults and their families.
It is also about having a stronger Administration for Community Living (ACL), which is the agency created to promote community living for older adults and persons with disabilities. This is the direction some of the newer services under Medicare Advantage are going and certainly, should the Build Back Better Act pass, we could see an historic infusion of new funds for home- and community-based services for older adults and persons with disabilities.
RB: This seems to mean that building the Aging Network requires an increased awareness on the part of state and local advocates about how the avenues being pursued relate to one another, and to assure that to the extent possible, they can provide synergies at the state and local level. You both are saying indirectly that given the diversity in the ways Congress and various administrations have chosen to authorize and fund things, relying on the OAA for growth to support the range of things needed by a growing older population is not very likely. That makes it more complicated, but it reflects how the federal government and Congress thinks.
RB: Legislative advocacy in the Aging space in Washington has always been about making alliances. Has that become harder or easier over time as the service world has expanded and evolved?
MPW: I personally feel that alliance-building has become a little easier over time. As an example, despite conflicting feelings that some have had over the formation of the ACL, it has provided a good starting point for the aging and disability networks to work together to provide care for populations that overlap in very significant ways.
Further, the continued rise of issue-specific coalitions in Washington (including coalitions on elder justice, malnutrition, social isolation, direct care workers, Medicare Part D, and transportation, to name a few) has made it easier for disparate organizations working on the same issues to find each other, learn from other organizations’ work, and come together to advocate for legislative and regulatory improvements in their specialty area.
Larger coalitions like the Leadership Council of Aging Organizations (LCAO), the Coalition on Human Needs, and the Consortium of Citizens with Disabilities (CCD) also are great places to network and collaborate—and as the service world continues to evolve, I hope that the “new players” in this space will work with existing groups in this manner as well.
BB: A formed alliance and an effective alliance are two different things. Coalitions and alliances are formed regularly. Some have been established for some time. No question they are important vehicles for collaboration, but effectiveness can deteriorate if either individual parochial interests come into play or the collaboration is not a central part of the leadership structure of a coalition. Also, the size of a coalition or alliance is important. If it is too big it cannot be nimble when it needs to respond quickly.
The OAA is a flexible law with forward-thinking provisions that enable local programs to evolve with the times.
RB: Advocates at all levels of government have had more experience working with actors that historically had stuck to other “lanes,” which reflects the points made above. At the same time, there are issues where the members of a coalition on one topic cannot agree on another. This introduces a tactical consideration to the pursuit of advocacy of which advocacy leaders need to be mindful. Sometimes, all it takes to make an opposing point of view successful is to slow things down. A contentious issue might be subordinated to another or sacrificed to maintain a larger alliance. That might add to the need for other more narrowly focused coalitions.
RB: Given the growing emphasis on “coordinating” health services with non-medical services in the community under Medicare- and Medicaid-financed health insurance systems, what do you see as the role of the OAA in the evolving federal response to our aging society?
MPW: I see OAA programs and services like home-delivered meals programs, non-medical transportation, and caregiver respite as the true bridge to provide this “coordination.” I believe that local OAA programs are the backbone of community-based non-medical services. I think federally funded health insurance and other healthcare systems are starting to recognize this, as evidenced by the growing numbers of OAA-funded programs that also contract with these healthcare systems and providers to provide non-medical services. I think that there is more awareness-raising needed for these healthcare entities about the value of locally based OAA services; in my experience, OAA programs and services can sometimes be excluded from the conversations that are taking place at the Centers for Medicare & Medicaid Services and other federal agencies outside ACL.
BB: Again, I generally agree and covered some of this in my answer to the first question. One point I would emphasize—there needs to be greater recognition of the policy and political importance of ACL in the Health and Human Services structure. External influence is enhanced when there is recognized internal influence. One step worth considering would be to have ACL be established and expanded through legislation and have it more accurately reflect its roles and responsibilities.
RB: I might have a few concerns about how haphazard the system is when you look across the country. I agree that the Aging Network under the guidance of the OAA has an increasingly important role to play as a lynchpin between healthcare service providers and responses to community needs. But virtually all aspects of healthcare systems in this country are left to choose how they will coordinate, if they choose to coordinate.
Social services, on the other hand, are dominated by state policy makers. Many states simply defer to Medicaid policy makers because they have the money and contract out the integration of healthcare and social services to Managed Care Organizations, most of which are profit-making organizations, multiplying the number of entities making decisions. On top of that, Medicaid agencies and managed care companies have the least experience of all in coordinating and managing social services. Assuring quality and coverage gets harder, and the checks and balances that have always tethered services in the Aging Network to local realities are fundamentally weakened. If the goal of the OAA is to assure supports for older people across the country, the goal may be getting harder to achieve.
RB: Do you see the OAA as still being fundamental and central to America’s response to the needs of its older citizens, or do you see it as having played its role legislatively?
MPW: I think the OAA remains fundamental, even though other, newer programs and entities might be trendier now. The OAA has been in place for over 50 years—it is the original version of these newer programs. But, despite its lengthy history, I think it is a very flexible law that has forward-thinking provisions which enable local programs to continue to evolve with the times. The need for reauthorizations of the Act every few years helps with this too, as new provisions and programs are added every time that bring the law up to speed with modern needs. In other words, let’s not be ageist about the OAA!
BB: I agree generally. The OAA is still unique with its stated intent to maintain the independence and dignity of older Americans in their communities and at home. The other two programs enacted the same year as the OAA, namely Medicare and Medicaid, now have a greater emphasis on home- and community-based care than when they first started, especially Medicaid. The OAA fulfills its role on the ground more than a lot of federal programs. You can see tangible services like nutrition and transportation being provided. It also remains the only federal program providing help to family caregivers. Its fundamental role could be enhanced with resources commensurate with its potential to reach even more older adults.
The OAA could also be a new model of a program committed to equity in how it does its outreach within communities, both in terms of new participants but also in making sure that existing participants are provided services reflective of racial and ethnic backgrounds. Those in Congress over the OAA’s 56-year history have done great work over its more than 15 reauthorizations. The tremendous funding provided in the four COVID emergency bills were a great recognition of the value of OAA programs, and it should build on this for the future.
RB: I would only add that the OAA’s importance is growing, even as the other programs grow in spending and coverage. Only one in ten Older Americans are eligible for Medicaid at any point in time. Impoverishing more older people as a strategy to finance their growing numbers in the community seems unfair and unsustainable. I would also argue that while the services for disabled older people and disabled younger adults overlap in many ways, they are distinct in others, and the needs of older Americans who are not yet severely disabled need to be better addressed to avoid accelerating even more extensive needs. The focus of the OAA on the needs presented by an aging America should not be sacrificed to the urge to follow the money. We need the OAA to focus on the big picture of an aging America.