Abstract:
The Older Americans Act’s (OAA) impending age of eligibility is a good time to review accomplishments and opportunities for improvement. The OAA is celebrated for bringing social care for older people to the forefront of U.S. aging policy and programs. But critiques say it has not kept pace with dramatic demographic, economic, and social changes during the almost 60 years since its passage. Older adults and their caregivers still need supports and services, yet these fall short, contributing to increasing vulnerability and ever-increasing investments in health and long-term services. This article examines the background of the OAA, its accomplishments, its failures, and aspirations for the future.
Keywords:
Home- and community-based services, policy, integrated care, OAA reauthorization, aging
As the population ages 65 and older, particularly those ages 85 and older, continues to increase dramatically, policy makers and practitioners need to shift strategies to ensure the necessary services and assistance are available in the future. Despite the importance of the Older Americans Act (OAA) as the first federal social care initiative targeted to serve older people, the program has not kept pace with the realities of aging in America. The OAA initial and subsequent legislation created a nationwide infrastructure of state and local agencies aimed at promoting the independence of older Americans.
Prior to its initial passage, nearly 30% of older Americans were socially and economically impoverished, with limited access to essential home- and community-based support (Achenbaum & Carr, 2014; U.S. Bureau of the Census, Current Population Survey, & Annual Social and Economic Supplements, 2017). In many ways, the challenges faced and the resources available have changed significantly over the six decades since the act was passed, but it is our contention that the OAA needs to continue to create a better social care system to complement the heavy investment in acute healthcare and medicalized long-term care that is so dominant in the United States.
The OAA, through its many reauthorizations, has changed its focus and funding priorities due to a number of social and economic factors. The earlier years of the OAA have been classified as a life-enhancing or an age-mitigating phase of the act (Applebaum & Kunkel, 2018) with a focus on age, as the primary eligibility criterion, to provide needed access to social, economic, housing, and health-related supports and services. Fostering adequate retirement income and promoting the notion of retiring with dignity, maximizing physical and mental health, providing suitable housing, offering restorative services, delivering employment opportunities, providing meaningful and productive activities (e.g., senior centers) and efficient community services, benefitting from research, and nurturing independence in managing one’s own life were all notable elements of the OAA during its earliest phase.
Services of that era included an emphasis on congregate meals, activities at senior centers, and senior employment. Additional services, such as transportation and home-delivered meals, were included at the latter stages of this initial phase. The emphasis of the OAA, during this early phase, was on aging in place and productive aging.
The second stage of OAA development saw a shift into a “vulnerability-mitigating” phase, with this juncture of the OAA spanning the 1980s (Applebaum & Kunkel, 2018). The act moved away from a universal focus on aging to an emphasis on providing supports and services to individuals with high need. During this time, the Home and Community-Based Services (HCBS) Medicaid Waiver Program was passed, shifting the spotlight to those most vulnerable. Reauthorization of services included in-home services designed with an emphasis on independence enhancement and avoidance of institutionalization.
‘Access and assistance with technology will be critical to the lives of older people.’
A third phase of the OAA, spanning from 1990s to modern day, is significant for its encapsulation of a care-integrating and management of chronic disabilities scope (Applebaum & Kunkel, 2018). During this time, the HCBS system was expanded, with financial management occurring in concert with other funding for healthcare services under Medicaid and/or Medicare. Care and coordination of services for vulnerable individuals living with chronic disability were at the forefront of policy and services delivery. A notable action during this phase of the OAA was the switch in the provider delivery system, including a dramatic expansion of proprietary providers in direct care and in the service management and coordination arena.
Building on the three time periods described in the model above, new work proposes that area agencies on aging (AAAs) are now entering a fourth phase called technology integrating (Gallo & Wilbur, 2021). Building on the earlier model (Applebaum & Kunkel, 2018), the authors argue that access and assistance with technology will be critical to the lives of older people. Whether it involves telehealth, medical appointment scheduling, or social interactions to address loneliness, the additional phase is anticipated to help elders bridge the technology gap, especially for very old and low-income individuals, suggesting that this function will be a critical role for AAAs in the future.
Social Care Under the OAA
One of the key components of the OAA has been the response by policymakers regarding the needed social care for a growing population of elders. The act created a vast aging network system of service programs through a national network of state AAAs, service providers, and tribal organizations. More than 11 million older adults and their family and friend caregivers rely upon services provided through the OAA (National Council on Aging [NCOA], 2020).
Support services through the OAA, including congregate and home-delivered meals, home care, adult day services, transportation, and caregiver supports in 2016 helped about 3 million people on a regular basis, with an additional 8 million older adults and their caregivers reporting receipt of services on a less-than-regular-basis (U.S. Department of Health and Human Services [HHS], Administration for Community Living [ACL], 2016). These numbers point to the real and needed benefits of this program. For example, more than 40% of federal OAA allocation supports meals, including congregate, home-delivered, and nutrition services. Tracking data reported that these meal services prevented 42% of congregate meal participants and 61% of home-delivered meal participants from skipping meals or eating less (National Center on Nutrition and Aging, 2017).
While the OAA has provided supportive services that have allowed older adults to age in place, reliance upon family and friend caregivers has remained a critical component of helping older people remain in the community. The National Family Caregiver Support Program was established in 2000 through the reauthorization and expansion of the OAA. To assist family and friend caregivers, a range of supports including information and referral, counseling, respite care, support groups, training, and supplemental services were introduced. However, the $181 million appropriated for family caregiver supports is a small fraction of the unpaid care they provide, estimated at $470 billion in 2013 (Reinhard et al., 2015), which is less than 1/25th of 1 percent (Ujvari et al., 2019).
The OAA social care services for older adults are critical, but the legislation is not without its faults. While federal funding for OAA services was $2.06 billion in FY 2019 (Colello & Napili, 2018), this is a mere fraction of the allocated long-term services and supports (LTSS) funds, estimated at $167 billion, through Medicaid (Eiken et al., 2018). Despite its reauthorization in 2020, the OAA has failed to keep up with inflation or the sheer growth in the number of older adults in need (Congressional Research Services, 2018).
OAA funding has increased 1.1% annually on average from FY 2001 to FY 2019 (from $1.68 billion in FY 2001 to $2.06 billion in FY 2019; Ujvari et al., 2019). The real reduction in funding is dramatic in looking at the 1980 OAA allocation of $1 billion, which in today’s dollars would be $3.41 billion when adjusted for inflation. Additionally, the larger 1980 allocation served a population of 36 million older people, compared to the $2.1 billion allocation today, currently covering 70 million elders (Applebaum & Heston-Mullins, 2020). The only significant increase in funding was the one-time funding allocations for the recent CARES response to COVID-19 (HHS, 2020).
‘The OAA has failed to keep up with inflation or the sheer growth in the number of older adults in need.’
Ironically, despite this underfunding, evidence suggests that social care services, such as home-delivered meals and personal care, can reduce the need for higher levels of care, highlighting the need for continued and adequate funding from the OAA (Thomas & Mor, 2013). States with higher percentages of low-care residents in nursing homes have fewer supportive services provided to their older adult residents (Thomas & Mor, 2013). High levels of unmet needs for supportive services have also been documented in a recent evaluation finding that, while 16.6 million older adults were eligible to receive meal services through the OAA, only 10% received such services (U.S. Government Accountability Office [GAO], 2015). To put this in perspective, more than four in five older adults who were food insecure did not receive any meal services (GAO, 2015).
OAA Gaps in the Context of the U.S. System of Care
The limited funding for social care under the OAA is particularly problematic because the U.S. strategy at federal and state levels has been to use Medicaid as the major source of funding for LTSS. While HCBS Medicaid services often include many supportive services needed by elders, there are two major problems with this approach. First, the restrictive economic criterion for Medicaid means that fewer than 10% of older Americans living in the community are eligible for Medicaid (Thomas & Applebaum, 2015).
A second problem is that the HCBS Medicaid functional eligibility criterion mirrors the state’s nursing home level of care eligibility, meaning that only the most disabled elders can receive in-home services. This means, for the vast majority of Americans, Medicaid becomes an option after the economic and service crisis has already occurred. Given the importance of social care in efforts to help individuals maintain community independence, this approach does not serve older people very well, and it does not prepare the U.S. for the ever-increasing older population that may need assistance over the course of the next two decades.
A comparative review of health and social care spending across the Organisation for Economic Cooperation and Development (OECD) countries provides mixed evidence about how this strategy contributes to the U.S. having the largest GDP healthcare expenditures in the world, typically double the OECD average and 25% higher than the second closest nations. In work based on 2013, OECD comparative data results showed the U.S. with the highest healthcare expenditures at 16% of GDP and the lowest overall expenditures on social care at 9% of GDP (Bradley & Taylor, 2013). A more recent study however, using 2015 data, found a narrower gap between the U.S. and the OECD social care spending average (16.1% GDP compared to 17.0% for OECD average) (Papanicolas, Woskie, Orlander, Orav, & Jha, 2019).
The 2015 study also found that the U.S. social care expenditures recorded a much higher share coming from private spending (5.7% of the 16.1% compared to 2.1% of 17% of the remaining OECD countries) And the study found that countries with higher social care expenditures also spent more on healthcare, perhaps a reflection of higher resource availability in wealthier nations. The authors suggest that higher U.S. health expenditures may not be the result of lower social care spending, but the study acknowledges that the large proportion of social care coming from the private sector in the U.S. may contribute to social inequality, which could contribute to higher healthcare expenditures.
Finally, it should be noted that it is difficult to interpret how social care expenditures are calculated for these studies, and our view is that the link between the two areas remains unclear. However, the results reported from U.S.-based studies suggest that social care limitations can play an important role in overall system costs and quality.
The almost total reliance on a Medicaid-driven strategy for LTSS and for social care for elders with disability is a major weakness in U.S. policy. The Medicaid dominance is part of federal and state DNA and means that most policy makers view the world primarily through a Medicaid lens. As an example, the proposed infrastructure bill included a large and important boost to in-home care funded through Medicaid. While critical, the system still faces a major problem in that nine in ten older people are not eligible for Medicaid based on either financial or functional disability criteria (Thomas & Applebaum, 2015).
The Path Forward
As it approaches eligibility age, a look back at the OAA indicates that it has a profound effect on the lives of older Americans. The establishment of the aging network has allowed communities across the nation to develop an infrastructure of information, services, and coordination to many elders in need. The area agency network has demonstrated the ability to coordinate and link older people to necessary services, to support family and friend caregivers, and to step up during challenging times such as during the COVID-19 pandemic or the Medicare prescription drug rollout. What the OAA has not done well enough is adapting to the myriad demographic, economic, and social changes that have occurred over the lifetime of the OAA.
‘Social care limitations can play an important role in overall system costs and quality.’
The exponential growth in the size of the nations’ older population is well known. While the overall financial status of older Americans, such as the population living at poverty or below, is far better than it was in 1965, the sheer increase in numbers means that many older people continue to have economic and social needs. Almost four in ten older people rely primarily upon Social Security, many below the average benefit level of $1,536 per month. Women, who are most likely to live alone at older ages, are more likely to be impacted, and this is particularly true for women of color. Still, most of these individuals are not eligible for Medicaid, but require social care that can allow independence and quality of life in the community.
Thus, the primary problem with the OAA continues to be the limited funding allocated. As noted, this is a particular problem because the vast majority of long-term services and supports available to older people comes through the Medicaid program and excludes the majority of community-based elders. Research evidence indicates that the lack of supportive care services can impact institutional use (Thomas & Mor, 2013).
Despite limited OAA funding, recent studies have highlighted the critical role that the AAAs play in coordinating services and even how they impact acute healthcare. Linking national survey data on AAAs with county level health data, a recent study found that AAAs that maintained informal partnerships with a broad range of organizations in healthcare had significantly lower avoidable hospital readmission rates and significantly fewer low care residents in nursing homes (Brewster, Kunkel, Straker, & Curry, 2018). This finding is particularly important in that it demonstrates the strength of coordination actions, even in the face of limited social care resources. Thus, in addition to service dollars, the recognition of the importance of the AAA coordination role is critical for system efficiency and effectiveness.
An additional concern about the OAA is support for family and friend caregivers. The dramatic rise in life expectancy, especially from ages 65 and older and the resultant increase in the sheer number of older people means that family and friend caregiving has never been more important or more prevalent in our history. Despite increases in support services, data consistently show that family and friend caregivers deliver more than 75% of services received by older people with LTSS needs.
However, the rise in dual worker households, in combination with a lower fertility rate and more elders, has placed rising pressure on this element of the care system. Incorporating the National Family Caregiver Support Program was an important step forward, but again the program has not kept pace with the societal changes impacting this area of care. The COVID-19 pandemic has accentuated this problem. Because of concerns about the safety of congregate settings, nursing homes, and assisted living residences, more caregiving is now occurring at home. While this trend was in place prior to COVID, it has now been magnified.
There also has been a drop in older people using nursing homes for rehabilitation after a hospital stay because of COVID-19. Finally, the pandemic has contributed to the growing shortage of home care workers, and many indicate that the workforce shortage problem has reached a crisis state. Each of these situations places more pressure on caregivers, and the resources available are woefully inadequate to provide the needed supports. If America is to be prepared for the continued increase in the size of the older population, it will be essential to recognize that, while caregivers will remain the backbone of the system, good supports for elders and their caregivers will be a core requirement for success.
Conclusion
As we celebrate the accomplishments of the OAA, which are many, we also must recognize that the world has changed over the past six decades. The OAA, as well conceived as it was in 1965, must adapt to the demographic, social, economic, and political changes that we have experienced as a nation. The seismic shifts that we will experience over the next 20 years will require a rethinking of the basic infrastructure for how we, as a nation, will support the continued interest that older people have in maintaining independence in their communities. Not only is it the right thing to do, but it is the most cost-effective approach we can take as a country. Here is a toast to a great 60th birthday, OAA. It is our hope that 60 will build on the past but embrace the future.
Robert Applebaum is a professor of Gerontology in the Department of Sociology and Gerontology and director of the Ohio Long-Term Care Research Project at the Scripps Gerontology Center, Miami University. Athena Koumoutzis is a doctoral candidate in Gerontology in the Department of Sociology and Gerontology, Miami University.
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