When my bones are stiff and aching,
And my feet won’t climb the stair,
I will only ask one favor:
Don’t bring me no rocking chair.
Excerpt from On Aging by Maya Angelou, 1978
The Benjamin Rose Institute, established in 1908, is one of the oldest charitable organizations in the United States dedicated to serving older adults. Rose made a fortune in the meatpacking industry and was a resident of Cleveland’s Millionaires’ Row during the Gilded Age, when the city’s leadership helped define the nation’s commerce and industry. In 1893, Rose described the purpose of the Trust and the Institute that would bear his name: to “enable old people to stay in their homes and maintain their comfort and dignity.”
Comfort and Dignity
The responsibility to care for vulnerable older adults is deeply embedded in our cultural and religious traditions. As the United States grew, territorial law and state constitutions often included provisions for the “poor and aged.” Religious and philanthropic organizations and benevolent societies, along with public relief efforts, pieced together a patchwork of support. Intergenerational households were the norm. County hospitals, “homes for the aged,” and orphanages offered a place to live and a level of care for people who had outlived family and financial resources, but the availability and quality of that care varied widely. The Social Security Act of 1935 established the first national program to offer financial support for elderly Americans.
Signing the Act in to law, President Franklin Roosevelt said,
“We can never insure one hundred percent of the population against one hundred percent of the hazards and vicissitudes of life, but we have tried to frame a law which will give some measure of protection to the average citizen and to his family against the loss of a job and against poverty-ridden old age” (Social Security Administration [SSA], n.d.).
The first recipient of a Social Security benefit was Ernest Ackerman, a retiree from Cleveland who received a lump sum payment of 17 cents based upon one day of participation in the program (SSA, n.d.).
While Social Security established basic financial support for older adults, it would take another 3 decades, and the adoption of the Great Society programs, for the components of the “aging network”—the modern safety net for older adults—to be fully in place.
Aging in the Great Society
Legislation passed in 1965 as part of President Lyndon Johnson’s Great Society agenda included the establishment of Medicare (health coverage for older adults), Medicaid (health coverage for low-income Americans), and the Older Americans Act, which set standards and a means of financial support for community programs serving older adults (Freidel & Sidey, 2006).
The OAA provided a structure for aging services across the country. Local programs, including councils on aging, senior centers, and social service agencies, were able to leverage federal funding to develop programs that addressed community needs. State Units on Aging and local Area Agencies on Aging (AAAs) provided coordination, planning, and oversight (Administration for Community Living [ACL], 2025).
The Home and Community Based Waiver program allowed Medicaid funding to be used for care provided outside of an institutional setting.
The OAA promoted community-level engagement, program development, and service delivery. Programs were organized and funded around community supports (including transportation, social and recreational programs, case management and home care services), and nutrition programs (congregate and home-delivered meals). Later amendments to the OAA added categories for health promotion and family caregiver supports (ACL, 2025). All of these programs were aimed at promoting the ability of older adults to age in place and remain active in their communities.
The Role of Medicaid Waivers
A change in Medicaid policy during the administration of President Ronald Reagan helped expand opportunities for aging-in-place for older adults who needed long-term supportive services. Introduced in 1981 as part of the Omnibus Budget Reconciliation Act, the Home and Community Based Waiver (HCBS) program allowed Medicaid funding to be used for care provided outside of an institutional setting. The Act defined programs covered under the HCBS, including case management services, homemaker services, home health aides, personal care, adult day health care services, habilitation, and respite care (Duckett & Guy, 2000). These categories were similar to those included in the Older Americans Act. Medicaid Waivers were designed to promote the use of community programs as an alternative to more restrictive, and costly, institutional care settings. The introduction of HCBS waivers expanded funding for programs and helped increase opportunities for older adults and people living with disabilities to live at home, to age in place and enjoy a greater degree of comfort and dignity.
An Evolving Landscape
As a provider of services for older adults, and later as the CEO of an Area Agency on Aging, I witnessed the impact of the OAA and Medicaid Waivers on community programs. Indiana’s AAAs provided case management services for older adults and people with physical disabilities, receiving HCBS through programs funded by the OAA and Medicaid, as well as a state funded program (CHOICE).
Eligibility for the programs varied, based upon income, age, or level of disability, but all of them served low-income older adults. Care plan services included a variety of non-medical supports, but the care plans for all participants generally included home-delivered meals and non-medical personal care/home care services. In 2007, one third of clients (800 out of 2,500 active participants) case managed by Central Indiana’s Area Agency on Aging (CICOA) received home-based services through Medicaid Waivers.
| Indiana’s CHOICE (Community and Home Options to Institutional Care for the Elderly and Disabled) was established in 1987, prior to the introduction of Medicaid Waiver programs in the state. The program is administered by the state’s Area Agencies on Aging as an alternative for older adults and individuals with disabilities who need assistance in maintaining their independence, but do not qualify for the Medicaid Waiver. (Bureau of Better Aging, n.d.) |
Medicaid Waivers programs in states are funded through Medicaid, but there are significant state-to-state differences in the programs. Medicaid covers medical expenses for low-income people of all ages. State eligibility standards vary, but the target population is those living at, or near, poverty levels.
Medicaid Waiver services include non-medical supports. (For example, Medicaid would cover an office visit with the patient’s primary care physician, but Medicaid Waiver would cover the transportation to get to the appointment.) Medicaid Waivers are directed toward individuals at risk of requiring institutional care. Individuals who need “nursing home level of care” may have household incomes that exceed Medicaid eligibility limits (in Indiana, the current threshold is 300 percent of federal Supplemental Security Income (SSI)). Services provided in the home or community setting help the individual to safely age in place and reduce the average cost of care incurred by Medicaid (Indiana Family and Social Services Administration, 2018).
‘Half of those ages 60 and older have an income that does not cover their basic needs, and many more would be unable to afford two years of in-home long-term services and supports.’
In 2008, Indiana expanded its Medicaid A&D (aging and disability) Waiver, effectively ending its waitlist for eligible individuals who met requirements for “nursing home level of care.” Within a decade, enrollment in the MAW “Aged & Disabled” programs grew dramatically. During that same period, enrollment in the OAA and CHOICE program (and state and federal funding) declined. In 2018, 64% of recipients of HCBS in Indiana were served through Medicaid Waiver programs. And 15,899 out of 24,807 people enrolled received HCBS services through the Medicaid Waiver, including those accessing traditional programs like transportation and home-delivered meals.
The overall effect of the Medicaid Waiver expansion was positive. Waiting lists for programs were reduced. The larger client census encouraged more providers to offer home care and personal services. Indiana was able to leverage additional federal dollars for direct care services and program administration. And, most importantly, more people were able to remain at home, receiving the care and support they needed in a comfortable and familiar setting, and reducing the costs of long-term supportive services for the state. 2018 was also the first year that more elderly Indiana residents received long-term services and supports in a community setting than in skilled nursing facilities.
At the same time, the expansion of Medicaid Waiver services also changed how programs operated. Medicaid and Medicaid Waiver programs are means-tested and have different, and more complicated eligibility requirements than OAA-funded programs. Rate setting and service descriptions are often different, as is the process for provider procurement and payment, making it challenging for many traditional service providers, such as community centers or meal sites, to participate.
Most older adults in the United States hope to age in place as they grow older. It is a consistent, universal sentiment captured inAARP’s Home and Community Preferences Survey. Three out of four survey respondents express a desire to remain in their homes and communities as they grow older (Lohmeyer, 2024). But for many, comfort and dignity can be elusive. An analysis by the National Council on Aging and LeadingAge LTSS Center at UMass Boston in 2024 shows that more than 27 million older adult households struggle financially. Half of those ages 60 and older have an income that does not cover their basic needs, and many more would be unable to afford 2 years of in-home long-term services and supports (National Council on Aging, 2024).
The articles in this issue of Generations Journal explore the opportunities and challenges in the evolving landscape of home- and community-based services for older adults. As our population ages, and more people require some level of assistance with activities of daily living, there is greater pressure on healthcare providers and the social services safety net to ensure a level of comfort and dignity for older adults. The authors explore who is served by the programs, what has worked, and areas where improvements are needed.
Orion Bell is president and CEO at Benjamin Rose in Cleveland, OH. He has more than 30 years of experience as a service provider in the aging network.
Photo credit: Shutterstock/ SewCreamStudio
References:
Administration for Community Living. (2025). Older Americans Act. United States Department of Health and Human Services. https://acl.gov/about-acl/authorizing-statutes/older-americans-act
Bureau of Better Aging. (n.d.) Community and home options to institutional care for the elderly and disabled. Indiana Family and Social Services Administration. https://www.in.gov/fssa/ddars/bba/community-and-home-options-to-institutional-care-for-the-elderly-and-disabled/
Duckett, M. J., & Guy, M. R. (2000). Home and community-based services waivers. Health Care Financing Review, 22(1). https://www.cms.gov/sites/default/files/repo-new/50/00Fallpg123.pdf
Freidel, F., & Sidey, H. (2006). The presidents of the United States of America. White House Historical Association. https://obamawhitehouse.archives.gov/1600/presidents/lyndonbjohnson
Indiana Family and Social Services Administration. (2018). Division of Aging State Savings–Annual Report December 31, 2018. https://iga.in.gov/publications/agency_report/2018-annual-report-division-of-aging-state-savings-fy18.pdf
Lohmeyer, S. (2024, December 10). Older adults want to age-in-place, but many don’t expect they’ll be able to. AARP. https://www.aarp.org/home-living/home-community-preferences-survey-2024/
National Council on Aging. (2024, September 26). 80% of older adults face financial insecurity. https://www.ncoa.org/article/80-percent-of-older-adults-face-financial-insecurity/
Social Security Administration. (n.d.). Historical background and development of Social Security. https://www.ssa.gov/history/briefhistory3.html
