What caused the Older Americans Act to come to fruition, how is it changing, how has it not changed, and what are its biggest challenges today? What impact has the push to integrate long-term services and supports into managed care organizations had?
Older Americans Act, Aging Network, managed care organizations, long-term services and supports
In 1971 I was employed as a rural outreach case worker in an early food and nutrition support program for isolated and low-income older adults. It was part of the mission of the Greater Erie Community Action Committee under the Office of Economic Opportunity. The majority of my clients were single mothers and older adults. Within three months we had begun a Meals on Wheels program, and by Spring we had started writing our first proposals for state grants to fund those meals, a senior center, and a medical transportation network in rural Erie County. All programs fell under what became the Social Services Block Grant.
Shortly after the Comprehensive Service Amendments to the Older Americans Act (OAA) passed, it allowed us to fund a Retired Senior Volunteers Program, a Foster Grandparents Program, begin the Community Service Employment Program, and later meals for older Americans. In two more years, it allowed us to leapfrog from three isolated (and uncollaborative) senior centers in the City of Erie to a network of nine centers and four nutrition satellites covering the entirety of Erie County, with the start of a senior transportation network to boot. As of January 1, 1974, we became the third designated Area Agency on Aging (AAA) in Pennsylvania, and I its Executive Director.
It was an exciting three years for us in Erie, and for me personally. It established an avocation for me that has lasted more than five decades. My story, with different details, was playing out in communities across the United States—during the birth of what we now call the Aging Network. In some places, it was truly a new idea. In most others, it began with the thought that coordination and policy rationalization was necessary to make additional resources more effective, efficient, and less confusing to older people and their families. It also gave life to both a movement and an industry.
In many locations, these were disparate organizations that had begun as a way to support and serve older people under the guidance of community leaders, some going back to the late 1800s and early 1900s. They grew out of industrialization, which caused people to move to the cities for work, at the same time as others began to age in place. These organizations sprung out of all sorts of related but disparate motivations, some religious, some philanthropical. Local philanthropists, many of them leaders of the industrial giants that drew workers to these new locations, then watched their former employees (more often their widows) outlive their savings and fall into severe poverty. The Great Depression, followed by World War II, pointed clearly to the conclusion that as America industrialized and grew, some people would be negatively impacted by social dislocation, discrimination, and some just bad luck that was beyond their capacity to overcome.
Agencies had sprung up, but collaboration among them was entirely voluntary. These organizations had proud traditions, established ways of doing things, and often commanded considerable social and political capital they were not afraid to use. Creating a coordinating structure over that was going to require some delicacy and sensitivity to local circumstances.
National leaders reasoned that getting disparate organizations to coordinate services and filling in gaps through program development were both necessary, but given the uneven history across the country, a standard template would not work. Not only did established interests have to be involved, but also under consideration was the fact that states and communities have distinct characteristics when it comes to the details of how communities work. Every bit of evidence told national leaders that for the most part, people liked this individualistic way of being. It seems Americans continue to feel that way.
Enduring issues elders experience point to the profound wisdom of ‘The Founders’ who developed and wrote the OAA in the 1960s and 1970s.
Hence, the OAA was designed with variability in mind. That variability has been a source of great strength and vulnerability. It was established with the view that the United States needed to foster a core of expertise in the field of aging that would be engaged on behalf of virtually all older people in many aspects of their lives, and available to support their efforts to navigate older age, but also never directly serve every older person who needed help.
The founders believed that Americans would expect those who had the resources to provide care for themselves, and that families would be a source of help as well. And rather than establish bureaucracies to manage eligibility intake like those existing in public welfare programs, direct services would be promoted to attract lower income older people instead of being restricted to specific income levels. The founders did not believe the public would support entitlements beyond medical care simply because of age, and they believed that most older Americans, to maintain independence, would be more comfortable getting help only with issues where they felt it was needed, which might be fewer services than a professional would recommend.
But in the 50-plus years since the OAA was put into place, the nation, and the circumstances its older citizens face, have changed significantly. At the same time, there are constants in the relationship between older people and their communities that endure. Those enduring issues point to the profound wisdom of “The Founders” who developed and wrote the OAA in the 1960s and 1970s, and point to the relevance of the OAA today and into the foreseeable future.
My experiences as a now “older person” have only reinforced my view that some things just don’t change, and that as a group, older people, particularly those who have not accrued the advantages of privilege, will continue to need the support of people who are trained to understand their challenges in all aspects of life in the community, and that coordination is needed among the growing army of profit-seeking and nonprofit organizations working to attract their attention and money.
What Is Changing
At its core, the OAA developed local approaches to respond to challenges faced by elders across the country—access to people trained to help an older person and their family figure out how to approach emergent problems in their lives, and access to individuals who could advocate for and highlight challenges facing older people in a community, a political jurisdiction, a state, or the nation. The OAA was unusual in how it mandated its Aging Network to be advocates, even when the powers that be believed there was no need for any action or increased support. The Act charges Aging Network advocates with the responsibility to analyze, educate, and empower older people and those they rely upon, case by case, and in public policy.
But as time has passed, the economic and policy environment around the Aging Network has changed, introducing a host of challenges and conflicts. The most profound changes come through growing efforts of the federal government and its state partners to integrate personal and residential supports (known as Long-Term Services and Supports, or LTSS) into the same management systems that manage medical care for low-income people with disabilities, including older adults. Because integrating LTSS into medical care requires entities to accept risk-based financing, and risk-based financing requires assurances of large numbers of enrollees to be feasible (i.e., profitable), commercial managed care companies that had been in the business of managing medical care have become the backbone of this new approach.
And the unending urge of elected and appointed officials to sweep clean and make new in state government has led to the urge to reorganize how services are produced and administered to meet the needs of managed care organizations, particularly in making connections to local resources more convenient by reducing their number and variability. In this way, a struggle over the future of the Aging Network has been set in motion in many states across the country.
The fact that these organizations are much more likely to be profit-seeking national companies raises concerns for many. Even PACE programs, which used to be all local nonprofit organizations, are open now to for-profit competitors, which have the capital to grow faster and are willing to enter markets where there are no local agencies prepared to take up the challenge.
Federal and state governments are putting considerable resources into making training available to components of the Aging Network, like Area Agencies on Aging, to become vendors to managed care companies. This includes developing administrative entities to sell services to managed care plans so that those plans need not work with multiple diverse and confusing communities around a state.
What Is not Changing
The introduction of managed care means systems of care decision-making are more all-encompassing, consolidated, and opaque, and significantly increases the need for trusted and objective local sources of information. The systems that people face in times of crisis are more complex than ever and becoming more so. In many parts of the country, people are less confident about the care being recommended by an organization that reaps the financial benefits of cheaper caregiving decisions. Most people have more confidence in locally based organizations and governments than in managed care health insurance companies.
Also, there is immense diversity inherent in America’s states and communities. In every aspect of public life, Americans continue to assert the importance of their distinctive characteristics, and to demand flexibility in how issues should be approached. It is hard to imagine anything more individualized and distinct than a person aging in their community. Yes, they face challenges that may be in the same analytical categories as others elsewhere, but the details of the response, including how services should be delivered, are entirely localized.
‘In every aspect of public life, Americans continue to assert the importance of their distinctive characteristics, and to demand flexibility in how issues should be approached.’
Also cost concerns loom on the horizon, though few people are talking about the problem, as elected officials demonstrate little insight into the drivers of increased Medicaid costs in general and LTSS specifically. The public knows even less. Costs are being driven up primarily by increasing numbers of people with disabilities acquired before age 65, and by increased service costs in LTSS service plans, including those under managed care plans. Most discussions of the cost of Medicaid blend multiple populations together in LTSS costs, which obscures the significant differences in costs among the different populations served.
Integrated Medicaid LTSS and Medicare care systems for persons with disabilities and older adults are dominated by profit-seeking managed care organizations, and policymakers are trying to tie more of the services in the LTSS domain and other social determinants of health into medical entitlement programs. Inevitably, costs will continue to rise, and taxpayers and elected officials are sure to become concerned. Eventually, if this trend follows the pattern in other growing entitlement programs, there will be a drive to cut costs and to search for people getting more than they should, along with the rates being paid to managed care companies. When that time comes, advocates for the interests of older people will need to make sure that older people do not bear a disproportionate share of any burdens created by retrenchment.
Older people in these plans usually are more numerous, but their costs of care are significantly lower. It might appear to some that because they cost less, they are “less needy.” Agism is alive and well in America, and there is no reason to believe it will be gone when a cost-of-care crisis hits.
So, What About the Older Americans Act?
The articles in this issue of Generations Journal speak to a tremendous range of services and legislation that have been created and continue to serve older people in the nearly 60 years since the OAA’s passage. They also capture many aspects of the vigorous response of the Aging Network to the reality that human services in this country are subject to numerous forces and shifting philosophies that make the administration and structure of the system a dynamic and often contentious process. If the organization and operation of the Aging Network was the only matter addressed by the OAA, it might not rise to a level of national legislative concern.
One can assume that the work of serving older people who do not have the personal or familial supports to live successfully in the community will always be there. If you believe that the United States and its state governments would respond vigorously and creatively to the growing and changing needs of its older citizens without national leadership and support, national legislation might not be necessary.
The OAA is a unique combination of aspiration in national policy, ambition in spreading services to all parts of America (including those with precious few supports for older adults), and optimism that a country as diverse as the United States can achieve the goal of enabling its older citizens to live successfully in their communities, while navigating the unique characteristics of those communities. And the OAA charges its State Units on Aging and Area Agencies on Aging with the job of highlighting the unmet needs of older people, community by community, state by state, and across the nation, including comment on how their decisions may impact other human service decisions. How necessary is it to continue this sort of effort?
Many arguments could be made, but to me there are a few key considerations, regarding human nature, public financing in the United States, and commitment and expertise.
Now that I am an older American, I view any question about how “most older people” would see things differently than I did 30 years ago. Older people and their opinions are as diverse as the population of all ages, so “most” is a risky word. But I believe in the idea that maintaining my independence on my own is how I prefer things, thank you very much, and that includes the idea that I don’t want the intrusion of some eligibility worker in my life (with all due respect to eligibility workers, who perform a necessary and often fraught responsibility). Directly connected to that is the idea that our country is a long way from creating an entitlement to LTSS, regardless of personal income or assets, and independent of being severely disabled.
This means there will always be older people who need advice and assistance related to LTSS needs, but who are not yet disabled enough or poor enough to qualify for Medicaid financed services. To deny them access to knowledgeable assistance and supports merely risks worsening their condition precipitously, and more quickly. There are many more people who are not poor enough to qualify for Medicaid (and don’t want to) than there are older people who are sufficiently disabled and poor to qualify for Medicaid LTSS. The OAA allows people access to a lower level of assistance, when that’s all they need, which is smarter public policy strategy.
Moreover, there are the many ways in which the OAA supports older people, from protecting the most vulnerable through the Ombudsman program and the Elder Justice components of the Act (along with the recently enacted Elder Justice Act, which engages other parts of the government in the work of protecting older people, as well as adding to the OAA’s capacities) to providing meals, senior centers, supports for families and caregivers, and more.
Much of the debate over the future of the OAA, and the Aging Network, is driven by the push to integrate LTSS into managed care organizations that also manage medical care for beneficiaries. There have been many conflicts caused by the clash of cultures and political and bureaucratic maneuvering involved in that movement. Among them is a fundamental issue that underlies most government spending and program design discussions in the human services arena. That is, for whom is this system being designed?
‘Much of the debate over the future of the OAA, and the Aging Network, is driven by the push to integrate LTSS into managed care organizations.’
As noted above, one of the premises of the OAA was that while most older adults will face similar needs for personal support to live in the community, the reality is that they vary widely in the level of economic and familial resources they have to deal with the challenges they face. This reality has been the founding principle of advocacy for Medicaid programs to better meet the needs of disabled younger people and frail and disabled older people who are too poor to meet their own needs. At the same time, older adults were expected to pay their own way if they could. In addition, they are encouraged to begin to meet needs as early as possible, rather than waiting until they become completely dependent upon support services, as is required for admission to most Medicaid programs. That expectation continues to this day.
The reason to consider legislation like the OAA is that while older adults with very low incomes may have difficulty paying for the care they might need and figuring out the care planning and navigation that well-coordinated supports in the community require, the same challenges with assessing needs and navigating the system are present among older adults of almost any income level. The greatest financial barriers probably lie in restrictions on financial assets, which would require an older adult to dissipate their assets before they would be eligible. Beyond that problem, older adults at all income levels, including those enrolled in Medicare/Medicaid managed care organizations, may have need of other features of the OAA, like the Ombudsman program, Adult Protective Services, socialization programs, counseling on health insurance choices, etc.
While it is hard to estimate nationally because of the variability in eligibility levels in Medicaid programs and differing levels of disability, it is likely that the number of older adults who would not be eligible for Medicaid-funded services and still need help in managing them or affording them is many times greater than the number who are Medicaid eligible. The number of older adults who could manage their needs at a lower cost while maintaining a greater sense of independence grows each day. The number of older adults who could delay increased dependence by earlier interventions, while reducing the stress on themselves and their family/friend caregivers grows each day.
Waiting until older adults need a global response to emerging needs and make themselves poor enough to qualify for that global assistance is a recipe for a lot of pain in people not yet disabled enough, and a financial catastrophe for the people who are trying to pay for the consequences of that thinking. It also undercuts support for the lower cost programs in the community by sucking up all the resources for the most expensive end of the system, as evidenced by the exploding costs of Medicaid LTSS spending in most parts of the country and the reduction of spending on community-based programs for older adults in many of the same states (COVID-19 spending aside).
There is a growing breach created by the focus on the high-cost end of the LTSS system and the support needed for a lower cost complementary system that responds on a day-to-day basis to the incremental changes in the lives of America’s growing population of older adults, which supports people in their communities and disrupts their economic security as little as possible.
The OAA has stood in that breach for decades. Yes, it needs more money. Yes, it needs to learn to coordinate and collaborate with healthcare systems (though in fact the evidence says that learning about what services work best needs to go the other way). But it is absolutely the case that the OAA and its approach to building support systems at the local level is even more important today than ever.
Richard Browdie is founder and principal at Browdie Consulting. Previous to consulting he spent 17 years as President and CEO of the Benjamin Rose Institute on Aging in Cleveland, and about four decades advocating for older adults.