Winter 2021–22 Generations Journal Guest Editor Rich Browdie in July 2021 spoke with Edwin Walker about the history of the OAA and his part in it.
Rich Browdie (RB): You joined the Administration on Aging (AoA) in the 1990s, but prior to that you were a part of the aging network. Is that correct?
Edwin Walker (EW): Yes, I fell into the field of aging right out of law school in Missouri. I needed a good group health plan, and I saw that state government had group healthcare. My wife was chronically ill, and more than anything else, that's what I needed. I often say my career was determined by the need for healthcare.
The division of aging was the first interview I got. I remember going to the interview and walking out thinking that would be the last thing in the world I’d ever want to do, because I really did not know what they were talking about. I thought the AAA was, you know, the American Automobile Association.
I knew absolutely nothing about aging but have since realized that I was destined for this work. I was raised to respect my elders and believe I was gifted with a heart for older people. As I think back, it was one of those moments in time that I’ll always remember, I just didn't think it was what I wanted to do. The HR director called me, and I remember trying to figure out how never to burn a bridge, which my grandmother taught me not to do. I was trying to figure out how to tell her I didn't want that aging job, but I was still interested in anything else she had. My wife was in the bed overhearing the conversation, and she said, “Take the job, you fool. It’s a day job with benefits!” That's why I say I fell into the field of aging.
Then, once I got there, I saw all these things I could do and had an interest in and saw where I could have an impact. But my initial job was as a monitor of AAAs, not knowing what an AAA was. That’s what I did at first for the state unit on aging, but what a great introduction to the field of aging and the OAA network.
Once I got there, I saw there were rules and regulations and policies and contracts, and there was a legal services program and the Long-Term Care Ombudsman program. As an attorney, I realized that I could help with those, so I started offering to help my colleagues with anything they needed. There was a lot going on. At that time, the Division of Aging in Missouri had responsibility for the OAA, for State-funded HCBS, for Medicaid HCBS waivers, as well as survey and certification of nursing homes—so it was broad in its scope. We even did Adult Protective Services (APS). I was eager to do more, so luckily for me several things I was doing were found to be helpful to the agency. Subsequently I became the director of the agency. So yes, I had a great experience in Missouri.
RB: You joined the AoA in 1992, correct?
EW: I started with AoA in June of 1992, so I’m nearing 30 years with the federal government. And I was fortunate to come into a career position, though originally I was asked to come in 1990 as a political appointee during the Bush-41 era. Dr. Joyce Berry was the Commissioner on Aging, and she reached out to me.
In Missouri, the Division of Aging had received an OAA discretionary grant to conduct long-term care planning and we used that grant to completely reform the long-term care system and to get rid of what we then called the institutional bias. The term used today is rebalancing. We did it by getting the legislature to see the value of home- and community-based services over nursing home services.
Medicaid was biased toward placing people in nursing homes. At that time in Missouri, 60 percent of all older persons discharged from hospitals went directly to a nursing home. So, we just arrested that and created a system of providing care options and asking people where they wanted to receive care. It was wildly successful. Today, it would be called care transitions.
RB: That also prepared you well for your new responsibilities in Washington. One of the things that you and I have shared over the years is the view that the OAA doesn’t always get the attention or the credit that it deserves.
EW: I would definitely agree that the OAA has never gotten the attention that it truly deserves. I believe the OAA has always been forward-leaning, as it has established many of the institutions we enjoy in the aging services network. From my perspective, it created the infrastructure for home- and community-based long-term services and supports (LTSS) in this country, and through many Government Accountability Office reviews it has been identified as a great model because there is a small federal presence that sets out broad parameters, with the strength of the aging services network at the local level and the funding flexible enough to respond to local needs. Further, this model has been lauded globally.
‘Let’s build it, let’s test it, and then build it out and replicate it if it works.’
RB: You were a member of the U.S. delegation to the second World Assembly on Aging. At that meeting, the OAA was recognized as a model.
EW: When I think of institutions, I think of how they develop, and I think of how the OAA was designed to test models and then to implement them after they have become successful, like the model of the AAAs started as a demonstration. The model of the Long-Term Care Ombudsman program started as a demonstration. The concept of where we are with home- and community-based long-term care—what we now call Home and Community Based Services (HCBS) or LTSS—came out of the OAA in coordination with the Assistant Secretary for Planning and Evaluation in the Channeling Grants. It was all about testing and being forward-leaning to find what the field of aging will need in the future. The model is, “Let’s build it, let’s test it, and then build it out and replicate it if it works.”
I believe in the OAA, I think it just hasn't gotten the appropriations that it deserves given how effective it has been.
RB: I understand that you’ve done some work in trying to capture the very rich, but not widely known history of the thinking that went into establishing the OAA, and some of the early activities of the early leaders in the arena. What has this work been like, what have you collected and what do you still have in mind?
EW: I call it “The AoA History Project” that was started during Dr. Fernando Torres-Gil’s time in the Clinton era. We developed a series of videos of former Commissioners during the 25th anniversary of the OAA. We had Bob Hudson do the interviews, he is renowned for his knowledge about how the OAA came about, the development of aging services in this country, aging policy, and so on.
It’s very much akin to what Ken Dychtwald did with the ASA Legacy series, and I’m very pleased that we were able to capture people who are no longer with us. We were able to record them on VHS tape.
We have Dr. Arthur Fleming talking about the original vision for the Aging Network and what the issues were and what his challenges were. I think we may have material from William Bechill as well. The idea was to ask each Commissioner or Assistant Secretary to talk about the challenges they faced during their respective tenures, what they felt they were able to achieve, and what were some of the barriers they faced.
We also have Fernando Torres-Gil and Joyce Berry, Lennie Marie Tolliver, and Carol Fraser Fisk, and I’m pretty sure subsequently, we captured Jeanette Takamura, and we were able to splice together remarks of Josefina Carbonell, and I think there’s a clip that we were able to put together from a speech Kathy Greenlee gave. Now, we have to review the pieces and put them all together.
It would be great to highlight some of the things that each of them identified as the challenges of their time, and what they’re known for, because I think each brought with them an appropriate initiative for the purpose of advancing the field of aging.
Dr. Fleming talked about the original vision and the power of the OAA. He talked about it in the context of being a true compliment to Medicare and Medicaid. I often talk about this when I’m providing introductory briefings about AoA and the OAA for new senior officials.
I talk about how it was one part of a three-part strategy of President Johnson to combat the War on Poverty, because at that time, before 1965, older people lived in poverty, didn’t have ready access to hospitals or physician services, and had no sense of a system of home care and support in the community.
In July of 1965, all three pieces were passed and really served as a compliment to one another, but because Medicare and Medicaid were entitlements, they grew rapidly. The OAA was an appropriated piece of legislation, and it has continued to be subject to the generosity of Congress, or lack thereof, and as a country we suffer from a lack of knowledge of the real issues and challenges that individuals and families face. The OAA hasn’t gotten the appropriations that have permitted it to keep pace with or respond to ongoing needs, nor to inflationary pressures either. So, that’s a real issue as our demographics and needs continue to increase.
The OAA never got the appropriations that would permit it to respond to the real needs, and certainly not to inflationary pressures, either.
Going back to Dr. Fleming, he ensured that woven into the OAA were the issues of the rights of older people and the aspirations of older people to have equal opportunity to participate in American society. The things in Title I of the OAA, as part of the Declaration of Objectives, were powerful. Because there are ten of them, we often call them the Bill of Rights for older individuals. He also spoke of the importance of input from consumers and actively involving older people and having them participate in decision-making and policymaking.
I feel honored to have been one of his regular guests, as I know you were, Rich, at the Dr. Fleming Table for lunch at the Capitol Hilton. There, he imparted his vision and his wisdom and what he wanted for the next generation, to make sure that we continued to build on the legacy.
RB: What have been some of the most important issues that the Aging Network has had to face that have had long-term consequences on the OAA, on the AoA, and on the Aging Network that you associate with leadership changes?
EW: You could start with Bob Benedict and his focus on the development of long-term care systems and long-term care as an issue. We developed research and resource centers around the country, which really sparked early thinking on the home- and community-based side of long-term care services.
Dr. Joyce Berry focused on the National Eldercare Campaign, where she recognized the strength of local communities and volunteers as being the underpinnings of this entire infrastructure we have as a national network.
Dr. Fernando Torres-Gil was our first Assistant Secretary for Aging. I loved the fact that he came in saying he was going to “gerontologize” America. He focused on redefining retirement to get people to begin to think about things in a different way and he was very successful in that.
There were also other things we encountered in my history—the first shutdown under the Contract with America. The most significant negative outcome was that our discretionary authority under Title-IV that gave us the ability to demonstrate things and test new models, was just slashed.
We’re talking 1993 and 1994. Title-IV was $25 million in the year before, and when we came out of that period it had been slashed to $2.85 million. I have always thought one of our greatest contributions under the OAA was the ability to develop and test innovations, and then take them to scale. After those cuts, we had no ability to do that and fulfill that original vision of looking forward and testing and preparing the country for its future aging population.
I consider that era a really shameful period. We should be ashamed as a country of what we did to the OAA, but in the absence of preparing the country for the issues related to longevity and long-term care in particular, is where the real failure has occurred.
RB: Dr. Jeanette Takamura came in after that, and she was known for really speaking about the gift of longevity and the concepts of successful aging.
EW: What Jeanette brought was a real sense of the importance of grounding our network and everything we do in evidence-based issues, science, and using rigorous approaches to prove the point that we were being effective in what we were doing. It was nice to implement the programs we had, but could we prove that they were really achieving good health outcomes or making a difference in people’s lives?
Following her, was Josefina Carbonell, who came from the local level, rather than from an academic or policy-oriented background. As a grassroots Aging Network person, she often said she grew up in the network. But what Josefina understood better than most, was the real value of the aging services network to older people. She had this sense of the relationships, intersections, and the value we represented to states, to local communities, and to the larger programs of Medicare and Medicaid. Intuitively, she understood what we now call the social determinants of health.
She got us started in this era of the business model and demonstrating value to the healthcare system. We developed Choices for Independence and had proposed a parallel strategy on the outside, trying to prove the case that what we were doing was capable of improving people’s health, but also saving Medicare and Medicaid money. It was based on the principle that healthcare expenditures would go down if we stabilized people's health and well-being in the community earlier, as their need for services increased.
Kathy Greenlee came in after that, and to her credit, continued developing and encouraging business acumen within the Aging Network. And she also took up the mantle of focusing on elder abuse, because, along with the Affordable Care Act, the Elder Justice Act passed and allowed us the platform to enter into an arena where there had been little federal policy related to APS and addressing elder abuse in a robust way.
‘We should be ashamed as a country of what we did to the OAA.’
Also, Kathy is known for creating the Administration for Community Living (ACL) and seeing the value of the alliance between aging and disability policy and services. The whole effort to rebalance the long-term care system was rejuvenated during that time, with Money Follows the Person being active and the concept of care transitions was being tested and expanded.
Then Lance Robertson came in. Lance continued support for business acumen, and he also had his Pillars framework, which were rooted in the core services that the Aging Network runs. He came from the network as a state director and recognized the importance of continuously introducing the Aging Network and its services to elected officials, policymakers, and the general public.
And now under the Biden administration, we are focused on how we enhance HCBS. How do we do that in connection with the investments in new benefits under Medicare that are proposed and with Medicaid? These resources potentially are tremendous, and they’re focused on Medicaid shifting its traditional sense of being institutionally-biased and instead, to really recognize that Medicaid should follow the person and provide care in people’s homes in the community. But Medicare and Medicaid use a medical service reimbursement model and is utilizing commercial healthcare plans to pursue its goals, bringing new challenges to the Aging Network.
RB: That was a really efficient retelling of the history and many of the consequences of the OAA. There have been some significant changes, starting in 1973 with the comprehensive service amendments. Looking at your experience, which changes do you think are the most significant?
EW: I would go back to the Takamura period where she focused on caregiving, and we were able to create the National Family Caregiver Support Program. It was done for the purposes of aligning with what families needed in this country and what they were facing. It took a lot of internal and external partnerships to bring that about. It took fortitude to bring it about. We worked with the Assistant Secretary for Planning and Evaluation to assist us in terms of the research and the underpinnings to justify and characterize the need, to articulate the need. We focused on building a very simple case that everyone could understand and with which they could identify.
Then we showed that it was a wise investment for the country. Because with a small amount of money, we could continue to support what has been referred to as the informal support network, but really was much larger and should have been called the formal unpaid ongoing support network. The bulk of all LTC is provided by this “informal” caregiver network of family members, friends, and neighbors.
And that had appeal to both sides of the aisle. Now we have data that shows that the value of unpaid family caregiving exceeds $522 billion a year. That is something we cannot afford to pick up and pay for in the public sector, so it’s a wise investment to support that “informal” network with a smaller amount of money to enable them to continue to do what they want to do, which is to care for their loved ones in their own homes and communities.
The informal support network should have been called the formal unpaid ongoing support network.
We also made the family caregiver program flexible because the research wasn’t there for us to determine everything that needed to be in it. We needed to really allow flexibility at the local level from an implementation standpoint, so we established the five categories of information; assistance; counseling, caregiver training and the development of support groups; respite care; and the fifth intentionally designed to be a catch-all, supplemental services; based on what is of value to a local family caregiver.
The design allowed the funding to be flexible enough to respond to local needs, and so, in my opinion, the caregiver program was a very significant addition to the OAA. It was the first time in quite a while that a whole section of the OAA was carved out and successfully attracted resources.
Elder abuse followed a different path. In 1992, Title-VII was created. The idea was to attract more resources to elder abuse and protective services, but the appropriations never seemed to accompany the authorization. Now, they are beginning to flow, but it took the passage of the Elder Justice Act and years of effective advocacy to do so.
We have been instrumental in making policy changes in LTC because of the OAA foundation and structure. The policy changes have related to Medicaid that supported the development of approaches like Money Follows the Person and going back to the early days of retooling and rebalancing the LTSS system toward HCBS.
These are all consistent with the goals of the OAA. It was necessary for us to advocate for these policy changes because Medicaid is where the bulk of the funding for home- and community-based LTSS resides, but it wasn’t aligned with people’s desire to receive care and support at home in their communities. These changes are significant items, because they really make a difference in people’s lives, and we’re pleased to play a vital role. At AoA and ACL, we don’t ever want to be forgotten. We are advocates for real people. That’s the role we play and have played over the years. And I hope it is the role we continue to successfully play well into the future.
Photo: Edwin Walker
Photo by Rohmteen Mokhtari, Department of Health and Human Services.