Title VI grants may never have happened were it not for a group of activists dedicated to advancing equity for Indian Country elders. In 1978, Congress created a Title VI under Amendments to the OAA, establishing grants funded by setting aside Title III funds explicitly for American Indian tribes. This article brings readers up to date on what has happened since with Title VI grants and the changed demographics of older adults who rely upon them.
American Indian/Alaska Native/Native Hawaiians, equitable services and funding, advocacy, sovereignty, nutrition, caregiving, healthcare, socialization, COVID, culture, evaluation
Honoring Our Past: The Roots of Title VI
The Older Americans Act (OAA) Title VI grants that provide nutrition and supportive services to American Indian and Alaskan Native and Native Hawaiian (AI/AN/NH) programs might never have happened had it not been for powerful advocacy efforts from a group of activists dedicated to advancing equity for Indian Country elders.
Brothers Joe and James DeLaCruz and Betty White from Washington, Curtis Crow and Steve Wilson from Oklahoma, and Larry Curley from Arizona dedicated countless hours and energy to ensuring their elders received the same services as older adults across the rest of the country. I was also part of this group, and that time was profoundly meaningful to my vocation then, and it continues to inform all that I do in my current role at the Administration for Community Living (ACL).
The original OAA legislation included grants only to states (what is today found under Title III) to provide support for older adults. And while the legislation emphasized serving those most in need, it was up to the states—which had historically excluded American Indians from services—to define those who were the neediest.
In 1975, activists were successful in moving Congress to amend the OAA to allow American Indian tribes to apply directly to the Commissioner on Aging to use Title III funds for services for AI/AN elders. However, to award such grants, the Commissioner first had to decide that AI/AN elders did not receive satisfactory services from the state and would be better served by direct funding to a tribe. This authority was never exercised.
Original OAA legislation included grants only to states—which had historically excluded American Indians from services—to provide support for older adults.
Activists representing AI/AN elders were not satisfied with this process and continued to push for change. And they were successful. In 1978, Congress created a Title VI under Amendments to the OAA, and through it, established grants funded by setting aside Title III funds explicitly for American Indian tribes, based upon the number of AI/AN elders ages 60 or older in each state. In 1980, $6 million in Title VI grants was awarded to 85 tribal organizations, representing nearly 20,000 elders.
Title VI grant authority and program execution were enhanced over the next three decades, with changes to the legislation that included:
- Separate appropriations for Title VI (funds were no longer set aside from Title III);
- Tribal authority to determine age of eligibility for who is considered to be an elder and eligible for services;
- Establishment of and funding for a program for Native Hawaiians; and
- Establishment of and funding for a caregiver support program.
By 2008, the program funding had increased to $34 million, and more than 240 AI/AN/NH organizations received grants. These programs represented more than 150,000 elders and caregivers.
In 2021, 282 Title VI grantees received more than $80 million in grant funding, including COVID-19 supplemental awards. More than 237,000 AI/AN/NH elders are represented by the grantees.
Clearly the program has grown, as the number of grantees has tripled and the number of elders represented has increased tenfold. But have the aims of the founding legislation been met? Are elders better served now than they were in 1978?
Where We Are Today: Results from the Title VI Evaluation
A recent study suggests “yes” to both questions above. In 2021, the ACL completed a culturally responsive, comprehensive evaluation of the Title VI program that highlighted the program’s impact. Title VI grantees were heavily involved in the evaluation and helped steer the course of the study. The findings of the study demonstrate that the program serves those most in need and helps them to live full, engaged lives in their communities. For example:
- Elders participating in Title VI services are older, have lower income, and are more likely to have difficulty with activities of daily living and instrumental activities of daily living than elders who are not using Title VI services.
- Elders using Title VI services reported an average of 36 percent fewer hospital visits (for all causes) and 10 percent fewer falls per person per year than elders who were not using Title VI services, suggesting that Title VI programs may reduce healthcare costs.
- Elders participating in Title VI services are almost 20 percent more likely to engage in cultural practices on a monthly basis compared to elders who do not participate in Title VI services.
- Elders participating in Title VI services reported 35 percent more social activities per month than elders who were not participating in Title VI services.
- Elders participating in Title VI programs that provide daily meals and a variety of “wrap around” services reported feeling happier than elders participating in programs that have less-than-daily meals and fewer complementary activities and services.
Also, there are areas for improvement. A majority of Title VI grantees do not have strong relationships with the traditional Title III–focused aging network and do not benefit from the infrastructure that network provides. As a result, there is a significant need for program capacity building. The Title VI evaluation also found that grantees report significant confusion about what qualifies as a Title VI service, and that the range of Caregiver Support Services provided varied considerably across the evaluation grantees (ACL, 2021). Enhanced and in-depth training and technical assistance is needed to provide the grantees with the tools they need to serve their elders well.
Where We May Go Next: Striving for Equity in Indian Country
AI/AN/NH people have long experienced lower health status when compared with other Americans. A combination of disproportionate poverty, barriers in accessing healthcare services, unequal educational and employment opportunities, and cultural differences have resulted in lower life expectancy and disproportionate disease burden for our Indigenous elders. These are broad quality-of-life issues rooted in economic adversity and adverse social conditions. COVID-19 only exacerbated the problem. Continued advocacy is needed to address these historical injustices, and work is needed to ensure that the multiply marginalized AI/AN/NH elder population is adequately served.
Annual funding for tribal aging services has historically fallen well below tribal needs, which, during the pandemic, have sharply increased. In a recent survey, 85 percent of Title VI grantees indicated that the number of elders and caregivers they served increased as a result of COVID-19, and 82 percent reported that the needs of their existing clients have increased (National Association of Area Agencies on Aging [USAging], 2021).
‘Elders participating in Title VI services reported 35 percent more social activities per month than elders who were not participating.’
Supplemental funding provided through the Families First Coronavirus Response Act, the Coronavirus Aid, Relief, and Economic Security Act, the Consolidated Appropriations Act, and the American Rescue Plan Act allowed Title VI programs to address some of that increased need. However, that demand is expected to persist long after the supplemental funding is no longer available.
President Biden’s proposed FY 2022 budget begins to address this by requesting a $35 million increase to Title VI appropriations, which represents a doubling of the FY 2021 appropriation. With the additional funding, ACL projects AI/AN/NH programs will be able to provide an additional 2.1 million home delivered meals, and 2.2 million congregate meals. Without the additional funding, tribes will be unable to maintain service levels for the significantly larger population of tribal elders who have been relying upon these services, many or all of whom are likely to remain at higher risk during FY 2022.
We are at a unique moment in our nation’s ability to chart a new course in effectively and adequately responding to the needs of AI/AN/NH elders. These needs are undeniably bound up with generational trauma and inequities (Substance Abuse and Mental Health Services Administration, 2018). The grant funds that were awarded in response to COVID-19 and the increased Title VI funds that were part of the Biden administration’s FY 2022 budget request begin to address the funding shortfalls that have plagued Title VI programs for decades.
However, if we are to meet this moment, a moment in which AI/AN/NH elders have suffered disproportionately from COVID, a moment in which climate change is upending the sacred and time-tested ways of foraging and subsistence living, and a moment in which Indigenous languages are being threatened with extinction, increased grant funding alone will not be enough.
Meeting this moment will require a new generation of activists, assuming the mantle of their Title VI-founding elders. It will require all of us—working together across generations—to speak for AI/AN/NH elders and to dream of, advocate for, and labor for a more equitable tribal aging services system, one that truly enhances the lives of elders.
Cynthia LaCounte is director of the Office for American Indian, Alaskan Native and Native Hawaiian Programs, at the Administration for Community Living in Washington, DC.
Administration for Community Living. (2021). Evaluation of the ACL Title VI Programs, Final Report. Retrieved from https://acl.gov/sites/default/files/programs/2021-05/ACL_TitleVI_Evaluation_Final_Report_508.pdf.
National Association of Area Agencies on Aging (USAging). (2021). Fast Facts: The Impact of COVID-19 on Title VI Native American Aging Programs and Services. Washington, DC. Retrieved from https://www.usaging.org/Files/Title%20VI-Fast%20Facts-Covid-508.pdf.
Substance Abuse and Mental Health Services Administration. (2018). Behavioral Health Services for American Indians and Alaska Natives. Treatment Improvement Protocol (TIP) Series 61. HHS Publication No. (SMA) 18- 5070EXSUMM. Rockville, MD: Substance Abuse and Mental Health Services Administration.