What’s missing from today’s policy conversation? What do you wish policy professionals (or anyone interested in policymaking) understood about the challenges we face?
In this “Policy Matters” feature, we invite leading thinkers to go beneath the surface, to highlight perspectives, research, and lived experiences that often escape public attention.
The overlooked legislation changing lives for older adults
By Michael Costa (MPP '82), commissioner, California Commission on Aging
Among the Great Society bills signed into law in 1965, three focused on healthcare and social services for older or low-income Americans. As a health policy professional, I grew very familiar with two of the bills, Medicare and Medicaid, early on. I only learned about the third bill, the Older Americans Act (OAA), a little more than 10 years ago. I've had the honor and privilege of working with OAA programs and their dedicated providers ever since.
The OAA has a unique policy focus: fund and facilitate services that help individuals over age 60 or living with disabilities remain independent and in their community for as long as possible. To achieve that, the range of services is necessarily broad, including home-delivered meals, transportation, home caregiver support, adult day care, legal assistance, elder abuse prevention, case management, home modifications, evidence-based disease management and falls prevention programs, and access to a long-term care ombudsman, to name a few.
Unlike Medicaid, OAA program eligibility is not primarily income based. Rather, the prime directive is to provide services to those with the greatest social or economic need, allowing for eligibility to middle-income Americans.
Numerous amendments to the Act over the years have allowed a regulatory and social services delivery system to develop independently of the healthcare delivery system. The Administration for Community Living in the U.S. Department of Health and Human Services administers the Act at the federal level; state departments on aging regulate at the state level; and Area Agencies on Aging (AAAs)—often county departments on aging—do so locally. AAAs serve a dual role: they provide services directly or contract out to local providers such as Meals on Wheels.
OAA must be reauthorized every four years, with Congress allocating the budget every one to two years as part of the budget process. This process creates uncertainty for service providers regarding the stability of ongoing funding sources. Some states have addressed this issue by passing their own versions of the Act (e.g., the Older Californians Act), which augment funding sources as a cushion and expand programming into new areas such as rental assistance.
So why don't we all know about the Act, a clear "merit-good"? It seems fair to say that interest in promoting "aging policy" has not been developed among national policy and political policy decision-makers, nor has it become a curricular focus in public policy schools. Social work and public health schools are often where aging policy research and development occur, as are foundations and community organizations such as Leading Age.
Two trends favor policymakers paying more attention to aging. The first is an increasing realization among healthcare providers and payers that integrating services provided by the OAA and related state programs into their offerings for older patients/subscribers can lead to better quality care as well as fewer hospital ER and inpatient admissions and readmissions. Payers' contracting with AAAs and emerging "Community Care Hubs"—local nexuses of social services and health care adjacent programs—is gaining traction across the country.
A second trend has generally been ignored politically, despite existing data. By 2030, 25% of many states' populations will be over age 60. Deemed a "silver tsunami," few states are prepared for the increased demand for services that this population shift will entail. Many states, including Michigan and California, have developed and are implementing state plans for aging to prepare for this future. The principal barrier will be securing adequate funding in lean budget times. Hopefully, states will provide a wake-up call at the federal level that the tsunami is right around the corner.
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