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Older Americans Act

OLDER AMERICANS ACT

The Older Americans Act (OAA) is the principal piece of federal legislation designed to provide a range of community services to adults age sixty and above. The law was enacted in 1965, during a time when the federal government was inaugurating a broad range of domestic social policies. The overarching goal of the OAAto promote the independence of older Americans has remained largely unchanged since its enactment. However, there have been important changes in emphasis and strategy within that overarching framework. In addition to assuring provision of a range of services to older Americans, the OAA was also central to creating an infrastructure of organizations and advocates working on behalf of older adults at the state and local levels and in the private as well as the public sector. Despite limitations in funding and modifications in direction over the years, the OAA can be judged to have generated significant improvements in the lives of older adults since 1965.

Development of the Older Americans Act

Important as it has been in making social services available to older people, the OAA was a relatively minor item among the legislation that was enacted by the federal government during the mid-1960s. The major aging-related policy event of the time was the enactment of Medicare, the federal health insurance program for the elderly. Yet, had it not been for the struggle surrounding Medicare, the OAA probably would never have been passed. That is because many different individuals and organizations mobilized on behalf of Medicare, but not all of them were doctors, hospitals or other providers concerned only with access to health care. Many older people and their advocates wanted the federal government to recognize the presence and needs of older Americans in a broader and more symbolic way than Medicare alone could do. Many professionals, providers of non-health-related services, also wanted federal financial support for their services (Binstock).

As a result of these twin pressures, the OAA was passed as a piece of legislation that served both to give symbolic recognition to the presence of older Americans in national life and to provide to them community-based services beyond those associated with health care alone. Title I of the OAA was very clear on both of these points, declaring that "the older people of our Nation are entitled to secure full and free enjoyment of the following objectives" and going on to list ten broad areas in which the federal government should act on their behalf.

While these objectives extended to income maintenance, employment, and housing, among others, the remainder of the OAA itself concentrated principally on the organization and provision of social services to be provided to older people living in their homes in their communities. Title II established the Administration on Aging within the federal Department of Health, Education, and Welfare (which became the Department of Health and Human Services in 1977). The Title III community grant program was by far the most important of the original titles in the act. It provided federal matching funds to the states to establish State Units on Aging, which would serve as focal points for state-level activities directed toward older people. Title IV authorized a research, demonstration, and training grants program, and the original Title V established an advisory committee on aging within the Department of Health, Education, and Welfare.

Despite its broad mandate, early funding under the OAA was very small by the standards of the federal government, only $7.5 million in 1966 and $10.3 million in 1967. These dollars were barely sufficient to help the new state agencies get off the ground and to fund a few service efforts, mainly in senior centers. Indeed, there was talk in 1970 of eliminating the program because so little was being done (Sheppard).

However, events in 1971 led to a massive and unexpected increase in the size and scope of the OAA program. The precipitating event was a speech that President Richard Nixon gave to the White House Conference on Aging held that year (Pratt). The president was opposing a 20 percent increase in Social Security benefits being proposed by the Democrats, and in order to please his audience of 4,500 older Americans, he focused his attention on the small but appealingly named Older Americans Act. The president called for a five-fold increase in appropriations to the level of $100 million and the creation of new sub-state area agencies on aging that would plan aging services in over six hundred planning and service areas. Thus, even though the president continued to oppose the much more expensive increase in Social Security benefits, the audience gave him a standing ovation for these remarks, and the Older Americans Actalmost over nightbecame one of the nation's largest social services programs.

OAA programs continued to grow rapidly throughout the 1970s. The area agencies on aging were established, and they succeeded in pressing both federal and state governments for more OAA money. In 1972 a new nutrition program was added to the OAA, one that today rivals the social services under Title III in size and importance. The best indicator of the OAA's growth, however, is the enormous increase in appropriations, increasing from $7.5 million in 1966 to over $900 million in 1980 (see Table 1).

The major spending increases came in the social services and nutrition programs and also in a new community services employment program for low income older people. By the end of the decade, there was in place what one analyst referred to as "the aging network" (Estes), consisting of the federal, state, and area agencies, and the literally thousands of direct service organizations that these governmental bodies contracted with for actual services provision.

This expansion of programs and spending under the OAA during the 1970s is important for several reasons. First, services were made available to many more older people than would have been possible with more modest growth. Second, the new aging network became a political force, being able to both lobby for increases in OAA expenditures and around issues of broader concern to older Americans. Third, the growth and the leveling off that came in the 1980s was indicative of broader changes in aging politics that were emerging by the late 1970s. And fourth, the aging network had sufficiently institutionalized itself by the dawn of the more conservative 1980s and the presidency of Ronald Reagan so that it was able to maintain itself quite successfully while programs elsewhere were being dramatically downsized (Hudson, 1994).

Since the early 1980s, the OAA has been largely in a consolidation mode. Some modifications and additions have occurred, but its size and mission have remained relatively unchanged. Thus, on the matter of funding, appropriations reached $953.7 million by 1983, but seventeen years later had only risen another $350 million to $1.3 billion. These increases average out to roughly $20 million a year in comparison to the 1970s, where the average annual increases approximated $90 million per year. Other significant legislative changes over this latter time period include new authorizations for in-home services for frail elders, long-term care ombudsman program, health education and illness prevention programs, prevention of elder abuse and neglect, and a heightened emphasis on the needs of older people with greatest economic and social needs (U.S. Administration on Aging, 1999). More recently, new attention has been devoted to intergenerational concerns and the needs of those providing care to the frail elderly. Organizationally, the biggest change was the elevation of the Commissioner on Aging head of the Administration on Agingto the rank of Assistant Secretary for Aging within the Department of Health and Human Services.

After considerable modification over the years, the titles authorized under the OAA most recently are as follows: Title I: Objectives; Title II: Administration; Title III: Supportive Services, Meals, In-Home Services Preventive Health Services; Title IV: State and Local Innovations and Projects of National Significance; Title V: Senior Community Service Employment Program (administered by the Department of Labor); Title VI: Grants to Indian Tribes; Title VII: Vulnerable Older Americans/Senior Rights.

Issues under the Older Americans Act

Eligibility for benefits. The spirit and formal wording of the OAA holds that all citizens over the age of sixty are eligible for OAA-funded services. Yet, whether the amount is $7.5 million or $1.3 billion, there is nowhere near enough funding for all those over sixty to benefit from the program. Even so, from the very beginning there has been strong pressure that the OAA should not be "means-tested," that is, have provisions whereby individuals would have to demonstrate that their income is below a given level before they could receive services. Such programs have long been associated with "welfare," and Congress has consistently made clear that it did not want services under the OAA to have any such connotation.

The eligibility dilemma OAA administrators have long faced, then, is how to concentrate or target benefits on older people deemed the most in need of services without imposing a formal means test. The emphasis on who, in fact, are vulnerable populations for OAA purposes has varied over time, but the following conditions and populations have been invoked: those in greatest economic or social need, rural older people, low-income minority individuals, the frail and disabled, and members of different racial and ethnic groups. Apart from these variations in emphasis, the more important point is that OAA programs in most parts of the country have devoted services disproportionately to older people who are poor, of minority status, and frail (Holt; Justice).

In more recent years, this last issue of frailty has increasingly dominated both eligibility and spending decisions under the OAA. The aging of the American population and especially the aging of the older population itself have meant that more individuals are suffering from chronic illness and disability than ever before. As a result, many state and area agencies find themselves doing what is occasionally referred to as "functional means-testing," that is, determining how limited people are when it comes to basic daily tasks such as dressing and walking. Services are now usually limited to those with several such "deficits," and they are frequently available only to individuals with limited incomes. Adding a home-delivered meals component to the OAA's nutrition program and adding a new subtitle to the act directed at in-home services makes clear this new emphasis on frail elderly people.

Mission and benefits

Within the rubric of supporting independent living for older people, the OAA has long had a multiple mission. Most clearly, the state and area agencies were to plan for the elderly's service needs and to contract with private agencies that would then provide those concrete services. But this entire aging network was also charged with serving as an advocate for older people and as a coordinator of services that were provided by large agenciessuch as mental health departmentsthat were outside of this network itself. Indeed, the very establishment of a "network" was seen by some as detracting from this larger infusion function that the OAA's designers had very much in mind (Hudson, 1986).

During the act's early years, there was concern that these different mandates would weaken the overall impact of the OAA and those working under it. However, more recent events, largely outside of the control of any of these individuals, have lessened that concern. First, the network has become sufficiently large in the context of other human services agencies that it could both provide and advocate in ways that made the functions synergistic rather than separate. Second, the growing frailty of the older population brought the OAA, and agencies operating under it, increasingly into the world of long-term health care. In this arena, aging network agencies found themselves involved with the much larger Medicaid health care program. While Medicaid serves low income people of all ages, roughly one-third of Medicaid expenditures are directed toward frail elders, living either in nursing homes or in the community. The nature of the OAA and Medicaid interface varies greatly around the United States, but in some states the Medicaid money dedicated to these older individuals has completely or partially come under the aegis of the state unit on aging. In recent years, many states have also appropriated additional money directed toward care of community-based elders, with these monies usually administered by aging network agencies. And, attesting in particular to the issue of disability, today roughly half of the traditional state units on aging also have administrative responsibility for disabled adults who are under the age of sixty (Justice).

Intergovernmental and administrative issues

In the formal terms of federalism, the OAA is a federal-state grant-in-aid (GIA) program whereby the federal government makes funds available to the states and requires that they follow certain guidelines and contribute monies of their own on a matching basis. Most of the grants initiated in the 1960ssuch as the OAAtended to be "categorical," that is they contained quite rigid federal requirements in order for states to receive federal funding. Because states were simultaneously administering many grants, they often found coordinating different federal requirements very cumbersome. As a result, more recent GIAs are "block grants," giving states much more flexibility in grant administration (Holt). This trend has held in the case of the OAA, where today states enjoy much greater choice in services to be delivered (e.g., home or congregate meals) and around agreements to be struck with other state-level agencies (e.g., the state Medicaid agency).

This trend in federalism, new pressures being brought on state governments by increasing numbers of frail elders living in their states, and twenty years of nearly level federal funding for the OAA have combined to make the states increasingly important in aging-related policymaking. Unlike the early years of the OAA, when the states were heavily dependent on both OAA dollars and AoA (Administration on Aging) approvals, the situation today finds the states in the lead in the design and funding of new programs with both the OAA and AoA playing a secondary role. Problematic as this might seem, ironically, it is in keeping with what OAA's founders actually had in mind in 1965. Their hope was that the OAA would stimulate initiative and innovation in state governments and that, having served as a catalyst, the OAA itself might become a less central player (Hudson, 1995).

Conclusion

After very shaky early years and a remarkable spurt of growth in the 1970s, the OAA has had a fairly stable history in more recent years. However, attention has shifted from addressing the preferences of relatively able older people living in the community to meeting the needs of very frail people in hopes of allowing them to remain in the community. As a result of this "geriatric imperative," the OAA, and especially the aging network agencies it brought into existence, have found themselves increasingly drawn to the world of long-term health care. Given that these clients' needs are multifaceted and the agencies serving them are multiple in number, it has become increasingly important for individual states to tailor their response to these new pressures in a coordinated manner. Many of the agencies created through the OAA have been key players across the nation in implementing these coordinated long-term care efforts.

Because the OAA itself has not grown during this period of long-term care expansion, it has become a relatively smaller element in this new and larger service universe. And the Administration on Agingcharged with running the OAA from Washingtonhas itself been weakened by years of personnel and funding cuts. Indeed, AoA's most recent strategic plan is again reminiscent of the symbolism of the early years, speaking of the need "to provide leadership," "promote cross-cutting initiatives," and "gerontologize America" (U.S. Administration on Aging, 1985). Yet, those who designed the OAA and those who continue to oversee it from today's AoA can take considerable solace in the fact that many state and other agencies operating from the now ubiquitous "aging network" are playing leadership and cross-cutting roles across the nation.

Robert B. Hudson

See also Administration on Aging; Area Agency on Aging; Congregate and Home-Delivered Meals; Home Care and Home Services; Meals; Medicaid; Senior Center.

BIBLIOGRAPHY

Binstock, R. H. "Interest-Group Liberalism and the Politics of Aging." Gerontologist 12 (1972): 265280.

Estes, C. L. The Aging Enterprise. San Francisco, Calif.: Jossey-Bass, 1979.

Holt, B. J. "Targeting in Federal Grant Programs: The Case of the Older Americans Act." Public Administration Review 54 (1994): 444449.

Hudson, R. B. "Capacity-Building in an Inter-Organizational Context: The Case of the Aging Network." In Perspectives on Management Capacity-Building. Edited by B. W. Honadle and A. Howitt. Albany: State University Press of New York, 1986. Pages 312333.

Hudson, R. B. "The Older Americans Act and the Defederalization of Community-Based Care." In Services to the Aged: Public Policies and Programs. Edited by P. Kim. New York: Garland Publishing Co., 1994. Pages 4176.

Justice, D. "The Aging Network: A Balance Between Universal Coverage and Defined Eligibility." In The Future of Age-Based Public Policy. Edited by R. Hudson. Baltimore: Johns Hopkins University Press, 1997. Pages 168177.

Pratt, H. J. The Gray Lobby. Chicago: University of Chicago Press, 1976.

Sheppard, H. The Administration on AgingOr a Successor? U.S. Senate Special Committee on Aging. Washington, D.C.: U.S. Government Printing Office, 1971.

U.S. Administration on Aging. "The Strategic Plan of the Administration on Aging." 1985. Available on the Internet at www.aoa.gov

U.S. Administration on Aging. "Historical Evolution of the Older Americans Act." 1999. Available on the Internet at www.aoa.gov

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