On Tuesday, April 19, 2016 the Older Americans Act (OAA) was reauthorized for three years – an important bipartisan accomplishment. Enacted in July 1965 along with Medicare and Medicaid, the law is a key piece of policy that empowers the Administration for Community Living (ACL) to fund programs across the country that are dedicated to helping seniors stay in their communities.
At this juncture, the OAA has never been more important: Looking at projected demographics, legislators working in the 1960’s created a framework of support services for older adults who need a helping hand, and which are organized and provided through a community-anchored network. Today, the future envisioned by these legislators for a robust community-anchored network has arrived. In 2016, it is time to do updated projections and take stock of what actions are required to ensure that these services can expand to meet rising needs.
We are in an unprecedented “age wave” era, when tens of millions of Americans are living into their 80’s, 90’s, and beyond. Multi-generational, blended families are becoming the norm. While our longer lives are a huge boon to society, this phenomenon – fueled by key improvements in public health and medical care -- also presents challenges that need to be thought through carefully in an era when fiscal resources must span many priorities. For older adults, one of the most formidable challenges stems from the way the U.S. arrays health care and social services programs: they are considered separately, with little thought about interactions, and almost no recognition of the impact of services in one sector on the other. This lack of congruence is mirrored in population and spending growth patterns, highlighted in the chart below:
Figure: The relationships of the growth of the Medicare population, the expenditures for Medicare, and the appropriations for services under the Older Americans Act.
Source: OAA Funding Appropriations: Congressional Research Service; Medicare Expenditures: the Centers for Medicare and Medicaid Services; Population: U.S. Census Bureau. Values have not been adjusted for inflation. Created by Ravi B. Parikh, MD, MPP, Brigham and Women’s Hospital, Boston, MA
A major take-away is that OAA funding for social services, which has no adjustment for inflation, has barely budged and is on track to shrink rapidly relative to steadily rising needs of an expanded population of older adults. Meanwhile, Medicare expenditures roughly doubled between 2005 and 2015, and projections forecast a near-doubling again by 2020.
What are the consequences of this pattern? One is that unmet social services needs are “medicalized” and delivered in high-cost settings. Seniors living alone who cannot get out of bed, for example, or out of the house to purchase food, easily become malnourished and dehydrated, contributing to higher hospitalization rates. Those who have difficulties engaging in basic self-care and who lack access to reliable personal assistance may develop skin ulcers. Without proper training and support for their needs (and those of their family caregivers) they may fall; the result can be a hip fracture, followed by surgery, rehabilitation and other high-cost medical interventions and institutionalization in nursing homes.
Such patterns cost us far more than a well-organized care system should – and this is being underscored by a growing number of better-organized (though still small-scale) care models. Medicare covers mainly “acute” medical services for elderly persons and individuals with disabilities who cannot work, and Medicaid pays the bills for institutional and home and community-based long-term care services for low-income adults only. The opportunity for the OAA’s network to partner meaningfully with these far larger programs in order to reduce overall per-capita costs remains largely unfulfilled.
A piece of good news to build on is that the scope and mission of the OAA is broad: As can be seen in the Table, the law provides a wide variety of community-based social and health-related services, long-term care ombudsman and elder justice services, and employment programs for older workers. There are home-delivered meals and “safety checks,” transportation for those who no longer drive, and respite “break” services that lessen the strain on family members and friends who often step in and do their best to care for parents and other loved ones.
Another bonus is that multiple analyses show that chronic disease self-management programs, which focus on individualized action plans for managing chronic diseases -- notably obesity and diabetes -- can prevent avoidable hospitalizations and improve seniors’ outcomes through weight loss and stabilization of blood sugar levels. These programs also work to train and empower seniors to take charge of their health and monitor it more carefully. A 2015 randomized control trial published by Meals on Wheels Association of America showed that older adults receiving nutrition assistance had fewer falls and hospitalizations, and reported less anxiety, isolation, and worry about living alone.  States with higher spending on nutrition assistance also report fewer low-needs nursing home residents – which saves taxpayers significant money.
More than 11 million people received OAA services in FY2010. Logically, that number needs to expand as the senior population grows. The major question is whether and how accountability can be extended to cover the full spectrum of services that older adults require to remain as independent and stable as possible – and out of crisis. We could consider fine-tuning and reassessing current budget policy priorities. The budget sequester of 2013 forced three-quarters of “Meals on Wheels” programs across the country to cut the number of meals they served to seniors, and caused waiting lists for meal delivery to triple. As a result, a 2015 Government Accountability Office report estimated that 83% of older “food insecure” adults do not receive meal services. In addition, two-thirds of older adults who reported difficulty with walking, dressing, bathing and other basic life activities reported they received either no services at all, or very limited help.
The slightly higher authorized funding levels in the OAA reauthorization of 2016 and the 2015 budget deal are steps in the right direction. Last year’s budget agreement on non-defense discretionary (NDD) caps are projected to increase total NDD funding by $80 billion over two years. Yet NDD funding remains 12% below 2010 levels when adjusted for inflation.
Absent further thoughtful reforms, inadequate investment in OAA-administered services for seniors living at home – which includes our parents, grandparents and ultimately many of us as we age -- will place a large burden on our health care system, which can only compensate by using higher-cost medical services to address basic socioeconomic needs. Bolder and more forward-looking solutions are needed to ensure that the U.S. remains a good place to grow up, to work and raise a family, and to grow old.
Table. Categories and examples of Older American Act Programs.
 Eiken, S., Sredl, K., Burwell, B., and Saucier, P. (2015). Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2013 Home and community-based services were a majority of LTSS Spending. Bethesda, MD: Truven Health Analytics. Retrieved from http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long....
Gordon, C., & Galloway, T. (2008). Review of findings on chronic disease self-management program (CDSMP) outcomes: Physical, emotional & health-related quality of life, healthcare utilization and costs. Centers for Disease Control and Prevention and National Council on Aging. Retrieved from http://patienteducation.stanford.edu/bibliog.html
 Thomas, K.S., & Dosa, D. (2015). More than a meal: results from a pilot randomized control trial of home-delivered meal programs. Providence, RI and Washington, DC: Brown University Center for Gerontology and Healthcare Research and Meals on Wheels America. Retrieved from http://www.mealsonwheelsamerica.org/theissue/research
 Thomas, K.S.& Mor, V. (2013) Providing more home-delivered meals is one way to keep older adults with low care needs out of nursing homes. Health Affairs, 32(10): 1796-802.
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 Greenstein, R. (2015). New budget deal, though imperfect, represents significant accomplishment and merits support. Washington, DC: Center for Budget and Policy Priorities. Retrieved from http://www.cbpp.org/press/statements/greenstein-budget-deal-though-imperfect-represents-significant-accomplishment-and