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Prepared Statement of Robert Dolsen

The overall objective of the Title III program is to strengthen or to develop at the substate or area level a system of coordinated and comprehensive services for older persons services which will enable older persons to live in their homes or other places of residence as long as possible."

- from "Grants for State and Community Programs on Aging." Federal Register, vol. 38, no. 196, October 11, 1973.


"It is the purpose of this title to encourage and assist State and area agencies to concentrate resources..., in order to

(1) secure and maintain maximum independence and dignity in a home environment
for older individuals capable of self care with appropriate supportive services;
(2) remove individual and social barriers to economic and personal independence
for older individuals; and

(3) provide a continuum of care for the vulnerable elderly."

- from The Older Americans Act of 1965, as Amended, Title III, Part A, Sec. 301 (a), 1988.

"Long-term care refers to an array of services needed by individuals who have lost some capacity for independence because of a chronic illness of condition."

- from A Call for Action, Report of The Pepper Commission, 1990.


The patterns for long term care in the United States were established in 1965, during the halcyon years of the Great Society, long before Long Term Care had become part of the American political lexicon.

That year Medicare and Medicaid were enacted, and our national optimism about our capacity to solve the nation's problems led us to believe that we had satisfactorily addressed the issues of the nation's health

Also enacted in 1965 was the Older Americans Act, a much more modestly funded social service program for older persons, aimed at providing a modicum of social opportunities for elders.

In the mid-sixties the activity theory of aging was fashionable. It held that if older persons had2Xincomehelter, and health care, they needed only social, educational, and recreational

activities to age successfully. The Older Americans Act was implemented to provide these


We had, of course, miscalculated the impact of basic public health measures and medical research, which had begun to make the possibility of longevity universal. We had begun to discover the exponential growth of large numbers of people who would evade death by infectious disease and accident, only to become victims of functional disabilities resulting from chronic disease in their advanced years.

Ironically, it was neither Medicare nor the Older Americans Act, the two aging programs, which was used to address this problem in the 1960s. It was Medicaid, the health program designed for poor families. And the primary setting for care was the nursing home, a medical facility. The net result was an explosion in the growth of the nursing home industry.

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By 1971, the year of the second White House Conference on Aging, it was recognized that something was amiss:

that an institutionalized system had gained center stage,

♦ that fewer than 25% of seniors in need could qualify for Medicaid,

that a growing group of elders struggling to stay in their own homes, their preferred setting for care, were not finding the support services they needed, and

♦ that the services in place were not being coordinated to the advantage of the seniors and were very often not the ones the most vulnerable seniors needed.

With these concerns in mind, key figures in the Nixon Administration and Congressional leaders met to devise a system to address these concerns. With the Medicaid experience fresh in mind, they settled on a system which would become the centerpiece in the 1973 Amendments to the Older Americans Act and would provide counterbalance to the Medicaid-funded, institutionally-focused system.

Where the Medicaid system was means-tested, the Aging Network would avoid the stigma of means-testing.

Where the Medicaid system was an entitlement based on strict eligibility, the Aging Network would have universal eligibility with services based on demonstrated need.

Where the Medicaid system was health-focused, the Aging Network would be capable of ranging across both social support and health care services, utilizing a variety of resources from public and private sources.

And, most importantly, where the Medicaid system focused its long term care efforts exclusively on nursing homes, the Aging Network would focus on the home. The mission of the new Area Agencies on Aging (AAAS) was clearly stated in the Federal Register, October 11, 1973:

The overall objective of the title III program is to strengthen or to develop at the sub-state or area level a system of coordinated and comprehensive services for older persons services which will enable older persons to live in their own homes or other places of residence as long as possible.

And the Area Agencies on Aging were given a unique advocacy role. So this advocacy would not be compromised, their direct service delivery was limited to those services relating to administration and advocacy, such as planning, system development, and access services.

The Evolution of the Role of Area Agencies on Aging in Long Term Care

With the reformulation of the mission of the Older Americans Act, AAAS dutifully undertook needs assessment and found a remarkable similarity across the nation in the kinds of seniors in greatest need and in the kinds of services these seniors needed. Those needing help to stay in their own homes tended to be older, more isolated, poorer, mostly female, and frequently minority. The services they needed, not surprisingly, tended to in-home services and those keeping the home manageable: home health aides, personal care, homemaker, chore services, minor home repair, etc.


The shift in focus drew in a new set of service providers, often ones with professional and specialized expertise, such as home health agencies, home maintenance agencies, durable medical equipment providers, hospitals, hospice agencies, and legal service bureaus. Although AAAs remained committed to coбmunity focal points, the setting for care provision and coordination was naturally the home, and the providers were professional agencies with a non-age-specific clientele, agencies that would not and could not operate appropriately out of a senior facility.

The AAAS generally used the senior-specific agencies to provide transportation services, public information, group education sessions, health promotion, and congregate dining. leaving the social and recreational activities to be funded locally or by the participants. In some cases senior-specific agencies provided adult day care or respite care, often competing with hospitals, mental health centers, and senior housing facilities for funding.

The AAAs did not effect the shift to the new mission overnight for they ran into the resistance that all change agents do. And in 1975 an impatient U.S Senate authorizing committee persuaded Congress to pass the Eagleton amendments requiring AAAs to spend at least 50% of Title IIIB funds on three priority services: in-home services, access services, and legal services.

The message was clear, and soon AAAs all over the nation were delivering home care through professional community agencies and had become fully conversant in the delivery of home health, homemaker, and home repair services.

This new Aging Network also abandoned the grant system used widely for OAA services before 1973 and adopted a contracting system combined with a competitive bidding process. Many AAAS were surprised to see the advantages the contracting system had over the reimbursement system used by Medicare. For example, in Southwestern Michigan our AAA could secure the same home health care as Medicare could, from the same agency using the very same personnel paid the same wages for less than one-third the cost. Today home health agencies, using subsidiary corporations, will charge our AAA less than $15 for service Medicare will pay almost $60. And our monitoring is better.


The potential of the AAAS became apparent very quickly. In several progressive states, administrators channelled state general funds, Title XX (now Social Services Block Grant) funds, and other monies earmarked for older persons through the AAAs to develop an integrated service delivery system, avoiding the problems disjointed systems can cause for program participants.

Today, most AAAs administer funds from a range of sources. For many AAAS, Title IIIB funds are a very small part of their services budgets.

The AAA contracting system has also allowed AAAs to macro-manage service delivery systems locally. For example, our AAA once funded just 'senior transportation.' Today we fund transportation limited to medical and mutrition trips, specialized transportation to tertiary medical care facilities outside the region, and transportation targeted to certain areas where demonstrated needs are particularly great. We include clauses in all our contracts requiring that those in greatest need comprise significant portions of those served, and our client tracking system, giving us unduplicated counts for political jurisdictions of the region, shows us if those areas where the neediest are concentrated are being targeted.

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