Robert B. Hudson

Analysis and advocacy in home- and community-based care: an approach in three parts.

A new chapter in health policy presents both challenges and opportunities for aging policy analysts and advocates concerned with long-term care. Millions of long-term care recipients and providers live today in a pubic policy netherworld, one principally associated with Medicaid. I suggest here that moving policy forward will entail three key steps: (a) to overcome structural lag in key home and community-based care (HCBC) policy arenas; (b) to reverse a contemporary pattern of risk-shifting from institutions to individuals; and (c) to inform and empower caregivers to have their own pressing needs recognized. Recent developments in Washington provide new optimism on these fronts. Voluntary long-term care and community-based care (LTC/HCBC) proposals are on the table within the broad context of health care reform. Whether they remain will be, in large, part a function of how far we have moved along the fronts described: modernizing policies, recognizing risks, and activating neglected policy constituencies.

Rational Planning and Organizational Imperatives: Prospects for Area Planning in Aging

The federal grant strategy found in the Older Americans Comprehensive Services Amendments of 1973 represents a marked departure from earlier strategies of the Older Americans Act. While the national goal of the legislation is more clearly specified and funding has sig nificantly increased, the introduction of new substate plan ning bodies—Area Agencies on Aging—is seen here as the most important change. The new national strategy is geared toward the development of these new agencies, and its success will depend very much on their discharging the functions assigned to them. This paper argues that, because the new legislative strategy is based on a rational goal model and conceptualizes the area agencies accordingly, it neglects certain requisites of organizational life. Using, instead, a social system perspective of the area agencies and their environment, the paper suggests that these agencies will, of necessity, concern themselves with matters other than those mandated in the legislation. These other con cerns will affect both the national objectives which the area agencies choose to emphasize and the intensity of their effort. Specifically, the area agencies may view the mandate to draw-in and mobilize resources at the area level as not in their organizational interests. The paper concludes that: their engaging in this role in tentative fashion will result in either incremental or goal-displaced activities; their em barking in this role wholeheartedly may prove dangerous to them organizationally and may result in substantial mod ifications in the national strategy and their role in it.

Emerging Pressures on Public Policies for the Aging.

O uting the last 15 years, political activity and policy enactments in aging have grown remarkably. Membership in aging-based organizations has increased by a factor of several hundreds to where it now approximates 10 million. New cadres of professionals have created and expanded aging specializations in planning, social service delivery, research, and training. Public agencies on aging, some with cabinet level status, are in place nationwide at all levels of government. Legislative committees on aging at the national and state levels are now well established, both lending political legitimacy to the aging and promoting their policy interests.

Politics and Policies of Aging in the United States

Until some 35 years ago, the politics of aging were relatively benign and policies for the aging were consistently expansionary. However, the more recent period of aging politics and policy has been much more contested. This chapter addresses these developments, reviews factors that account for the transformation in understanding of the policy place of older Americans, and identifies a series of policy-related issues that aging politics will confront in the years ahead. Central to the discussion are political legitimacy and power, institutional barriers and pathways, public and elite opinion, issue framing, population characteristics, and the ever-expanding scope of conflict around aging policy.

The New Political Environment in Aging: Challenges to Policy and Practice

The last quarter-century has seen a notable shift in the context of social policy as it relates to older adults in the United States and those who work with them. Critical dimensions in this shift include changes in the size and makeup of todays older population, the rise of conservatism in contemporary U.S. politics, and the more central place older Americans are coming to assume in policymaking around a host of social and economic policy issues. After briefly reviewing these contextual developments, the author presents 5 challenges they bring to social workers and other professionals working with the aged. Each of these reflect changing expectations, opportunities, and options confronting both policymakers and older people themselves as the dynamics of aging politics and policy evolve in ways that would have been hard to imagine 25 or 30 years ago.

A Block Grant to the States for Long-Term Care

This article addresses the policy issues and outcomes associated with the block grant option in long-term care (LTC). Block grants are being considered in a number of human service areas currently, especially in the wake of the 1980 elections. The article assumes that Medicaid and other LTC-related policies would be consolidated in a formula-based, capped block grant. The potential advantages are in the areas of responsiveness, coordination and institution-building at the state level. Potential problems include new organizational demands on the designated LTC state agency; political dislocations caused by disaffected agency and provider groups; and unequal competition for LTC resources resulting from the removal of legislative safeguards and hierarchical support. The article concludes on the note that proponents of the block grant option have not addressed a number of the major shortcomings that may accompany an LTC block grant.

Draining the swamp while making America great again: senior dissonance in the age of Trump

ABSTRACT In his surprise election as president, Donald Trump enjoyed disproportionate electoral support from older voters, many of whom saw in Trump a person who would work to reverse demographic, economic, and cultural forces that had transformed American life as they had long seen it. Yet, Trump’s campaign and incumbency has also been very much about gutting the Washington policy establishment of officials, bureaucrats, and lobbyists (aka, “the swamp”) which, for more than half a century, has been instrumental in enacting and expanding legislation that has benefitted older Americans far more than any other social policy constituency in the country. This article contrasts the value-oriented electoral support Trump enjoyed from older Americans with their interest concerns centered on policies such as the Affordable Care Act, Medicaid, and a host of smaller grant-in-aid programs. It then reviews the strong institutional base seniors and their advocates have in Washington, posing whether interest-oriented concerns may outweigh ideological ones as policy options emerge from a Republican-controlled government prior to the 2018 elections.

Dementia Cal MediConnect: Creating Partnerships Between Health Plans and Alzheimer’s Organizations to Improve Care in the Dual Eligibles Pilot

People who are living with dementia are highly reliant on family and other unpaid caregivers because of their cognitive impairment and inability to manage self-care. Family caregivers are essential members of care teams, as they carry out care plans and facilitate access to support services. Hence, health care for this population is best delivered in active partnership with family caregivers and community-based Alzheimer’s organizations. With the innovations inspired by the Affordable Care Act, there have been opportunities to implement more coordinated systems of care that seek to engage unpaid caregivers and community providers in the care process and to improve outcomes while controlling costs. One such opportunity is the Federal Centers for Medicare and Medicaid Services’ (CMS) Financial and Administrative Alignment Initiative, a national demonstration program operating in 13 states. This demonstration project (sometimes called the Duals Demonstration) seeks to better coordinate medical care and long-term services and supports (LTSS) for individuals who are dually eligible for Medicare and Medicaid. For dually eligible people living with dementia, these demonstrations have the potential to deliver care in less expensive, community-based settings, which are preferred by most patients and families. In 2013, the State of California’s Department of Aging, in partnership with Alzheimer’s Greater Los Angeles, was awarded a grant from the Alzheimer’s Disease Supportive Services Program of the federal Administration for Community Living (ACL). The aim was to better the care coordination provided to people with dementia in Cal MediConnect (CMC), California’s Financial Alignment Initiative pilot. The project, called Dementia Cal MediConnect (Dementia CMC), built upon the opportunities provided by the federal demonstration’s primary objectives: to improve health care outcomes and expand access to health care and LTSS while controlling cost. With a capitated payment for each member served, CMC incentivized plans to provide necessary care in the appropriate environment. It offered an opportunity to strengthen homeand community-based LTSS and to integrate them better with medical care with the hope of improving care processes and reducing hospitalizations and institutionalization (two of the main drivers of medical expenses for the duals population and for people living with dementia). While the Dementia CMC Project focused on dually eligible health plan members in the CMC pilot, it offered the possibility of improving dementia care more broadly, as it was well known that health plans tend to disseminate

The Transformed Political World of Older Boomers

In their later years, baby boomers will encounter a political world far different from that experienced by either their parents or grandparents. On the one hand, they will face greatly altered economic, ideological, and budgetary circumstances; on the other, their generation’s size and influence will cast them in a more glaring light than was true for those elders who came before them. These factors—both internal and external to the boomers—will have profound effects on the policy experiences of this 76 million member cohort. A promising way of appreciating and anticipating these changes is to explore how older adults, understood as a target population of political and policy activity, have changed over time. Using a typology of such populations, we can see that political perceptions of older people have shifted at least twice over the course of the past several decades. Anne Schneider and Helen Ingram (1993) proposed a simple twodimension, four-fold model to characterize how different target populations of policy-related activity can be understood politically. As seen in Table 1, the first dimension speaks to legitimacy (high or low) and the second addresses political power (high or low). The four derivative target categories are: advantaged (high legitimacy; high power); dependent (high legitimacy; low power); deviant (low legitimacy; low power); and contender (low legitimacy; high power). Writing in the 1990s, Schneider and Ingram found the elderly to be Exhibit #1 in the advantaged grouping, a categorization that few would have disputed. What the authors did not address is how these characterizations can change over time. In the case of older adults, that possibility is a two-time

Introducing the policy forum.

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