Last month, the Administration on Aging (AoA), the part of the Department of Health and Human Services that is responsible for the programs under the Older Americans Act (e.g., meals, senior centers, and aging and disability resource centers), was reorganized and will now be a division within the Administration for Community Living. According to Secretary Sebelius in her statement, “For too long, too many Americans have faced the impossible choice between moving to an institution or living at home without the long-term services and supports they need. The goal of the new Administration for Community Living will be to help people with disabilities and older Americans live productive, satisfying lives."
I’m sure that in some way, this reorganization is an outgrowth of the debacle over CLASS, the ill-fated title VIII of the Affordable Care Act that tried to create a voluntary long-term care insurance benefit for the old and young who need long-term support. I suspect that on the one hand, advocates and agency staff learned how related the interests of older adults and younger disabled can be around consumer-directed long-term care benefits. On the other, I suspect they learned how hard it will be to create a long-term care system and as a consequence have decided to focus on community living instead of long-term care or aging as more acceptable framings of the issue.
There are two things that I take from this action and the statements made by senior leadership about the reorganization. One has to do with organizational structure and the second has to do with ideology.
First, while I am not an expert interpreter of government organizational structure, I know that many times partisans of an issue want to see its priority reflected in the appointment of a “Czar,” or a cabinet secretary, or even an independent department. Yet as far as I can see this reorganization suggests a definite “downgrade” of the priority given to aging issues right at the time that the aging of the baby boom cohort is producing the so-called “silver tsunami” of demographic change.
For now, Kathy Greenlee, who came to Washington from Kansas with HHS Secretary Kathleen Sebelius, will serve in the dual roles of Administrator for Community Living and Assistant Secretary for Aging. But will this tradition of wearing both hats continue? Will the head of the aging division of ACL be as prominent in the future?
Second, ideologically, the philosophy of the reorganization seems to be that Aging is the same as Long-Term Care and that “institutional” long-term care is invariably bad for people. If so, I think this is wrong on both points. Aging is far more than long-term care, and AoA’s part in preparing the nation for the aging population through evidence-based health promotion work and hospital readmissions reduction programs has been vital. In the more distant past, under title IV of the Older Americans Act, AoA funded scholarships and human capital investments that have produced many of the leaders in the field of aging today.
Moreover, while we must reverse the “institutional bias” towards favoring nursing homes for long-term care over home-based solutions, I think that high-quality institutional care is likely to be an important part of the spectrum of care for many people in the future. (For example, see Executive Director Cory Rieder’s post on her parents). Perhaps the disability community feels that institutional care is never appropriate, but for older adults I would not want to see the national struggle to create high quality, person-centered institutional long-term care abandoned in favor of an unrealistic hope of total community residence. At any given time, about four percent of the older adult population resides in more-or-less institutional settings. That should be less–perhaps two or even one percent ought to be in an institutional setting–but it won’t be and shouldn’t be zero.