An increasing population of older adults is one indicator of societal progress—a demographic shift that comes with both benefits and challenges to individuals, families, and communities. One result of a growing aging population is increasing health and long-term care costs. Medicare and Medicaid, the two largest public health care programs in the nation, have increased dramatically, due to both the growing aging population and rising health care costs. Federal funding allocated to social care, however, has been relatively stagnant for decades. Critics of current spending patterns suggest that limiting federal funding on social care services contributes to increasing health and long-term care costs (Thomas and Applebaum, 2015). For example, one study found that states with fewer supportive services (e.g. meals and personal assistance) had higher proportions of low-care residents in nursing homes (Thomas and Mor, 2013). Another study demonstrated that congregate meals lowered nursing home and hospital admission rates (Malbi et al., 2018).

A dramatic expansion of home and community-based services (HCBS) through Medicaid waivers that provide services such as personal care, home-delivered meals, and medical transportation has been an important federal and state initiative in response to this challenge. Although Medicaid HCBS waiver expenditures for older people and adults with disability topped 60 billion in 2019, more than 90% of older Americans are not eligible for Medicaid (Murray et al., 2021; Thomas and Applebaum, 2015). For many older people who do not meet the strict income and disability threshold for Medicaid eligibility, the gap in long-term services and supports coverage is considerable.

For many older people who do not meet the strict income and disability threshold for Medicaid eligibility, the gap in long-term services and supports coverage is considerable. This funding strategy means that most older Americans with moderate or severe levels of disability are not eligible to receive social care until they have become impoverished.

The major federal program of social care to support older people in the community has been the Older Americans Act (OAA), and funding has been dramatically reduced over the last four decades. In 1980, the OAA allocated $1 billion ($3.41 billion when adjusted for inflation) to support 35.6 million older adults, whereas in 2024, the OAA has received an allocation of $3.14 billion to support more than 70 million older adults (Congressional Research Service, 2018; U.S. Department of Health and Human Services, 2024). This funding strategy means that most older Americans with moderate or severe levels of disability are not eligible to receive social care until they have become impoverished.

Public Policy & Aging Report, https://doi.org/10.1093/ppar/prae009

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