Abstract
Objectives:
Some communities across the nation are utilizing alternative funding sources to better support home and community-based services for older adults.
Methods:
A variety of methods identified local initiatives across the United States. An online survey was distributed to a total of 377 communities in 15 states identified as using locally raised funds to provide aging services, yielding a 55% response rate.
Results:
Total funding from programs generated almost 400 million dollars annually with funding ranging from $8000-$47 million. Commonly provided services with local funds include home-delivered and congregate meals, transportation, and homemaker services with provision varying by the size of the levy initiative. Additionally, six in 10 initiatives reported local funds being used to provide at least one family or friend caregiver service.
Conclusion:
Locally-funded initiatives fill a gap in long-term services needs for older adults, yet policy concerns regarding potential inequities across states and communities warrant attention.
This is the first study to identify and survey local initiatives across the United States designed to support aging services that are supported by local funding initiatives including property levies, payroll, and sales taxes.
Locally-funded program operations and management differ within and across states.
The study discusses the critical nature that social care provides in supporting older people to remain independent in the community.
Local funds to support aging services span 377 communities across 15 states.
About $400 million is generated annually in local funds for aging services.
Policy implications are discussed in light of federal and state funding.
Background
While the nation celebrates improvements in life expectancy, the dramatic increases in Medicaid and Medicare expenditures to meet the health and long-term services needs for older people represent a growing policy challenge. A major criticism of the U.S. system is the limited social care investment in comparison to our efforts in response to acute medical conditions. In particular, funds allocated to the Older Americans Act (OAA), the major federal level social support and care initiative, have not increased with inflation or in conjunction with the growth of the older population (Congressional Research Services, 2018). The OAA supports a range of home and community-based services (HCBS) including home-delivered and congregate meals, family caregiver support, health promotion, and others. However, the limited social care expenditures have been identified as one of the reasons that the U.S. experiences much higher health and institutional long-term care expenditures than other countries with similar economic profiles (Squires & Anderson, 2015). Over the last two decades, states, in partnership with the federal government, have expanded HCBS through Medicaid waivers as a response to these concerns. Services, such as personal care, home delivered meals, and medical transportation have been dramatically expanded, allowing states to substantially shift Medicaid funding from institutional to home and community-based care (Eiken et al., 2018).
Despite this considerable progress in creating a more balanced long-term services and supports (LTSS) system, critics continue to express concern that the Medicaid driven LTSS approach excludes many older adults with disability. The major weakness of the current approach is that the vast majority of funding for LTSS comes through Medicaid, even though only 11% of older adults are Medicaid eligible (Lee & Jarosz, 2017). This creates a large gap in service coverage, especially for older people with low and moderate incomes who are above the Medicaid eligibility criterion.
When HCBS services are not available or financially accessible, families are often called upon to fill in and provide needed care and support (National Academies of Sciences, Engineering, and Medicine, 2016). In 2017, over 41 million U.S. family caregivers provided an estimated 34 billion hours of care to an adult with limitations in daily activities (Reinhard et al., 2019), and the number of persons providing care for someone age 50+ has steadily increased in recent years in step with the growing older adult population (National Alliance for Caregiving & AARP, 2020). While HCBS is rightfully focused on the needs of the older adult with disability, family and friend caregivers are also affected by the provision—or lack of—services. Unpaid family caregiving has been shown to have negative impacts on caregiver work-life, health, and emotional, social, and financial well-being (National Alliance for Caregiving & AARP, 2020). There have been repeated calls for increased attention to caregivers and a more person- and family-centered approach to the implementation of HCBS, including caregiver assessment and services and resources targeted directly to family and friend caregivers (Feinberg, 2014).
The rationale for an expansion of social care or support services has been highlighted through several important studies. For example, one study of states found that those with fewer supportive services have a higher proportion of low care residents in nursing homes (Thomas & Mor, 2013). Another study found individuals receiving congregate meals were less likely to be admitted into nursing care facilities or be admitted to the hospital compared to older adults who did not participate in congregate meals (Mabli et al., 2017). Research on homebound older adults with a previous history of falls revealed a reduction in risk of falls among those who received daily meal delivery services (Thomas et al., 2018). Additionally, findings indicate that older adults who obtain meal delivery services receive multiple benefits, on top of the nutritional advantages, such as social support and bonds with the Meals on Wheels staff and drivers (Thomas et al., 2020).
While these and other studies demonstrate the importance of the services funded through the OAA, the 2018 $2.1 billion allocation was well below the 1980 amount when corrected for inflation of $3.41 billion and when combined with a doubling of the older population, the resource limits are evident (Congressional Research Service, 2018). State funded home care programs have been one solution to this challenge, but budgetary pressures have limited these efforts. One unique response from local communities has been to use alternative funding strategies, such as property tax levies, to provide social care to older residents (Koumoutzis et al., 2021). As such, this work describes the first national study of community initiatives developed to provide services to older adults through locally generated tax revenues and provides insight into their caregiver support efforts.
Methods
There is no existing database available to identify which communities, or even which states, are using locally supported tax initiatives to fund services for older people. To identify and subsequently survey local programs, an array of resources and techniques were employed. In the initial stage of the study, the research team sought to identify states that had at least one locally supported effort. Several actions were implemented to accomplish this task including: using the 2019 Advancing States national survey of state units on aging that asked about locally-funded home and community-based services programs; telephone calls to state units on aging, area agencies on aging, aging services providers, county auditor offices, and Secretary of State offices; online reviews of county budgets for special levies; and web searches for local levies and ballot initiatives. These efforts identified 15 states reporting the existence of local programs generating funding for services to support older people in 377 unique communities. The search process also identified contacts for each of the local community initiatives in preparation for a national survey. Study protocols were reviewed and approved by the Miami University institutional review board (03244e).
The second step involved the development of an online survey to be completed by the identified local communities. The survey focused on the following aspects of the local initiative: type of host organization and its role as related to the funding initiative; source and amount of local funding; services provided to older individuals and their family and friend caregivers; number of individuals served or units of service provided; amount of local funds spent for each service; and program characteristics such as eligibility criteria, cost share, and use of local funds as a match. A 30-question Qualtrics survey was distributed via email to local funding organizations in January and February 2020. Follow-up protocol included a reminder email sent via Qualtrics to contacts who had not completed the survey within 3 weeks and phone calls to contacts who had not responded within 5 weeks. Follow up calls were scheduled to begin in mid-March 2020, just as the severity of the COVID-19 outbreak was becoming apparent and organizations across the nation were closing to follow public health safety protocols. As a result, calls to host organizations to encourage survey completion were delayed until June 2020, severely interrupting the survey completion process. In all, researchers made 397 phone calls and resent links to 164 organizations in the follow-up process. See Supplemental Appendix A for survey instrument and interview guide.
Completed surveys were received from 228 organizations for a response rate of 55%. To supplement the online surveys, we collected data from local tax records allowing us to have data on the actual initiative dollar amounts in 347 communities or 92% of the identified localities. Descriptive analyses, including measures of frequency and central tendency of quantitative survey data were conducted using SPSS (IBM Corp, 2020) and SAS v9.4 (SAS Institute Inc., 2016). Following initial summary statistics, additional descriptive analyses were conducted. Aging services levy initiatives were categorized based on variations in the per capita resources generated by programs across states (n = 216). The average per capita generated by the local initiatives was $36 (SD = 46.18). The range of these per capita resources varied greatly from less than one dollar to $287. A large number of levy initiatives generated per capita resources that were $10 or less. Based on program access to resources and sample distribution analysis groups were broken down by programs that generated $10 or less (n = 85), $10.01-$30 (n = 55), $30.01-$65 (n = 37), and greater than $65 (n = 39) per-person age 60 and older in the community served. Initiatives where per capita rates could not be calculated due to missing data on the generated dollar amounts were excluded from these analyses (n = 12).
Because of the importance of family and friends in the care and support of community-dwelling older adults, the study was also designed to better understand how such local initiatives supported unpaid caregivers. To examine this area, two strategies were used. First, the online survey included a series of questions about the types and amounts of services that were targeted directly to family and friend caregivers. A second approach involved semi-structured telephone interviews with respondents from 29 service organizations who indicated in their online survey that they provided caregiver services with local funds. Service organizations were selected to provide representation from each of the states with local funding identified through the online survey and to include different types of organizations such as area agencies on aging, councils on aging, county departments on aging, senior centers, and community service providers. Online survey respondents were asked to provide a contact for the person within their organization who could best speak about caregiver services. The telephone interviews inquired about current services and strategies used to support caregivers, gaps in knowledge, needed resources, and barriers to enhancing caregiver support. Telephone interviews were audio-recorded and transcribed to assist in analysis and interview transcripts were reviewed for accuracy by three research team members. A priori codes based on the interview questions were applied to the transcripts and common themes between interviews were then identified through multiple reviews of the transcripts and repeated discussion between the three research team members until consensus was reached. See Supplemental Appendix B for survey instrument and interview guide.
Results
Table 1 shows states and counties with aging services levies. Although most levies are generated at the county level only, levy initiatives in townships, villages, or cities also exist within some counties and when this occurred total dollar amounts reported reflected all initiatives in the locality. The 377 communities distributed across 15 states generated about $400 million annually in local funds to support aging services. There was considerable variation in the number of initiatives by state and the size of those efforts. States with widespread initiatives for local funding programs included Ohio (74), Michigan (69), Missouri (55), and North Dakota (49). California and Washington had one levy program operating in the cities of San Francisco and Seattle, and Kentucky and South Carolina had three initiatives each. The average funding amounts varied within and across states. Annual funding ranged from a low of $8500 for a small county to a program in an urban area that topped $47 million. The average initiative in Missouri was $29,000 per year, while Ohio programs averaged $2.73 million annually. The county property tax levy was the most common source of local funding reported, but payroll, sales, and income taxes were used in a small number of communities across states.
Local Funding Amounts Within States (Mean and Range).
Note. Most initiatives are county-wide, but some are at the township, village, or city level within a county.
Dollar amounts are based on data from 347 initiatives, so the total is an underestimate of the dollars generated locally across the nation
Operational approaches to administer local efforts varied between and within states (see Table 2). In about one-third of the initiatives (35%), the locally generated funds were administered by governmental entities, often the county auditor’s office. One in five initiatives were administered through a County Council or Commission on Aging (21%) or a local senior center (18%). Area Agencies on Aging administered the local funds in 13% of the cases and one in 10 were some other type of non-profit entity (11%). The majority of these host organizations indicated either receiving and using funds for services directly for older adult and/or their family or friend caregivers and/or contracting with other agencies to provide services. In some instances, local funds were distributed by an organization who did not provide services (e.g., county clerk’s offices, county auditor’s offices, or volunteer boards appointed by county commissioners).
Locally-Funded Program Management and Responsibilities.
Note. N = 228 survey respondents.
Table 2 also shows locally-funded program management activities. Functional criteria, such as impairments in the ability to perform activities of daily living (34%), and income criterion (15%) were used as an indicator of service eligibility. Nearly four in 10 programs reported requiring a payment or cost share by the older adult based on income for at least some services. Programs rarely (6%) reported that family/friend caregivers were able to hire their own aide or homemaker with the use of local funds.
Almost 90% of programs reported that local funds were used for operational or administrative expenses such as utilities, building maintenance, wages, or for office supplies. Programs also reported that local revenue was used as a match for other funding sources. Specifically, programs indicated support for the Older Americans Act (44%) and state funds (29%) but rarely as a match for Medicaid (4%).
Locally-funded program monitoring strategies were also described, with half of the agencies reporting the use of consumer satisfaction surveys (56%) and provider audits (49%) to monitor services. Lesser reported strategies included provider certification, family satisfaction surveys, and unannounced home visits. Some programs also indicated other strategies used to monitor locally funded services including required budget reports, communication with clients and providers, National Council on Aging and National Institute of Senior Centers accreditation, and governing boards.
As shown in Table 3, the services for older adults most commonly provided with local funds were home-delivered (81%) and congregate (73%) meals, non-medical (61%) and medical transportation (61%), and homemaker services (49%). Nearly four in 10 programs (38%) also indicated that care/case management was provided with local funds. Local funding was used for a wide array of additional services such as, emergency response systems (22%), home modifications (17%), and mental/behavioral health services (11%).
Locally-Funded Program Services.
Six in 10 initiatives (63%) indicated that local funds were used to provide at least one family or friend caregiver service, as indicated in Table 3. However, an array of services directed to caregivers were not routinely offered. For example, respite, a widely known caregiver support service, was provided in about one-third of these programs; assessment of caregiver needs occurred in three in 10 initiatives. Caregiver support groups and educational programs were also provided by about one-third of these local initiatives. Although most programs provided only one or two services directly targeted to caregivers, over one-half of initiatives indicated that they would be interested in learning about a variety of service options to better support family or friend caregivers with their local funds.
Table 4 shows how the locally-funded program management differed in communities based on varying per capita resources generated by programs. There were wide variations in the per capita resources generated by programs across and within states, ranging in size from $.49 per-person age 60 and older in Crawford County, Kansas to $287 per person 60+ in Belmont County, Ohio. Results indicated that areas with larger per capita rates reported more management activities, program management and operations, and strategies to monitor locally funded services. For example, initiatives with per capita rates that were larger than $65.00 reported using functional (46%) and income criteria (21%) at higher rates compared to programs whose per capita rates were $10 or less (17% and 14%, respectively). Consumer or self-direction was more often reported in those initiatives where per capita rates were higher than $65.00 (12%) compared with those programs whose generated levy resources ranged between $30.01-$65 (6%), $10.01-$30 (5%), and $10 or less (5%). Programs with larger generated per capita resources also reported higher rates of using local funds as a match such as for the Older Americans Act, state, and Medicaid. Monitoring strategies, such as provider audits, consumer satisfaction surveys, provider certifications, unannounced home visits, and family satisfaction surveys, were also used more frequently in those programs with higher per capita expenditures.
Program Management in Communities with Varying Per Capita Levy Rates.
Service provision also varied based on differing per capita resources generated by programs (see Table 5). On average, areas with higher per capita rates reported providing more services such as meals (i.e., home delivered, congregate), transportation services (i.e., non-medical, medical), and homemaker services. One of the largest differences observed is in the provision of homemaker services. About 32% of those programs whose generated levy resources ranged between $10 or less per capita compared to 78% who generated between $30-$65 per capita. Similar trends are also seen with medical transportation and home repair services. However, providing mental/behavioral health services did not vary by per capita rates of levy support, with programs generating $10 or less per capita (14%) reporting similar service expenditure proportions as programs with more than $65 per capita (15%). Programs whose generated levy resources were greater than $65 also reported providing more care management with local funds (53%) compared to programs that generated $10 or less per capita (31%).
Program Services in Communities with Varying Per Capita Levy Rates.
More robust provision of caregiver services was observed among areas with larger per capita rates. Programs with higher per capita expenditures were more likely to provide at least one caregiver service compared to smaller initiatives. For example, 54% of programs with per capita rates below $10 reported providing services for caregivers, while 78% of those programs whose initiatives generated $30 or more per capita funded caregiver services. Larger initiatives also reported providing more respite, education/training programs, assessments of caregiver need, family or friend caregiver support groups, counseling programs, and programs for family or friend caregivers with specific illnesses or impairments.
The telephone interviews with service providers found that not all reported services were directed specifically to family and friend caregivers, but were often services targeted to older adults, with the potential to also benefit caregivers. While there were a handful of organizations that reported providing very robust services for caregivers in multiple categories, such as respite, education, and support groups, many organizations offered limited support to directly benefit caregivers. Nearly all interview respondents reported limited financial resources and staffing for caregiver support and that the caregiver services they provide are funded through a combination of sources including OAA Title III, the National Family Caregiver Support Program, and in some cases, state funds; sharing that the local funds they received allowed them to expand and enhance services to serve more people.
Respondents also reported barriers they encounter in delivering and enhancing caregiver services. Technology and “digital divide” challenges were frequently mentioned and multiple respondents expressed the need for training and resources to assist in providing virtual services to caregivers during the COVID-19 pandemic. Respondents reported Wi-Fi access and reliability, especially in rural and frontier regions, as an added barrier. The reluctance of family and friends to self-identify as “caregivers” was also regularly reported as a challenge in marketing and providing caregiver support. Nearly all respondents expressed interest in learning from other service organizations about best practices and available resources for enhancing their caregiver programming.
The study faced several limitations. There was no national database of local initiatives, and while the study used every means available to identify local communities generating funds for aging services, there were likely some initiatives that were missed. The height of the COVID-19 pandemic occurred during the survey process and the 55% response rate, while respectable under the conditions of the study, limits our ability to generalize results. Being able to collect local initiative dollar amounts for 92% of all initiatives in the study did however provide a good accounting of the total dollars generated by these efforts. The service organizations selected for the caregiver telephone interviews were chosen to represent different states and types of organizations, but the sample of organizations is not representative of all organizations providing services to caregivers with local funding support.
Policy Implications
Combining the projected growth of the older population in the U.S. with the very high health and long-term services expenditures highlights the need for reform. Critics of the aging service delivery system have identified the lack of finances for social care and supports as a contributor to the high acute and long-term services costs and a higher reliance on institutional care. Compounding these concerns are the Medicaid driven policies in the long-term services arena that channel most public support through Medicaid, even though about 90% of older people are not eligible for this program (Lee & Jarosz, 2017). As described, evidence exists to indicate that social support services, such as home-delivered meals and personal care, can reduce the need for higher levels of care (Thomas & Mor, 2013). Critics have also consistently argued that the current efforts fail to allocate resources to preventive or supportive services, contributing to the higher costs of the U.S. system. The one federal program designed to provide preventive and supportive services, the OAA, has been cut in real dollars, except for the recent CARES response to COVID-19 with a one-time funding allocation (Congressional Research Service, 2018; DHHS, 2020).
Federal and state reliance on Medicaid as the safety net program for a small proportion of older adults has motivated local communities to seek alternative funding. The more than $400 million annually generated by local communities represents a sizeable resource, particularly considering that the comparable services allocation nationally under the OAA is about $1.3 billion. If this approach, now in less than 400 communities across the nation continues to increase, it is quite possible that over the next decade, it could eventually be comparable to OAA funding. That local initiatives spent a substantial proportion of their funds on core social care services, such as home delivered meals, transportation, personal care and homemaker services, lifeline, and supports for caregivers highlights the inadequacy of the current system. While such services are supported by both the OAA and Medicaid HCBS programs, the high use of these services by locally funded programs is an indicator of the amount of unmet need that currently exists. It is also noteworthy that four in 10 programs provided care management services, often unavailable for the non-Medicaid HCBS population. The services funded by these local initiatives provide a window into the failures of the current system. It is often difficult to understand the impacts of not providing services in a community, but the financing of these social care services provides strong evidence about what older adults could use if adequate funds for social care services were made available.
While the local initiatives have been praised as an innovative funding source, critics have also raised policy questions about this approach. An area of criticism focuses on whether the widely used property tax levy approach fuels community level inequities, such as those that occur in school funding. Does this approach provide even more resources to affluent regions, widening the disparity between high- and low-resourced counties across a state? This debate has been one of the dominant concerns expressed about inequities in America’s schools, and such an approach could result in similar outcomes for older adult care. While proponents of local levies recognize this concern, they argue that the federal and state policy failures have left so many older people without the needed supports in their communities, that not doing something is worse than adding to societal funding inequities.
One argument is that the type of services provided by these local initiatives should be provided nationally as a federal program and the proliferation of such efforts will justify the federal government’s lack of action in this arena. Critics contend that if a growing number of communities established local programs, a national effort will not have the necessary political support and this will result in more inequities within and between states. This debate has been a consistent one throughout the history of social welfare, and as a nation, we have developed programs using both of those strategies. Areas, such as schools and services for individuals with developmental disabilities, have largely fallen to states and local communities; Social Security and Medicare operate nationally; and Medicaid represents a state/federal partnership. Each of these have unique legislative histories, and while individual ideology may dictate ones preferred approach to program financing, the politics of the era ultimately determine acceptability and passage.
Regardless of one’s policy perspective on local initiatives, these efforts appear to be very good politics. For example, in a review of property tax levies in Ohio across six recent elections, the passage rate was 98%, with voting margins at about 70% (Applebaum & Goldstein, 2019). The Ohio analysis also found no difference in passage rates between red and blue counties across the state. While there is a growing debate in Washington about tax policy and program support, at the local level, such efforts receive consistent and widespread support. It appears that when local voters can see the specific outcome of their tax dollars, some of the partisan divide is put aside.
The challenges we face as an aging nation are considerable. Our lack of investment in social care contributes to the inefficiency of the health and long-term services system. National policy efforts now being proposed could represent a partial response to some of these concerns; however, the new funds are still linked to the Medicaid program. Such an approach does very little to help the 90% of older Americans not eligible for Medicaid. An approach that includes both preventative services and social care for older people with low to moderate income levels and moderate levels of disability is critical to achieving a high quality and rational delivery system. The role of local communities in achieving such a goal has grown considerably. While such local initiatives may not be the ideal approach for some policy analysts, right now it is the strategy that has made great strides in recent years. It is difficult to tell local communities to wait for a national program, which was the message that the first levy program in Ohio received more than 40 years ago. Perhaps a state/federal/local program can be designed to support such efforts moving forward. While the ultimate solution is not clear, what is evident is that the current strategy that ignores social care for America’s older population is a failed approach.
Supplemental Material
sj-docx-1-jag-10.1177_07334648221090945 – Supplemental material for If You Ask Them, They Will Support: A National Study of Local Initiatives Developed to Provide Social Care to Older Adults in the Community
Supplemental material, sj-docx-1-jag-10.1177_07334648221090945 for If You Ask Them, They Will Support: A National Study of Local Initiatives Developed to Provide Social Care to Older Adults in the Community by Athena Koumoutzis, Jennifer Heston-Mullins, Pamela S. Mayberry and Robert Applebaum in Journal of Applied Gerontology
Supplemental Material
sj-docx-2-jag-10.1177_07334648221090945 – Supplemental material for If You Ask Them, They Will Support: A National Study of Local Initiatives Developed to Provide Social Care to Older Adults in the Community
Supplemental material, sj-docx-2-jag-10.1177_07334648221090945 for If You Ask Them, They Will Support: A National Study of Local Initiatives Developed to Provide Social Care to Older Adults in the Community by Athena Koumoutzis, Jennifer Heston-Mullins, Pamela S. Mayberry and Robert Applebaum in Journal of Applied Gerontology
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article was supported by RRF Foundation for Aging (Grant No. #2018-162).
Supplemental Material
Supplemental material for this article is available online.
References
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