Aging with Dignity and Justice: Opportunities to Meet the Needs of All of Us through a National Plan on Aging – Justice in Aging

Introduction

Older adults anchor our families and communities and connect our families through the generations. But after working all their lives, nearly half of our nation’s older adults living alone struggle to pay for food, rent, and medical care. Older adults in two-person households fare only slightly better—one out of five lack the resources to pay for basic needs. Justice in Aging’s vision for aging in America is that all of us have the opportunity to age with dignity, regardless of financial circumstances—free from the worry, harm, and injustice caused by lack of health care, food, or a safe place to sleep. We believe that we should all be able to access the resources, services, and programs we need to thrive as we grow older, no matter our financial circumstances, where we come from, our race, gender, gender identity, sexual orientation, ability, or language.

In 2020, as part of the reauthorization of the Older Americans Act, Congress created the Interagency Coordinating Committee on Healthy Aging and Age-Friendly Communities (ICC). They were tasked with developing a national set of recommendations on key aging issues, and, as the first step in this process, the Administration for Community Living (ACL) convened 16 federal agencies and departments to create a framework and strategic vision. In May 2024, the ICC issued their Strategic Framework for a National Plan on Aging. It is organized into four domains set forth by statute: (1) Age Friendly Communities; (2) Coordinated Housing and Supportive Services; (3) Increased Access to Long-Term Services and Supports; and (4) Aligned Health Care and Supportive Services. The Strategic Framework is intentionally aspirational and high level, and emphasizes the cross-cutting values of person-centeredness; inclusion; respect; and collaboration and innovation.

All of us are aging, and all of us have a stake in how older adults live and thrive in our families and communities. This paper is designed to identify opportunities that building a National Plan on Aging presents. It provides examples of specific policies that a National Plan on Aging could advance to improve the lives of older adults, families, and communities, particularly those who have experienced economic hardships and systemic discrimination.

What can a National Plan on Aging Do?

Identify the Big Issues

First of all, a National Plan on Aging is a critical way for us to identify the biggest issues that we must address for everyone to age with dignity and justice. All of us benefit when older adults can share their contributions and wisdom with our families and communities. By strengthening the programs that older adults rely on, we promote inclusion, respect, and collaboration. From our perspective, some of the biggest issues to address in a National Plan on Aging are in the following areas:

• Strengthen Medicare and Medicaid and expand coverage through new programs so that everyone can access the health care and long-term services and supports that they need to age in their homes and communities.
• Bolster Social Security and Supplemental Security Income (SSI) to address senior poverty and ensure that all older adults have financial security.
• Invest in affordable, accessible housing so that all older adults have a place to call home and are not forced to live on the streets.
• Promote elder rights and prevent and respond to elder abuse and neglect broadly, with a focus on disproportionately impacted communities.

Focus on Older Adults with Greatest Social and Economic need

A successful National Plan for Aging must ensure that how people experience aging is more universal and fair. A plan centered on older adults who are most marginalized will be a plan that addresses the needs of all of us as we age. It must address and end inequities and meet the needs of all low-income older adults, including older adults of color, older women, LGBTQ+ older adults, older adults with disabilities, older adults who are immigrants or have limited English proficiency (LEP), and older adults who are geographically isolated. As the Strategic Framework identifies, almost eight million older adults live at or near the poverty level. And those numbers are even more stark at the intersection of race, gender, and age with nearly one in five Latinas and Black women ages 65 and over living in poverty. To ensure that all of us can age with dignity and justice, laws and policies must address the needs of older adults who experience inequities based on income, age, race, gender, sexual orientation, ability, language, and other identities. This is consistent with the Older Americans Act, which asks service providers to prioritize those with the greatest economic and social needs, such as older adults experiencing cultural, social, or geographical isolation, including isolation due to racial or ethnic status and those facing housing instability or interpersonal safety concerns.

The development of a National Plan on Aging presents unique opportunities to advance the goals set forth in Executive Order (E.O.) 13985, the “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government,” and E.O. 14091, “Further Advancing Racial Equity and Support for Underserved Communities Through the Federal Government.” As part of these orders, each federal agency has been developing an equity action plan and equity leadership—and the National Plan for Aging must be factored in and build upon these efforts.

As the federal government develops a National Plan for Aging, equity should be centered in at least three different dimensions: (1) substantive goals and initiatives, (2) outreach and engagement, and (3) measurement and evaluation. In this context, a national plan can address the biggest issues by identifying equitable goals and initiatives; it should contain an engagement process that includes voices of older adults from traditionally marginalized groups; and the plan should be evaluated on whether and how it has improved the lives of all older adults, especially those experiencing systemic discrimination.

Promote a Whole of Government Approach to Aging

A National Plan on Aging presents the opportunity to elevate aging issues across the federal government. People 65 and older represented 17% of the population as of 2022, and the percentage is anticipated to grow to 22% by 2040. All federal agencies have a role to play in creating policies that allow all of us to age in dignity and justice. Additionally, all federal agencies must consider the needs of older adults, who will soon make up almost a quarter of the population, in every policy created. The ICC has already taken the first steps, by including 16 agencies and departments in the development of the Strategic Framework, and shining a spotlight on how aging intersects with every aspect of government.

Working together, federal agencies and departments can promote coordination of programs and benefits. For example, the Elder Justice Coordinating Council (EJCC), established as part of the Elder Justice Act in 2010, brings together a range of federal partners who work to address elder abuse, neglect, and exploitation. Such work not only strengthens partnerships across the federal government, it can also bring together and catalyze stakeholders to become more involved.

A whole of government approach is not limited to federal government entities. States have growing experience with their multi-sector plans for aging (MPA), including how to make them work, how to fund them, and what roadblocks they have encountered. By designing a National Plan for Aging that incorporates lessons learned from state MPAs, and complements the work being done in states, we can create a National Plan that meets the needs of older adults across the country.

Promote Engagement for Everyone

To be most effective, the process of developing a National Plan for Aging should be inclusive and collaborative. Foremost, it needs to center the voices of older adults, including older adults who have historically had the greatest difficulty being heard. We applaud the efforts currently underway to develop listening sessions and hear from older adults’ voices through projects such as The People Say. Such efforts must also include groups such as Tribal elders, LGBTQ+ older adults, and older adults with Limited English proficiency, and others who have not traditionally been included in policy-making.

Second, federal leaders must promote engagement from all sectors. Everyone needs to be involved. This includes government agencies, but also service providers, advocates, and philanthropy. And we can’t just hear from those whose focus is aging issues—we need aging advocates, disability advocates, and advocates who don’t traditionally work on aging and disability issues. There are many issues that impact how we age, including housing, health, civil rights, and climate change. When everyone is at the table, we develop better solutions.

The process also needs to be transparent and data-informed. Here, the federal government could learn from efforts in state multisector plans to leverage data in implementing plan initiatives, like California’s MPA Data Dashboard. By sharing information and identifying where we have data (and where we don’t), we can develop policy options that work in the real world.

Goals and Opportunities in Each Domain of the Strategic Framework

The Strategic Framework for a National Plan on Aging is organized into four domains: (1) Age Friendly Communities; (2) Coordinated Housing and Supportive Services; (3) Increased Access to Long-Term Services and Supports; and (4) Aligned Health Care and Supportive Services. The next section of the paper examines each domain and some of the opportunities they could present to improve the lives of older Americans, particularly those who are low-income and have the greatest social and economic needs. For each domain, we describe several opportunities for impact and sample policy initiatives that we believe would fulfill the promise of a national plan on aging. These opportunities and policy initiatives are meant to be illustrative of the type of work that can be done in the domain.

Domain 1: Age Friendly Communities

Domain Focus Areas: Purpose and Engagement; Social Connection; Accessibility and Universal Design; Transportation; Economic and Financial Security; Age-Friendly Health Systems

Economic Security is Key

We appreciate that the Administration for Community Living included economic security in the Age-Friendly Communities domain. Without economic security, older adults cannot age with dignity, make choices, contribute to, and participate in our communities. Despite working all their lives, raising families, and building our communities, nearly half of the nation’s older adults living alone have trouble paying rent, buying food and medicine, and keeping the lights on. Discrimination, wealth inequality, and inadequate Social Security benefits all contribute to high rates of senior poverty and homelessness. Over seven million older adults live in poverty today.

Opportunity for Impact:

• Help low-income older adults obtain access to and maintain critical income and related benefits, especially Supplemental Security Income (SSI) and Social Security.

Sample policy initiative:

• Low-income older adults who are eligible for SSI have trouble accessing this critical benefit because of the program’s complex and confusing rules. Key features of the SSI program have not been updated in decades, leading to even fewer eligible older adults obtaining benefits. Legislation to update this program, for example, allowing individuals to receive benefits while saving for emergencies, or removing penalties SSI recipients currently incur if they decide to get married, would remove significant barriers to participation and allow more older adults to get the support they need.

Age-Friendly Communities that Include All of Us

For age-friendly communities to be successful, all of us must be able to access the services we need, especially those of us who have been marginalized and face systemic discrimination. When programs are designed to be as accessible as possible, using universal design principles, all of us can live in communities that work for all ages and abilities.

Opportunities for Impact:

• Ensure that the programs and services older adults rely on are serving older adults equitably.
• Increase language access for older adults with Limited English Proficiency.
• Promote equitable health, economic security, and justice for Tribal elders.
• Increase access to benefits and services for older adults who are reentering the community from carceral settings.

Sample policy initiative:

• A growing number of older adults have limited English proficiency. Federal programs and activities, as well as those receiving federal financial assistance, are required to provide meaningful access for all individuals with LEP, including possibly oral interpretation and written translation services. Despite this requirement, many older adults with LEP frequently encounter barriers to accessing critical language assistance services, sometimes having to rely on unqualified family members and friends or, even worse, navigate a program or service without any assistance. A national plan on aging should work with existing efforts at a federal level to advance language access, like the HHS Language Access Coordinator and the federal language access plans. The plan is an opportunity to ensure that all older adults with LEP receive qualified, timely, and free language assistance services across all federal programs and activities and those receiving federal financial assistance.

Domain 2: Coordinated Housing and Supportive Services

Domain Focus Areas: Housing Stability through Coordinated Services; Affordable Housing; Accessible Quality Housing; Homelessness Prevention

Affordable, Accessible Housing is Key

Regardless of economic status or where we live, we should all be able to live and age in accessible, affordable, age-friendly housing in our communities. Yet, older adults are at the epicenter of the national housing affordability and homelessness crisis.

Nationally, almost one in three older renter households pay more than half of their monthly income for rent, leaving them just one surprise medical bill away from being pushed into the streets. Because of systemic inequities that have compounded throughout their lives, older adults of color are more likely to face extreme rent burdens, and are at much greater risk of becoming homeless.

Legal assistance can play a critical role in helping older adults remain housed. For example, studies show that tenants who have legal representation in eviction cases are two to three times more likely to remain in their homes than those without representation.

Opportunities for Impact:

• Increase access to affordable, accessible housing.
• Protect older tenants’ rights to remain in their housing by strengthening eviction and civil rights protections and improving access to legal assistance.
• Prevent and reduce homelessness for low-income older adults.

Sample policy initiative:

• Housing discrimination based on disability, race, and other characteristics contributes to housing instability among low-income older adults. Legislative measures must increase investments in programs serving older adults at risk of or experiencing homelessness while also addressing systemic housing discrimination. Increased funding for HUD’s Fair Housing Initiatives Program (FHIP), Fair Housing Assistance Program (FHAP), and the Office of Fair Housing and Equal Opportunity (FHEO) would strengthen enforcement of fair housing policies and protect older adults at risk of homelessness.

Domain 3: Increased Access to Long Term Services and Supports

Domain Focus Areas: Paid and Unpaid Caregivers; Whole-Person Health Financing; Elder Justice; Person-Centered Access System – “No Wrong Door” and Other Statewide Access Systems

Long-Term Services and Supports are Key

Most older adults and people with disabilities will require assistance to remain living in their homes and communities at some point over their lifetime. A strong long-term services and support system, including but not limited to Medicaid, and one that considers the people providing both paid and unpaid care, is essential for all of us to age with dignity and justice. We need a care economy that works for everyone.

Medicaid is the largest payer of the wide range of services and supports—known as home- and community-based services (HCBS) —that enable many people with disabilities of all ages to live independently and fully participate in their communities as they choose. HCBS are also more cost effective for states and the federal government than institutional care, making this investment an all-around win for individuals, families, workers, and state and federal governments.

Opportunities for Impact:

• Increase affordability of LTSS and expand coverage.
• Strengthen and expand equitable access to Medicaid Home and Community-Based Services.
• Improve quality of assisted living and nursing facilities.

Sample policy initiative

• Increasing Medicaid financial eligibility limits would make LTSS more affordable and accessible to millions of older adults who today cannot afford care. Current Medicaid income and asset limits are exceedingly low, forcing older adults into deep poverty in order to obtain the care they need to remain living at home and in their communities. Research shows that increasing Medicaid financial eligibility would particularly benefit older adults of color who, due to discrimination, have lower incomes and resources.

Ensuring dignity and autonomy for everyone

Older adults are valued members of all vibrant communities. Elder justice is about fostering social structures and creating policies that enable older adults to remain engaged in their communities and society as whole—free from the threat of abuse, neglect, and exploitation. As people age, loneliness and isolation can lead to abuse. When older adults have access to the supportive services they need, including legal assistance to help them assert their rights, they stand a better chance of remaining engaged, empowered, and able to advocate for themselves as they age.

Responses to elder abuse need to be designed to work for everyone. Communities who have experienced discrimination and harm in structures such the criminal legal system, may be hesitant to report or seek help for abuse. Supporting policies and solutions that provide alternatives, such as access to civil legal assistance and restorative justice, help us address elder abuse in marginalized communities.

Opportunities for Impact:

• Ensure that older adults with the greatest social and economic needs have access to quality, person-centered legal assistance.
• Improve quality and address inequities in the guardianship and elder abuse response systems.

Sample policy initiative

• Federal demonstration grants to legal assistance providers, such as through the Legal Assistance Enhancement Program, have helped programs build capacity to better serve older adults with the greatest social or economic need. Increasing the availability of these grants through robust Older Americans Act funding can bolster the quality and effectiveness of legal services for older adults throughout the country, particularly those services that protect elder rights and assist with access to long-term services and supports that help older adults age safely in the community of their choice.

Domain 4: Aligned Health Care and Supportive Services

Domain Focus Areas: Benefits Access; Optimize Health, Well-Being, and Functioning; Aligning Health and Human Services

Medicare and Medicaid are Key

Medicare and Medicaid cover many essential services and supports and are the only source of health and LTSS coverage for older adults with limited income and wealth. Yet, gaps in scope, availability, and affordability of this coverage mean that many older adults cannot live in their own homes if they need help with activities of daily living or get basic care like dental, vision and hearing. These programs need to be expanded and streamlined so they are easier to qualify for and access.

Due to systemic injustices and discrimination that compound over their lifetimes, older adults from marginalized communities face barriers in accessing the care they need and suffer poorer health as a result. According to some estimates, by 2060, older adults of color will comprise almost 50 percent of the 65+ population, or 95 million people. As the COVID-19 pandemic demonstrated, older adults of color, LGBTQ+ older adults, older adults with disabilities, older adults with Limited English proficiency, and those with intersecting identities face the most barriers and are most reliant on Medicare, Medicaid, and other public programs to meet their needs.

Opportunity for Impact:

• Expand eligibility and strengthen Medicare and Medicaid for low-income older adults.
• Reduce inequities in health care access by streamlining rules and addressing discrimination.
• Improve the delivery of care for individuals dually enrolled in Medicare and Medicaid.

Sample policy initiative

• Adding a dental benefit to Medicare Part B would improve access to dental care for over 67 million older adults and people with disabilities enrolled in Medicare. Currently, Medicare does not cover routine dental care, and, as a result, half—or approximately 30 million older adults and people with disabilities—did not visit a dentist in the last year. This is even more severe among communities of color: 68% of Black and 61% of Hispanic Medicare enrollees did not see a dentist in the last year compared to 42% of white Medicare enrollees. Adding a dental benefit to Medicare would address these inequities in access and ensure all Medicare enrollees have access to dental care.

Conclusion

Creating a national plan on aging is an opportunity to ensure that programs and services are available, accessible, and coordinated for all older adults. The Strategic Framework issued by the ICC is a needed first step. If we create an inclusive plan, we can build a world where our experiences aging in this country are not fraught with barriers, discrimination, and invisibility, but rather are filled with recognition, dignity, and celebration.