Aug 11
We have no national aging policy. Medicare and Social Security provide a critical foundation, but are politically vulnerable and long overdue for an upgrade. More importantly, the vast array of supports and opportunities that need to go along with a rapidly aging population – from long term care and housing to new technology – are going completely unattended. The national silence about the demands of our aging population is deafening. Read more
For all the attention that is going to the turbulence in Washington, it is easy to overlook some exciting and reasonably large-scale social policy innovations happening in cities and states. These initiatives involve significant scale and commitments of resources, and if fully implemented could produce a statistical bump in life opportunities for low-income and vulnerable populations.
Los Angeles has elevated homelessness to the Mayor’s top priority and has begun implementing a series of significant policy and program steps to respond to an estimated 21,000 people on the street. The Comprehensive Homelessness Strategy Report, released in January, has provided the framework for the City’s approach. This has been followed up by a series of public hearings, the passage of Proposition HHH, and budget commitments. In all of these efforts, Los Angeles has conveyed real seriousness-of-purpose about addressing housing, social service, and health needs of the homeless population. Highlights of the proposal include a “housing first” approach, a coordinated social service (“no wrong door”) system, and targeted services for veterans. The plan estimates a commitment of $1.8 billion over ten years. Proposition HHH itself supports $1.2 billion in bonds for housing options for the homeless.
Mayor Garcetti has proclaimed homelessness “the moral issue of our time” and argues it is eminently solvable in the foreseeable future.
In New York City, Mayor Bill De Blasio is moving to provide free universal preschool for 3-year olds. This initiative follows on the success of De Blasio’s program to provide universal pre-kindergarten for all 4-year olds in the City. De Blasio has invoked the research of James Heckman and others in making this case. The additional budget commitment for the program is about $36 million; fully implemented it is estimated that the program would cost an additional $177 million over what the City already spends on preschool.
At the other end of the School pipeline, Governor Andrew Cuomo has implemented a program to provide free college tuition in New York state, city, and community colleges for students with family incomes less than $125,000.
The federal government is in retreat, and the leadership of HHS, HUD, Justice, and Education is backpedaling federal initiatives as fast as possible. For so many areas of social policy – aging, child welfare, community development, education, housing, mental health, poverty, public health, and substance abuse treatment – the action will be local, regional, and state.
A number of organizations, sites, and blogs keep track of these social policy innovations in cities and states. To follow this work, monitor the Stanford Social Innovation Review, Fixes at the New York Times, Next City, the Center for the Study of Social Policy, Policy and Practice, and Governing for States and Localities.
Look at what is happening in cities and states if you want to feel some optimism at the moment.
In defending the administration’s budget proposals, OMB Director Mick Mulvaney singled out Meals on Wheels and after-school programs as programs that “don’t show results” and are thus deserving of significant cuts in funding. Later, Mulvaney described these cuts as “about as compassionate as you can get.” (More on his comments about after-school programs in another post.)
In the interest of full disclosure:
The choice of Meals on Wheels as Mulvaney’s example is remarkable, because in so many ways it is the model for a social program designed and operated using conservative principles: voluntarism, public-private funding, state and local block grant discretion, and high levels of efficiency. Funding for the program comes through Older American’s Act support; Community Development Block Grants; state, county and city funds; and private philanthropy.
It is also a remarkable choice because unlike so many social programs, there is a corpus of evaluation literature demonstrating program effectiveness, cost effectiveness, and indirect benefits to recipients and communities.[i] The evaluation literature shows improved nutrition, socialization, health status (e.g., reductions in falls), and diversion from nursing homes that otherwise would have been paid for by Medicaid. Costs per meal, costs per year, and cost offsets that would be necessary from other health and social service programs are extremely impressive.
The United States has had less consciousness of social isolation than many other countries, especially the U.K. From personal experience though, I can say that Meals on Wheels is one of the only, and certainly one of the most effective, interventions for older people and disabled persons who are isolated and homebound. Often, the person who delivers the meal – and has a regular conversation – will be the only human contact a home-bound person will have.
Over the past decade, funding for Meals on Wheels has dropped precipitously, especially under the Sequestration limits. Meals on Wheels America reports that 23 million fewer meals are being served now than in 2015. Waiting lists for services are reported across the country.
In an earlier post, I worried that Mulvaney and the administration would use claims for evidence-based budgeting as a stick for rampant budget cuts, irrespective of what the actual evidence shows.
Identifying Meals on Wheels as the exemplar of an ineffective program is not only wrong-headed, it is also extremely stone-hearted. Targeting a cheap and effective program that serves socially isolated older and disabled persons? Really?
You have to wonder if Mulvaney’s use of Meals on Wheels as an example is calculated, a declaration of a budgetary war where there will be no sacred cows. Even some of the most fiscally conservative members of Congress had an immediate allergic reaction to this announcement. The response from the media, advocacy groups, and social media has been scathing.
When the dust settles, it is likely that Meals on Wheels will fare well in the budget process. Nonetheless, it is an early and telling example of how evidence based budgeting will be used to justify some very draconian funding proposals.
[i] See for example, Kali S. Thomas and Vincent Mor, “Providing More Home-Delivered Meals Is One Way To Keep Older Adults With Low Care Needs Out Of Nursing Homes,” Health Affairs (October 2013), pp. 1796-1802; “The Relationship between Older Americans Act Title III State Expenditures and Prevalence of Low-Care Nursing Home Residents,” Health Services Research 49:3 (June 2013), pp. 1215-1226; and Huichen Zhu and Ruopeng An, “Impact Of Home-Delivered Meal Programs On Diet And Nutrition Among Older Adults: A Review,” Nutrition and Health 22:2 (June 2014), pp. 89-103.
This week: Human Trafficking, Criminal Justice Fines and the Poor, A Universal Child Benefit, MediCaring Communities, and Settling Refugees in communities.
We have the oldest slate of presidential candidates in history, but this has not led to policy proposals or policy discussion of the needed responses to our aging society. This is somewhat surprising given the political centrality of Florida in this upcoming election. The agenda and need for a national aging policy could not be more compelling, but we have experienced radio silence in this campaign. Read more
Social Policy 