WINTER 2018–19 volume 42 number 4

Journal of the American Society on Aging

Politics and Aging

Aging politics in the age of Trump The politics of immigration The state—and fate—of aging policy

Resources from the Aging and Disability Business Institute Hosted by n4a, the Aging and Disability Business Institute focuses on preparing, educating, and supporting CBOs and healthcare payers to collaborate and provide quality care and services. Visit ASA’s website to find information and resources produced by ASA that you can access at any time. · Web seminars available to you at no cost include complimen- tary CE credits · Articles from Aging Today & Generations · Blog posts on ASA’s website · Podcasts that you can download and listen to at your convenience · Two field guides, Generations supplements that you can view online and download. Access these resources at Planning to attend the 2019 Aging in America Conference in New Orleans? Don’t miss the Managed Care Summit at the conference on Thursday, April 18. Visit for more information.

is the quarterly journal of the American Society on Aging.

Each issue is devoted to bringing together the most useful and current knowledge about a specific topic in the field of aging, with emphasis on practice, research, and policy.

Peer review consists of the following practice: the Genera- tions editorial board invites a guest editor, selected because of prominence within his or her subject area, to organize an issue of the publication around themes identified by the board. Authors are then proposed by the guest editor and are evaluated by the board on the basis of demon- strated knowledge, achievement, and excellence in their respec- tive fields. All manuscripts are reviewed by the guest editor, editor, and, when appropriate, members of the editorial board. As occurs in any peer review process, revisions may be re- quired, and articles that do not meet the editorial standards of Generations will not be published. Generations (ISSN 0738-7806) is published quarterly by the American Society on Aging, 575 Market Street, Suite 2100, San Francisco, California 94105-2869. The American Society on Aging (ASA) is the essential resource to cultivate leadership, advance knowledge, and strengthen the skills of those who work with, and on behalf of, older adults.

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GENERATIONS – Journal of the American Society on Aging

ASA Executive Committee Chair, Board of Directors Karyne Jones, Washington, DC Chair-Elect Michael Adams, New York, NY Immediate Past Chair Robert B. Blancato, Washington, DC Secretary Robert E. Eckardt, Cleveland, OH Treasurer Lisa Gables, Alexandria, VA ASA Board of Directors Jean Accius, Washington, DC Cynthia Banks, Los Angeles, CA Richard Browdie, Cleveland, OH David Casey, Woonsocket, RI Paul Downey, San Diego, CA Brian M. Duke, Radnor, PA Joyce Gallagher, Chicago, IL Maria Henke, Los Angeles, CA Brooke A. Hollister, San Francisco, CA Karen N. Kolb Flude, Chicago, IL Daniel Lai, Hong Kong Rebecca C. Morgan, Gulfport, FL Scott Peifer, San Francisco, CA Kevin Prindiville, Oakland, CA Deborah Royster, Washington, DC Phil Stafford, Bloomington, IA John M. Thompson, Atlanta, GA Joyce Walker, Richmond Heights, OH President and CEO Robert G. Stein, San Francisco, CA

GENERATIONS STAFF Publisher Robert G. Stein Editor

Alison Hood Senior Editor Alison Biggar Typography & Production Michael Zipkin | Lucid Design, Berkeley Generations cover and book design by Lisa Rosowsky, Blue Studio. Generations Editorial Advisory Board Susan C. Reinhard Chair Richard Browdie Immediate Past Chair Wendy Lustbader

Chair-Elect Jean Accius Gretchen Alkema Patrick Arbore Letia Boseman Louis Colbert Walter Dawson Brian Lindberg Robin Mockenhaupt Laura Mosqueda Kevin Prindiville Anne Tumlinson

Front cover image ©iStockphoto/ adamkaz © 2019 American Society on Aging

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Politics and Aging

inside generations Politics and Aging

57 The Politics of Aging and Diversity: Moving Toward a Majority-Minority Nation By Juan Fernando Torres-Gil and Courtney Demko 65 Prospects for Senior Power By Frederick R. Lynch moving forward: perspectives on aging advocacy and policy 73 Reflections on Aging Advocacy— and Imperatives for Its Future By William Benson 79 Aging Policy: Where Is it Now, and Where Is It Going? By Robert Blancato and Marie C. Gualtieri

4 Our Guest Editors Robert B. Hudson and Robyn I. Stone

aging and politics: the state of play 6 Nostalgia and the Swamp: Aging Politics in the Age Of Trump By Robert B. Hudson 14 State Politics and Aging Services By Richard Browdie 20 Local Support for Aging Services: An Island of Progress in a Sea of Uncertainty By Robert Applebaum and Chelsea Goldstein 26 The Presence of Older Women in Current U.S. Electoral Politics By Judith G. Gonyea 34 Policies for Aging Americans: A Look at Public Opinion and the Role of Government By Rachel L. Moskowitz the current American landscape: we, the (older) people 42 Beyond the “Haves” and “Have Nots” By Dale Dannefer, Chengming Han, and Jessica Kelley 50 The Politics of Immigration: Who Will Care for Grandma? By Robyn I. Stone and Natasha Bryant

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Our Guest Editors

Politics, Policy, and America’s Aging (and Changing) Population A mid a turbulent and divisive time in American politics—with poor

many times in Congress on legislation pertinent to older adults. “I’m dedicated to analyzing the political place of older adults in a man- ner that captures the complexity of the issue, notably to disentangle the notion that ‘the elderly’ are a largely monolithic population,” he says. Stone, too, emphasizes the impor- tance of the older population’s increas- ing diversity, as she is currently focused on immigration policy and the direct care workforce needed to support America’s elders. She has worked for more than four decades in aging ser- vices policy development, practice, and research at various levels of the federal government, and in the private, non- proft sector. “Much of my work has focused on how to better serve modest and low-income older adults,” says Stone, “including how to design policies and evidence-based interventions that will improve the fnancing and delivery of long-term services and supports and their integration with acute and pri- mary care.” Stone also has achieved impressive career milestones and received many awards. In 1987, she conducted the frst national study of family caregivers and led efforts to pass long-term-care reform through the Pepper Commission and the 1993 Clinton Health Care Reform effort, which set the stage for ongoing

pitted against rich, with women fght- ing the ongoing and rising tides of mis­ ogyny, with race-

‘Older Americans have an obligation to concern themselves with the welfare of younger generations.’ ROBERT B. HUDSON

baiting coming from our nation’s leader- ship, and a dearth of bipartisanship—it was ASA’s good fortune to have two expert Guest Editors, Robert B. Hudson and Robyn I.

Stone , guide this Winter 2018−19 issue of Generations on “Politics and Aging.” Hudson, professor of Social Wel- fare Policy in the School of Social Work at Boston University, and Stone, senior vice president of research at Leading­ Age and co-director of the LeadingAge LTSS Center at University of Massachu- setts Boston, collaborated to produce an issue aimed at explicating the complex intersection of U.S. politics and policy, ongoing and new issues impacting our nation’s aging population, and the older electorate’s evolving face, place, and in­ fluence in America’s political landscape. Hudson has been analyzing aging policy and politics for several decades, using his writing to clarify issues in this arena and to inform the public. He has published more than 100 papers, given countless presentations, received numerous awards from academic and aging organizations, and has testifed

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debates. Stone oversaw the develop- ment, evaluation, and implementation of the Cash and Counseling program in three states, and was, in 1993, appointed the frst Deputy Assistant Secretary for Disability, Aging and LTC Policy in the U.S. Department of Health and Human Services. She created LeadingAge’s Cen- ter for Applied Research and developed and oversaw Better Jobs Better Care— a $15 million policy and research effort to raise awareness of and change pol- icy and practice around the direct care workforce. Workforce remains one of Stone’s greatest concerns: “I believe strongly that we need a quality, affordable system for all older adults and am concerned about the future of service availability and affordability for the baby boomers as they age over the next few decades.” In this issue, she writes about immi- gration and how current policies could lead to a dearth of homecare workers and increase care costs for older adults (page 50). She sees the increasing diver- sity and growing proportion of people of color within the older cohort as oppor- tunities for new policy and services and supports design. Hudson, in his work to simplify the complexities of aging policy and politics, clearly states in his introductory article (page 6) that older adults are key players in American politics, emerging recently as a critical electoral component in Donald Trump’s election, but also exhibiting disparities in well-being across multiple dimensions, making for a clashing political reality. “Regarding policy, I’ve tried to emphasize both the widely disparate economic and related

conditions found among older adults and the shortcomings of many of our policies in reducing those disparities,” he says. Both Guest Editors view the future with trepidation. Hudson, remarking on the emerging generational challenges around resources, says, “There is a dif- ference between how old you are and when you were born; it seems increas- ingly clear that to have been born in the 1920s and 1940s will prove to have been a better period than to have been born in the 1960s and 1970s.” Referencing the

‘I am concerned about the future of service availability and affordability for the baby boomers as they age over the next few

politics of poverty, Stone echoes Hud- son’s thinking: “I believe that the poli- tics of poverty will become more relevant for newer cohorts of older adults as they fnd themselves liv- ing longer on fxed

decades.’ ROBYN I. STONE

incomes with little or no assets and a lack of adequate housing,” she says. But both think this new state of aging may spur activism. Hudson places the responsibility to act upon older adults. “Because older Americans are the princi- pal benefciaries of the American welfare state, I believe that they have an obliga- tion to concern themselves with the wel- fare of younger generations, whether the issue is income, housing, health, or cli- mate change,” he says. Stone agrees, adding, “I am hopeful that these circumstances will usher in a whole new wave of advocacy around the aging of our population.” —Alison Biggar and Alison Hood

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Nostalgia and the Swamp: Aging Politics in the Age Of Trump By Robert B. Hudson New realities indicate a fracturing of the

common political understanding of older adults.

T o a degree hard to imagine half a century ago, older adults have become prominent players in American politics. From once having voted less than any other age group, now they vote more; from once having virtually no presence in Wash- ington, now they are represented by nearly 100 organized interests; from once being recipients of meager public benefts, now they receive the majority of the nation’s social expenditures; and from once voting much in line with younger vot- ers, recently they have moved to the political right, emerging as a critical electoral component to Donald Trump’s election as president. Yet elders are far from a homogenous demo- graphic. They exhibit disparities in well-being along multiple dimensions, often exceeding those found among younger populations. These clashing political and population realities— formidable political standing mixed with wide- spread social and economic deprivation—have transformed and muddied our understanding of the place of older Americans in today’s politics. Are today’s elders dependent or advantaged? Do they constitute “the third rail of American poli-

tics” that no politician dares offend, or do they remain members of the “deserving poor,” whose political legitimacy is such that it obviates the need for political power? It is time to shed more light on these contrasting realities. Today’s Elders Skew Conservative Prior to the turn of the century, older Americans voted largely in line with younger populations (Binstock, 1997, 2009). Yet the current genera- ‘Many policy benefits elders enjoy have emanated from “inside the Beltway”—aka the Swamp.’ tion of elders has moved distinctively to the right. In 1992, older voters preferred Bill Clinton, with 54 percent of older adults saying they were Democrats or leaned Democratic, in contrast to 39 percent of older adults who said they were Republicans or leaned in that direction. By 2013, those numbers had reversed, with 48 percent of older adults skewing Republican

abstract Older adults are players in American politics, recently emerging as a critical electoral component to Donald Trump’s election. Their formidable political standing, with widespread social and economic deprivation, have transformed and muddied our understanding of the place of older Ameri- cans in today’s politics. Are today’s elders dependent or advantaged? Do they constitute “the third rail of American politics” that no politician dares offend, or do they remain members of the “deserving poor,” whose political legitimacy obviates the need for political power? This article addresses these contrasting realities. | key words: older adults, Trump, Medicare, Social Security, SNAP, the Swamp

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favored Trump 62 to 34, and adults ages 65 and older favored him by 58 to 39. Trump received 71 percent of the vote among non-college-educated whites ages 45 and older (Frey, 2016). In recent state-level elections, older voters also proved more conservative. In the 2017 Vir- ginia gubernatorial race, voters ages 18 to 44 favored Democrat Ralph Northam over Republi- can Ed Gillespie by a margin of 64 to 34, whereas voters ages 45 and older tilted slightly to the Republican, 51 to 49. In the 2018 special election in Pennsylvania’s 18 th Congressional District, vot- ers ages 18 to 45 evenly split between the Repub- lican and Democratic candidates, those ages 46 to 64 favoring Democrat Conor Lamb 55 to 44, with those ages 65 and older favoring the Republican, Rick Saccone, 56 to 43 over the victorious Lamb. And, in the Alabama Senate race, voters ages 18 to 44 favored Democrat Doug Jones by a margin of 61 to 38, whereas voters ages 45 and older sup- ported Republican Roy Moore, 54 to 44. Elders are Central to “Make America Great Again” The above phrase clearly harks back to a golden age when life was presumptively better for Americans. This presumption has energized much of the electorate, while being highly offen- sive and ahistorical to millions of others. Yet this message clearly resonated with a large majority of older whites. Observers have highlighted the role of nostalgia in the affections of older Ameri- cans. Frey (2016) has labeled their fondly looking backward as a “cultural generation gap,” a dis- connect between “older primarily working class Whites and the increasingly diverse and global- ized nation we are becoming.” In that hallowed narrative: for boys, there were “Ford families” and “Chevy families.” For girls, Barbie had only one skin color. “Made in Japan” meant shoddy workmanship. International cuisine was Ameri- can chop suey and Chef Boyardee. In line with these sentiments, a 2016 PRRI survey (Cooper et al., 2016a) found 60 percent of respondents ages 18 to 29 felt things in recent years had changed

and 45 percent trending Democratic. As well, two big age-based crossovers occurred in the 2000s: in 2008, voters ages 18 to 29 and those ages 65 and older switched political positions, with the former now skewing Democratic and the latter Republican; in 2010, a majority of older voters reported now supporting Republicans over Democrats (Jones, 2014). Yet more striking, the 2010 off-year elections found the most remark- able age-break in decades, with older voters— having been led to believe that the Affordable Care Act (ACA) would gut Medicare (Nagourney, 2009)—leading the charge that allowed Republi- cans to pick up sixty-three seats in the House of Representatives and capture its majority. The role of older voters in the election of Donald Trump is clear. All voters ages 45 and older favored Trump over Hillary Clinton by eight points, 52 to 44, whereas voters younger than age 45 favored Clinton by fourteen points, 53 to 39. However, racial differences within these groups were stark. Overall, white vot- ers favored Trump 57 to 37, whereas black vot- ers favored Clinton 89 to 8. Whites ages 45 to 64

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for the better, whereas only 42 percent of those ages 65 and older believed that to be the case. The Pew report, Millennials in Adulthood (2014), contrasts age-group support for different issues, revealing a pattern indirectly validating Frey’s construct, with older respondents regis- tering the least support for mixed-race marriage, LGBT individuals raising children, legalizing marijuana, and sanctioning same-sex marriage. Two other Pew surveys clarify generational dif- ferences. The frst (Pew Research Center, 2015) found younger respondents most supportive of scientifc research, the educational system, and the environment, whereas older respondents favored reducing the influence of lobbyists, restricting immigration, and funding roads and bridges. In the second survey (Pew Research Cen- ter, 2017a), younger adults most prioritized pro- tecting the environment (16-point difference), global climate change (14-point difference), and addressing race relations (10-point difference). Older respondents prioritized strengthening the military (25-point difference), reducing lobbying influence (25-point difference), improving trans- portation (25-point difference), and controlling immigration (20-point difference). Two other reports confrm the generation- ally troubling fnding regarding immigration. When asked if immigrants are strengthening the country through their hard work and talents, 76 percent of Millennials, 60 percent of Gen Xers, 48 percent of Baby Boomers, and 41 percent of Silents answered in the affirmative (Jones, 2016). A PPRI poll (Cooper et al., 2016b) yielded similar results: where 68 percent of those ages 18 to 29 responded that immigrants coming to the United States strengthen the country, while only 19 per- cent believe them to be a threat to American val- ues. In contrast, only 36 percent of those ages 65 and older believe that newcomers strengthen the country, whereas 44 percent believe immigrants to be a threat. The nostalgia theme is clearly seen in Hochs- child’s (2016) prize-winning ethnography, detail-

ing the high degree to which middle-age and older Louisiana whites feel besieged by forces over which they seem to have no control—cul- tural marginalization, shaky economy, demo- graphic decline—and by factions that they see as “jumping the line” and transforming the Ameri- can narrative. The Swamp Has Been Good to Older Voters Older Americans are disproportionate benefcia- ries of the nation’s largest social programs: Social Security, Medicare, and Medicaid. Why that is the case has been subject to numerous and com- peting narratives (Myles and Quadagno, 2002; Campbell, 2003; Hudson, 2016). Clearly, there has been at work a mix of older adults’ demonstrable needs, growing recognition of their political pres- ence, and advocacy on their behalf. Many policy benefts elders enjoy have emanated from “inside the Beltway”—aka the Swamp. Policy developments during the New Deal (Social Security) and Great Society (Medi- care/Medicaid) periods owed much to Wash- ington insiders such as Edwin Witte, John Commons, Wilber Cohen, and Arthur Flemming. As Skocpol (1995) notes in the New Deal case, “ . . . the policy process through which Social Security was planned and drafted in the mid- 1930s was strikingly closed.” In detailing the road to Medicare, Marmor (1970) highlighted the role of D.C. insiders, concluding, “Federal Secu- rity Agency strategists . . . were left with fnding a socioeconomic group whose average mem- ber could be presumed to be in need. The aged passed this test easily . . . .” As forcefully articulated by Campbell (2003), the expansion and effects of these programs have been central to the creation of what now consti- tutes the imposing electoral and interest group presence that older Americans and organizations working for them enjoy. In the case of Social Security, Campbell fnds policy enactment and expenditures creating political self-identity and engagement among elders and organizational opportunities among their advocates. Closer to

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‘Today’s elders will fare better in old age than those who are now in their 40s, 50s, and 60s.’ The role of Beltway insiders was perhaps most forcefully articulated by Lowi (1969), whose “interest group liberalism” formulation found elected officials, lobbyists, and bureau- crats in a positive-sum symbiotic relationship centered, in order, on votes, programs, and jobs. The birth and evolution of the Older Americans Act and the so-called aging network comports to this understanding, with provider groups eager to play the role of middleman in the deliv- ery of services funded through extant programs. As argued more broadly by Walker (1983), the creation and growth of aging-related advocacy groups and trade associations occurred largely in the wake of program developments rather than in advance of them. To the degree that “the Swamp” captures the (perhaps insidious) inter- play of policy and politics, it is clearly the case that many, though far from all, older Americans have beneftted from its machinations. the ground, conservative think tanks are well aware of and condemn these independent effects of aging policy on subsequent politics. Tim Phil- lips of the Koch brothers–backed Americans for Prosperity speaks of the “incredible politi- cal power policies generate, building constitu- encies and powerful special interests whose jobs depend on it” (Peters, 2017). Thomas Miller (2015) of the American Enterprise Institute refers to these entitlements as a “demilitarized zone,” where one engages at one’s own peril.

proposals coming out of the Oval Office make it appear that they are very much on the table. His FY 2018 budget called for signifcant cuts in Social Security’s Disability Insurance program, three-quarters of whose benefciaries are older than age 50. Congressional proposals that he supported to repeal the ACA would have eliminated the Medi- care payroll surtax on high earners and would have eliminated the 3.8 percent net investment tax on capital gains and dividends, moves which would have accelerated the Medicare Hospital Insurance Trust Fund’s depletion by two years, from 2028 to 2026 (Van de Water, 2017). Repub- lican proposals would also have imposed a so- called age tax on people ages 50 to 64 under the ACA (Hickey, 2017). Several other aging-related programs have been on the cutting room floor, although Con- gress has resisted enacting many of them. The Administration’s budget would have reduced Medicaid enrollment by 14 million people over ten years, affecting many elders in need of long- term services and supports (Solomon and Schubel, 2017). Other such cuts proposed in the FY 2017 and 2018 budgets included a per capita funding formula capping federal Medicaid pay- ments, severe cuts to the Community Services Block Grant, the Low Income Energy Assis- tance program, the Senior Community Ser- vice Employment program, health professions education and nursing training programs, and Amtrak’s long distance train service, dispropor- tionately used by older adults (Gleckman, 2016; Ambrose, 2017). When asked, older respondents have nega- tive to neutral reaction to proposals such as these. Whether or not those concerns will guide them politically is uncertain, especially given the much larger contested environment centered on immi- gration, so-called identity politics, LGBT concerns, and the makeup of the Supreme Court, among other issues. The response of the ages 50 to 64 white populationmay prove most notable. This age bracket was strongest in its support of Trump, but

Elders Supporting Trump—Not a Two-Way Street

It is difficult to discern President Trump’s posi- tion on any number of public policy issues, in­ cluding those that are aging-related. He has said that Social Security and Medicare are off the table, but—whether he is aware of it or not—

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a Quinnipiac poll found three-ffths of the same group opposed the ACA age tax, and a Washing- ton Post −ABCNews survey (Goldstein and Clem- ent, 2017) reported three-quarters of older adults opposed the proposal to allow states to reduce the number of essential benefts under Medicaid. These concerns may have clear consequences in the current political environment in that sev- enteen of twenty-two House Republicans who opposed Speaker Paul Ryan’s initial attempt to repeal the ACA in April 2017 represent districts where the median age is above the national aver- age, and sixteen are in districts where the share of older adults exceeds the national average (Brownstein and Askarinam, 2017). In voting behavior and political attitude, older white voters clearly skew in a conservative direc- tion. But when attention turns to specifc policy issues and existing programs, a far different pic- ture appears. First recognition of this difference often is ascribed to Free and Cantril (1969) whose book, The Political Beliefs of Americans , captured the notion of individuals frequently being “ideo- logically conservative” but “operationally liberal.” Years later, the Harris Poll highlighted this dis- tinction by noting that respondents “hated the forest but liked the trees” (Harris Poll, 2011). This distinction is important in seeking to understand the relationship between older Americans, aging policy, and Donald Trump. While roughly as many Americans express a preference for a bigger government providing more services as they do for a smaller govern- ment providing fewer services, they show lit- tle appetite for spending cuts in specifc areas. The majority says it would maintain or increase spending in all fourteen of the program areas included in the survey (Pew, 2017a). Similarly, the Harris Poll (2011) found the most popular services—supported by more than 80 percent of respondents—to be crime-fghting and preven- tion, Medicare, Social Security, national parks, Older Voters Want Policy Benefits and Smaller Government

and defense. Unemployment benefts, aid to pub- lic schools, and Medicaid were supported by more than 70 percent of respondents, includ- ing 60 percent or more of Republicans. Smaller majorities supported food stamps and immigra- tion. The only program not supported by a majority of the public was foreign aid. A tension arises when respondents’ ages and particular programs are introduced. On the one hand, voters of all ages have long supported programs that disproportionately beneft older Americans. Responses to the General Social Sur- vey found more than 90 percent of respondents saying either “too little” or “about right” was being spent on Social Security, with massive sup- port across all age groups: ages 18 to 29, 86 per- cent; ages 30 to 49, 91 percent; ages 50 to 64, 94 percent; and ages 65 and older, 95 percent (Cook and Moskowitz, 2014). Yet, older respondents do not appear to recip- rocate when many non-aging-specifc areas are in question. In a Pew study (2017b), adults younger than age 30 (57 percent) and between ages 30 and 49 (54 percent) say they would rather have a big- ger government providing more services, with only a minority of adults ages 50 to 64 (38 per- cent) and ages 65 and older (40 percent) agreeing. Are Today’s Elders Doing Well or Poorly? While many of today’s elders look back fondly on mid-twentieth century life in light of con- temporary demographic and economic develop- ments, it seems increasingly likely that these Silents (born between 1930 and 1945) and early Baby Boomers (born between 1946 and 1955) will experience a more secure old age than the younger generations following them. If there is to be “demographic conflict,” it may be less about old versus young than about growing life- long challenges that are confronting today’s late Baby Boomers (born 1956 to 1964) and Gen Xers (born 1965 to 1985). Dannefer (2003) and Crystal (1982, 2018) have been leaders in raising and framing these issues. Crystal is frst associated with what he has called

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“the two worlds of aging,” the investigation of cumulative advantage and disadvantage over the life course in which he fnds—contrary to popu- lar opinion—that economic inequality does not lessen in old age but continues to expand. His more recent work, however, centers on genera- tional inequality, where individuals born at one point in time may experience more inequality at each point in the life course than did members of previous generations. In these terms, it appears that today’s elders will fare better in old age than those who are now in their 40s, 50s, and 60s. Silents and early Baby Boomers grew up in a post–World War II environment marked by a manufacturing-cen- tric economy, a period of rising wages, expand- ing social safety net programs, defned beneft pension plans, health plans with low deductibles, Several aging-related programs were in line for cutting, but Congress has resisted enacting them. and an unprecedented rise in real estate values. As Crystal argues, late Baby Boomers are facing growing economic inequality, the loss of manu- facturing jobs, and declining union power, while Gen Xers have been hard hit by the Great Reces- sion of 2008–2010, falling real estate values, the continuing disappearance of defned beneft plans, and a sharp increase in economic inequal- ity when compared to earlier generations. Crystal coins another apt phrase, referring to these people born between 1956 and 1975 as “the hollowed-out generation.” Whatever prob- lems Silent and early Baby Boomer elders are experiencing—and they are widespread—they seem likely to prove less severe than what late Baby Boomers and Gen Xers may face in old age. Crystal forecasts these individuals approach- ing retirement age accompanied by poor health status, morbidity, mortality, substance abuse, suicide rates, opioid addiction, and increasing age-specifc death rates. In the case of Millen-

nials approaching old age, the period they live through is likely to be marked by high levels of student debt, unaffordable housing, and height- ened job insecurity.

Two Worlds: Dependent and Advantaged Elders

The seeming dissonance in older whites’ views of Donald Trump and his policy initiatives— endorsing his conservatism, but uncertain about some of his policy proposals—would appear to create a blurred political picture. Yet there emerges an unfortunate clarity. On the one hand, the Administration takes a harsh stance toward low-income and vulnerable people of all ages, while on the other, enacts tax breaks and eschews beneft cuts for those who are better off. Thus, initiatives to reorganize the federal bureaucracy by moving the SNAP program into a reconstituted human services department, now with “welfare” in the title, tightening eligibility for public assistance programs, and scaling back Disability Insurance benefts further threaten the well-being of vulnerable adults of all ages. In contrast, the recently enacted tax package generates average savings of $70 for the poorest 20 percent of Americans; $7,460 for the richest 20 percent; and $61,090 for the wealthiest 1 per- cent. Programmatically, the pledge not to touch the Old Age and Survivors components of Social Security speaks more to the political standing of middle-income elders than to their less-well-off peers. Together, these moves speak directly to and would exacerbate the so-called two worlds of aging identifed by Crystal (2018), centered on the notion of cumulative advantage and disad- vantage over time. Invoking terms from a typology of political target populations (Hudson and Gonyea, 2014), we can speculate that the fate of disadvantaged or “dependent” elders (possessing positive social construction and only weak political power) will continue to suffer relative to the second group- ing of “advantaged” older adults (possessing both positive social construction and high politi-

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cal power) as time progresses. Advantaged elders will fare well under prevailing political condi- tions, conveying an image of a life of hard work, earned benefts, and, one must add, being pre- sumptively white, straight, and male. Cutting Medicaid funding and tightening regulations will inevitably affect very old and low-income elders in need of long-term-care services. Work requirements for SNAP and pro- posed cuts to the DI program would severely impact highly vulnerable individuals in their 50s and 60s, ones who might be chronologically in the Third Age but who functionally certainly are not. Not at all unrelated, a major ideological shift likely to be seen in the make-up of the new Supreme Court seems probable to lead to a weak- ening of federal protections for people of color, members of the LGBT community, and very old women. These are the dependent elders. Given a widening gap in well-being and po­ litical power, Hudson and Gonyea (2014) and Crystal (2018) fear a fracturing of the common political understanding there has long been of “the elderly.” While there has never been denial of the empirical heterogeneity of the old age pop- ulation, the vibrancy of aging politics has always lain in older adults being understood normatively

to be a singular and deserving constituency. Thus, in a third component of the target popula- tion formulation, it seems increasingly likely that older adults may be seen as contenders (nega- tive social construction; high political power). It is this combination that has generated the age- directed ire of a host of commentators, including Kotlikoff and Burns (2004), Samuelson (2013), and Alstott (2016). Crystal forecasts a continued weakening in the common stakes and social solidarity identity of elders. From a pre-1980 understanding that “you can’t do enough for the elderly” (depen- dent), perceptions gravitated toward “the elderly are the third rail of American politics” (advan- taged), to what may increasingly be captured by epithets along the lines of “we haven’t prepared for the aging monster” (contender) (Samuelson, 2017). This political reconstruction of aging is of enormous importance, more so in an era assault- ing the legitimacy of domestic social policy and promoting what Crystal terms as no less than a “plutocratic-friendly” agenda. Robert B. Hudson, Ph.D., is a professor in the Social Welfare Policy Department at Boston University’s School of Social Work in Boston, Massachusetts.

References Alstott, A. 2016. A New Deal for Old Age . Cambridge, MA: Harvard University Press. Ambrose, E. 2017. “Budget Cuts Programs for Seniors: Health and Social Services for Elderly, Poor Hit Hard.” AARP Politics & Soci- ety Advocacy (blog). ybnuysgu. Retrieved June 14, 2018. Binstock, R. H. 1997. “The 1996 Election: Older Voters and Impli- cations for Policies on Aging.” The Gerontologist 37(1): 25–39. Binstock, R. H. 2009. “Older Voters and the 2008 Election.” The Geron- tologist 49(5): 697–701.

Brownstein, R., and Askarinam, L. 2017. “Older Voters Are Com- plicating Plans for Health Care.” The Atlantic , May 2. y76nbzgq. Retrieved June 14, 2018. Campbell, A. L. 2003. How Poli- cies Make Citizens: Senior Political Action in the United States . Prince­ ton, NJ: Princeton University Press. Cook, F., and Moskowitz, R. 2014. “The Great Divide: Elite and Mass Opinion About Social Security.” In R. B. Hudson, ed., The New Politics of Old Age Policy . Baltimore, MD: Johns Hopkins University Press.

Cooper, B., et al. 2016a. The Divide over America’s Future: 1950 or 2050? Findings from the 2016 Amer- ican Values Survey. PRRI. tinyurl. com/y9pwwbff. Retrieved June 14, 2018. Cooper, B., et al. 2016b. How Amer- icans View Immigrants, and What They Want from Immigration Reform . Retrieved June 14, 2018. Crystal, S. 1982. America’s Old Age Crisis: Public Policy and the Two Worlds of Aging . New York: Basic Books.

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Crystal, S. 2018. “Cumula- tive Advantage and the Retire- ment Prospects of the Hollowed- out Generation: A Tale of Two Cohorts.” Public Policy & Aging Report 28(1): 14–18. Dannefer, D. 2003. “Cumulative Advantage/Disadvantage and the Life Course.” The Journals of Ger- ontology, Series B: Psychological Sciences and Social Sciences 58(6): S327–37. Free, L., and Cantril, H. 1969. The Political Beliefs of Americans . New York: Simon & Schuster. Frey, W. H. 2016. “Race, Aging, and Politics: America’s Cultural Gen- eration Gap.” Public Policy & Aging Report 28(1): 9–13. Gleckman, H. 2016. “What the Trump Presidency Means for Seniors.” Forbes , November 9. Retrieved June 14, 2018. Goldstein, A., and Clement, S. 2017. “Public Pans Republicans’ Latest Approach to Replacing the Afford- able Care Act.” Washington Post − ABC News Poll. 5fpq4. Retrieved June 14, 2018. Harris Poll. 2011. “New Harris Poll Underlines Political Difficulty in Cutting Government Services.” Retrieved June 14, 2018. Hickey, M. C. 2017. “Older Ameri- cans Oppose Age Tax in Health Care Bill.” AARP Politics & Soci- ety Advocacy blog . y8fqeckc. Retrieved June 14, 2018. Hochschild, A. R. 2016. Strangers in Their Own Land . New York: The New Press. Hudson, R. B. 2016. “Theories of the Politics and Policies of Aging.” In V. Bengtson and R. Settersten, eds., Handbook of Theories of Aging . New York: Springer.

Hudson, R. B., and Gonyea, J. G. 2014. “The Shifting Political Con- struction of Older Americans as a Target Population.” In R. B. Hud- son, ed., The New Politics of Old Age Polic y. Baltimore, MD: Johns Hopkins University Press. Jones, B. 2016. Americans’ Views of Immigrants Marked by Widen- ing Partisan Divide . Pew Research Center. Retrieved June 14, 2018. Jones, J. 2014. “U.S. Seniors Have Realigned with the Republican Party.” lo7usa4. Retrieved June 14, 2018. Kotlikoff, L., and Burns, S. 2004. The Coming Generational Storm . Cambridge, MA: The MIT Press. Lowi, T. 1969. The End of Liberal- ism . Chicago: W. W. Norton & Company. Marmor, T. 1970. The Politics of Medicare . Chicago: Aldine Pub­ lishing Company. Miller, T. 2015. “Beyond Makers and Takers: Retargeting Entitle- ment Reform.” American Enter- prise Institute. yugjg. Retrieved June 14, 2018. Myles, J., and Quadagno, J. 2002. “Political Theories of the Welfare State.” Social Service Review 76(1): 34–57. Nagourney, A. 2009. “Politics and the Age Gap. The New York Times , September 13. Retrieved June 14, 2018. Peters, J. 2017. “A Republican Principle Is Shed in the Fight over Health Care.” The New York Times , May 7. Retrieved June 14, 2018. Pew Research Center. 2014. Mil- lennials in Adulthood . pbpw3tv. Retrieved June 14, 2018.

Pew Research Center. 2015. “Pub- lic’s Policy Priorities Reflect Changing Conditions at Home and Abroad.” Retrieved June 14, 2018. Pew Research Center. 2017a. “After Seismic Political Shift, Modest Changes in Public’s Pol- icy Agenda.” Retrieved June 14, 2018. Pew Research Center. 2017b. “With Budget Debate Looming, Growing Share of Public Prefers Bigger Gov- ernment.” Retrieved June 14, 2018. Samuelson, R. 2013. “We Need to Stop Coddling the Elderly.” The Washington Post, November 3. Retrieved June 14, 2018. Samuelson, R. 2017. “We Haven’t Prepared for the Aging Monster.” The Washington Post, December 6. Retrieved June 14, 2018. Skocpol, T. 1995. “The Road to Social Security.” In T. Skocpol, ed., Social Policy in the United States .” Princeton, NJ: Princeton Univer- sity Press. Solomon, J., and Schubel, J. 2017. “Medicaid Cuts in House ACA Bill Would Limit Availability of Home- and Community-based Services.” Center on Budget and Policy Pri- orities. Retrieved June 14, 2018. Van de Water, P. N. 2017. “Trump Budget May Break Promise to Pro- tect Social Security, Medicare, and Medicaid.” Center on Budget and Policy Priorities. 5hbpc. Retrieved June 14, 2018. Walker, J. 1983. “The Origins and Maintenance of Interest Groups in America.” American Political Sci- ence Review 77: 390–406.

Volume 42 . Number 4 | 15

GENERATIONS – Journal of the American Society on Aging

State Politics and Aging Services By Richard Browdie

What might be the effect of the aging network losing political importance at the state level?

A s someone who has worked in the aging net- work at local, state, and national levels, I have always believed that state decision-making, and the political environments surrounding those decisions, deserved a lot more attention through the work of national organizations and their funders. Somehow, national analysts and advo- cates think that if they can just get the policy right, it will take care of everything: money will be there for the right programs and services and, at the local level, people will use the money effec- tively for its intended purposes. States will do their job of licensing, managing, and assuring coordination and compliance with national policy. The problem is that this formulation ignores several important realities, starting with how the role of federal and state governments histori- cally has been interpreted in regard to human services. In general, the citizenry’s welfare is thought to be the responsibility of the states, and states zealously preserve their independence from federal direction. Federal resources are targeted to specifc problems. Depending on the program, state gov- ernments often pass on these resources, with additional direction, to local governments or

entities designated to carry out the mission. Hopefully, when all parties are in alignment, there also will be effective coordination with other available state and local resources. How- ever, varied state and local interpretation of poli- cies can lead to very different implementation strategies. When combined with widely different resource bases from which states and communi- ties draw additional resources, the results often achieved by national policies can differ dramati- cally. As national Medicaid experts often say, “When you’ve seen one state Medicaid program, you’ve seen one state Medicaid program.” The same can be said for Older Americans Act pro- grams and the “aging network.” The Older Americans Act (OAA) was designed to take advantage of this general out- line of how things work. Conceptually, it rec- ognizes that older people’s needs vary widely across population and location, and meeting these needs would require the cooperation of a broad array of extant service systems. The OAA’s designers recognized that strategies to support successful aging in American commu- nities would have to take into account America’s tremendous diversity. Also, because the risk of

abstract State decision-making and surrounding political environments deserve more attention through national organizations and funders. National analysts and advocates think if they can get the policy right, the money will follow and local level agencies will use it effectively, but this ignores the role of federal and state governments. This article explains why and how the aging network’s political importance has diminished at the state level, despite the growing older adult population and potential impacts of that cohort’s growth. | key words: aging network, state politics, aging services, Older Americans Act, long-term services and supports, Medicaid, Medicare, Area Agencies on Aging

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‘When you’ve seen one state Medicaid program, you’ve seen one state Medicaid program.’ evolved. Originally, it was assumed that Con- gress would be interested in the needs of older Americans for the long haul, given the certainty of the older population’s growth. The origi- nal OAA design anticipated that publicly autho- rized agencies and advocates would generate an ongoing flow of information to states and to Con- gress regarding how older Americans were sup- ported and how their needs changed and grew. Through the appropriations process, Congress would grow the resources needed as the situa- tion evolved. Whether members of Congress lost interest, or were overwhelmed by the political changes that swept the country since 1980, their willing- ness to keep up with the growth in the numbers of older Americans has not happened. For many years, states found the wherewithal to carry an increasing share of the weight. But eventually, the structure of the funding partnership began to falter among the federal government, states, and local communities. At the same time, spend- ing on healthcare entitlements has grown rap- idly. This situation re-energized a debate among advocates that had been simmering since the beginning of the Great Society programs in the mid-1960s, resulting in a fundamental shift in disability in old age was seen as related to the life course, not to how hard one might have worked, there was a reluctance to think of poverty as causing the need for publicly funded support. Medicaid was health insurance for poor people, and even though it included nursing home care that might last for years, it was healthcare none- theless. Older adults needing community sup- ports shouldn’t have to declare themselves poor. While it remains a serviceable concept, much has changed over the years. For one, the political environment has

the way federal and state governments orga- nized their response to older Americans’ needs. National Influence on State Policy in Aging Evolves with Financing Three main factors stand out to explain why the political importance of the aging network has diminished in most states, despite continu- ing growth in the number and proportion of older people. They are as follows: the emergence of Medicaid as the primary source for fnanc- ing services for older Americans, as well as for younger persons with disabilities; the ascen- dance in national policy of the medical model as the dominant organizing principle for meeting long-term services and supports (LTSS) needs; and the shifting focus of national advocacy orga- nizations to “reframe aging”—embracing only the positive aspects of aging and none of the challenges. There has long been an argument between those who believe the needs of people with dis- abilities at any age should be addressed through a comprehensive health system entitlement, albeit one that addresses relevant social sup- port needs (think Medicaid), as opposed to those who think older people’s needs are more appro- priately met by relying on a localized strategy supported by legislative responsiveness to the growing population of older people (think the OAA). And because most older Americans, at least those who are older than age 65, are already entitled to medical care through Medicare, the logical response is to extend that healthcare sys- tem to LTSS. Entitlement won. Medicaid eclipsed the OAA as the dominant organizing federal policy instrument affecting services for older people, and this eliminated any concern that older peo- ple would be stigmatized by accepting services through a means-tested system. And, because advocacy energy flows toward the money, now interest is concentrated on decisions made asso- ciated with Medicaid fnancing and manage- ment. Under Medicaid, one’s age is of little

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