Policy Initiatives in Geriatric Care: Legislative Frameworks, Government Funding, and Institutional Policies

Abstract

The profound demographic transformation of the United States, marked by a rapidly expanding older adult population, places escalating demands on an already complex healthcare infrastructure. This comprehensive research report undertakes an in-depth analysis of the intricate web of legislative frameworks, governmental funding mechanisms, and institutional policies designed to address the multifaceted challenges inherent in geriatric care. Specifically, it meticulously examines how these policy initiatives influence crucial domains: geriatric workforce development, the evolution and implementation of innovative care delivery models, and the sustained promotion of home and community-based services (HCBS) that empower older adults to age in place. Through a rigorous evaluation of seminal policies such as the Older Americans Act, the Geriatrics Workforce Improvement Act, and the transformative Medicare and Medicaid reimbursement reforms, alongside the burgeoning Age-Friendly Health Systems movement and Programs of All-Inclusive Care for the Elderly (PACE), the report assesses their efficacy. It scrutinizes their success in mitigating critical issues like the chronic shortage of geriatric specialists, fostering incentives for comprehensive and person-centered care approaches, and robustly supporting ‘aging in place’ paradigms. Furthermore, the report extends its analysis to the broader economic and social ramifications of these policies, offering a holistic perspective on their pivotal role in shaping the trajectory and quality of geriatric care provision across the nation. This detailed exploration aims to inform policymakers, healthcare providers, and stakeholders about the enduring impact and future imperatives for an equitable and effective geriatric healthcare system.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

1. Introduction

The United States is in the midst of an unprecedented demographic shift, characterized by a substantial and sustained increase in the proportion of its population aged 65 and older. This phenomenon, often referred to as the ‘graying of America,’ is projected to see the number of older adults surpass that of children for the first time in history within the coming decades, profoundly altering the societal and economic landscape. By 2030, all baby boomers will be over age 65, leading to one in five Americans being of retirement age. This demographic imperative underscores an urgent and undeniable need for a healthcare system not only capable of, but specifically designed for, delivering specialized, compassionate, and holistically integrated care tailored to the unique and often complex needs of the elderly population.

Geriatric care, unlike general adult medicine, necessitates a distinct understanding of age-related physiological changes, multi-morbidity, polypharmacy, functional decline, cognitive impairments, and the pervasive influence of social determinants of health. The health challenges faced by older adults frequently transcend acute medical conditions, encompassing chronic diseases, functional limitations, mental health issues, social isolation, and financial vulnerabilities. Consequently, the provision of effective geriatric care demands an interdisciplinary approach that considers the entirety of an individual’s well-being, preferences, and living circumstances.

Against this backdrop, policy initiatives emerge as the fundamental architects shaping the very foundation of geriatric healthcare. They establish the legislative and regulatory frameworks that govern everything from the education and training of the healthcare workforce to the design of care delivery models and the critical integration of supportive home and community-based services. These policies serve as powerful instruments, capable of incentivizing innovation, promoting equitable access, and ensuring quality of care, while also navigating budgetary constraints and competing priorities.

This comprehensive report embarks on a deep exploration of the pivotal legislative and policy measures that have been conceptualized and implemented to address the burgeoning challenges in geriatric care. It delves into their historical context, intricate mechanisms, and practical applications, with a particular focus on evaluating their demonstrated effectiveness, identifying persistent gaps, and understanding their broader economic and social implications. By dissecting key federal acts, funding reforms, and institutional movements, this analysis aims to provide a nuanced understanding of how policy influences the capacity of the US healthcare system to adequately serve its aging citizens, fostering independence, dignity, and optimal health outcomes for all older adults.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2. Legislative Frameworks and Government Funding Mechanisms

The architecture of geriatric care in the United States is fundamentally underpinned by a series of legislative acts and sophisticated government funding mechanisms. These foundational elements establish the legal mandates, financial incentives, and programmatic structures that dictate the scope, accessibility, and quality of services available to older adults. Understanding these frameworks is crucial to appreciating the evolving landscape of geriatric healthcare.

2.1 The Older Americans Act of 1965

Enacted in 1965, amidst President Lyndon B. Johnson’s ‘Great Society’ initiatives, the Older Americans Act (OAA) stands as a landmark piece of federal legislation. It was the nation’s first comprehensive commitment to providing community-based services for older adults, reflecting a growing societal awareness of the unique challenges faced by an aging population. Prior to the OAA, support for the elderly was largely fragmented, primarily institutional, and often tied to poverty relief. The OAA shifted the paradigm towards promoting independence, dignity, and community integration.

The OAA established the National Aging Network, a tripartite system comprising the Administration for Community Living (ACL) – formerly the Administration on Aging (AoA) – at the federal level, State Units on Aging (SUAs) in each state and territory, and Area Agencies on Aging (AAAs) at the local level. This intricate network is responsible for planning, coordinating, and delivering a wide array of services. The AoA, as the principal agency, provides leadership, advocacy, and funding guidance. SUAs develop state plans, oversee AAAs, and allocate federal funds. AAAs, numbering over 600 nationwide, are the direct link to local communities, identifying needs, pooling resources, and contracting with local service providers.

Over its nearly six decades of existence, the OAA has undergone numerous reauthorizations and amendments, adapting to evolving demographic realities and emerging needs. Key amendments have expanded its scope to include caregiver support programs, elder abuse prevention initiatives, and provisions addressing the unique needs of low-income, minority, and rural older adults. For example, the 2006 reauthorization introduced important measures to protect vulnerable elders from abuse, neglect, and exploitation, while the 2016 reauthorization emphasized evidence-based health promotion and disease prevention programs.

The OAA primarily operates through formula grants to states, which then allocate funds to AAAs. These funds support a diverse portfolio of services categorized under various ‘Titles’ of the Act:

• Title III: Provides the bulk of funding for supportive services and senior centers (Title III-B), nutrition services (Title III-C, including congregate and home-delivered meals like Meals on Wheels), and caregiver support programs (Title III-E). Supportive services encompass transportation, information and assistance, legal aid, health promotion activities, and ombudsman services for residents of long-term care facilities.
• Title IV: Focuses on research, demonstration projects, and training to improve the quality of services.
• Title V: Supports the Senior Community Service Employment Program (SCSEP), providing job training and part-time community service employment for low-income older adults.
• Title VI: Specifically addresses the unique needs of Native Americans, Alaska Natives, and Native Hawaiians.

The OAA has been instrumental in promoting ‘aging in place’ by facilitating access to essential services that enable older adults to maintain their independence and remain in their homes and communities for as long as possible. Its focus on preventive and supportive care helps to delay or prevent institutionalization, thereby enhancing quality of life and potentially reducing healthcare costs. However, despite its critical role, the OAA has consistently faced challenges related to chronic underfunding relative to the growing demand, leading to waiting lists for critical services in many areas and varying levels of service provision across different states and localities.

2.2 The Geriatrics Workforce Improvement Act and Related Initiatives

The severe and escalating shortage of healthcare professionals trained in geriatrics represents one of the most pressing challenges to providing quality care for the aging population. The demand for geriatricians, nurses, social workers, and other allied health professionals with specialized knowledge in gerontology far outstrips the current supply. For instance, projections indicate a need for approximately 30,000 geriatricians by 2030, while the current number hovers around 7,000, with an aging cohort of these specialists themselves. Factors contributing to this shortage include lower comparative reimbursement for geriatric services, the perceived complexity of geriatric patients, and insufficient exposure to geriatrics in medical education.

Recognizing this critical deficit, the Geriatrics Workforce Improvement Act (often associated with legislative efforts to reauthorize existing programs) aims to bolster the geriatrics workforce through targeted funding for education and training programs. This act typically seeks to reauthorize and expand programs such as the Geriatrics Workforce Enhancement Program (GWEP) and the Geriatrics Academic Career Awards (GACA).

• Geriatrics Workforce Enhancement Program (GWEP): Administered by the Health Resources and Services Administration (HRSA), GWEP is the primary federal program designed to improve the health of older adults by developing a healthcare workforce that maximizes patient and family engagement and can integrate geriatrics and primary care. GWEP grantees, typically academic medical centers or health systems, focus on four key areas:

  • Training healthcare professionals: Providing education and clinical training to primary care providers, nurses, pharmacists, social workers, and other health professionals in geriatric care principles.
  • Developing interprofessional teams: Fostering collaborative practice models that bring together diverse healthcare professionals to provide comprehensive geriatric assessment and care.
  • Community outreach and education: Educating older adults, families, and caregivers on health promotion, disease prevention, and self-management strategies.
  • Integrating geriatrics into primary care: Developing models for embedding geriatric expertise into primary care practices to enhance routine care for older adults.
    GWEP emphasizes the ‘4Ms’ framework (What Matters, Medication, Mentation, Mobility) of the Age-Friendly Health Systems movement, promoting its adoption among trainees and community partners.

• Geriatrics Academic Career Awards (GACA): GACA aims to attract and retain talented faculty members in academic geriatrics. These awards provide funding to junior faculty committed to careers in academic geriatrics, supporting their research, clinical, and teaching endeavors. The goal is to build a robust pipeline of future leaders in geriatric medicine who can train the next generation of healthcare professionals and advance geriatric knowledge.

Beyond these specific programs, other federal initiatives contribute to workforce development. Title VII of the Public Health Service Act supports various health professions programs, some of which include geriatric training components. Professional organizations, such as the American Geriatrics Society (AGS), also play a crucial advocacy role, highlighting the geriatrician shortage and pushing for increased federal investment.

While these programs have demonstrated success in enhancing the quality of geriatric education and increasing the number of healthcare professionals with geriatric competencies, they have not yet fully stemmed the tide of the overall shortage of board-certified geriatricians. Challenges persist in attracting sufficient numbers of medical students to the field, making sustained and expanded investment in these initiatives critical. The economic benefits of such investments are substantial; a study in Kentucky, for example, found that every $1 invested in GWEP yielded up to $102 in healthcare savings by preventing hospital readmissions and delaying nursing home placements, underscoring the long-term cost-effectiveness of a well-trained geriatric workforce.

2.3 Medicare and Medicaid Reimbursement Reforms

Medicare and Medicaid constitute the bedrock of healthcare coverage for older adults in the United States, collectively providing essential health and long-term care services to millions. Reforms within these massive government programs have profound implications for the delivery, quality, and accessibility of geriatric care.

2.3.1 Medicare Reimbursement Reforms

Medicare, primarily a federal health insurance program, covers individuals aged 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease. Its structure includes Part A (hospital insurance), Part B (medical insurance for outpatient services), Part C (Medicare Advantage plans offered by private companies), and Part D (prescription drug coverage). Reimbursement policies within Medicare directly influence what services are offered, how providers are paid, and ultimately, patient access to care.

A significant reform was the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, which culminated in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Sustainable Growth Rate (SGR) formula, enacted in 1997, aimed to control Medicare spending on physician services by linking annual updates to national economic growth. However, it consistently led to threatened payment cuts, requiring Congress to pass temporary fixes to avert drastic reductions, creating immense uncertainty for providers. MACRA fundamentally altered this by repealing the SGR and establishing a new framework for rewarding value over volume.

MACRA introduced two primary pathways for physician reimbursement:

• Merit-based Incentive Payment System (MIPS): This system consolidates several previous quality reporting programs into one, measuring performance in four categories: Quality, Improvement Activities, Promoting Interoperability (EHR use), and Cost. Physicians receive positive, negative, or neutral payment adjustments based on their MIPS scores. For geriatric care, MIPS incentivizes attention to quality measures relevant to older adults, such as chronic disease management, preventive screenings, and medication reconciliation.
• Alternative Payment Models (APMs): APMs are innovative payment approaches that reward providers for delivering high-quality and cost-efficient care. Examples include Accountable Care Organizations (ACOs), bundled payments for episodes of care, and patient-centered medical homes. Participation in advanced APMs offers bonus payments and exemption from MIPS. These models are particularly relevant for complex geriatric patients, as they encourage care coordination, population health management, and a holistic approach to patient needs, often leading to better outcomes and reduced costs through preventing unnecessary hospitalizations or complications.

Beyond MACRA, other Medicare reforms have impacted geriatric care. The Medicare Quality Cancer Care Demonstration Act of 2009 was an important precursor, focusing on improving the quality and efficiency of cancer care for Medicare beneficiaries. While specific to oncology, it highlighted the broader imperative for specialized, integrated care models for complex conditions prevalent in older adults. More generally, Medicare has introduced reimbursement for Chronic Care Management (CCM) services, incentivizing non-face-to-face care coordination for patients with multiple chronic conditions—a large demographic among older adults. Similarly, Annual Wellness Visits (AWVs) encourage preventive care, health risk assessments, and personalized prevention plans, all critical for proactive geriatric health management.

2.3.2 Medicaid Reimbursement Reforms

Medicaid, a joint federal and state program, provides health coverage to low-income individuals, including many older adults who may also be dually eligible for Medicare and Medicaid. Medicaid is the primary payer for long-term services and supports (LTSS) in the US, covering nursing home care, but critically, also a growing array of home and community-based services (HCBS).

Reforms in Medicaid have increasingly focused on shifting the balance of LTSS away from institutional settings towards HCBS, supporting the ‘aging in place’ philosophy. The Medicaid Home and Community-Based Services (HCBS) waivers (under Section 1915(c) of the Social Security Act) are paramount in this effort. These waivers allow states to offer a broad range of services to individuals who would otherwise require institutional care, providing flexibility in service design to meet specific local needs. HCBS can include personal care assistance, adult day health services, skilled nursing, home health aide services, case management, and environmental modifications to homes. Their expansion has been a significant policy objective to enhance quality of life and autonomy for older adults and individuals with disabilities.

However, HCBS waiver programs face challenges, including waiting lists in many states due to capped enrollment or insufficient state funding, and variations in service availability and eligibility criteria from state to state. Recent federal legislative efforts, such as those proposed during the COVID-19 pandemic, have sought to temporarily increase federal matching funds for Medicaid HCBS, recognizing their essential role.

Medicaid also plays a critical role for dual eligibles, individuals who qualify for both Medicare and Medicaid. These beneficiaries often have complex health needs, multiple chronic conditions, and require extensive LTSS. State demonstration programs and integrated care models, such as the Financial Alignment Initiative (FAI) for dual eligibles, have sought to coordinate care between the two programs to improve outcomes and reduce costs. Furthermore, the growth of Medicaid managed care for LTSS is another reform, aiming to improve care coordination, quality, and cost-effectiveness by shifting financial risk to managed care organizations.

In summary, both Medicare and Medicaid reimbursement reforms are continuously evolving to address the fiscal sustainability of these programs while striving to improve the quality, coordination, and appropriateness of care for older adults. The shift towards value-based care, care coordination, and the prioritization of HCBS are central themes in these ongoing efforts.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3. Institutional Policies and Care Delivery Models

Beyond legislative frameworks and funding mechanisms, the actual delivery of geriatric care is shaped by institutional policies and the innovative care models developed within healthcare organizations. These initiatives translate high-level policy goals into actionable strategies, directly influencing how older adults experience healthcare.

3.1 Age-Friendly Health Systems Movement

The Age-Friendly Health Systems (AFHS) movement is a groundbreaking initiative launched in 2017 by the Institute for Healthcare Improvement (IHI), in partnership with the John A. Hartford Foundation (JAHF), the American Hospital Association (AHA), and the Catholic Health Association of the United States. Its core mission is to improve the quality of care for older adults by embedding evidence-based practices into all care settings, ranging from primary care offices to hospitals and nursing homes.

The AFHS movement is anchored by the ‘4Ms’ framework, a set of interconnected, evidence-based practices that guide the provision of care for older adults:

1. What Matters: This M emphasizes understanding and aligning care with each older adult’s specific health outcomes goals and care preferences, including end-of-life care. It necessitates active engagement in shared decision-making, where the patient’s values, priorities, and life context drive care plans. This includes discussions about advance directives, goals of care, and preferences for daily living, ensuring that medical interventions are congruent with the individual’s definition of a good life.
2. Medication: This M focuses on judicious medication management. It calls for using age-friendly medications that do not interfere with ‘What Matters,’ Mentation, or Mobility, and deprescribing medications that are unnecessary or potentially harmful. Older adults are particularly susceptible to polypharmacy (the use of multiple medications) and adverse drug events due to age-related changes in drug metabolism and increased sensitivity. This principle encourages regular medication reviews, adherence to guidelines like the Beers Criteria for potentially inappropriate medication use in older adults, and patient education.
3. Mentation: This M addresses mental acuity, encompassing the prevention, identification, and management of delirium, dementia, and depression. Age-friendly health systems implement systematic screening for these conditions, provide appropriate interventions, and educate patients and families. For example, screening for delirium upon hospital admission, implementing protocols for its prevention (e.g., adequate hydration, early mobilization, sleep hygiene), and ensuring cognitive status is routinely assessed in primary care are key components.
4. Mobility: This M aims to ensure that older adults move safely every day to maintain function and independence. It involves assessing mobility, identifying risks for falls, and implementing strategies to prevent functional decline during hospitalization or illness. This includes early ambulation protocols, physical therapy consultations, fall risk assessments, and provision of assistive devices, all tailored to the individual’s capabilities and goals.

Healthcare organizations that adopt the AFHS framework commit to becoming ‘Age-Friendly’ by demonstrating consistent implementation of the 4Ms across their settings. The John A. Hartford Foundation, a leading philanthropic organization dedicated to improving the care of older adults, has been a principal driver of the movement, providing grants and technical assistance to accelerate its spread. The IHI also offers various resources, including guides, webinars, and a recognition program for health systems that achieve AFHS status.

The impact of the AFHS movement is multifaceted. It standardizes best practices in geriatric care, promotes an interdisciplinary team approach, improves patient and family satisfaction, and has shown promise in reducing healthcare costs by preventing complications like delirium, falls, and adverse drug events. By fostering a culture that prioritizes the unique needs of older adults, AFHS aims to ensure that all interactions within the healthcare system are respectful, effective, and person-centered.

3.2 Programs of All-Inclusive Care for the Elderly (PACE)

The Programs of All-Inclusive Care for the Elderly (PACE) model represents a highly integrated and comprehensive approach to healthcare and social services for frail older adults. Originating in the 1970s in San Francisco’s Chinatown-North Beach community, PACE began as a community-based effort to provide culturally sensitive care to a vulnerable population, preventing institutionalization. It later became a federal demonstration project and was formally recognized as a permanent Medicare and Medicaid benefit in 1997.

PACE serves individuals aged 55 and over who meet specific eligibility criteria:

• They must be aged 55 or older.
• They must live in a PACE organization’s service area.
• They must be certified by the state as needing a nursing home level of care.
• They must be able to live safely in the community with the support of PACE services at the time of enrollment.

The defining feature of PACE is its interdisciplinary team (IDT) approach. Each participant has a dedicated IDT, typically consisting of a primary care physician, nurses, social workers, physical and occupational therapists, dietitians, transportation specialists, and personal care aides. This team works collaboratively to assess the participant’s needs, develop a comprehensive care plan, and coordinate all medical and social services. The IDT meets regularly to review each participant’s status and adjust care plans as needed.

PACE operates on a capitated payment model, meaning that the PACE organization receives a fixed monthly payment from Medicare and Medicaid (or private pay) for each participant, regardless of the services utilized. In return, the PACE organization is fully responsible for providing all necessary healthcare and long-term care services determined by the IDT. This includes:

• Primary and specialty medical care (physician, nursing, dental, optometry, podiatry, audiology).
• Hospital and nursing home care when necessary.
• Prescription drugs.
• Physical, occupational, and speech therapy.
• Home care services (personal care, light housekeeping).
• Adult day health center services (socialization, meals, activities, medical monitoring).
• Medical transportation.
• Social services, including counseling and support for caregivers.
• Nutritional counseling and meals.
• Durable medical equipment.

The overarching goal of PACE is to keep older adults out of nursing homes and within their communities for as long as medically and socially appropriate, enhancing their quality of life and maintaining their independence. Research consistently demonstrates that PACE participants experience lower rates of hospitalizations, emergency department visits, and nursing home admissions compared to similar populations. They also report higher satisfaction with their care and improved health outcomes. Furthermore, studies have shown PACE to be a cost-effective model, reducing overall healthcare expenditures compared to traditional fee-for-service care for this frail population.

Despite its documented benefits, PACE still covers only a small fraction of eligible individuals. Challenges include limited geographic availability (PACE centers are not in all states or all counties), the complexity of establishing new PACE organizations, and the intensive capital investment required. However, ongoing efforts are aimed at expanding access to PACE through legislative support and increased awareness.

3.3 Other Innovative Care Models and Institutional Initiatives

Beyond AFHS and PACE, numerous other innovative care delivery models and institutional policies contribute to improving geriatric care:

• Geriatric Emergency Departments (GEDs): Recognizing that older adults presenting to emergency departments (EDs) often have complex, atypical symptoms and are at higher risk for adverse outcomes, dedicated GEDs have emerged. These specialized units are designed with age-friendly environments (e.g., non-slip floors, enhanced lighting, recliners instead of gurneys) and staffed by teams trained in geriatric principles. They implement protocols for cognitive screening, fall risk assessment, medication reconciliation, and appropriate discharge planning, often connecting patients with community resources to prevent re-admissions. The American College of Emergency Physicians (ACEP) offers accreditation for GEDs, promoting best practices.

• Acute Care for Elders (ACE) Units: These specialized hospital units focus on preventing functional decline and improving outcomes for older hospitalized patients. ACE units typically feature an interdisciplinary team (geriatrician, nurses, physical therapists, social workers, dietitians, pharmacists) that conducts comprehensive geriatric assessments, promotes early mobilization, addresses nutrition and hydration, prevents delirium, and plans for safe discharge. Environmental modifications and patient-centered care approaches are also hallmarks of ACE units.

• Hospital Elder Life Program (HELP): Developed by Dr. Sharon Inouye, HELP is a proactive intervention program aimed at preventing delirium and functional decline in hospitalized older adults. Volunteers and staff implement non-pharmacological interventions such as daily visits to orient patients, therapeutic activities, early mobilization, feeding assistance, and sleep enhancement protocols. HELP has been widely adopted and demonstrated to significantly reduce the incidence of delirium and maintain functional independence.

• Patient-Centered Medical Homes (PCMHs) with Geriatric Expertise: The PCMH model emphasizes comprehensive, coordinated, and patient-centered primary care. When infused with geriatric expertise, PCMHs can provide integrated care that addresses the multiple chronic conditions, psychosocial needs, and functional issues common in older adults. This often involves embedded social workers, pharmacists, and behavioral health specialists working alongside primary care physicians and nurses.

• Telehealth and Remote Monitoring: The COVID-19 pandemic significantly accelerated the adoption of telehealth. For older adults, telehealth offers increased accessibility to specialists, reduced travel burden, and continuity of care for chronic disease management, particularly in rural or underserved areas. Remote patient monitoring technologies can track vital signs, glucose levels, or activity patterns, allowing proactive intervention and preventing exacerbations of chronic conditions. Institutional policies are rapidly evolving to integrate these technologies while addressing digital literacy, equity, and reimbursement challenges.

These innovative models, supported by evolving institutional policies, demonstrate a growing commitment within the healthcare system to tailor care specifically for the aging population, moving beyond a one-size-fits-all approach.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4. Challenges in Geriatric Care and Policy Responses

Despite significant policy advancements, several persistent challenges impede the optimal delivery of geriatric care in the United States. Addressing these complex issues requires ongoing, adaptive policy responses that target root causes and foster sustainable solutions.

4.1 Geriatrician Shortages

The chronic and worsening shortage of healthcare professionals specializing in geriatrics stands as perhaps the most critical barrier to providing high-quality care for older adults. As previously noted, the number of board-certified geriatricians falls far short of the projected demand. This deficit extends beyond physicians to include geriatric-trained nurses, social workers, pharmacists, and other allied health professionals.

Root Causes of the Shortage:

• Limited Pipeline: Relatively few medical students choose geriatrics as a specialty. This is often attributed to insufficient exposure to geriatrics in medical school curricula, a perception of geriatrics as less procedurally oriented, and a lower average compensation compared to other subspecialties.
• Aging Workforce: The current geriatrician workforce is itself aging, with many approaching retirement, exacerbating the impending crisis.
• Complexity of Care: Geriatric patients often present with multiple chronic conditions, cognitive impairments, functional decline, and complex psychosocial needs. While deeply rewarding, this complexity can be daunting for trainees without adequate support and training.
• Reimbursement Disparities: Historically, fee-for-service models have not adequately compensated for the time-intensive, cognitive, and care coordination efforts central to geriatric practice, making it financially less attractive.

Policy Responses:

Federal and state policies have attempted to address this shortage through multiple avenues:

• Geriatrics Workforce Enhancement Program (GWEP) and Geriatrics Academic Career Awards (GACA): As detailed earlier, these programs are crucial for increasing exposure to geriatrics, funding specialized training, and supporting academic careers. Their continued reauthorization and increased funding are vital.
• Loan Repayment Programs and Incentives: Policies that offer student loan forgiveness or financial incentives for healthcare professionals who choose to practice geriatrics, particularly in underserved areas, can help attract more individuals to the field.
• Interprofessional Education: Promoting interprofessional geriatric education across various health disciplines ensures that all healthcare providers have foundational geriatric competencies, even if they are not specialists. This strategy aims to create a ‘geriatrics-capable’ workforce across the board, mitigating the impact of the specialist shortage.
• Expanding Scope of Practice: Policies that allow advanced practice registered nurses (APRNs) and physician assistants (PAs) to practice to the full extent of their education and training, especially in primary care and long-term care settings, can help expand access to geriatric-informed care.
• Advocacy and Awareness Campaigns: Efforts by professional organizations (e.g., American Geriatrics Society) and foundations (e.g., John A. Hartford Foundation) to raise awareness about the rewards and importance of geriatric careers are essential for shifting perceptions and attracting talent.

While these initiatives represent important steps, a comprehensive, sustained national strategy involving substantial investment in education, training, and appropriate reimbursement is required to close the projected gap.

4.2 Incentivizing Comprehensive and Personalized Care

Older adults often present with complex health profiles, including multiple chronic conditions (multi-morbidity), cognitive impairments, functional limitations, and significant psychosocial needs. Standard, episodic, disease-specific care models are often inadequate for this population. Comprehensive and personalized care, which considers the whole person, their preferences, and their life context, is essential. Policies are evolving to incentivize this shift.

Challenges in Traditional Care Models:

• Fragmented Care: Fee-for-service models often encourage volume over value, leading to multiple specialist visits, redundant tests, and poor coordination, which can be detrimental for older adults with complex needs.
• Lack of Integration: Medical care is often disconnected from social services, even though social determinants of health (e.g., housing, nutrition, transportation, social isolation) profoundly impact older adults’ well-being.
• Limited Time for Complex Patients: Physicians in traditional settings often have limited time for comprehensive assessments, shared decision-making, and care coordination required for geriatric patients.

Policy Responses:

Policy responses have largely focused on moving healthcare reimbursement and delivery towards value-based care and models that prioritize coordination and holistic assessment:

• Value-Based Care Models (MACRA, ACOs, Bundled Payments): As discussed in Section 2.3, MACRA’s MIPS and APM pathways incentivize quality outcomes, cost-efficiency, and care coordination. Accountable Care Organizations (ACOs), for example, hold providers accountable for the total cost and quality of care for a defined population. This encourages integrated care teams, preventive services, and proactive management of chronic conditions, all of which benefit older adults.
• Reimbursement for Care Coordination and Chronic Care Management (CCM): Medicare now offers specific billing codes for CCM services, recognizing the time and effort involved in coordinating care for patients with multiple chronic conditions. This includes managing medications, communicating with other providers, and facilitating access to community resources.
• Age-Friendly Health Systems (AFHS): The AFHS movement, with its ‘4Ms’ framework, directly promotes comprehensive and personalized care by focusing on ‘What Matters’ to the patient, judicious medication use, mentation assessment, and mobility maintenance. The institutional adoption of AFHS principles is a policy-driven effort to standardize person-centered care.
• Patient-Centered Medical Homes (PCMHs): Certification and payment models for PCMHs encourage a team-based approach, enhanced access, care coordination, and a focus on preventive care and chronic disease management, which are highly beneficial for older adults.
• Shared Decision-Making and Advance Care Planning: Policies and guidelines promoting shared decision-making and advance care planning ensure that older adults’ preferences for care, especially at the end of life, are respected and integrated into their treatment plans. This moves care from a paternalistic model to a truly personalized approach.

Challenges remain, including the administrative burden associated with some value-based models, the complexity of data collection and reporting, and the need for robust risk adjustment mechanisms to ensure that providers caring for the sickest, most complex older adults are not unfairly penalized.

4.3 Supporting ‘Aging in Place’ Initiatives

‘Aging in place’ refers to the ability of older adults to live independently and safely in their own homes and communities for as long as possible, rather than relocating to institutional settings like nursing homes. This preference is overwhelming among older adults and is strongly correlated with improved quality of life, autonomy, and social engagement. Policies supporting aging in place also offer significant cost advantages, as institutional care is typically much more expensive than community-based alternatives.

Policy Mechanisms Supporting Aging in Place:

• The Older Americans Act (OAA): As detailed in Section 2.1, the OAA is a cornerstone of aging in place policies. Its funding for nutrition programs (e.g., Meals on Wheels), transportation services, in-home support, caregiver assistance, and senior centers directly enables older adults to remain in their communities and homes.
• Medicaid Home and Community-Based Services (HCBS) Waivers: These waivers (Section 1915(c) of the Social Security Act) are critical for providing a range of services—such as personal care, skilled nursing, adult day services, and case management—to individuals who require a nursing home level of care but can remain at home with support. HCBS waivers have been instrumental in rebalancing long-term care spending away from institutions.
• Programs of All-Inclusive Care for the Elderly (PACE): PACE, with its comprehensive, capitated care model delivered in community settings, is a prime example of a successful aging in place initiative. By integrating medical, social, and long-term care services, PACE proactively addresses participants’ needs, thereby preventing or delaying institutionalization.
• Affordable Housing and Home Modification Programs: Policies supporting affordable, accessible housing for older adults are crucial. This includes programs like Section 202 Supportive Housing for the Elderly and Low-Income Housing Tax Credits (LIHTC) projects with senior living components. Additionally, programs that provide financial assistance for home modifications (e.g., ramps, grab bars, widened doorways) enable older adults to safely navigate their living environments as their mobility changes.
• Transportation Services: Accessible and affordable transportation is essential for older adults to maintain independence, access healthcare, attend social activities, and run errands. Federal and state grants, often channeled through AAAs or public transit agencies, support specialized senior transportation services.
• Technology and Remote Monitoring: Policies that incentivize the adoption and reimbursement of telehealth services and remote patient monitoring technologies can support aging in place by extending care into the home, allowing for proactive health management and emergency response.
• Age-Friendly Communities Movement: Building upon the AFHS, the Age-Friendly Communities movement (often inspired by the WHO Global Network for Age-Friendly Cities and Communities) encourages municipalities to implement policies and programs across various domains (e.g., outdoor spaces, transportation, housing, social participation, health services, communication, civic participation, respect and social inclusion) to better support residents of all ages. This holistic approach creates environments conducive to aging in place.

Policy Gaps and Challenges:

Despite these efforts, significant gaps remain. Funding for HCBS waivers often falls short of demand, leading to extensive waiting lists. Workforce shortages for in-home caregivers are acute, impacting service availability. Moreover, the integration of housing, health, and social services remains a complex challenge, requiring more coordinated policy strategies. Addressing these gaps is paramount for truly realizing the potential of aging in place for all older adults.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5. Economic and Social Impacts of Policy Initiatives

The policy initiatives discussed—from legislative frameworks to care delivery models—exert profound and far-reaching economic and social impacts across individual lives, healthcare systems, and society at large. Understanding these impacts is critical for evaluating policy effectiveness and guiding future directions.

5.1 Economic Impacts

Policies aimed at improving geriatric care carry substantial economic implications, influencing healthcare expenditures, cost savings, workforce productivity, and economic growth.

• Cost Savings through Prevention and Delayed Institutionalization: Perhaps the most compelling economic argument for robust geriatric care policies is their potential to generate significant cost savings. Programs like PACE exemplify this; by providing comprehensive, coordinated care in a community setting, PACE demonstrably reduces reliance on expensive institutional care (nursing homes, hospitals). Studies have shown that PACE participants have lower rates of emergency department visits and hospital readmissions compared to matched control groups, leading to substantial savings for Medicare and Medicaid. Similarly, investments in geriatrics workforce development, such as through GWEP, have shown remarkable returns. As referenced earlier, a Kentucky study indicated that every $1 invested in GWEP could yield up to $102 in healthcare savings, primarily by preventing adverse events and readmissions, underscoring the long-term economic dividends of a well-trained geriatric workforce.

• Healthcare Spending Rebalancing: Policies that prioritize home and community-based services (HCBS) over institutional care (e.g., Medicaid HCBS waivers) are gradually rebalancing national long-term care spending. While nursing home care historically dominated expenditures, federal incentives and state efforts have shifted a greater proportion of Medicaid LTSS funds towards community-based options. This shift aligns spending with patient preferences and is generally more cost-effective per beneficiary, though the sheer volume of need means total expenditures remain high.

• Workforce and Economic Contribution: Investing in the geriatric care workforce not only improves patient outcomes but also creates jobs within the healthcare sector. Furthermore, by supporting older adults in maintaining their independence and health, these policies can enable them to remain economically productive for longer, whether through continued employment, volunteering, or contributing to their families and communities. Policies that support family caregivers (e.g., tax credits, respite care) can also mitigate the economic strain on families, potentially allowing caregivers to maintain their own employment.

• Impact on Medicare and Medicaid Budgets: Given that older adults are significant beneficiaries of Medicare and Medicaid, reforms within these programs directly impact federal and state budgets. Value-based payment models (e.g., MACRA, ACOs) aim to control costs by incentivizing quality and efficiency, thereby curbing unsustainable growth in expenditures. However, the initial administrative costs of implementing complex reforms can be substantial, and the long-term savings often take time to materialize and can be challenging to precisely quantify across diverse patient populations.

• Economic Burden of Unmet Needs: Conversely, a lack of adequate geriatric care policies leads to significant economic burdens. Unaddressed chronic conditions, preventable hospitalizations, falls, and cognitive decline contribute to higher healthcare costs, increased reliance on institutional care, and lost productivity for both older adults and their caregivers. For example, the economic burden of dementia is staggering, encompassing direct medical and social care costs, as well as indirect costs of informal care, highlighting the need for early detection and intervention policies.

5.2 Social Impacts

Beyond economic considerations, geriatric care policies profoundly shape the social fabric, influencing the well-being, dignity, and societal integration of older adults, as well as the experiences of their families and communities.

• Enhanced Quality of Life and Independence: Policies supporting ‘aging in place’ through programs like the OAA and PACE are instrumental in promoting autonomy and dignity. By providing essential services such as transportation, nutrition, and in-home support, older adults can maintain their independence, continue living in familiar surroundings, and remain connected to their social networks. This contributes significantly to mental health, reducing feelings of isolation, loneliness, and depression, which are prevalent among older adults.

• Improved Health Outcomes and Reduced Disparities: Policies that incentivize comprehensive, person-centered care (e.g., Age-Friendly Health Systems, value-based care models) lead to better health outcomes, including improved functional status, better management of chronic diseases, and a reduction in preventable adverse events. By focusing on the ‘4Ms,’ for instance, AFHS help to address critical areas like medication safety and cognitive health. Moreover, equitable access to quality geriatric care, promoted by broad policy frameworks, can help mitigate health disparities experienced by minority, rural, and low-income older adults, fostering a more just and inclusive society.

• Support for Family Caregivers: The vast majority of long-term care for older adults is provided by unpaid family caregivers, who often face immense physical, emotional, and financial strain. Policies like the OAA’s National Family Caregiver Support Program, which offers respite care, education, counseling, and supplemental services, provide crucial relief. By supporting caregivers, these policies indirectly enhance the well-being of older adults by enabling their primary support system to sustain its efforts. Further policy development, such as paid family leave or direct financial assistance for caregivers, could have even more transformative social impacts.

• Community Integration and Social Engagement: Programs funded by the OAA, such as senior centers and congregate meal sites, serve as vital hubs for social interaction, learning, and physical activity, combating social isolation and fostering community cohesion. The PACE model, with its adult day health centers, also emphasizes social engagement as a critical component of holistic care. These initiatives ensure older adults remain active participants in society, sharing their wisdom and experiences.

• Shifting Societal Perceptions of Aging: The cumulative effect of these policies contributes to a broader societal shift in how aging is perceived. By emphasizing independence, active living, and high-quality care, policies move away from a deficit-based view of aging towards one that values older adults’ contributions and supports their continued engagement. Movements like Age-Friendly Communities aim to transform entire environments to be inclusive and supportive of all ages, promoting intergenerational solidarity.

In essence, geriatric care policies are not merely about healthcare delivery; they are about fostering a society that values its older members, safeguards their health and independence, and ensures their continued ability to thrive, contributing to a richer and more equitable social fabric for everyone.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6. Future Directions and Recommendations

The landscape of geriatric care in the United States, while marked by significant policy achievements, remains dynamic and faces evolving challenges. As the older adult population continues to grow in number and diversity, future policy directions must be proactive, comprehensive, and adaptable to ensure an equitable, high-quality, and sustainable system of care.

6.1 Emerging Policy Areas

Several areas warrant intensified policy focus and innovation:

• Long-Term Care Financing Reform: The current system for financing long-term care remains largely reliant on Medicaid for low-income individuals and out-of-pocket spending for others, leading to significant financial strain for many families. Future policies must explore innovative models, such as public-private partnerships, expanded long-term care insurance options, or universal social insurance programs, to create a more sustainable and equitable financing structure.

• Integration of Medical and Social Services: The artificial divide between healthcare and social support systems often results in fragmented care. Future policies should explicitly mandate and incentivize the integration of social determinants of health (e.g., housing stability, food security, transportation) into healthcare delivery models, perhaps through new payment structures or expanded roles for community-based organizations within healthcare networks. The Accountable Communities for Health model, which brings together health, social services, and other sectors, offers a promising pathway.

• Leveraging Technology and Artificial Intelligence (AI): The rapid advancements in telehealth, remote patient monitoring, smart home technologies, and AI present immense opportunities for geriatric care. Policy needs to focus on expanding broadband access, ensuring equitable access to technology for all older adults, developing clear reimbursement policies for technology-enabled services, and establishing ethical guidelines and regulatory frameworks for AI use in diagnostics, care planning, and monitoring to protect patient privacy and prevent bias.

• Enhanced Caregiver Support Mandates: Given the indispensable role of informal caregivers, policies must expand beyond basic support programs. This could include federal and state initiatives for paid family leave, direct financial assistance or tax credits for family caregivers, comprehensive training programs, and stronger legal protections and workplace flexibility for those balancing caregiving with employment.

• Addressing Health Disparities: Older adults from racial and ethnic minority groups, LGBTQ+ individuals, rural populations, and those with lower socioeconomic status often face significant health disparities and barriers to accessing quality geriatric care. Future policies must incorporate explicit equity goals, collect disaggregated data, and implement targeted interventions to ensure that all older adults receive culturally competent and appropriate care.

• Preventive Care and Wellness Initiatives: While some preventive services are covered, there is a need for broader, more integrated wellness programs focused on healthy aging, fall prevention, exercise, nutrition, and mental health promotion across the lifespan, starting well before older age. Policies incentivizing preventive primary care and community-based wellness programs can significantly improve healthspan and reduce future healthcare costs.

6.2 Recommendations

Based on the analysis, the following recommendations are put forth for policymakers, healthcare providers, and researchers:

1. Sustain and Significantly Increase Funding for Workforce Development: Congress must reauthorize and substantially increase funding for programs like GWEP and GACA to expand the geriatric workforce across all disciplines. This should be coupled with targeted incentives (e.g., loan repayment, scholarships) to attract more students and professionals to geriatrics and to retain them in academic and clinical settings. Expanding interprofessional education across all health disciplines is also paramount.

2. Advance Value-Based Care Models that Prioritize Geriatric Needs: Policymakers should continue to refine and expand value-based payment models (e.g., MACRA, ACOs) to ensure they adequately compensate for the complexity, time, and care coordination inherent in geriatric care. This includes appropriate risk adjustment for multi-morbid older adults and incentives for comprehensive geriatric assessments and advance care planning. Explore innovative capitated models like PACE for wider adoption.

3. Strengthen and Expand Home and Community-Based Services (HCBS): Federal and state governments should increase funding for Medicaid HCBS waivers and other community-based programs to eliminate waiting lists and ensure universal access. This includes bolstering the direct care workforce through improved wages, benefits, and training, making these critical roles sustainable.

4. Promote Universal Adoption of Age-Friendly Health Systems: Healthcare systems should be strongly incentivized, and potentially mandated over time, to adopt the ‘4Ms’ framework of Age-Friendly Health Systems across all care settings. This requires sustained support from federal agencies, foundations, and professional organizations for implementation, training, and continuous quality improvement.

5. Foster Research and Innovation in Geriatric Care: Increased federal funding for research into age-related diseases, innovative care delivery models, health disparities in aging, and the effectiveness of integrated health and social services is crucial. This research should inform evidence-based policy development and drive continuous improvement in geriatric care.

6. Develop Integrated Care Systems for Dual Eligibles: Policies must continue to promote and refine models for seamlessly integrating Medicare and Medicaid benefits for dual-eligible beneficiaries, who represent some of the most complex and vulnerable older adults, to improve care coordination and outcomes.

7. Support Age-Friendly Communities: Local, state, and federal policies should collaborate to foster the development of Age-Friendly Communities, which holistically address the physical, social, and economic environments to support healthy and active aging for all residents.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

7. Conclusion

The health and well-being of the United States’ aging population represent one of the most significant societal challenges and opportunities of the 21st century. Policy initiatives are not merely supplementary; they are the bedrock upon which an effective, equitable, and sustainable geriatric care system must be built. Legislative frameworks, governmental funding mechanisms, and institutional policies collectively exert profound influence over every aspect of geriatric care—from the cultivation of a specialized workforce to the design of patient-centered care models and the empowerment of older adults to age with dignity in their chosen communities.

While substantial progress has been made through landmark legislation like the Older Americans Act, strategic funding for workforce development, and transformative movements like Age-Friendly Health Systems and PACE, persistent challenges remain. The chronic shortage of geriatric specialists, the need to consistently incentivize comprehensive and personalized care, and the imperative to expand robust ‘aging in place’ initiatives are ongoing battles that demand continuous attention and innovative solutions.

The economic and social impacts of these policies underscore the inherent value in sustained investment in geriatric care. By reducing avoidable healthcare costs, enhancing quality of life, supporting family caregivers, and fostering vibrant, age-inclusive communities, these policies yield dividends far beyond the healthcare sector. They represent an investment in the foundational strength and compassionate character of our society.

Moving forward, a truly effective geriatric care system will require a concerted, multi-sectoral approach. This entails sustained political will, increased financial commitment, ongoing innovation in care delivery, and a fundamental shift towards prevention and integration across the health and social care continuum. By embracing these principles and acting decisively on well-informed policy, the United States can aspire to not only meet the demands of its aging population but also to serve as a global exemplar for how a society cares for its elders, ensuring that every older adult can experience health, dignity, and purpose in their later years.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

References

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