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December 31, 2017

Assessing and Meeting the Needs of LGBT Older Adults via the Older Americans Act

LGBT Health
By Michael Adams and Aaron Tax

ABSTRACT

SAGE and its partners have been focused on bridging the chasm between the greater need that LGBT older adults have for care, services, and supports, and the lower rate at which they access them, compared with their heterosexual and cisgender counterparts. The chasm is caused by discrimination, social isolation, disproportionate poverty and health disparities, and a lack of access to culturally competent providers. SAGE has used federal administrative and legislative advocacy to encourage the Aging Network to bridge this chasm by assessing and meeting the needs of LGBT older adults that can be addressed via the programs created under the Older Americans Act.

Introduction

In recent years, the health-related public policy goals of SAGE and its partners have focused, to a substantial degree, on bridging the chasm between the greater need that LGBT older adults have for aging care, services, and supports, and the lower rate at which they access these services and supports, compared with their heterosexual and cisgender older adult counterparts. This article will highlight a primary focus of SAGE's advocacy efforts—targeting LGBT older adults as a priority population for services and supports under the Older Americans Act (OAA)—recognizing that community-based care and supports are critical to the health outcomes of LGBT elders.

The available data and research and the experience of SAGE, its affiliates, and partners across the country elucidate three primary barriers that inhibit healthy aging by LGBT older adults: (1) social isolation; (2) disproportionate poverty and health disparities; and (3) a lack of access to culturally competent care, services, and supports. All of these factors impact the health outcomes of LGBT older adults adversely.1

In a society where nonpaid caregivers (partners and children) are the primary caregivers for elders,2 LGBT older adults are more likely to be single and less likely to have children than their heterosexual and cisgender older adult peers.3–6 LGBT older adults are also much more likely to be disconnected from families of origin than their heterosexual and cisgender older adult peers.3 These sparse support networks often result in significant social isolation among LGBT elders.

While there is a widespread misperception that LGBT people are affluent, certain segments of the LGBT older adult population are more likely to live in poverty than their heterosexual, cisgender older adult peers.7 Older lesbian couples are more likely to be poor than similarly situated heterosexual couples7 and 15.9% of gay and bisexual men and transgender men older than 65 live in poverty, compared with just 9.7% of heterosexual cisgender men their age.7 (Table 4, page 10)

LGBT older adults face pronounced health disparities compared with their heterosexual and cisgender older adult peers. HIV impacts certain populations within the LGBT community disproportionately,8 and it is affecting an increasing number of older adults.9 The National Institutes of Health (NIH) and National Institute on Aging (NIA)-funded Aging and Health Report outlines a number of other disparities, including that LGB older adults face higher rates of disability and mental health challenges; older bisexual and gay men face higher rates of physical health challenges; bisexual and lesbian older women have higher obesity rates and higher rates of cardiovascular disease; and transgender older adults face greater risk of suicidal ideation, disability, and depression compared to their cisgender peers.1 LGBT older adults experience violence, discrimination, and stigma throughout their lives, and transgender older adults may face health consequences from the long-term use of hormone therapy.10 Transgender older adults 65+ face specific health challenges. Sixteen percent have attempted suicide one or more times, 70% have delayed transitioning to avoid discrimination in employment, and 13% have abused drugs and alcohol as a coping mechanism.11 As a result of these pronounced health disparities, poverty, and social isolation, LGBT older adults have a greater need for services and care than their heterosexual and cisgender peers. However, because of discrimination, lack of culturally competent services and care, and fear of mistreatment, they are much less likely than their heterosexual and cisgender peers to take advantage of the supports that are theoretically available to them.3,12–14

The OAA

Congress passed and President Lyndon Johnson signed the OAA into law in 1965 as part of the Great Society.15 Social Security theoretically provides income, Medicare provides healthcare, and the OAA is designed to provide services and supports that enable people to age in place in their communities. “Aging in place” means aging in one's home, as opposed to aging in an institution such as a nursing home or long-term care facility. The OAA is the United States' primary vehicle for the organization and delivery of social and nutrition programs for older adults and their caregivers.16 The US Department of Health and Human Services funds the OAA at $2 billion/year, through the Administration for Community Living's (ACL) Administration on Aging (AoA). ACL administers the OAA, funding an expansive aging services network to provide programs and services, including senior centers, home and congregate meals (such as Meals on Wheels), chore assistance, transportation assistance, and caregiver support.17 The OAA is generally reauthorized every 5 years. When Congress reauthorized the OAA 5 years late in 2016, it legislated only a 3-year reauthorization through 2019. Unlike the target communities referenced in the next section, LGBT older adults are not identified in this cornerstone of federal aging policy.

OAA Target Populations

As of the latest version of the OAA, updated in 2016, Congress targets rural elders as well as (1) those with severe disabilities; (2) those with limited English proficiency; (3) those with Alzheimer's and related disorders; (4) those at-risk for institutional placement; (5) those with greatest economic need (with particular attention to low-income elders who are members of racial and ethnic minority groups, and older individuals residing in rural areas); and (6) those with greatest social need (also with particular attention to elders who are members of racial and ethnic minority groups, and rural elders).18,19 The OAA defines greatest social need as, “[N]eed caused by noneconomic factors, which include—(A) physical and mental disabilities; (B) language barriers; and (C) cultural, social, or geographical isolation, including isolation caused by racial or ethnic status, that—(i) restricts the ability of an individual to perform normal daily tasks; or (ii) threatens the capacity of the individual to live independently.”20

Implications of Being Defined as a Greatest Social Need Population

The Aging Network* is required to prioritize the delivery of services and supports to the aforementioned groups, and to specifically address their needs as it develops resources, engages in advocacy, and participates in planning.21Defining a group as a greatest social need population under the OAA offers critical support to the targeted cohort. The designation requires the Aging Network to collect data on the presence of the population, target services and supports to the population, and assist service providers in reaching the population.20 In short, the designation aims to ensure that the provision of OAA services and supports matches a particular population's specialized needs.

LGBT Older Adults Fit the Definition

Beyond economic challenges, LGBT older adults fit the OAA's definition of greatest social need in multiple ways outlined in the introduction, all of which threaten their ability to live independently. Discrimination and stigma, including internalized stigma, for LGBT elders3,22,23 and, for LGBT elders of color, stigma associated with racial or ethnic status,24 often exacerbate cultural and social isolation and lack of social support. Reluctance to engage services and supports presents an additional challenge.3,12,13 In fact, in 2012, ACL used its website to clarify that the OAA's definition of greatest social need does not preclude state units on aging and area agencies on aging (AAAs) from targeting other populations facing social, cultural, or geographic isolation because of other factors not specifically delineated in the statute:

Does “greatest social need” as defined in the Older Americans [Act] allow communities to target funds to populations they identify as experiencing cultural, social or geographic isolation other than isolation caused by racial or ethnic status?

While the definition of “greatest social need” in the Older Americans Act includes isolation caused by racial or ethnic status, the definition is not intended to exclude the targeting of other populations that experience cultural, social or geographic isolation due to other factors. In some communities, such isolation may be caused by minority religious affiliation. In others, isolation due to sexual orientation or gender identity may restrict a person's ability to perform normal daily tasks or live independently. Each planning and service area must assess their particular environment to determine those populations best targeted based on “greatest social need[.]”21

Some states have been leaders in targeting LGBT older adults for services and supports. In 2012, for example, Massachusetts' state unit on aging, the Executive Office of Elder Affairs (EOEA), designated LGBT elders a population of greatest social need under the OAA.25 EOEA requested that local agencies that work with older adults “identify and assess the LGBT population as a part of their plan development.”26 As a result of this directive, a number of Massachusetts AAAs hosted community needs assessment meetings, particularly for LGBT older adults and caregivers, to learn what is needed by this segment of their constituents. They also include LGBT elders as a priority population in requests for proposals. The New York State Office for the Aging targets LGBT older adults for services, and is implementing sexual orientation and gender identity data collection, but it has not yet designated LGBT elders as a population of greatest social need.27

ACL's 2012 clarification that “greatest social need” can encompass LGBT elders, however, has proven insufficient to prompt most of the Aging Network to assess and target the needs of LGBT older adults. Despite the data that LGBT individuals live in every state,28 some providers still operate on the mistaken premise that no LGBT older adults live in the communities that they serve and that treating everyone the same is sufficient.28–30 Providers inform SAGE that in an era of strained budgets, they lack the resources to assess and address the needs of LGBT elders. These provider perspectives are a powerful barrier to the provision of responsive, culturally competent services for LGBT older adults. Therefore, it is essential that this highly vulnerable population is identified as a population of greatest social need under the OAA. SAGE's federal legislative and administrative advocacy has aimed to address the failure to apply the OAA to recognize LGBT older adults' greater need for and lower rate of accessing services and supports than their heterosexual and cisgender peers.

Navigate ArticleTop of pageAuthor informationABSTRACTIntroductionThe OAAOAA Target PopulationsImplications of Being Def...LGBT Older Adults Fit the...Legislative Advocacy <<Administrative AdvocacyConclusionAuthor Disclosure Stateme...ReferencesCITING ARTICLES

Legislative Advocacy

During the most recent reauthorization of the OAA, SAGE focused its advocacy efforts on the Senate, which led the way on reauthorization. Senator Michael Bennet (D-CO) introduced the LGBT Elder Americans Act of 2012 and Rep. Suzanne Bonamici (D-OR1) introduced a companion House bill in 2014.31 Both would specifically designate LGBT elders as a population of greatest social need in the OAA. The original bill introductions and reintroductions in 2015 failed to attract bi-partisan support. No Republican in either chamber signed on to support the LGBT amendments to the OAA. Republican refusal to support the LGBT-inclusive legislation ended any prospect for passage.

While this legislative effort was not successful, in general the legislative approach is preferable to an administrative approach. At the federal level, only Congress can add to its specific delineation of greatest social need populations by explicitly including a new population. ACL, on the contrary, cannot change the terms of the OAA legislation; it can only provide guidance on implementation of the statute. One form of guidance is called a program instruction, a prescriptive, explicit form of guidance that ACL promulgates to the Aging Network in memo format. The weight of administrative guidance, however, will not necessarily make the Aging Network more responsive to LGBT elder needs, especially in an era when Aging Network budgets have decreased. With a new Congress and President who appear unreceptive to LGBT concerns, advancing a legislative solution also appears very unlikely at this time.

Navigate ArticleTop of pageAuthor informationABSTRACTIntroductionThe OAAOAA Target PopulationsImplications of Being Def...LGBT Older Adults Fit the...Legislative AdvocacyAdministrative Advocacy <<ConclusionAuthor Disclosure Stateme...ReferencesCITING ARTICLES

Administrative Advocacy

SAGE and its partners have also engaged in federal administrative advocacy to encourage the Aging Network to both assess and meet the needs of LGBT older adults. This advocacy led to the ACL clarification discussed previously. While it raises awareness about LGBT older adults as a population that faces particular challenges and it gives license to providers who are inclined to address those challenges, it is not binding on the Aging Network, and it does not require the Aging Network to take any specific actions. Indeed, since the 2012 ACL clarification, the Aging Network has, for the most part, neither assessed nor targeted the needs of LGBT older adults.

As of fall 2016, only nine states and the District of Columbia have attempted to assess and meet the needs of LGBT older adults, as determined by a SAGE review of state aging plans (unpublished data). A total of 22 states have some mention of LGBT older adults in their state plans and attempt to address their needs in various capacities (unpublished data). For example, New Jersey's 2013–2017 state plan only references LGBT older adults under “Goal 4: Ensure the rights of older people and prevent their abuse, neglect, and exploitation.” In that section, the state plan looks at its progress from 2009–2013 and states, “[p]rogram staff received training in working with individuals with mental illness, including obsessive compulsive disorder and related hoarding behaviors, traumatic brain injuries, the LGBT senior population, deaf and hard-of-hearing seniors, Megan's Law offenders, and individuals suffering from addiction.” It neither designates LGBT older adults a greatest social need population nor addresses other methods of targeting LGBT older adults.32

Minnesota's 2013–2016 state plan talks about the growing diversity of the state, and notes that, “…only a small percent of counties believe that their providers are ‘very prepared’ to deliver care that is culturally competent” to “racial and ethnic minority communities,” “new American/immigrant/refugee communities,” and LGBT older adults. However, that is the plan's only mention of LGBT older adults. It does not designate LGBT older adults as a group of greatest social need, and it does not address other methods of targeting this population.33

As a result, SAGE has advocated for ACL to develop and issue a program instruction as formal, mandatory guidance to the Aging Network. It would explicitly notify the Aging Network that it has a statutory duty to prioritize the allocation of resources to populations with “greatest social need,” that it must assess whether its aging services are meeting the needs of LGBT older adults, and that it must develop mechanisms to address unmet needs. SAGE advocated for this type of ACL guidance as a centerpiece of its advocacy in connection with the 2015 White House Conference on Aging (WHCOA).

Indicating a desire to gather more evidence before acting, ACL announced during the WHCOA that it would join SAGE in sponsoring a convening of the Aging Network, LGBT-serving organizations, and LGBT older adults in November 2015.34 The convening documented the challenges facing LGBT older adults and the need for a robust federal response. In June 2016, ACL released a draft program instruction that would require the Aging Network to assess the needs of LGBT elders (and other marginalized elder populations) to determine the extent to which those needs are unaddressed, such that targeting of services would be appropriate under the OAA.35 SAGE, other organizations, and individuals in 48 states submitted nearly 3000 comments in support of the guidance. Together, SAGE and its partners supported ACL in advancing guidance that would:

  • Require the Aging Network to affirm that it assesses all groups that may be eligible for designation as a greatest social need population.

  • Expressly include LGBT older adults as one of the populations whose needs the Aging Network must assess.

While the public comment period concluded in August 2016, ACL is yet to issue the final guidance, the fate of which has unclear in light of the new Administration.

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Conclusion

Opportunities to advance LGBT-inclusive federal aging policies are likely to be limited with the new Administration and a Republican-controlled Congress. As a result, the time is opportune for researchers to do more to build a foundation of research that could inform future policy efforts, including research that addresses and quantifies the health benefits of assessing and meeting the service and care needs of LGBT older adults. The unreceptive federal climate toward an LGBT-inclusive aging policy also highlights the need to do more at the state and local level. The Aging Network can use the discretion ACL provided in its 2012 policy clarification to do more to assess and meet the needs of LGBT older adults. Advocacy can drive policy changes at the state and local level that address the acute challenges facing LGBT elders. State-level advocates, for example, can urge their state unit on aging to designate LGBT elders as a population of greatest social need. They can also consider promoting LGBT aging commissions, as San Francisco and Massachusetts have done, to conduct systematic assessments and make recommendations for improvements in policy and elder services. Private sector leadership in areas focused on healthcare, long-term care, and senior housing can also forge progress where the federal government is unwilling to act. Without such policy innovation, the health of LGBT older adults who do not receive the care, services, and support they need will continue to suffer.

References

1. KI Fredriksen-Goldsen, HJ Kim, CA Emlet, et al.: The Aging and Health Report: Disparities and Resilience Among Lesbian, Gay, Bisexual, and Transgender Older Adults. Seattle, WA: Institute for Multigenerational Health, University of Washington, 2011.

2. LongTermCare.gov U.S. Department of Health and Human Services: Who will provide your care? Available at https://longtermcare.acl.gov/the-basics/who-will-provide-your-care.html Accessed February 16, 2017.

3. LGBT Movement Advancement Project and Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders: Improving the lives of LGBT older adults. 2010. Available at www.lgbtmap.org/file/improving-the-lives-of-lgbt-older-adults.pdf Accessed February 16, 2017.

4. M Adelman, J Gurevitch, B de Vries, JA Blando: Openhouse: Community building and research in the LGBT aging population. In: Lesbian, Gay, Bisexual, and Transgender Aging: Research and Clinical Perspectives. Edited by Kimmel DC, Rose T, David S. New York: Columbia University Press, 2006.

5. D Rosenfeld: Identity work among lesbian and gay elderly. J Aging Studies 1999;13:121–144.

6. B de Vries: Aspects of life and death, grief and loss in lesbian, gay, bisexual and transgender communities. In: Living with Grief: Diversity in End-of Life Care. Edited by Doka KJ, Tucci AS. Washington, DC: Hospice Foundation of America, 2009.

7. MV Lee Badgett, LE Durso, A Schneebaum: New Patterns of Poverty in the Lesbian, Gay, and Bisexual Community. The Williams Institute, UCLA School of Law, 2013. Available at http://williamsinstitute.law.ucla.edu/research/census-lgbt-demographics-studies/lgbt-poverty-update-june-2013Accessed February 16, 2017.

8. Centers for Disease Control and Prevention: HIV among gay and bisexual men. 2016. Available at https://www.cdc.gov/hiv/group/msm Accessed February 16, 2017.

9. Centers for Disease Control and Prevention: HIV among people aged 50 and over. 2017. Available at https://www.cdc.gov/hiv/group/age/olderamericans Accessed February 16, 2017.

10. Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities: The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press, 2011.

11. JM Grant, LA Mottet, J Tanis, et al.: Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. Available at www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdfAccessed March 21, 2017.

12. Administration on Aging U.S. Department of Health and Human Services: Fact Sheet: The Many Faces of Aging. Washington, DC: Administration for Community Living, 2001.

13. M Adams: LGBT Advocate Sees Hurdles Ahead. AARP, 2011. Available at www.aarp.org/relationships/family/info-04-2011/biggest-issues-facing-older-lgbt-americans.html Accessed February 16, 2017.

14. KH Mayer, JB Bradford, HJ Makadon, et al.: Sexual and gender minority health: What we know and what needs to be done. Am J Public Health 2008;98:989–995.

15. LB Johnson: 354—Remarks at the Signing of the Older Americans Act. 1965. Available at www.presidency.ucsb.edu/ws/?pid=27079 Accessed February 16, 2017.

16. Administration for Community Living U.S. Department of Health and Human Services: Administration on Aging (AoA): Older Americans Act. Available at https://aoa.acl.gov/AoA_Programs/OAA/index.aspx Accessed February 16, 2017.

17. W Fox-Grage, K Ujvari: Insight on the issues, the Older Americans Act. 2014. Washington, DC: AARP Public Policy Institute. Available at www.aarp.org/content/dam/aarp/research/public_policy_institute/health/2014/the-older-americans-act-AARP-ppi-health.pdf Accessed February 16, 2017.

18. U.S. Government Accountability Office: Older Americans Act: Options to better target need and improve equity. GAO-13-74: Published: November 30, 2012. Publicly Released: December 11, 2012. Available at www.gao.gov/products/GAO-13-74 Accessed August 16, 2017.

19. Administration for Community Living: 2016 Older Americans Act (OAA) Reauthorization Act (P.L. 114-144). Available at https://www.acl.gov/sites/default/files/about-acl/2017-04/OAA-Summary-Final.pdf Accessed August 15, 2017.

20. Older Americans Act of 1965, Public Law 89–73, as amended through P.L. 114–144, enacted April 19, 2016. Available at https://legcounsel.house.gov/Comps/Older%20Americans%20Act%20Of%201965.pdf Accessed February 16, 2017.

21. Administration for Community Living U.S. Department of Health and Human Services: Administration on Aging (AoA): Frequently asked questions. Available at https://aoa.acl.gov/AoA_Programs/OAA/resources/faqs.aspxAccessed February 16, 2017.

22. KI Fredriksen-Goldsen, CA Emlet, HJ Kim, et al.: The physical and mental health of lesbian, gay male, and bisexual (LGB) older adults: The role of key health indicators and risk and protective factors. Gerontologist2013;53:664–675.

23. SAGE (Services and Advocacy for GLBT Elders) and National Center for Transgender Equality (NCTE): Improving the Lives of Transgender Older Adults: Recommendations for Policy and Practice. 2012. Available at https://sageusa.org/files/TransAgingPolicyReportFull.pdf Accessed October 23, 2017.

24. HJ Kim, S Jen, KI Fredriksen-Goldsen: Race/ethnicity and health-related quality of life among LGBT older adults. Gerontologist 2017;57:S30–S39.

25. Special Legislative Commission on Lesbian, Gay, Bisexual and Transgender Aging: Report to the Commonwealth of Massachusetts. Boston, MA: Joint Committee on Elder Affairs, 2015; Appendix A, p 57. Available at http://archives.lib.state.ma.us/bitstream/handle/2452/334782/ocn930400356.pdf?sequence=1&isAllowed=y Accessed August 16, 2017.

26. Services and Advocacy for GLBT Elders (SAGE): MassEquality & LGBT aging project applaud Patrick administration for outreach to LGBT older adults. 2012. Available at https://www.sageusa.org/newsevents/news.cfm?ID=100&print=1 Accessed August 17, 2017.

27. National Resource Center on LGBT Aging and Services and Advocacy for GLBT Elders (SAGE): Strengthen your state and local aging plan: A practical guide for expanding the inclusion of LGBT older adults. 2017. Available at www.lgbtagingcenter.org/resources/pdfs/Sage_StrengtheningGuidebook2017.pdf Accessed August 16, 2017.

28. GJ Gates, F Newport: LGBT percentage highest in D.C., lowest in North Dakota. 2013. Available at www.gallup.com/poll/160517/lgbt-percentage-highest-lowest-north-dakota.aspx Accessed February 16, 2017.

29. SK Choi, IH Meyer: LGBT aging: A Review of Research Findings, Needs, and Policy Implications. 2016. Los Angeles, CA: The Williams Institute, UCLA School of Law. Available at http://williamsinstitute.law.ucla.edu/wp-content/uploads/LGBT-Aging-A-Review.pdf Accessed February 16, 2017.

30. Inclusive Questions for Older Adults: A Practical Guide to Collecting Data on Sexual Orientation and Gender Identity. 2016. New York: National Resource Center on LGBT Aging. Available at www.lgbtagingcenter.org/resources/pdfs/Sage_CollDataGuidebook2016.pdf Accessed February 16, 2017.

31. 112th Congress (2011–2012): S.3575—LGBT elder Americans Act of 2012. 2012. Available at https://www.congress.gov/bill/112th-congress/senate-bill/3575 Accessed February 17, 2017.

32. Department of Human Services: New Jersey State strategic plan on aging, October 1, 2013–September 30, 2017. p 28. Available at www.nj.gov/humanservices/news/reports/2013%20State%20Plan%20Final%20for%20Web%20Posting%2012.4.13.pdfAccessed August 16, 2017.

33. Minnesota Board on Aging: Minnesota board on aging state plan: FFY 2013–2016. Available at www.mnaging.org/About%20Us/∼/media/MNAging/Docs/FFY2013-2016_StatePlan_2012-07-01.ashx Accessed August 15, 2017.

34. 2015 White House Conference on Aging: Final Report. 2015. Washington, DC: The White House Conference on Aging. Available at https://whitehouseconferenceonaging.gov/2015-WHCOA-Final-Report.pdf Accessed March 6, 2017.

35. Department of Health and Human Services Administration for Community Living/Administration on Aging: Agency information collection activities; proposed collection; comment request; request for new information collection for a program instruction on guidance for the development and submission of state plans on aging, state plan amendments and the intrastate funding formula. Federal Register, Volume 81, Number 119 (Tuesday, June 21, 2016). Available at https://www.gpo.gov/fdsys/pkg/FR-2016-06-21/html/2016-14612.htm Accessed February 17, 2017.

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