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Initial lump-sum payments (1937–1939):

Before monthly checks began, the first payments were one-time lump-sum refunds for payroll taxes paid by those turning 65.

The very first Social Security payment ever made was a lump-sum check for 17 cents, issued to Ernest Ackerman in 1937.

Initial monthly payments (1940):

The original law set the age for receiving individual retirement benefits at 65.

The first person to receive a monthly Social Security benefit was Ida May Fuller, who received her first check in January 1940. She lived to be 100 years old.

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It caused a divide within the upper class

Conservative elites: strongly opposed the act, seeing it as government overreach. Groups like the American Liberty League (funded by the DuPont family and other wealthy industrialists) campaigned against it.

Progressive elites: some wealthier reformers, philanthropists, and academics supported it, seeing it as a stabilizer for capitalism. They believed giving older Americans security would reduce radical demands for wealth redistribution.

There were overall suspicions of socialism, worries about taxation, and resistance through courts, but the upper class it didn't feel one particular way about it. But those who had those suspicions and were against it were seen as out of touch and got labeled as "economic royalists," and got a bad image in history because of their exclusivity and inability to show compassion in this sense.

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It was stigmatized compared to Social Security. Social Security was seen as an “earned right” (because workers paid in), while OAA was considered “welfare.” This social perception shaped later reforms.

It disproportionately helped women.
Because many women hadn’t worked in wage-paying jobs covered by Social Security (due to exclusions and gender roles), they often qualified for OAA instead.

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Interesting Facts about the Social Security Act

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Interesting Facts about the Social Security Act

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The original act provided only old-age benefits (pensions), not payments to widows or children of deceased workers. Survivors’ insurance was added later in 1939, after heated debate.

It excluded huge groups of workers at first.

Agricultural and domestic workers, who were disproportionately Black, immigrant, and women workers, were left out of Social Security coverage until the 1950s.

The payroll tax started before benefits.

Workers began paying into the system in 1937, but no monthly benefits were paid until 1940. People were “paying in” for several years before they got anything out.

The first monthly Social Security check was only $22.54. Ida May Fuller of Vermont received it in 1940. She had paid in just $24.75 in taxes but collected more than $22,000 over her lifetime.

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By 1870, almshouses (poorhouses) existed in nearly every Virginia county and city.

Served multiple roles: hospitals, homeless shelters, long-term care, and relief for families/single mothers.

Operated as poor farms, often run by a superintendent and wife, aiming for self-sufficiency and community.

Unique in allowing both Black and white residents, unlike later segregated state institutions.

Progressive Era reformers criticized poorhouses as filthy and unfit; closures began in 1926.

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In the 1800s and early 1900s, people who were poor or sick often had to live in places called poorhouses or workhouses. These places were crowded and not very nice, and many people felt ashamed to go there. Later, hospitals started to grow, often run by churches or community groups, and they tried to help people while also finding ways to pay for their care. Over time, more people worked to make healthcare fairer and better, which helped lead to the changes we see today.

In the 1800s–1900s, charity care shifted from informal local aid to institutionalized systems such as poorhouses and workhouses, which often carried stigma and harsh conditions.

Reformers criticized the practice of housing all dependents together, leading to the separation of the sick and elderly into infirmaries and the gradual professionalization of nursing.

Voluntary hospitals, often founded by religious and ethnic groups, expanded access but increasingly balanced their charitable missions with financial sustainability as medical costs rose.

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State of Residential Long-Term Care from 1990-2020

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State of Residential Long-Term Care from 1990-2020

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Moss Amendments to the Social Security Act

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Moss Amendments to the Social Security Act

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Nursing homes receiving Medicaid funding need to meet federal standards (staffing, safety, quality of care)

More regulations and inspections

Growing concern over fraud, neglect, and poor conditions

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In the late 1900s and early 1920s, churches and charitable organizations began opening specialized homes for the elderly

More dignified option than almshouses

Often had large grounds and gardens

Sometimes included hospitals as well

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Homelike Models of Care Become more Popular 

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Homelike Models of Care Become more Popular 

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-Assisted living

-Eden alternative housing

-Green House Project cottages

-These alternatives are often more beneficial to patients / residents than institutional settings

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-due to concern over persistent poor quality of care in nursing homes, combines with the growing share of federal and state dollars flowing into nursing homes

-led to congressional calls for an investigation into nursing home standards, oversight, and enforcement

-the Institute of Medicine in 1986 released its report on the quality of nursing homes and the Congress enacted the Omnibus Budget Reconciliation Act (OBRA) of 1987

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Shifted focus from structural compliance (pre-1987) to resident outcomes, emphasizing quality of care and quality of life for nursing home residents.

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American Association of Nursing Homes Lobbies Congress

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American Association of Nursing Homes Lobbies Congress

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American Association of Nursing Homes lobbies congress to allow for-profit orgs to obtain nursing home funding from Small Business Admin and Federal Housing Admin

For profit orgs can now receive the same funding!

Legitimized commercial ownership in LTC

Rapid growth in the LTC industry

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Legislation that expanded vocational training and guaranteed certain rights to people with disabilities. It was one of the first US federal civil rights for individuals with disabilities

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1. Provide income security for people who can't earn it

2. Assist vulnerable populations (elderly, unemployed, disabled, children, etc.)

3. Create a social security insurance system

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Provided federal-state matching funds for the medically needy, including nursing home residents, and expanded home care services.

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Identified services required of nursing homes participating in Medicare and Medicaid. Also providing standards for delivering these services

- the law requires care to be consistent with ensuring that all residents receive services that enable them to reach and maintain their highest physical, mental, and psychosocial well-being.

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This act played a huge role in that time period being it helped build or modernize 1/3 of U.S hospitals also improved healthcare access in rural areas of the country.

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Evolution of Long -Term Care in America 

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Evolution of Long -Term Care in America 

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Institutionalization

-Residential institution for long-term care.

Colonial Period:

1820 - Care of the poor and the ill was community-based and flexible

Communities offered poor relief in ways that did not stigmatize the poor and that did not rely on eligibility criteria. Later then attitudes towards poverty started to grow, this was encouraged by economic changes and growing populations (some places started to break down)

The Dominance of the Almshouse

-1820 - 1865 marked a deliberate turn to institutional poor relief

Almshouses were meant to serve as a deterrent to poverty, but they did not serve a single population.

-1865 - 1935 Institutional poor relief became harsher, hospitals were biased toward acute care, and older people dominant population of the almshouse.

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Amendments to the Hill-Burton Act (1954)

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Amendments to the Hill-Burton Act (1954)

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Provided grants for public and not-for-profit facilities

Facilities receicing grants needed to be associated with a hospital

Promoted medical model of care within LTC facilities

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The American Association of Nursing Homes (founded in 1949) lobbied successfully so for-profit owners could access federal loans (SBA + FHA)

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- This law established the Prospective Payment System for Medicare funded post-hospital services.

- PPS is a reimbursement method where payment is based on a fixed amount for a service, rather than the actual cost of the service that was provided.

-patients can experience more predictable and affordable costs

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Individuals with Disabilities Education 

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Individuals with Disabilities Education 

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Written in 1991 shortly after the ADA act giving children with disabilities an appropriate public education. Providing services and support for children within the community

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US Supreme Court’s 1999 Olmstead v. L.C. Decision 

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US Supreme Court’s 1999 Olmstead v. L.C. Decision 

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-Prohibits the unnecessary instituzilination of individuals with disabilities

-This leads to an increase in home and community based services → helps individuals with disabilities live independently

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Part of the Omnibus Budget Reconciliation Act (OBRA) of 1981

-Medicaid began offering waiver programs which allow states to create new home and community based services (HCBS) programs

-participating states must demonstrate that the medicare cost per participant for such services is no greater than the cost of institutional care

-states can choose to target specific groups and impose certain eligibility requirements like medical and financial criteria

-states can also limit eligibility

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Opened doors for federal funding of LTC facilities

Legitimized small businesses to receive government dollars (great for small businesses)

Set the stage for future debates about the balance between public vs. private provision of LTC

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This period ended with legislators arguing that dolling out small sums of money to older people was a cost-saving solution to almshouses. This gave way to the passage of the Social Security Act in 1935, including the Old Age Assistance (OAA) program, which gave money to poor, individual elders to support them.

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Facilities couldn’t discriminate based on race, color, national origin, or creed of the individual.

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From the early 1970s through 1990, the government expanded efforts to regulate healthcare and control provider abuses. Medicare was extended to people with disabilities. In the late 1970s antifraud measures for Medicaid and Medicare were introduced In 1983, Medicare adopted diagnosis related groups (DRGs) to control hospital costs, shifting more care to ambulatory and nursing home settings. In 1987, the Omnibus Budget Reconciliation Act established stricter enforcement systems for nursing homes

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Graph of Individuals Who Receive SSI Payments (2022)

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Graph of Individuals Who Receive SSI Payments (2022)

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Written in 1990 and it identified discrimination against individuals with disabilities. The act helped with giving individuals accommodations by employers for employees with disabilities. It also helped with increasing accessibility requirements for public accommodations

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Traditionally, families cared for their aging family members at home

However, that model was challenged by urbanization and longer working hours

This led to a rise in institutionalization

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By the 1950s, new legislation created public financing for building nursing home facilities and paying for long-term care services

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"If someone couldn't be taken care of by family or neighbors, then they were put in an institution that was locally-run by the county, village or other government entity,"

Almhouses hosted not only the oldest old, but also orphans, people with disabilities and those facing addiction or without homes. They provided shelter, daily meals and that's about it.

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-Market-based reforms → gave consumers more choice as well as increased competition in the healthcare industry

-Demonstration programs → testing new healthcare policy ideas (on a small scale)

-Private insurance expands to include long term care → prior to this there was very limited coverage

-Goal: control costs and improve efficiency in the healthcare industry

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Created the Administration on Aging, supporting community-based services for older adults (nutrition, transportation, legal aid).

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Signed in 1973 by President Nixon and it expanded vocational training programs for individuals with disabilities and prohibited unfair hiring practices by agencies receiving federal monies

However it did stop identifying disabilities as a potential civil rights concern

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Long-Term Care Management Aspects of the Social Security Act

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Long-Term Care Management Aspects of the Social Security Act

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The Act created the foundation for old-age insurance and public assistance, but it did not directly cover long-term care (LTC) services like nursing homes or in-home care.

Instead, it focused on providing financial support to the elderly and unemployed.

Through Medicaid (and, to a smaller extent, SSI and Medicare), the Social Security Act provides a safety net for vulnerable populations needing LTC.

The Social Security Act became central to long-term care management once it was amended to include Medicare, Medicaid, and SSI. While Medicare offers limited short-term support, Medicaid is the primary long-term care payer, making the Act the backbone of U.S. long-term care financing and policy.

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In 2022, Social Security made up at least half of total personal income for 38.3 million people, or 63.2% of adult recipients, according to the SIPP data. For 26.5 million people (43.6% of recipients), it accounted for three-quarters of their income. For 16.4 million (27%), it was their only source of income.

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Mix of vulnerable populations: the elderly, disabled, mentally ill, poor and orphaned lived together in the same facilities without any specialized care

Overcrowding

Unsanitary

Minimal medical care

Lack of governmental oversight

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" It was during the late sixteenth century that the medieval craft guilds founded many hospitals to provide care for the “elderly decayed” members in their declining years.... Scandalous conditions of the workhouses inspired wealthy philanthropists to endow almshouses, generally for their local area and in groups of 6-12 dwellings."

The history of philanthropy engaging in long-term care services

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The OAA program was replaced by the federal Supplemental Security Income (SSI) program in 1974, as a more comprehensive approach to assisting low-income elderly and disabled individuals.

SSI was generally considered better than OAA because it corrected many of the weaknesses of the older program and created a more equitable safety net. For example:

Standardized eligibility rules and benefit levels across the country, ensuring a consistent safety net.

Centralized under the Social Security Administration, making it simpler and more efficient

Paid from federal general revenues, ensuring more stable and reliable funding

Removed barriers like the 'lien laws', making assistance more accessible to vulnerable individuals.

Guaranteed a federal minimum payment, with states free to supplement but not reduce it

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1. 1950 Amendments extended coverage to more groups of workers (like agricultural and domestic workers)

2. 1965 Amendments created Medicare and Medicaid

3. 1972 Amendments made a 20% increase to benefits and added an automatic mechanism to adjust benefits on the cost of living.

4. 1983 Amendments covered all federal employees, taxed a portion of benefits for higher earners, and gradually increased the retirement age to 67.

https://www.ssa.gov/history/law.html

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OAA began with the Social Security Act of 1935. OAA provided cash payments to elderly people who were poor and in need. It was a vital improvisation for those who couldn't contribute enough to the new old-age insurance program to receive actual, meaningful benefits.

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Institutionalised care

Also referred to as "poor houses" or "poor farms"

Care was not specialised as also focused on orphans, the mentally ill and the disabled

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This study examines whether government benefits discourage labor supply among older adults. Fetter and Lockwood analyze the Old Age Assistance (OAA) program, introduced in the 1930s before Social Security expanded.

Using 1940 census data on over 6 million men aged 55 to 74, it was found that OAA benefits significantly reduced labor force participation beginning at age 65. States with more generous OAA benefits saw greater declines in work, while participation among those under 65 remained similar across states.

Overall, OAA reduced labor supply among men aged 65–74 by 5.7 percentage points, nearly half of the nationwide decline during the 1930s. The effect was strongest among those with limited education or weak job prospects.

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1. In your small groups, read and then summarize the paragraph(s) related to your time period in Chapter 1.

2. Each fact, idea, opinion, or point should be its own post. You should have at least 10 posts.

3. Once you have summarized the paragraph(s) in post form, go looking elsewhere on the internet for additional information that provides deeper context than what is found in the textbook.

4. Be creative using Padlet. Include pictures, links, etc to make your part of the timeline as fun, interactive, and informative as possible.

5. One member of the group may be asked to present your findings during the last part of class. You may choose who represents your group.

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2020 to Present

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Affordable Care Act and Integrative LTSS

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Affordable Care Act and Integrative LTSS

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2010-2020

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Market-Based Reforms and Federal Demonstrations

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Market-Based Reforms and Federal Demonstrations

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1990-2009

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1970-1989

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Public Financing for Senior Housing and Care

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Public Financing for Senior Housing and Care

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Social Security Act and Old Age Assistance

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Social Security Act and Old Age Assistance

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1935 to 1949

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COVID-19's Effect on Nursing Home Residents

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COVID-19's Effect on Nursing Home Residents

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"Impact of COVID-19 on Long Term Care in Illinois" by Gorges&Konetzka

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"Impact of COVID-19 on Long Term Care in Illinois" by Gorges&Konetzka

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As of June 26, long-term care (LTC) facilities were associated with 22,170 cases and 3,772 deaths, accounting for 16% and 55% of all cases and deaths in the state respectively.

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Was created in 2012 to help ensure that older adults and people with disabilities can live independently and participate fully in their communities.

They combined three groups that were already part of the government: Administration on Aging, Office on Disability, Administration on Developmental Disabilities.

They focused on: Giving people more control over their care, making sure government programs work together to help people, supporting family members and caregivers, removing barriers that make it harder for people to live independently.

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The LTC emergency actions in response to COVID-19

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CDC recommends everyone ages 5-64 years, including people who live and work in long-term care (LTC) settings, get 1 dose of a 2024-2025 COVID-19 vaccine.

CDC recommends everyone ages 65 years and older, including people who live and work in LTC settings, get 2 doses of a 2024-2025 COVID-19 vaccine 6 months apart.

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COVID-19 Vaccination for Long-term Care Residents

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Information about COVID-19 vaccines for long-term care residents.

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"Adults over 65 years of age represent 80% of hospitalizations and have a 23-fold greater risk of death than those under 65"

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"Adults over 65 years of age represent 80% of hospitalizations and have a 23-fold greater risk of death than those under 65"

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Why does COVID-19 disproportionately affect older people?

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The severity and outcome of coronavirus disease 2019 (COVID-19) largely depends on a patient’s age. Adults over 65 years of age represent 80% of hospitalizations and have a 23-fold greater risk of death than those under 65. In the clinic, COVID-19…

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The ARP of 2021 was passed to help the US economy post COVID-19 to recover and provide assistance for aging and disability services.

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Held every decade since 1961 to "to identify and advance actions to improve the quality of life of older Americans"

In 2015, the United States marked the 50th anniversaries

of Medicare, Medicaid, and the Older Americans Act, as

well as the 80th anniversary of Social Security.

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Administration for Community Living (2012)

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Administration for Community Living (2012)

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1. Expanded Insurance Coverage:

had to have insurance

stay until 26 years old yay!!

Expanded Medicaid to cover more low-income individuals: state law.

Created Health Insurance Marketplaces where individuals and small businesses could purchase coverage

2. Protections for Patients:

Prohibited insurance companies from denying coverage from pre-existing conditions

Required insurers to cover

Preventive care

Prescription drugs

Maternity and newborn care

Mental health services

3. BETTER COST

Provided subsidies to help lower-income individuals afford insurance.

Implemented value-based payment models for quality care.

Introduced penalties for hospitals with high readmission rates.

4. Better for employees.

Required businesses with 50 or more full-time employees to offer health insurance.

5. Preventive Care:

Expanded coverage for preventive services such as vaccines and cancer screenings at no additional cost to patients

6. Awesome changes

Prevented insurers from charging women higher premiums than men.

Limited age-based premium differences to a 3:1 ratio

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U.S. Department of Health and Human Services

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5 Things About The Affordable Care Act (ACA)

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Provided $1.43 billion for OAA (Older Americans Act) programs including nutrition services, family caregiver support, disease prevention, and elder abuse prevention.

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COVID caused a significant loss of staff and substantial difficulties in hiring, training, and retaining new staff. Many nursing homes used outside staffing agencies to fill gaps, which had significant downsides.

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1800's to 1930s

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The early 1990s saw a wave of market-based reforms and innovative demonstration programs that reshaped long-term care.

Managed long-term care

State-level programs

Capitated payment models (fixed per-person amount for care)

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

Provider competition and quality accountability

Government mandated the use of the Minimum Data Set (MDS) in all nursing homes.

Public Quality Reporting

Growth of consumer-directed care

providers began shifting toward resident-centered care that emphasized quality of life

more choices in hiring and managing caregivers

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Expansion of Private Long-Term Care Insurance

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Expansion of Private Long-Term Care Insurance

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During this period, private insurance products for long-term care expenses expanded, offering more options beyond government programs.

Shift to comprehensive coverage

Increased home care options

Inflation protection

Shorter policy durations

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Passed in 1935.

Provided pensions for older adults with the stipulation that anyone who lived in a public facility (like an almshouse) couldn't receive a pension.

Also included other vulnerable groups such blind persons, dependent and crippled children, and maternal and child welfare.

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Intended to end almshouses (a house built originally by a charitable person or organization for poor people to live in). Established voluntary nursing homes for people with physical/mental disabilities.

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-Failed to provide coverage for many groups of workers, such as agricultural laborers, domestic servants, civil servants, etc.

-Funded by a tax structure that disproportionately burdened the poor, placing a heavier tax burden on them than on wealthier individuals.

-Absence of social insurance to cover medical costs.

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Congress passed the ADA, extending legal protections to people with disabilities and prohibiting discrimination.

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-It was a response to the Great Depression.

-The best estimates are that in 1934 over half of the elderly in America lacked sufficient income to be self-supporting.

-A shift from rural to urban life meant fewer families lived together, weakening the traditional support network for the aged.