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.

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.

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.

-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. 

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

The history of philanthropy engaging in long-term care services

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.

• Shift to comprehensive coverage

• Increased home care options

• Inflation protection

• Shorter policy durations

-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.

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

-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 

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.

• 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

-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

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

- 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

-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.

- 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.

• For profit orgs can now receive the same funding!

• Legitimized commercial ownership in LTC

• Rapid growth in the LTC industry

-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

• 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

-Eden alternative housing 

-Green House Project cottages 

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

• 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

• 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.

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.

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.

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.

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.