Second Review and Appraisal of the Madrid International Plan of 

Action on Ageing

United States of America

2011
Executive Summary

Methodology

Brief review of national progress (include 3-5 major achievements and 3-5 

that need improvement

Conclusion

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General Information

United States of America

Name and information about author

Contact details for author

Name and contact of official national focal point on ageing

Name, reference, and date of adoption or status of preparation of national 

strategy, action plan or similar policy document on aging.

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Section I: Introduction

This report is in response to the United Nations (UN) request for information on progress 

UN Member States have made in implementing the Madrid International Plan of Action 

on Ageing (MIPAA) 2002. Member States will have the opportunity to present this 

information at the February 7-16, 2007 meeting of the UN Commission for Social 

Development. Following the UN Secretariat suggestion to Member States, this report 

will: 

1. Indicate the priority areas for review; and 

2. Identify laws, regulations, institutions, policies, and programs that have been 

introduced or altered in response to the MIPAA. 

Section II: Background

The United States of America affirms its commitment to the themes addressed in the 

MIPAA. In her address to the Second World Assembly on Ageing in 2002, the Assistant 

Secretary for Aging, Josefina G. Carbonell, stated: 

“For the United States Government, the continued improvement in the lives of older 

Americans and their families is a priority. ...We are committed to strengthening and 

modernizing our health insurance program for the elderly, improving access to health 

care, expanding prescription drug benefits, and preventing diseases.” 

The body of this report highlights major initiatives being advanced that address Priority 

Area II of the MIPAA – Advancing Health and Well Being into Old Age. These 

initiatives include: 

• Empowering our citizens by giving them more choices and greater control over 

their own health—and their health care—including more control over the types of 

benefits and services they receive and the manner in which those benefits and 

services are delivered. 

• Moving towards a more balanced system of long-term care which respects the 

wishes of the individual and which dismantles the bias toward institutional care in 

favor of home and community-based services. 

• Changing our reimbursement policies to make prevention benefits more widely 

available, and promoting the rapid translation of research into practice.

• Encouraging more competition in health and long-term care and greater 

involvement by the private commercial sector in offering new products and 

services to a growing private-pay market. 

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The United States is experiencing unprecedented growth and diversity in its aging 

population. By 2030, almost 20 percent (approximately 71.5 million) of all Americans 

will be 65 or older. Those aged 85 and older are the most rapidly growing segment of 

our population. As our post-Second World War “baby boom” generation ages, this 

number is expected to increase even more. At the same time that these demographic 

changes are occurring, we are also witnessing sweeping and fundamental transformations 

in the way we think about and deliver health and long-term care. 

Our system of long-term care is supported by a variety of public and private sources, with 

the largest share coming from the personal contributions and efforts of family caregivers. 

Families account for nearly 80 percent of all the long-term care provided in the United 

States. Today nearly 21 percent of all American households have taken on some form of 

caregiving responsibility. Many Americans, mostly women, are caring for both children 

and or/aging parents.

The economic value of this informal care is significant. The Department of Health and 

Human Services has estimated that replacing informal long term care services for seniors 

with professional care would cost as much as $306 billion a year.

When it comes to public financing for long-term care, our largest source of funding 

comes from Medicaid – a joint federal/state program that provides health care to people 

who have limited incomes and assets or who are disabled. 

When Medicaid was enacted in 1965, it was designed as a program for poor families. 

Because it was the only public source of financing for nursing home coverage, it quickly 

became our nation’s long-term care program and it helped to create a system of care for 

our seniors that is dominated by expensive nursing homes. Nationally, institutionally 

based care accounts for as much as 70 percent of long-term care spending in Medicaid 

and some states are spending over 90 percent of their long-term care budgets on nursing 

home care. This approach to long-term care does not reflect the overwhelming 

preference of older people to receive care at home, and it is also a financially 

unsustainable policy. 

Bottom Up Approach 

Providing the elderly, their families and professional advocates an opportunity for input 

is at the core of our approach to programs and services for adults as they age and for

persons with disabilities. In addition to the elderly, their families, and persons with 

disabilities, our stakeholders include federal, state, and local governments, business and 

industry, national and local organizations and coalitions, non-profit organizations, health 

and social welfare organizations and academic institutions. This “Bottom Up” approach 

is described below. 

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Local and National Planning Activities: The Older Americans Act

In the United States, our foundation for addressing the issues of aging is the Older 

Americans Act (OAA), further described in Section III. The OAA has always been based 

upon a philosophy of planning from bottom to top. Our programs are created through the 

priorities set at the national level together with the needs expressed in states and local 

communities. 

Our state and local planning offices are required to submit plans of action showing the 

types of services they plan to create and provide, based upon citizen input, advisory 

committees, and public hearings. The state and local advisory committees are 

representatives of communities, the public and private sector and consumer groups. In 

addition, federal officials hold “listening sessions” around the country to provide input on 

needs of older persons. This “bottom up” model has proven successful for over 40 years 

and has resulted in community based services that respond to the needs of local citizens. 

This approach is also consistent with the methods discussed for the follow-up to the 

MIPAA. 

Local and National Planning Activities: White House Conferences on Aging 

A future-oriented planning process used in the United States, and outlined in the OAA, is 

the White House Conference on Aging (WHCoA). These conferences are held 

approximately every ten years and are designed to provide input and recommendations to 

the President and Congress. They are models of citizen participation to develop and 

evaluate policies and programs. Stakeholders include local communities, academic 

institutions, business and industry, national and local organizations, non-profit 

organizations, and federal, state and local governments. 

The first official conference was held in 1961, and the most recent conference in 

December 2005. These conferences lay the foundation for legislation and programs, such 

as the enactment of Medicare, Medicaid and the OAA. 

The input process for the 2005 WHCoA included more than 400 events convened around 

the country and involved more than 130,000 citizens. Over 3,000 people participated in 

the conference, including 1200 delegates representing every sector of society. Forty-two 

International Observers also attended from twenty three countries. 

Delegates discussed, debated and agreed upon 50 resolutions to send to the President 

and Congress to help guide the national aging policies for the next ten years and beyond. 

In addition, thousands of Implementation Strategies were developed. For the full report, 

go to www.whcoa.org. The three top priorities are: 

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 The reauthorization of the OAA within six months of the WHCoA (this 

has been achieved); 

 The development of a comprehensive and coordinated strategy for 

affordable and accessible long term care including caregiving support; and 

 The importance of mobility and transportation options for older 

Americans. 

Evaluations have shown that the OAA has created flexibility, policies, programs and 

services that respond to the needs identified by consumers through our “bottom up” 

process.

Section III provides further details on how the United States is realigning its health and 

long-term care systems to give consumers more choice and control. 

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Section III: Review of Changes since the 

Second World Assembly on Ageing 2002: 

Advancing Health and Well Being into Old Age

This section will provide more details on how the Federal government is leading the way in 

responding to many of the actions recommended by the MIPAA pertaining to advancing health 

and well being into old age. As mentioned in Section II, we are in the process of transforming 

and rebalancing our long- term care system. We have made impressive strides to empower 

individuals to make informed choices; target our resources to high-risk individuals; and build 

prevention into community-living. Some of our significant activities to date include: 

President Bush’s New Freedom Initiative 

One of the first official acts President Bush took when he came into office was to create the New 

Freedom Initiative. This initiative outlined his vision for maximizing the independence and 

dignity of people with disabilities of all ages in the United States. Central to that vision is a 

fundamental rebalancing of our system of long-term care and supports to emphasize providing 

care in the least restrictive setting and on giving people more choices and control over their care 

options. Our system has been biased toward more expensive institutional care – the opposite of 

what older people and their families want. The fundamental goal of this initiative is to remove 

barriers that prevent people with disabilities of all ages from living independently at home and 

fully integrated in their communities. Since 2001, the Department of Health and Human 

Services, with the support of Congress, has provided states and communities with a variety of 

new tools to help them advance the goals and values embedded in the New Freedom Initiative.

The Older Americans Act

In the United States, our foundation for addressing the issues of aging is the Older Americans 

Act (OAA) – national legislation created in 1965 as part of a comprehensive package of social 

welfare legislation designed to combat poverty. The OAA complemented Medicare, which 

provides insurance coverage for healthcare, and Medicaid, which provides health, long-term care 

and nursing home care for low-income or impoverished individuals. 

The overall goal of the OAA is to enable older individuals maintain their dignity and to live 

independently in their own homes and communities for as long as possible. The OAA 

established a national infrastructure of home and community-based services and established the 

Administration on Aging (AoA) within the Department of Health and Human Services to serve 

as a “Federal Focal Point” on issues related to aging. 

The OAA provides leadership and support through the Department of Health and Human 

Services to a nationwide network of organizations and individuals whose mission is to enable 

older citizens to remain in their own homes and communities as long as possible. In the last few 

years, the Aging Network has taken on a central role in the transformation of health, and most 

importantly long-term care services in the United States.

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The OAA provides about $1.5 billion in funding each year to the states, and leverages at least 

twice that amount, to support a wide range of social services, such as home-delivered meals, 

adult day care, specialized transportation services, and the like. 

The newly reauthorized OAA, which governs the work of the AoA, advances the President’s 

New Freedom initiative and also affirms the commitment to health promotion and disease 

prevention, value and ownership. The OAA embeds the principles of the Administration’s 

Choices for Independence initiative. The legislation modernizes community based long-term 

care systems to further empower consumers to manage their own care and make choices that will 

allow them to avoid unnecessary institutional care and live healthy lives in the community.

One of our major initiatives builds on the fact that the Aging Services Network is viewed by 

older people and their families as a “trusted source of information”. In 2003, we partnered with 

the Centers for Medicare and Medicaid Services to launch the Aging and Disability Resource 

Center program. Under this program we have provided over $40 million in funding to the 

states to set up “single points of entry” to long-term care at the community level to make it 

easier for consumers and their families to learn about the options that are available in their 

communities.

These Centers also provide consumers with streamlined access to publicly supported long-term 

care programs by consolidating multiple client-intake, assessment and care planning procedures 

into single, integrated systems of access. 

Together with federal science agencies, we are enlisting the Aging Network in the nation-wide 

deployment of low-cost evidence-based prevention programs that have proven effective in 

reducing the risk of disease, disability and injury among the elderly.

We are promoting strategies involving better nutrition and exercise, fall prevention and the selfmanagement of chronic conditions that can empower seniors to take more control of over their 

own health and to reduce health costs. 

Finally, OAA programs are assisting the President’s initiatives to help seniors who are at highrisk of nursing home placement – but not eligible for Medicaid – to remain at home. This will 

give consumers the option of directing their own care and it will become the OAA nursing home 

diversion program. 

Executive Order – Community-Based Alternatives for Individuals with Disabilities

This Executive Order directed federal agencies to evaluate and recommend ways to expand 

community-based services for individuals with disabilities.

We have provided our states with more flexibility under the Medicaid program, and have 

encouraged them to implement a new model of self directed care - Cash and Counseling. This 

self directed model gives clients control over individualized budgets to manage the types of 

services and supports they receive, and the manner in which they are provided, including the 

option of paying family members, as well as friends and neighbors, to help them stay at home. 

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Federal Agencies – Real Choice Systems Change 

As part of the New Freedom Initiative, the President authorized funds for Real Choice System 

Change Grants to help design and implement improved ways of providing community supports 

and services to enable children and adults of any age who have a disability or long term illness to 

live and participate in their communities. Over the last five years, the Centers for Medicare and 

Medicaid Services (CMS), the part of the Department of Health and Human Services that 

administers the grants, has provided over $300 million in funding to help states realize essential 

changes to their systems of care to make them more consumer-directed and more supportive of 

community-living. 

Congressional Action – Deficit Reduction Act

The Money Follows the Person initiative, included as part of the Deficit Reduction Act (DRA) 

of 2005 is an essential part of our comprehensive, coordinated strategy to assist states, in 

collaboration with stakeholders, to make widespread changes to their long-term care support 

systems. Seventeen states are being assisted in their efforts to further reduce their reliance on 

institutional care while developing community-based long-term care opportunities, enabling the 

elderly and people with disabilities to fully participate in their communities. This initiative will 

provide $1.75 billion in new funding over five years to support state efforts to transition people 

out of nursing homes and back into the community. 

The “Own Your Future Campaign” - a federal/state partnership of the Department of Health 

and Human Services and the National Governors Association – is designed to increase awareness 

about the importance of planning ahead for one’s long-term care. To date, we have supported 

campaigns in 14 states, and we plan to reach all states within the next four years. 

The National Clearinghouse for Long Term Care Information. This is the first federal web 

site designed to specifically help consumer plan ahead for their long-term care. It is developed 

by the Department of Health and Human Services and found at 

http://www.longtermcare.gov/LTC/Main_Site/index.aspx. 

Leveraging Public Funding with Private Financing Approaches. The looming retirement of 

the baby boom generation presents a number of challenges to our current financing system for 

long-term care. Its current reliance on public funds will be tested to the limit as 70 million 

Americans enter retirement. One of our strategies we are using to prepare is the development of 

private/public financing options. The goal of these options is to encourage Americans to make 

planning for long-term care a part of their overall retirement planning. Currently, only about 4 

percent of Americans age 45 and older with incomes of $20 thousand or more have long-term 

care insurance coverage. The DRA enables all states to offer such an incentive through a 

program entitled the Partnership for Long-Term Care. This program encourages the use of 

private long-term care insurance by offering Medicaid as a form of re-insurance. The program is 

designed to make private coverage more affordable and, therefore, expands the number of people 

able to purchase coverage. 

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A second financing approach is the use of reverse mortgages. This permits people of age 62 

years and older to use the equity in their homes for health and long-term care services.

Prevention and healthy aging

Just as Medicaid and the OAA have undergone significant changes in the past five years to better 

reflect the needs and preferences of consumers and to improve sustainability, Medicare, too, has 

undergone a transformation. 

Medicare now covers a variety of preventive benefits, including a complete physical exam when 

people first join Medicare, screening for a variety of diseases such as cancer so they can be 

detected and treated early, and, of greatest note, prescription drug coverage. 

Additionally, Medicare recipients can now choose from a number of private plans to find the one 

that best serves them - and these private plans are competing for seniors' business. The result is 

that seniors are saving money and getting the coverage they want. The results are:

• Over 90 percent of people with Medicare (38 million) have drug coverage;

• They are receiving this coverage at a cost that is at least 25 percent less than what was 

initially estimated; and

• Beneficiary satisfaction rates exceeded 80 percent. 

The Aging Network, a highly visible and trusted community source of information for older 

people, partnered with CMS to successfully implement the new Prescription Drug Benefit, Part 

D, under the Medicare program. Affiliates of the Aging Network provided the vast majority of 

the education, outreach and individualized counseling to the 38 million seniors who were 

provided access to the benefit.

Building on the success of the prescription drug program, the Federal Department of Health and 

Human Services is now turning its energies to a national educational campaign to inform seniors 

about the other preventive benefits available through Medicare. 

Conclusion 

The Assistant Secretary for Aging, Josefina G. Carbonell, in her address to the World Assembly 

on Ageing in 2002 provided the essence of the position of the United States. She stated:

 “For the United States Government, the continued improvement in the lives of older 

Americans and their families is a priority. ...We are committed to strengthening and 

modernizing our health insurance program for the elderly, improving access to health care, 

expanding prescription drug benefits, and preventing diseases.”

The United States has made significant progress since the Second World Assembly on Ageing in 

advancing the health and well being of its citizens into old age by continuing our investment in 

transforming and rebalancing our long-term care system. Future reports will indicate additional 

progress made in this area.

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