The Older Americans Act: should participants share in the cost of services?

Since its inception in 1965, the Older Americans Act has provided social services free of charge to older people, regardless of income. In recent years, the scarcity of resources has sparked a debate as to whether participants who can afford to pay for services should be required to do so. Of concern is whether charging fees will change the fundamental nature of these popular programs by imparting a "welfare" stigma. Other programs that require fees vary enormously by state, and there has been little documentation of their impact on participation, equity of service delivery, or public attitudes. In order to evaluate current proposals, it is necessary to analyze the distributional effects of the cost-sharing system, how the program will be administered, what impact it will have on service use, which services would be subject to cost sharing and at what income levels, and what constitutes a "reasonable" fee for service.