Governor pushes aging plan for North Carolina

By Thomas Goldsmith

During Gov. Roy Cooper’s final full year in office, his administration will make a first-time, major push to benefit North Carolina’s fast-growing older population through new funding and changes in state operations according to interviews with principals and state documents.

Cooper’s legislative initiative will emerge during 2024 as the result of a public-nonprofit-business collaboration called “All Ages, All Stages NC: A Roadmap for Aging and Living Well,” which is set forth in an executive order on the topic. 

Support from North Carolina’s Republican-led General Assembly will be required to fulfill any of the new plan’s far-reaching approaches, including increasing the state’s supply of direct-care workers and improving older people’s access to transportation, housing and such services as senior centers and respite care.

“No. 1 is supporting the direct care industry,” said Cooper, a Democrat, after the announcement. “We know that there is a critical shortage right now to look after seniors and to make sure they receive the direct care that they need.”

While focused on older residents, the “All Ages, All Stages” plan and title reflects its aim “to make sure that individuals of all ages and stages of life can thrive and age gracefully within the state.”

A mansion presentation 

In May, Cooper — who turned 66 in June — walked onto the picturesque grounds of the Executive Mansion in Raleigh to present the executive order through which he would lead state agencies, local governments and nonprofits toward goals that include making North Carolina the nation’s 10th state designated as “age-friendly” under an AARP program.  

It was an optimistic presentation, served up with lemonade and chocolate chip cookies. But the event contained no emphasis on any new laws or regulations, which would be required to drive its ambitious, collaborative plan involving government, nonprofits and business, as well as other key sectors such as health care and the environment. Nor did anyone mention new spending to support financial goals that an official later agreed could cost hundreds of millions of dollars. 

“There is no question but that we’re going to need significant resources to be the kind of age-friendly state that we want to be,” Cooper said after the announcement. 

Preliminary budget requests arising from the new plan are to be produced by February. The process is being led by the NC Division of Aging and Adult Services and the Division of Health Benefits, which manages the state’s Medicaid program.

Which plan is which?

On July 1, the state Division of Aging and Adult Services released a detailed state aging plan for 2023-27, a document required every four years by the federal Older Americans Act

Division staff and leaders, along with the state Area Agencies on Aging, have conducted multiple listening sessions across the state, especially in underserved communities, to learn what older people wanted this plan to include. Planners emerged with a focus on equity and goals that often reflect those announced by Gov. Roy Cooper in May.

However, Cooper’s “All Ages, All Stages NC: A Roadmap for Aging and Living Well” is a separate document with policy and political changes at its center. Much of it would require several state agencies to work together on specific changes to benefit a broad range of North Carolinians, including aging residents and people with disabilities. 

Many of its changes would require approval by the General Assembly, whose Republican leaders have typically been at odds with Cooper, a Democrat.

— Thomas Goldsmith

Do changes lie ahead for state aging programs?

With other issues topping the items for consideration on Jones Street, there’s no guarantee of passage for Cooper’s comprehensive plan, which is designed to prepare North Carolina for a near future in which one in five people is 65 or older. Efforts to expand Medicaid and bills changing the way charter schools are funded are among the causes that have occupied legislators’ time — not aging issues.

Heather Burkhardt, executive director of the nonprofit North Carolina Coalition on Aging, noted that Medicaid expansion, a top Cooper priority, could provide health insurance for about 60,000 state residents between ages 55 and 64. But Republican leaders said a revamp of state aging policies is not on the table during the current budget wrap-up.

“We have not discussed the long-term [aging] plans,” said Sen. Joyce Krawiec (R-Kernersville) when asked during budget deliberations about the cascading increase in older North Carolinians. “One budget at a time. We just have to work on this budget this time.”

Cooper laid out his plan’s roles for state departments, including:

  • Commerce and  Health and Human Services in addressing the dire shortage of direct caregivers through recruiting and retaining workers.
  • DHHS in examining ways to bolster Adult Protective Services as it works to shield North Carolinian adults at risk of exploitation and abuse.
  • Natural and Cultural Resources in providing access to parks and other outdoor facilities. 
  • Increases in Department of Transportation services to the state’s older people, for many of whom simply getting from place to place shows up in surveys as a top need.
Shows a group of older Black men and women who are looking at the camera. They're sitting among a group of tables and chairs, it looks like there was recently a meal that was served.
Hertford County residents gather in May at the Murfreesboro Nutrition Center. Congregate meals at the center are funded through Home and Community Care Block Grants. There’s a statewide waiting list of more than 11,000 for this program and for a broad range of additional aging services. Credit: Thomas Goldsmith

Who picks up the bills?

Money to assist older North Carolinians comes from a complex mix of federal, state, local and other sources, not all of which are controlled by the governor’s administration. 

Big chunks of spending for older people lie in providing long-term care for people on Medicaid. Federal Home and Community Care Block Grants, which require state and county matches, pay for public-facing services such as congregate and home-delivered meals, respite care, senior centers and transportation.

While helping older North Carolinians has traditionally been a Democratic policy staple, recent years have seen state Republican leaders promoting increases in spending for specific state aging services. These have occurred in some cases where Cooper had not included the items in his proposed budgets. 

For instance, Republican legislators have led the effort to increase the amounts of spending money available to Medicaid-supported long-term care residents. State Sen. Jim Burgin (R-Angier) said Republicans decided to back it after talking to residents and others about the scant funds that allow them to buy items from snacks to a haircut or a trip to church.

“They just need to have [access] to more money to do that,” Burgin said. “And some of these people are pretty well — that’s all they’ve got. We just feel like, with the way everything’s getting expensive, if we don’t, they’re doing without.”

Bill Lamb, a Raleigh activist with long experience in state government and in advocating for older people at the legislature, said Cooper’s job of pushing “All Ages, All Stages” will be harder because it will require Republican majority buy-in during a time when billions in tax cuts are on the negotiating table.

“The driver on all of this is the General Assembly,” Lamb said. “It’s not the executive. I think there’s more action in working that side of the street.

“You don’t want to get into a fight, a crossfire between the executive and the legislature. Okay. But frankly, the focus is on the legislature.”

Using COVID dollars to move forward

As the “All Ages, All Stages” process moves forward, Cooper has assigned officials from various state agencies, as well as nonprofits and the private sector, to collaborate on the project, according to Joyce Massey-Smith, director of the state Division of Aging and Adult Services. COVID-related allocations from a federal fund are one source of needed funds.  

“We need to be planning, and it’s not something that we as a department can do alone,” Massey-Smith said. “We are working on the notion of a sustainability plan around the American Rescue Plan dollars, because we’ve received a huge tranche of [federal] funding to expand services under it. And we are working very hard to consider the services that have been highly utilized and most needed for frail individuals.

“But I can’t tell you that there’s a magic bullet. There’s work that private entities are going to need to do just because of the sheer growth in the population.” 

State getting older

According to demographic data from the state Department of Commerce, people older than 65 are in the majority in 56 of North Carolina’s counties. By 2031, one in five of all North Carolinians will be over 65, creating a need for more services. Massey-Smith said the challenges have to be met.

“We have this multi-sectoral plan on aging that will develop to try to spread the work and the knowledge and the need across different sectors of government and in the private world — to be able to prepare for this,” Massey-Smith said.

An “All Ages, All Stages” committee of 100 met June 5, and organizers started on July 10 signing up members for workgroups on key topics, including strengthening communities’ safety, access to transportation, affordable housing and supporting older adults and their families. 

Shows several people planting rhododendron outside a brick building. One woman is on her hands and knees, smoothing dirt around the plant's stem, a second holds a shovel and looks over the first oman's
People who spend time at a Wake County adult-day care center prepare a garden in this February 2018 file photo. Adult-day care is one of several services paid for by a mix of state federal and county funds. Credit: Tommy Goldsmith

“We know that caregivers provide the bulk of the care that older adults receive,” Massey-Smith said. “We have got to continue supporting caregivers, and we do that with different resources from both Medicaid and our division.” 

One of the collaborations would partner the Department of Health and Human Services with the state commerce department

Under one of the “All Ages, All Stages” efforts across sectors, private insurers could hire direct-care workers for older clients through nonprofit agencies that get some of their support from Home and Community Care Block Grants, a DHHS spokeswoman said in an email.

“There is a national movement of aging services providers/Area Agencies on Aging to develop their ‘business acumen’; i.e., be able to operate more as a business by contracting to deliver services,” wrote Summer Tonizzo, a DHHS communications staffer. “This would allow them to reach more people than is possible through public funding alone and help alleviate concerns of sustainability, given the funding has not kept pace with the growth of the population.”  

Request for bipartisan support lies ahead

A host of North Carolina advocates for older people showed up at the Executive Mansion to welcome the “All Ages, All Stages” process, and they continue to support its goals. However, they say, legislative approval may face a hard road in 2024, when there’s a “short session” usually devoted to budget adjustments. Looming federal and state elections next year are likely to be a distraction as well.

“We’ve got to have bipartisan support, especially knowing that it’s the end of the governor’s term,” said Burkhardt, of the North Carolina Coalition on Aging. “It’s a short session, and we’re looking at the 10-year plan so we can’t ask for everything in the first year. This is going to be a multi-year strategy.”

The timing raises questions about whether Cooper can exercise his muscle in areas he has not typically emphasized, especially as Republicans in the legislature have taken to noting that, approaching the end of his term, Cooper is a “lame duck.”

The governor, for his part, seems interested in making up for lost time.

“I think that it’s clear that our aging population has given more back to the state than the state has ever given,” Cooper said. 

NC Health News editor Rose Hoban contributed reporting.

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