Managed Decline to Radical Autonomy: Reimagining Reimbursement

Dedicated to the radical spirit of Maggie Kuhn

If we are serious about transforming elder care in America, we must follow the money.

For decades, our reimbursement system has been built around crisis—not prevention. We pay when something goes wrong: a fall, a hospitalization, a decline. But we invest very little in keeping people strong, independent, and at home. The result is a system that quietly manages decline instead of promoting autonomy.

It doesn't have to be this way.

The Problem: Paying for Managed Decline

Although Medicare and Medicaid provide limited preventative measures, they are largely reactive and reimbursement is time limited and costly. Following the money we find the system incentivized by managed decline. Care intensifies only after a crisis—often a preventable one such as a fall. Hospitals are incentivized to discharge quickly, and rehabilitation is cut short by insurance limits. Too often, this cycle funnels older adults into nursing homes or institutional settings where independence steadily erodes.

For many, this is not a choice—it's a default.

“Person-directed care” becomes an oxymoron in a system that rarely prioritizes home as the first option. Most people want to age in place, in familiar surroundings, with privacy and dignity. Yet outdated policies—like the three-day hospital stay requirement for rehab eligibility—make that harder than it should be.

We can do better.

A New Direction: Paying for Strength

Reimagining reimbursement starts with a simple shift: invest before the crisis.

Instead of waiting for a fall, why not fund what prevents it? Balance training, home safety modifications, and ongoing support can dramatically reduce risk. When combined with home-based care—physical therapy, nursing, and expanded roles for caregivers—recovery and stability can happen where people actually want to be: at home.

This doesn't eliminate the need for nursing homes or assisted living. But it does redefine their role: high-quality, short-term care with a clear path back to the community when that's the resident's goal.

Reimbursement should reward that outcome.

Models That Already Work

We don't need to start from scratch. Proven models already point the way:

• Village to Village Network: A grassroots approach that connects older adults with volunteers for transportation, home support, and social engagement—helping people remain active and connected in their communities.

• CAPABLE (Community Aging in Place—Advancing Better Living for Elders): Developed by Johns Hopkins University, this program includes clinical care (nurses and therapists) and home modifications. It has shown remarkable results, including significant reductions in hospitalizations and overall costs.

The future lies in combining these approaches into a social-medical hybrid—where community support and clinical care work together, funded as core benefits rather than optional add-ons. We would like to see these two models integrated and funded to create a synergy of efficiency, coordination, and opportunities for elder support in their homes.

Investment Over Impoverishment

Our current system often forces older adults to “spend down” their savings to qualify for care. This is not just inefficient—it's unjust.

We must raise Medicaid eligibility thresholds and ensure access to preventive services for all, not just those who can afford them. Prevention should not be a luxury.

That includes reimbursing for what we call a “Strength Menu”:

• Physical resilience: Tai Chi, yoga, strength training, swimming

• Therapeutic supports: Massage, acupuncture

• Mental vitality: Mindfulness, reading groups, lifelong learning

• Social connection: Community programs like Socrates cafés and peer groups

Frailty is not inevitable. In many cases, it is the result of a system that fails to invest early.

A Call to Action

This transformation requires more than policy tweaks—it requires a shift in the paradigm.

We must move:

• From institutional default to home-first care

• From reactive treatment to preventive investment

• From scarcity thinking to building a robust elder care workforce

• From task-driven systems to human-centered support

Yes, prevention requires upfront investment. But it saves money over time—and more importantly, it preserves dignity, autonomy, and quality of life.

The generation that built this country deserves more than managed decline.

The movement sparked by Maggie Kuhn challenged ageism and demanded a system that honors independence and choice.

JFK led a national vision to reach the moon, which seemed like a long shot, and it was achieved. Reimagining elder care with the same ambition is totally realistic and necessary!

It is our moment to act!

---

About the Authors

Jeff Jerebker, BS, MS holds a B.S. in Accounting and an M.S. in Sociology. He is the Founder and CEO of Piñon Management, which he led from 1979 to 2012, and co-founded the Live Oak Project. He has served on the Board of Directors of the Eden Alternative, as Treasurer of the Pioneer Network, and as Vice President of the Colorado Health Care Association. He is the recipient of numerous awards in the field of long-term care.

Gail Meehan, MPH, LNHA, CSA has specialized in public health and gerontology for over forty years. She holds a B.S. from the University of Vermont and an M.P.H. from Boston University School of Medicine, and is currently Principal of AgeWise Advisors and Founder and Chair of Senior Health Advocates Colorado. Her career has spanned executive leadership roles—including Executive Director, Administrator, and Senior Vice President—across government agencies, hospitals, nursing homes, and businesses such as the Veterans Administration Geriatric Research, Education and Clinical Center, Harvard Division on Aging, and the NY Presbyterian Healthcare Network. She received a Geriatric Fellowship from the University of Massachusetts to study mental health and aging, and was funded by the World Health Organization to investigate elder care alternatives in Denmark and Sweden. She has developed and administered hospital and nursing home-based continuums of care, and has served on the Live Oak Advisory Committee and the Colorado Strategic Action Committee on Aging.