Agency theory, which we touched on only briefly, highlights the leaders' roles as agents, but there is no reason to believe that these agents ought to be passive receptors of a cacophony of demands that they then convert into policies, programs, and practices. If ascribed leaders do behave in this manner, the policy response can only be expected to be as discordant as the stimuli. Rather, the public's agents--and, as the Oregon case vividly illustrates, these include dynamic visionary bureaucrats as well as legislators--who want to craft effective policy must orchestrate the sounds coming from their principals, namely, advocates for elderly independence. In Oregon, the waiver, the Negotiated Investment Strategy, the congressional support needed to keep the waiver in place are all instruments in this orchestration. The audience that judges the quality of the orchestration, of course, had to pay to get to hear it, in terms of the time and energy that sustained advocacy consumes. But they first had to be convinced that there was a high probability they would get their money's worth; they had to recognize the existence of responsive, effective leadership.
North Carolina has embarked on a strategy to establish some features of Oregon's structure and process for policymaking: a more consolidated budget for publicly funded aging services (albeit one that does not include Medicaid), and a "Plan" with clearly stated objectives, strategies, and tactics. And North Carolina is in the fortunate situation, at least from the perspective one acquires from a review of the Oregon case, of having a very limited nursing home supply. This state also is experiencing a constriction in the availability of public funding. All in all, the time appears propitious to launch major aging policy reform.
However, what does not augur well for such reform is the lack, at least up until now, of statewide sustained informed advocacy in North Carolina of the sort we have described in Oregon. In the dynamic combination of forces we have identified as influential in effecting such reform, that is a crucial shortcoming, and one that can be overcome only by effective leadership.