What Was Promised

A PACE Series — Article 1

Everyday Elders · Ars Moriendi Project

In 1971, in his one-room office in San Francisco’s Chinatown, a public health dentist, Dr. William L. Gee, and a Swiss-born social worker, Marie-Louise Ansak, began work on what would become one of the most quietly remarkable eldercare programs in the United States.

Dr. Gee had spent years watching the elders of his community, whose families could no longer adequately care for them, grow frail in their apartments. The Chinatown-North Beach neighborhood was home to first-generation Chinese, Italian, and Filipino immigrants, many of whom had crossed oceans to build lives in America and had no intention of ending those lives in institutions where no one spoke their language. The committee Dr. Gee chaired concluded that the community needed a nursing home. They hired Marie-Louise Ansak as a consultant to assess the feasibility of building one.

Her study produced a different answer.

She reported that a nursing home would be financially infeasible to build and — more importantly — culturally inappropriate for the families it would purport to serve. Chinese, Italian, and Filipino elders did not want to live in a nursing home, and their daughters and sons did not want to send them there. The shame would have been unbearable, and the cultural distance too great. What was needed, Ansak proposed, was something different: a model of care that allowed elders to remain in their own homes, with their own families, in their own neighborhoods, while still receiving the medical and social support needed to do so safely.

Dr. Gee and his committee accepted her recommendation. They named the new organization the Chinatown-North Beach Health Care Planning and Development Corporation, a name a planning committee often gives an organization before it knows what it will become. The name they later gave the program itself was drawn from Cantonese: On Lok, meaning peaceful, happy abode. That name stuck.

In 1973, On Lok opened one of the first adult day centers in the United States. Nineteen elders enrolled. The center offered meals, medical care, social activities, physical therapy, and a place to spend the day with others who spoke their language and shared their world. Participants went home each evening. Their families kept them.

The model grew slowly and on its own terms. By the late 1970s, On Lok had become more ambitious than a day center. The program assumed full responsibility for its participants’ medical care — not as a supplement to whatever else they were receiving, but as the sole source. A doctor, a nurse, a social worker, a physical therapist, and an aide formed a team that knew each participant as a small-town doctor of an earlier era knew a patient: by name, by history, by family circumstances. The team met weekly to discuss every elder enrolled in the program. If a participant fell, the team knew. If a participant stopped eating, the team knew. If a participant’s daughter was burning out, the team knew.

This was, and remains, an unusual way to deliver medical care to older adults in the United States.

Ansak and Gee made an effective pair. Ansak, by all accounts, was a fighter who refused to take no for an answer from regulators and legislators. Dr. Gee was politically connected and cultivated relationships on both sides of the aisle so that On Lok would retain its support when administrations changed. Between them — passion and politics, vision and patience — they built something Washington had not asked for and Sacramento had not imagined.

In 1983, On Lok received a federal waiver allowing it to operate under a single capitated payment from Medicare and Medicaid. Instead of billing for each service rendered, the program received a flat monthly amount per participant and used those funds to provide whatever the participant needed. The financial logic was the inverse of fee-for-service medicine. A program paid by visit makes more money the sicker its patients get. A program paid by head makes more money the healthier its patients stay. On Lok had every incentive to keep its elders out of the hospital, the emergency room, and the nursing home.

It largely succeeded. Hospital admissions among On Lok participants were lower than those of comparable elders receiving fee-for-service care. Nursing home placements were vanishingly rare. Participants stayed in their homes, on average, until very near the end of their lives. The model did what Ansak and Gee had built it to do.

In 1986, Congress authorized the federal government to replicate the model. By 1990, the first replication sites were operating in cities nationwide. In 1987, On Lok named the model the Program of All-Inclusive Care for the Elderly, now known by the acronym PACE. A decade later, in 1997, the Balanced Budget Act made PACE a permanent part of Medicare and Medicaid.

Congress’s structure was deliberate and remained in place for nearly twenty years.

By federal regulation, PACE programs could be operated only by nonprofit organizations. They could not be owned by investors. They could not distribute earnings. They could not be sold. Any surplus a PACE program generated had to remain in the program, supporting the participants who generated it. The reasoning was straightforward: a model that depended on keeping frail elders well — and that received payment whether or not it delivered the care those elders needed — required a particular kind of organizational discipline. Nonprofits were not perfect, but they were not structurally obligated to extract returns for distant owners. Congress and the Centers for Medicare and Medicaid Services concluded that this constraint was load-bearing. They were probably right.

For more than two decades, PACE grew slowly and quietly. By 2015, 116 PACE programs operated in 32 states, serving roughly 35,000 participants. Every one of them was a nonprofit. The model was unglamorous, hard to scale, and dependent on the kind of slow institutional trust that only develops over years between a program and the families it serves. It was not the kind of business that attracted investors’ attention. It was, however, the kind of program that — when people learned about it — made them ask why their own mother’s care did not look like this.

There is a center in San Francisco where elders gather six days a week. There are centers in Sacramento, San Bernardino, Riverside, and Los Angeles County. There are centers in Denver, Albuquerque, Pittsburgh, and Tampa. At a typical PACE center on a typical morning, a van pulls up to the front door, and an aide helps a woman in her eighties down the step. Inside, a nurse takes her blood pressure. A physical therapist checks the swelling in her ankles, a concern. A social worker asks how her daughter is doing — the daughter has been her primary caregiver, and the social worker has been watching for signs of strain. Over lunch, the woman sits with five other participants and, in her usual way, complains about the soup. In the afternoon, she does her exercises. At three, she gets back in the van. By four, she is home, in the apartment she has lived in for forty years, with the things she loves around her.

She will continue to live there, the model promises, for as long as possible. When that is no longer possible, the program will care for her as needed. She will not go to a nursing home. She will not be moved away from her daughter. She will not disappear into a system that bills by the procedure and forgets her name.

This is what PACE was built to do. It is what PACE has, for fifty years, mostly done.

In 2016, the federal government changed the rule, allowing for-profit organizations to run PACE programs.

The next article in this series — “The Year Everything Was Supposed to Change” — will appear later this week.

Rick Beeman is the author of Bought for Parts: How Wall Street is Profiteering on Your Mother’s Pain (April 2026) and President of Ars Moriendi Project, a California 501(c)(3) public charity working on accountability in long-term care.

Everyday Elders is a publication of Ars Moriendi Project.

Sources for this article: On Lok’s institutional history; “On Lok: A Pioneering Long-Term Care Organization for the Elderly, 1971–2008”, Lehning and Austin, Mack Center for Nonprofit Management, UC Berkeley; National PACE Association; CalPACE; “Remembering Marie-Louise Ansak, a Pioneer in Senior Care”, On Lok.