Older Americans Act
Preliminary Observations on Services Requested by Seniors and Challenges in Providing Assistance Gao ID: GAO-10-1024T September 7, 2010Administered by the Administration on Aging (AoA) in the Department of Health and Human Services (HHS), Title III of the Older Americans Act (OAA) is intended to assist individuals age 60 and older by providing supportive services. Title III, Medicaid and Medicare, state, and other sources of funding provide for several types of services, including congregate and home-delivered meals, transportation, and support for caregivers. This testimony reports on ongoing GAO work in preparation for the reauthorization of the OAA and a full report to be issued by GAO in 2011. Based on preliminary findings, GAO describes (1) Title III services most requested by seniors and how state and local agencies reach those most in need, and (2) how agencies have coped with increasing requests in the current economic environment. To do this, GAO reviewed aging plans from the 50 states and District of Columbia; conducted site visits to 4 states; interviewed national, state, and local officials; and analyzed preliminary responses to a Web-based survey of 125 Local Area Agencies on Aging for fiscal year 2009. The survey data used in this document reflect a 54 percent response rate as of July 30, 2010. The survey is still in progress and our results are not generalizable at this time. GAO shared its findings with AoA and incorporated their comments as appropriate.
Seniors frequently requested home-delivered meals and transportation services, and based on preliminary responses to GAO's survey and information from site visits, demand for some Title III services may be increasing. Some agencies said they were unable to meet all requests for services in fiscal year 2009. For example, 13 of 67 survey respondents said they were generally or very unable to serve all seniors who requested home-delivered meals, and 15 of 63 said they were generally or very unable to serve all who requested transportation assistance. Local officials cite seniors' desire to remain in their homes as they age, and the economic downturn as possible reasons for increased requests. Given this demand, providers must make decisions about which applicants will receive services. OAA requires providers to target those with the greatest economic and social need,--low-income, minority, lacking proficiency in English, and rural residents--and local officials said they advertise, conduct outreach, and coordinate with other local organizations to identify and serve these groups. Additionally, most local agencies reported screening potential clients to assess level of need, for example, to determine those most at risk of hospitalization due to poor nutrition. In addition to these known service needs, an unknown number of other seniors may need services but not know to contact OAA providers, some officials told GAO. Local agencies who responded to GAO's survey reported using the flexibility afforded by the OAA to transfer funds among Title III programs to meet increased requests for specific services. Twenty-eight of 61 local agencies said they transferred funds in fiscal year 2009, most often removing funds from congregate meals to home-delivered meals or other services. Although the American Recovery and Reinvestment Act (Recovery Act) provided an additional $97 million specifically for meal programs, Title III programs are heavily reliant on state funds, and 44 of 64 local agencies responding to our survey said their state funding was reduced for fiscal year 2010. To cope with funding reductions, some reported cutting services to seniors. Twenty-seven of 65 local agencies said they cut administrative expenses in fiscal year 2010; others relocated offices or left agency positions vacant. Some state and local officials said they provided less service to individuals so that more could get some amount of assistance. Some agencies said they used Recovery Act funds to replace lost state and local funding or created new programs, but the funding was restricted to meal services and was a relatively small percentage of total OAA allocations. The proportion of Americans age 60 and over will continue to grow over the coming decades, and demand for Title III services also will likely grow. Therefore it will be increasingly important for service providers to focus services on those most in need.
GAO-10-1024T, Older Americans Act: Preliminary Observations on Services Requested by Seniors and Challenges in Providing Assistance
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Testimony:
Before the Special Committee on Aging, U.S. Senate:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 1:00 p.m. EDT:
Tuesday, September 7, 2010:
Older Americans Act:
Preliminary Observations on Services Requested by Seniors and
Challenges in Providing Assistance:
Statement of Kay E. Brown, Director:
Education, Workforce, and Income Security Issues:
GAO-10-1024T:
GAO Highlights:
Highlights of GAO-10-1024T, a testimony before the Special Committee
on Aging, U.S. Senate.
Why GAO Did This Study:
Administered by the Administration on Aging (AoA) in the Department of
Health and Human Services (HHS), Title III of the Older Americans Act
(OAA) is intended to assist individuals age 60 and older by providing
supportive services. Title III, Medicaid and Medicare, state, and
other sources of funding provide for several types of services,
including congregate and home-delivered meals, transportation, and
support for caregivers.
This testimony reports on ongoing GAO work in preparation for the
reauthorization of the OAA and a full report to be issued by GAO in
2011. Based on preliminary findings, GAO describes (1) Title III
services most requested by seniors and how state and local agencies
reach those most in need, and (2) how agencies have coped with
increasing requests in the current economic environment.
To do this, GAO reviewed aging plans from the 50 states and District
of Columbia; conducted site visits to 4 states; interviewed national,
state, and local officials; and analyzed preliminary responses to a
Web-based survey of 125 Local Area Agencies on Aging for fiscal year
2009. The survey data used in this document reflect a 54 percent
response rate as of July 30, 2010. The survey is still in progress and
our results are not generalizable at this time. GAO shared its
findings with AoA and incorporated their comments as appropriate.
What GAO Found:
Seniors frequently requested home-delivered meals and transportation
services, and based on preliminary responses to GAO‘s survey and
information from site visits, demand for some Title III services may
be increasing. Some agencies said they were unable to meet all
requests for services in fiscal year 2009. For example, 13 of 67
survey respondents said they were unable to serve all seniors who
requested home-delivered meals, and 15 of 63 said they were unable to
serve all who requested transportation assistance. Local officials
cite seniors‘ desire to remain in their homes as they age, and the
economic downturn as possible reasons for increased requests. Given
this demand for services, providers must make decisions about which
applicants will receive services. OAA requires providers to target
those with the greatest economic and social need,”low-income,
minority, lacking proficiency in English, and rural residents”and
local officials said they advertise, conduct outreach, and coordinate
with other local organizations to identify and serve these groups.
Additionally, most local agencies reported screening potential clients
to assess level of need, for example, to determine those most at risk
of hospitalization due to poor nutrition. In addition to these known
service needs, an unknown number of other seniors may need services
but not know to contact OAA providers, some officials told GAO.
Local agencies who responded to GAO‘s survey reported using the
flexibility afforded by the OAA to transfer funds among Title III
programs to meet increased requests for specific services. Twenty-
eight of 61 local agencies said they transferred funds in fiscal year
2009, most often removing funds from congregate meals to home-
delivered meals or other services. Although the American Recovery and
Reinvestment Act provided an additional $97 million specifically for
meal programs, Title III programs are heavily reliant on state funds,
and 44 of 64 local agencies responding to our survey said their state
funding was reduced for fiscal year 2010. To cope with funding
reductions, some reported cutting services to seniors. Twenty-seven of
65 local agencies said they cut administrative expenses in fiscal year
2010; others relocated offices or left agency positions vacant. Some
state and local officials said they provided less service to
individuals so that more could get some amount of assistance. Some
agencies said they used Recovery Act funds to replace lost state and
local funding or created new programs, but the funding was restricted
to meal services and was a relatively small percentage of total OAA
allocations.
The proportion of Americans age 60 and over will continue to grow over
the coming decades, and demand for Title III services also will likely
grow. Therefore, it will be increasingly important for service
providers to focus services on those most in need.
View GAO-10-1024T or key components. For more information, contact Kay
Brown at (202) 512-7215 or brownke@gao.gov.
[End of section]
Mr. Chairman:
Thank you for inviting me here today to discuss the preliminary results
of our work that you requested on services and funding provided under
the Older Americans Act of 1965 (OAA).[Footnote 1] Title III of OAA
provides for a broad range of home-and community-based services for
older Americans and their caregivers, including providing meals,
transportation, assistance with personal care and housekeeping, and
time off (respite) for seniors' caregivers. About 10 million seniors
age 60 and older, or about 18 percent of the national 60 and over
population, benefited from these programs in fiscal year 2008, the most
current year for which these data were available. In fiscal year 2009,
Congress provided $1.2 billion for grants to states for home-and
community-based services under Title III of the OAA.[Footnote 2] Future
funding will be determined in the reauthorization process in 2011.
Demographic studies show that older Americans will make up a larger
proportion of the country's population in coming decades, with those
aged 65 and older projected to increase from 40 million in 2010 to 72
million in 2030.[Footnote 3] Delivery of services related to long-term
care, nutrition, and other needs of seniors will likely be increasingly
in demand as well, particularly services that help individuals remain
in their homes and communities.
Currently, an economic downturn has challenged many seniors' ability to
meet basic needs as well as the resources of agencies that provide
assistance. The American Recovery and Reinvestment Act of 2009
(Recovery Act)[Footnote 4] provided a one-time addition of $97 million
for Title III home-delivered and congregate meals for seniors. The
Administration on Aging (AoA) requires states to expend these funds by
December 30, 2010.
For today's testimony, we focused on the following questions: (1) Which
Title III services are most requested, and how do state and local
agencies reach those seniors most in need? (2) How have agencies coped
with increasing requests in the current economic environment?
Our analysis is based on preliminary responses to a GAO Web-based
survey of a random national sample of 125 local area agencies on
aging.[Footnote 5] As of July 30, 2010, our response rate was 54
percent. These agencies are the frontline administrators of Title III
services for seniors, and our survey asked them about fiscal year 2009.
We also reviewed 51 aging plans from states and the District of
Columbia, reviewed relevant statutory provisions, conducted site visits
to 4 states, and interviewed national, state, and local officials
involved in Title III programs. This testimony is part of ongoing work
for a report requested by the Special Committee on Aging and scheduled
to be issued in early 2011 in which we intend to estimate need for and
potential gaps in Title III services, and provide results from our
completed survey. We discussed our preliminary results with AOA and
incorporated their comments as appropriate. For more information on our
scope and methodology, see appendix I.
We conducted this performance audit from December 2009 to August 2010,
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions.
Background:
The purpose of Title III of the OAA is to help seniors maintain
independence in their homes and communities by providing appropriate
support services and promoting a continuum of care for the vulnerable
elderly.[Footnote 6] The OAA laid the foundation for the current aging
services network. This network is comprised of 56 state units on aging
(SUA), 629 area agencies on aging (AAA), 244 tribal and Native American
organizations, and 2 organizations serving Native Hawaiians, as well as
nearly 20,000 local service provider organizations.[Footnote 7] These
organizations are responsible for the planning, development, and
coordination of a wide array of home and community-based services
within each state under Title III of the OAA. This testimony focuses on
three categories of services--those provided under parts B, C, and E of
Title III of the OAA. Part B covers, among other things, supportive
services and senior centers, including transportation, help with
homemaker tasks and personal care, and adult day care.[Footnote 8] Part
C covers nutrition services, including home-delivered and congregate
meals.[Footnote 9] Part E authorizes the National Family Caregiver
Support Program, which provides counseling, support groups, and relief
from caregiver duties (respite services) for caregivers.[Footnote 10]
(See table 1.)
Table 1: OAA Expenditures on Title III Services, Parts B, C, and E, FY
2008:
Select services provided through OAA Title III:
Part B: Support (Assistance) Services: Other Services;
OAA Title III expenditures[A] by service: $105.5 million.
Part B: Support (Assistance) Services: Transportation;
OAA Title III expenditures[A] by service: $68.0 million.
Part B: Support (Assistance) Services: Information and Assistance[B];
OAA Title III expenditures[A] by service: $53.2 million.
Part B: Support (Assistance) Services: Case Management;
OAA Title III expenditures[A] by service: $34.4 million.
Part B: Support (Assistance) Services: Homemaker;
OAA Title III expenditures[A] by service: $27.1 million.
Part B: Support (Assistance) Services: Legal Assistance;
OAA Title III expenditures[A] by service: $24.8 million.
Part B: Support (Assistance) Services: Personal Care;
OAA Title III expenditures[A] by service: $12.7 million.
Part B: Support (Assistance) Services: Adult Day Care/Health;
OAA Title III expenditures[A] by service: $11.8 million.
Part B: Support (Assistance) Services: Outreach;
OAA Title III expenditures[A] by service: $11.4 million.
Part B: Support (Assistance) Services: Chore[C];
OAA Title III expenditures[A] by service: $5.8 million.
Part B: Support (Assistance) Services: Assisted Transportation;
OAA Title III expenditures[A] by service: $3.7 million.
Part C: Nutrition Services: Congregate Meals;
OAA Title III expenditures[A] by service: $265.5 million.
Part C: Nutrition Services: Home-Delivered Meals;
OAA Title III expenditures[A] by service: $228.2 million.
Part C: Nutrition Services: Nutrition Education;
OAA Title III expenditures[A] by service: $3.5 million.
Part C: Nutrition Services: Nutrition Counseling;
OAA Title III expenditures[A] by service: $1.0 million.
Part E: Caregiver Services: Respite Care;
OAA Title III expenditures[A] by service: $55.1 million.
Part E: Caregiver Services: Access Assistance[D];
OAA Title III expenditures[A] by service: $30.9 million.
Part E: Caregiver Services: Counseling/Support Groups/Caregiver
Training;
OAA Title III expenditures[A] by service: $15.9 million.
Part E: Caregiver Services: Supplemental Services[E];
OAA Title III expenditures[A] by service: $14.1 million.
Part E: Caregiver Services: Information Services[F];
OAA Title III expenditures[A] by service: $13.6 million.
Source: State Program Reports Data from the Administration on Aging's
AGIntegrated Database (AGID) - http://www.agidnet.org/ (last accessed
Jan. 29, 2010).
[A] Expenditures for the 50 states, District of Columbia and U.S.
territories.
[B] Information and assistance refers to brochures, literature, and
information provided to seniors and care givers about services,
programs and resources they may wish to access.
[C] Chore Services includes assistance with heavy housework, yard
work, or sidewalk maintenance.
[D] Access Assistance refers to assistance to caregivers in locating
services from a variety of private and voluntary agencies.
[E] Supplemental services are provided on a limited basis to complement
the care provided by caregivers. Home modifications, assistive
technologies, and emergency response systems are examples of
supplemental services.
[F] Information services refers to information given to caregivers
about available services within their communities.
[End of table]
The Administration on Aging (AoA) at the Department of Health and Human
Services provides grants to the states through the SUAs. Grant amounts
are based on funding formulas weighted to reflect a state's age 60 and
over population, which is generally the group eligible for
services.[Footnote 11] For example, in fiscal year 2009, the state of
Florida received about $87 million in Title III dollars compared to the
state of Montana, which received $6 million, because more seniors
reside in Florida. SUAs then typically allocate funds to Area Agencies
on Aging (AAA) to directly provide services or to contract with local
service providers. In a few states, the SUA directly allocates funds to
local providers or provides services. (See figure 1.)
Figure 1: Flow of Title III Funds:
[Refer to PDF for image: flow chart]
Path 1:
Administration on Aging, HHS:
State Units on Aging:
Area Agencies on Aging:
Local Service Providers;
Direct Services.
Path 2:
Administration on Aging, HHS:
State Units on Aging:
Local Service Providers;
Direct Services.
Source: GAO.
[End of figure]
A significant amount of program funding is also provided to state and
local agencies by other sources, such as federal Medicare and Medicaid,
states, private donations, and voluntary contributions from seniors for
services they receive. According to a 2009 study published by the
National Association of Area Agencies on Aging and Scripps Gerontology
Center of Miami University, 99 percent of AAAs secure funds from
additional sources, and the average AAA utilized funding from six
sources to provide services in their communities[Footnote 12]. The
amount secured by AAAs varies.
OAA services are available to all people age 60 and older who need
assistance. The law did not, however, establish an open ended
entitlement available to all seniors, nor was it intended to meet all
of seniors' needs. OAA requires providers to target, or place a
priority on reaching, seniors with the greatest economic and social
need, and defines them as individuals who have an income at or below
the poverty level, or who are culturally, socially, or geographically
isolated, face language barriers, or have physical and mental
disabilities.[Footnote 13] Targeting these seniors who are most in
need may include a local agency locating a congregate meal site in a
low-income neighborhood or working collaboratively with organizations
that represent minority seniors. In addition, some services are
targeted to vulnerable groups by definition. Examples of these include
the long-term care ombudsman program, family care-giver support
services, home, and assisted transportation to those with limited
mobility. OAA gives state and local agencies flexibility in
determining which populations to target.
The recent health care reform legislation--the Patient Protection and
Affordable Care Act--contains new provisions for senior health care,
including one removing barriers to home-and community-based services
under Medicaid.[Footnote 14] While these changes may shift the
provision of some services for seniors from OAA to Medicaid, the extent
of this shift is unknown; nevertheless, seniors will likely continue to
look to OAA-funded providers for a range of assistance.
Agencies Report Increased Requests For Meals And Transportation, And
Varied Efforts To Reach Those Most In Need:
Local agencies who responded to our survey identified home-delivered
meals and transportation as frequently requested services in fiscal
year 2009. These agencies also said they receive many requests for
information and assistance services--help locating resources and
programs--and for respite for caregivers. In preliminary responses to
our survey, 49 of those 61[Footnote 15] local agencies said more
seniors requested home-delivered meals than congregate meals. Forty-
four of our 67 survey respondents thus far cited transportation and 43
cited information and assistance as the support services requested most
frequently.[Footnote 16] One local official we spoke with in Wisconsin
highlighted the importance of transportation services for his rural
clients,[Footnote 17] while an agency official in Massachusetts said
OAA transportation services can be important in urban settings because
seniors often prefer them to mass transit options.[Footnote 18] In
addition, 36 of the 63 local agencies who have responded to our survey
and track such requests said respite services were most frequently
requested by caregivers in fiscal year 2009. Respite care provides
temporary caregiving for seniors so that a family member can take a
break or engage in other activities.
Some agencies responding to our survey said they are currently unable
to meet all requests for services. Thirteen of 67 agencies said they
are generally or very unable to serve all clients who request home-
delivered meals; 15 of the 63 agencies that provide transportation
services said they are generally or very unable to meet all
transportation requests. Of the 64 agencies that provide respite care,
17 said they were generally or very unable to meet all requests.
State and local officials we spoke with also said requests for some OAA
services are increasing. Specifically, officials at several local
agencies we visited described increased requests for home-delivered
meals, transportation, or home-based services.[Footnote 19] Officials
attributed these increases to several factors. First, some agency
officials said there are increasing numbers of Americans who are age 60
and older and eligible for services. According to U.S. Census data,
more than 9 million more Americans were 60 years and older in 2009 than
in 2000, and the Census Bureau projects that population group will
continue to grow. Secondly, some agency officials told us requests for
OAA services such as home-delivered meals and home-based care are
increasing as more seniors stay in their homes longer rather than move
to assisted living facilities or nursing homes.[Footnote 20] For
example, state officials in Wisconsin said their client population is
increasingly older and those who remain in their homes less likely to
go out, leading many to request home-delivered meals.
Lastly, most agencies who responded to our survey said requests for
services have increased since the economic downturn began. Forty-eight
of 61 said they have received increased requests for home-delivered
meals, 44 of 62 for support services such as transportation, and 40 of
61 agencies for caregiver services since the downturn began. Twenty-
five of 60 agencies said they had increased requests for congregate
meals, even as long-term trends show a decline in use of this
service.[Footnote 21] A survey conducted by the National Association of
State Units on Aging to determine the impact of the economic crisis on
state-provided services also found requests for the types of services
provided by OAA increased, particularly for home-delivered meals,
transportation, and personal care.[Footnote 22] Some researchers have
concluded that older Americans have been hard hit by the economic
recession for reasons such as depreciating home values and retirement
accounts.[Footnote 23] These increasing economic challenges may lead to
increased need for services like those provided by OAA programs.
Given the number of agencies that cannot meet all requests for services
and the increasing demand for certain services, agencies must make
decisions about which applicants to serve. To reach and serve seniors
with the greatest economic or social need, local agencies responding to
our survey reported a range of strategies. Over 50 of 67 agencies said
they advertise, conduct outreach, and coordinate with other local
organizations to reach and provide services to seniors who are targeted
by OAA: seniors who are low-income, minority, or live in rural areas.
At least 47 of 67 said they use these approaches to reach seniors who
speak limited English, another group targeted by OAA. Additionally,
most local agencies reported screening potential clients to assess,
whether seniors requesting home-delivered meals or respite care had
physical limitations that made these types of services particularly
beneficial. For example, at one local agency where demand often exceeds
supply, an official said preference may be given to those most at risk
for hospitalization due to diagnosed malnutrition or chronic diseases
managed through nutrition, such as diabetes. Most local agencies did
not screen for congregate meals or transportation services.
Some officials we spoke to said there are additional seniors who need
services but do not contact OAA providers to request them. For example,
one local official in Illinois said needs assessments and anecdotal
information indicate a much greater need for services than requests to
the agency indicate. Similarly, researchers from one organization we
spoke with surmised that if more seniors knew about the types of
services available through Title III, the requests for such services
would be greater. [Footnote 24]
Agencies Often Move Funds Among Programs To Meet Requests And Cut Costs
To Cope With Reduced Funding:
Increased requests and, for some local agencies, static or decreased
funding has led local agencies to adopt a number of coping mechanisms.
Preliminary responses to our survey indicate agencies utilize the
flexibility provided by the OAA to transfer funds among Title III
programs to meet requests from seniors for services.[Footnote 25]
Twenty-eight of 61 local agencies responding to our question said they
transferred funds among programs in fiscal year 2009, most often
removing funds from congregate meals, which are less requested, to
home-delivered meals or other services. On a national level, nearly 20
percent of OAA funding for congregate meals in fiscal year 2008 was
transferred out of the program by states and split almost evenly
between home-delivered meals and support services, AoA data show. (See
figure 2.)[Footnote 26] As a result, support services and home-
delivered meal programs experienced an 11 percent and 20 percent net
increase, respectively, in Title III funds. On the state level, 34
states transferred funds from congregate meals to home-delivered meals
in fiscal year 2008, according to AoA data.
The ability to transfer funds offers states flexibility, yet some
officials have questioned the need for meal funding to arrive in two
streams. For example, Wisconsin state officials said maintaining
separate funding for congregate and home-delivered meals creates a
cumbersome process in which the state has to deal with multiple rules
to allocate funds to services that are most needed. Similarly, Rhode
Island state officials said they would like to see a single Title III,
Part C, meal program because requests for congregate meals have
decreased. In addition, in fiscal year 2008, 32 states transferred
funds from the congregate meal program to Title III, Part B, services
such as personal care, homemaker assistance, and transportation
services. Local officials in Wisconsin told us federal funding for Part
B services is not sufficient to meet requests.
Figure 2: Fund Transfers among Title III Programs, Fiscal Year 2008:
[Refer to PDF for image: illustration]
Congregate meals:
$39 million to 34 states for Home delivered meals;
$250,000 transferred from 1 state.
$39 million to 32 states for Support Services;
$418,000 transferred from 2 states.
Home delivered meals:
$2.5 million transferred from 7 states to Support Services;
Support Services:
$1.7 million transferred from 7 states to Home delivered meals.
Source: GAO analysis of AoA Fiscal Year 2008 State Program Reports.
[End of figure]
In addition to receiving federal funding, the programs created by Title
III of OAA receive funding from other sources as well. (See fig. 3.)
OAA funds to states and local agencies increased in fiscal year 2009 by
$97 million due to Recovery Act funding explicitly for meal programs.
But many of the local agencies responding to our survey reported
overall decreases in funding from fiscal year 2009 to fiscal year 2010.
Forty-four of 64 local agencies said state funding - the second largest
source of funding for these programs nationally--decreased for fiscal
year 2010. This is consistent with information reported by the National
Association of State Units on Aging (NASUA). NASUA found that most
states reported state budget shortfalls in fiscal year 2010 and reduced
budgets for aging services. Local agencies also use funds from local
governments, voluntary client contributions, and private sources, and
preliminary survey results indicate these funds also declined in fiscal
year 2010.
Figure 3: Percentage of Funds from Various Sources, as Reported by 58
Local Agencies, Fiscal Year 2009 (preliminary data):
[Refer to PDF for image: vertical bar graph]
Source of funding: OAA Title III;
Average percentage of funding[A]: 44%.
Source of funding: Other OAA Titles;
Average percentage of funding[A]: 2%.
Source of funding: Medicaid Home and Community Based Waivers;
Average percentage of funding[A]: 9%.
Source of funding: Other Federal Programs;
Average percentage of funding[A]: 4%.
Source of funding: State Government;
Average percentage of funding[A]: 23%.
Source of funding: Local or County Government;
Average percentage of funding[A]: 7%.
Source of funding: Voluntary Client Contributions;
Average percentage of funding[A]: 4%.
Source of funding: Private Sources;
Average percentage of funding[A]: 3%.
Source of funding: Other;
Average percentage of funding[A]: 3%.
Source: GAO analysis of preliminary survey data from 58 local agencies.
[End of figure]
Some local agencies responding to our survey reported reducing services
as a result of funding cuts. Twelve of 64 local agencies said they
reduced support services, an additional 12 of 63 reported reducing
nutrition services, and 9 of 64 reported reducing caregiver services.
To replace lost state and local monies and maintain service levels to
seniors, just under half of those responding to our survey said they
took some steps to reduce administrative and operations costs and used
Recovery Act funds to fill budgeting gaps. In our preliminary survey
results, 27 of 65 agencies reported cutting administrative expenses, 22
of 54 reported cutting capital expenses, and 26 of 62 reported cutting
operating expenditures in fiscal year 2010. Local agencies responding
to our survey said they cut expenses in many ways such as by relocating
to a smaller building with lower overhead costs, stretching meal
service supplies, decreasing travel expenses, and limiting raises for
employees. Additionally, 29 of 63 said they did not fill vacant
positions. These preliminary survey data are consistent with what we
heard from state officials on our site visits. State officials in
Wisconsin, for example, told us that as a result of the state's budget
deficit, the agency was unable to fill vacant positions and had cut
planning, administration, and monitoring activities in order to avoid
cutting services to seniors. Illinois state officials told us the last
budget cycle included a 10 percent decrease in state funds for aging
services, and there were layoffs, required furlough days, and positions
left vacant as a result.
Some state and local agencies we visited also told us they adapt to
limited funding or increased requests for services by providing less
service to all rather than full service to only some. For example, a
local official in Massachusetts said that some seniors are given fewer
transit rides so others can be accommodated. A state official in
Illinois said some local areas resolve the funding shortfalls by
reducing the number of hours they provide respite services for each
caregiver.
Local agencies said they used Recovery Act funds to fill meal budget
gaps or to expand existing nutrition programs or create new ones.
Nationwide, the Recovery Act provided $65 million for congregate meals
and $32 million for home-delivered meals, or about 13 percent of the
total OAA allocation for meals in fiscal year 2009.[Footnote 27] States
distributed Recovery Act funds to over 600 AAAs. Unlike regular Title
III meal funds, Recovery Act meal funds could not be transferred among
programs. Thirty-nine of 61 local agencies said it was moderately to
extremely challenging that Recovery Act funds could not be transferred
among meal programs.
Many local agencies responding to our survey said they used Recovery
Act funds to replace funds lost from other sources; 35 of 52 local
agencies said they used Recovery Act funds to expand existing nutrition
programs. Fourteen of 43 local agencies said they used Recovery Act
congregate meal funds to create new programs and 6 of 37 used Recovery
Act home-delivered meal funds to do so. City of Chicago officials said
that they used excess congregate meal funds to create a new breakfast
program since they could not transfer the funds to their home-delivered
meal program. But many of those responding to our survey expressed
concerns about how expenses covered by Recovery Act funds will be met
when the funding ends. Fifty of 61 local agencies said sustaining
services currently paid with Recovery Act funds will be a moderate to
extreme challenge. A local agency director in Wisconsin told us
Recovery Act funds helped replace lost state funds and delayed a blow
to nutrition programs which is now expected to hit in fall 2010 after
the funds are spent. City of Chicago officials expressed concern about
their ability to maintain their new breakfast program.
Concluding Observations:
OAA Title III programs are an invaluable support mechanism for many
seniors, providing a varied network of care and services as they age.
Seniors' needs for the types of services provided through these
programs will only increase over time since demographic studies show a
larger proportion of Americans will be age 60 and older over the next
few decades. Programs that allow seniors to remain in their own homes
and communities afford seniors the independence and dignity they
desire. As current fiscal stress and looming deficits continue to
constrain available resources, it will be increasingly important for
all elements of the home and community-based service network to focus
services on those in greatest need.
Mr. Chairman, This concludes my prepared statement. I will be happy to
answer any questions you may have.
[End of section]
Appendix I: Objectives, Scope, and Methodology:
To determine the Title III services requested most often, local
agencies' use of federal funds, and steps agencies take to deliver
resources to those most in need, we conducted a web-based random
national sample survey of 125 Area Agencies on Aging (AAA). The survey
included questions about: (1) utilization of OAA Title III services,
(2) requests for OAA Title III services, (3) approaches for measuring
unmet need to target resources to areas of greatest need, (4) use of
OAA Title III funds, and (5) the economic climate and use of American
Recovery and Reinvestment Act (Recovery Act) funds. We drew a simple
random sample of 125 agencies, from a pool of 638 agencies. This
included all 629 area agencies on aging (AAA) that operate in the 50
states and District of Columbia, as well as nine State Units on Aging
(SUA) in states that do not have AAAs. We included these nine state
agencies in our pool for sample selection because the SUA performs the
function of AAAs in those states. We conducted four pretests to help
ensure that survey questions were clear, terminology was used
correctly, the information could be obtained, and the survey was
unbiased. Agencies were selected for pre-testing to ensure we had a
group of agencies with varying operating structures, budget sizes, and
geographic regions of the country. As a result of our pretests, we
revised survey questions as appropriate. In June 2010, we notified the
125 AAAs that were selected to complete our survey and e-mailed a link
to complete the Web survey to these agencies beginning July 1, 2010.
The survey is on-going, and the information included in this testimony
presents preliminary results, based on the 67 responses (54 percent) we
received as of July 30, 2010. Some individual questions have lower
response rates. The practical difficulties of conducting any survey may
introduce nonsampling errors. For example, difficulties in interpreting
a particular question, sources of information available to respondents,
or entering data into a database or analyzing them can introduce
unwanted variability into the survey results. We took steps in
developing the questionnaire, collecting the data, and analyzing them
to minimize such nonsampling error. Due to the preliminary nature of
the results, the information presented in this testimony is not
intended to be generalizable to all AAAs.
We also reviewed relevant statutory provisions and used site visit
interviews and Administration on Aging (AoA) State Program Report data
to answer all three of our research questions. In March 2010, we
visited Illinois, Massachusetts, Rhode Island, and Wisconsin. These
states were selected due to varying sizes of the population age 60 and
over and Title III expenditures. Additionally, we considered
geographic region, proximity to AoA regional support centers, and a
desire to interview at least one state without AAAs (Rhode Island). We
interviewed officials from the SUA, AAAs, and AoA regional support
centers. We also analyzed AoA State Program Report data available on
the agency's Web site and at [hyperlink, http://www.agidnet.org]. We
assessed the validity and reliability of this data by interviewing AoA
officials, assessing official's responses to a set of standard data
reliability questions, and reviewing internal documents used to edit
and check data submitted by states. We determined the data were
sufficiently reliable for purposes of this review.
To determine steps agencies take to deliver resources to those most in
need, we also analyzed the most recently available state aging plan for
the 50 states and District of Columbia. Each state is required to
submit a state aging plan to AoA for review and approval covering a
two, three, or four year period. The aging plan should include state
long care reform efforts with an emphasis on home and community-based
services, strategies the state employs to address the growing number of
seniors, and priorities, innovations and progress the state seeks to
achieve in addressing the challenges posed by an aging society.
Contact and Acknowledgments:
For future contact regarding this testimony, please contact Kay Brown
at (202) 512-7215 or email brownke@gao.gov. Key contributors to this
testimony were Kimberley M. Granger-Heath, Susan Aschoff, James
Bennett, Ramona Burton, Andrea Dawson, Justin Fisher, Luann Moy,
Barbara Steel-Lowney, and Craig Winslow.
[End of section]
Footnotes:
[1] Pub. L. No. 89-73, 79 Stat. 219 (codified as amended at 42 U.S.C.
§§ 3001 - 3058ee). It was most recently reauthorized by the Older
Americans Act Amendments of 2006, Pub. L. No. 109-365, 120 Stat. 2522.
[2] Services funded through the OAA are not entitlements. The number of
clients served is limited by available funding, and funding from OAA
funds make up about one-third or less of total funding for services,
which are delivered by state and local providers. Other funding sources
include Medicaid, Medicare, state government, Social Services block
grants, and voluntary contributions and donations.
[3] Population Division, U.S. Census Bureau. "Table 2. Projections of
the Population by Selected Age Groups and Sex for the United States:
2010 to 2050 (NP2008-T2)." Released August 14, 2008.
[4] Pub. L. No. 111-5, 123 Stat. 115, 179 (2010).
[5] Because the survey is still in progress and the desired response
rate had not been achieved by September 1, 2010, as we prepared for
today's testimony, our results are not generalizeable at this time. Our
full report is to include final survey results intended to be
generalizeable.
[6] 42 U.S.C. § 3021.
[7] The 56 SUAs include states, the District of Columbia, and
territories.
[8] 42 U.S.C. § 3030d.
[9] 42 U.S.C. §§ 3030e-3030g-22.
[10] 42 U.S.C. §§ 3030s-3030s-2.
[11] 42 U.S.C. § 3024.
[12] Area Agencies on Aging: Advancing Access for Home and Community-
Based Services, 2008 Area Agencies on Aging Survey, National
Association of Area Agencies on Aging and Scripps Gerontology Center of
Miami University (June 2009).
[13] 42 U.S.C. § 3025(a)(1)(E) and (2)(C) and (E).
[14] Pub. L. No. 111-148, § 2402, 124 Stat. 119, 301-04. Medicaid law
already authorized waivers under which states could, if certain
conditions were met, cover most home and community based services under
Medicaid. 42 U.S.C. § 1396n(c).
[15] At the time of this testimony, 67 local agencies had responded to
our survey. Because not all respondents answer every question, the
numbers of total responses vary from question-to-question.
[16] Support services provided through Title III, Part B, include
transportation, information and assistance, and a number of home-based
care services. For a full list of Part B support services, see table 1
above.
[17] Our past work has noted the importance and difficulty of providing
transportation to seniors in rural areas because alternatives to
seniors' own transportation are less likely to be available and special
transportation services are limited. GAO, Transportation-Disadvantaged
Seniors: Efforts to Enhance Senior Mobility Could Benefit from
Additional Guidance and Information. [hyperlink,
http://www.gao.gov/products/GAO-04-971], (Washington D.C.:
August 2004).
[18] Our past work has found that mass transit options may pose
scheduling and accessibility challenges for seniors. See GAO-04-971.
[19] Agency officials' observations about seniors' increased interest
in home-delivered meals are echoed by data describing trends in the use
of OAA meal services. Although congregate meal programs still served
more clients than home-delivered meal programs in fiscal year 2008, the
Congressional Research Service found that from 1990 to 2008, the number
of home-delivered meals served grew by almost 44 percent, while the
number of congregate meals served declined by 34 percent. See Collelo,
Kirsten J. Older Americans Act: Title III Nutrition Services Program,
Congressional Research Service, RS21202, (November 2009).
[20] In addition to home-based services provided by OAA programs, many
receive services through Medicaid. Provisions of the Patient Protection
and Affordable Care Act, such as that authorizing the Community Choice
First Option which establishes an additional Medicaid waiver, and that
constituting the CLASS Act, which establishes a national voluntary
insurance program, may provide additional sources of coverage for in-
home care services. Pub. L. No. 111-148, §§ 2401 and §§ 8001 - 8002,
124 Stat. 297-301 and 828 - 47.
[21] See Collelo, Kirsten J. 2009.
[22] National Association of State Units on Aging. The Economic Crisis
and Its Impact on State Aging Programs: Results of All State Survey
(November 2009).
[23] Hicks, Jennifer and Eric R. Kingston. "The Economic Crisis: How
Fare Older Americans?" Generations Journal of the American Society on
Aging (Fall 2009).
[24] In our final report, we hope to estimate the numbers of
individuals in need of meal, transportation and home-based care
services, and to provide information on what characteristics are
related to need for these services and to the likelihood that these
needs are being addressed. We plan to do this by conducting regression
analyses of publicly available national data on the 60 and over
population.
[25] OAA allows states to transfer funds among Title III Part B support
services and Title III Part C meal programs. 42 U.S.C. § 3023(c)(2).
States may transfer up to 40 percent of funds among Part C meal
programs, and may transfer up to 30 percent of support services funds
to the meal programs and vice versa. The Assistant Secretary of Aging
also can grant a waiver that allows states to transfer additional
funds. Funds for Title III Part E caregiver services cannot be
transferred under this authority.
[26] Fiscal year 2008 is the most recent year for which state level
data are available.
[27] SUAs that administer Medicaid programs received additional
Recovery Act funds. 42 U.S.C. § 3023(c)(2). State officials in
Wisconsin said although the funds were not specifically for OAA
programs, they did help maintain some SUA program operations.
[End of section]
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