Administration on Aging
U.S. Department of Health and Human Services (HHS)
Senior Hunger and the Older Americans Act
Committee on Health, Education, Labor and Pensions
Subcommittee on Primary Health and Aging
United States Senate
Tuesday June 21, 2011
Thank you, Chairman Sanders, Ranking Member Paul, and members of the Subcommittee on Primary Health and Aging, for the opportunity to testify at this important hearing on hunger, senior nutrition programs and the role of the Older Americans Act (OAA) in helping some of our most vulnerable seniors maintain their health and well-being in their homes and communities, avoiding more costly hospital and nursing home care.
Hunger and food insecurity is a serious problem among many older Americans. Research sponsored by the Meals on Wheels Association of America in 2008 found that nearly six million seniors faced the threat of hunger in 2007. Half of these at-risk seniors had incomes above the Federal poverty line. These individuals and households, at some time during the year, had difficulty providing nutritionally adequate and safe foods due to a lack of resources. Yet, study after study show that adequate food and nutrition is vitally important for promoting health, decreasing the risk of chronic disease, maintaining functionality, and helping older adults remain independent at home, and in their communities.
OAA nutrition services programs have been one of the core elements of our national strategy for reducing food insecurity among the elderly for nearly 40 years. These vital community-based programs, which serve persons aged 60 and over, provide access to meals in a group setting or delivered to the home, a service that is not provided by other Federal nutrition programs.
As currently authorized, OAA nutrition services programs include:
- Congregate Nutrition Services (Title III-C1): Provides funding for the provision of meals and related services in a variety of congregate settings, which help to keep older Americans healthy and prevent the need for more costly medical interventions. Established in 1972, the program also presents opportunities for social engagement and meaningful volunteer roles, which contribute to overall health and well-being. In FY 2009, more than 92 million meals were provided to nearly 1.7 million seniors in a variety of community settings.
- Home-Delivered Nutrition Services (Title III-C2): Provides funding for the delivery of meals and related services to seniors who are homebound due to illness, disability or geographic isolation. Established in 1978, home-delivered meals are often the first in-home service that an older adult receives, and serve as a primary access point for other home and community-based services. In FY 2009, nearly 149 million home-delivered meals were provided to more than 880,000 homebound individuals.
- Nutrition Services Incentive Program (NSIP) (Title III-A): Provides additional funding to States, Territories, and eligible tribal organizations that is used to provide meals. Funds are awarded to States and Tribes based on the number of meals served in the prior Federal fiscal year. States and Tribes have the option to purchase commodities directly from the U.S. Department of Agriculture with any portion of their award if they determine that doing so will enable them to better meet the needs of the older persons they serve.
Although many of the older adults who participate in both the congregate and home- delivered programs are low income, income alone is not an adequate measure of need for nutrition services. Many of the recipients of this assistance are functionally impaired, meaning that they may not be able to drive to a grocery store, carry their groceries, stand for even short periods of time, or they may have hands that are too affected by arthritis to prepare a meal. In other words, provision of groceries is not sufficient to eliminate food insecurity and hunger in this population.
In sum, each year the OAA nutrition services programs help more than two and a half million older adults, many of whom are functionally impaired and are at risk of serious health consequences, receive the meals they need to stay healthy and decrease their risk of disability.
OAA Nutrition Programs Effectively Target Those With Special Needs. The OAA does not require that all people be served, nor is it means tested, but it does require that services be targeted. The OAA nutrition programs are generally targeted to those with the greatest levels of food insecurity, including those who are poor or near poor, socially isolated, functionally impaired, and in poor health. Serving Elders at Risk, a national evaluation of the Administration on Aging’s (AoA) nutrition program clients, found that recipients of this assistance are older, poorer, more likely to live alone, more likely to be minorities, in poorer health and nutritional status, more functionally impaired, and at higher nutritional risk than older individuals in the general population.
Based on data gathered through FY 2009 and via the 2009 National Survey of Older Americans Act program participants, we know the following about the participants in the OAA nutrition programs:
For the home-delivered meals programs:
- 44 percent are in poverty and 52 percent are at high nutritional risk;
- 24 percent do not have enough money or food stamps to purchase enough food to eat;
- 63 percent rely on their home-delivered meal for one-half or more of their total food for the day;
- 17 percent report they choose between purchasing food and medications;
- 55 percent of white, 63 percent of African American and 38 percent of Hispanic home-delivered meal participants report their health as fair to poor.
For the congregate meals programs:
- 34 percent are in poverty and 19 percent are at high nutritional risk;
- 13 percent do not have enough money or SNAP benefits to purchase enough food to eat;
- 58 percent rely on their congregate setting meal for one-half or more of their total food for the day;
- 27 percent of white, 38 percent of African American and 26 percent of congregate meal participants report their health as fair to poor.
AoA’s annual performance data further demonstrate that these programs are an efficient and effective means for helping seniors remain healthy and independent in their homes and in the community. Ninety-one percent of home-delivered meal clients rate service as good to excellent. In addition, the number of home-delivered meal recipients who have severe disabilities (those with three or more impairments of activities of daily living) totaled more than 357,000 in FY 2009. This level of disability is frequently associated with nursing home admission, and demonstrates the extreme frailty of a significant number of persons served by the home-delivered meals program.
Additionally, data from AoA’s 2009 national survey of elderly program participants show that the nutrition services programs are effectively helping seniors improve their nutritional intake and remain at home: 73 percent of congregate and 85 percent of home-delivered meal recipients say they eat healthier meals due to the programs, and 58 percent of congregate and 93 percent of home-delivered meal recipients say that the meals enabled them to continue living in their own homes.
For the majority of program participants, the program provides more than one-half or more of their total food intake and enables them to continue living in their own homes.
AoA continues to build upon the successes of the senior nutrition programs and further increase their effectiveness by implementing a multi-year, comprehensive evaluation. In addition to providing detailed information on how the nutrition programs currently operate at the State and local levels, the evaluation is designed to measure the programs’ effects on food insecurity and hunger, social isolation and the health and well-being of program participants. AoA is working with the Centers for Medicare and Medicaid Services (CMS) to identify an appropriate comparison group of non-participants and measure healthcare utilization and cost. The evaluation will answer how and why program results are achieved.
The OAA nutrition programs are a good investment in reducing food insecurity. To help address hunger and food insecurity among older Americans during the economic downturn, $100 million in funding was provided as part of the American Recovery and Reinvestment Act of 2009 to the OAA senior nutrition programs. Since March, 2009, this supplemental funding has provided more than 22 million meals to help combat food insecurity among more than 1.1 million older Americans.
The nutrition programs help to support family caregivers, who provide most of the care for older adults. The provision of a home-delivered meal, which includes not only a meal, but also a mid-day contact, may allow a family caregiver to continue to work and provide care for a loved one in the morning before work and in the evening. Home-delivered meals provide a critical service as a part of a formal comprehensive and coordinated service system that individualizes care for older adults and their families. Congregate meals provide a daily social interaction that is also a gateway to volunteer opportunities and civic engagement, other home and community based services, and a meal that promotes health and reduces the risk of chronic disease. Nutrition services are not simply access to food, but to a system that meets social service, health, and food security needs.
Nutrition services are but one component of a larger system of both formal and informal supports authorized by the OAA that help older individuals maintain their health at home and out of hospitals and nursing facilities. In Fiscal Year 2009, nearly 11 million older Americans and their family caregivers have been supported through the OAA’s comprehensive home and community-based system. These services include: transportation; case management; information and referral; in-home services such as personal care, chore, and homemaker assistance; community services such as adult day care; support for family caregivers; protections against elder abuse; nursing home ombudsmen who serve as advocates for residents of long-term care facilities; legal assistance; pension counseling and assistance programs; prevention and reporting of waste, fraud and abuse in the Medicare and Medicaid programs, and a host of other supports that are tailored to meet individual needs.
This nationwide network of community-based assistance complements medical and health care systems, helps to prevent hospital readmissions, provides transport to doctor appointments, and supports some of life’s most basic functions, such as assistance to elders in their homes by delivering or preparing meals, or helping them with bathing. This assistance is especially critical for the nearly three million seniors who receive intensive in-home services, half a million of whom meet the disability criteria for nursing home admission but are able to remain in their homes, in part, due to these community supports. An analysis of the OAA’s program data reveal that, through FY 2009 (the most recent year data are available), most indicators have steadily improved.
- OAA programs help older Americans with severe disabilities remain independent and in the community: One approach to measuring the value of OAA’s programs is the newly developed nursing home predictor score. The components of this composite score are predictive of nursing home admission based on scientific literature and AoA’s Performance Outcome Measurement Project (POMP) which develops and tests performance measures. The components include such items as percent of program recipients who are transportation disadvantaged and the percent of congregate meal individuals who live alone. As the score increases, the prevalence of nursing home predictors in the OAA service population increases, meaning AoA is reaching those most in need of help. In 2003, the nursing home predictor score of program participants was 46.57. In FY 2009, this score increased to 61.0.
- OAA programs are efficient: The national aging services network--comprised of 56 State and territorial units on aging, 629 area agencies on aging, 246 Indian tribal and native Hawaiian organizations, nearly 20,000 direct service providers, and hundreds of thousands of volunteers--is providing high-quality services to the neediest elders, and is doing so in a prudent and cost-effective manner. AoA and the national aging services network have significantly increased the number of persons served per million dollars of OAA funding. Without controlling for inflation, OAA programs have increased efficiency by over 36 percent between FY 2002 and FY 2009, serving 8,524 clients per million dollars of funding in FY 2009 compared to 6,103 clients served per million dollars of AoA funding in FY 2002. This increase in efficiency is understated, since the purchasing power of a million dollars in 2009 is significantly less than in 2002 due to inflation.
- OAA programs build system capacity: One of the main goals of OAA program funding is to encourage and assist State agencies and area agencies on aging to concentrate resources in order to develop greater capacity, and foster the development and implementation of comprehensive and coordinated systems. This capacity-building at the State and community level is evidenced by the fact that for every dollar of Federal OAA funding provided, States and communities leverage nearly three dollars in other funding from other sources.
Taken as a whole, AoA’s performance measures and indicators form an interconnected system of performance measurement akin to the three legs of a stool (efficiency, outcomes and targeting) holding up AoA’s mission and strategic goals that include:
- Empowering older people, their families, and other consumers to make informed decisions about, and to be able to easily access, existing health and long-term care options;
- Enabling seniors to remain in their own homes with a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers;
- Empowering older people to stay active and healthy through Older Americans Act services and the preventative care benefits under Medicare;
- Ensuring the rights of older people and prevent their abuse, neglect and exploitation; and
- Maintaining effective and responsive management.
As the former Secretary of Aging in Kansas, and now having the honor to serve as the U.S. Assistant Secretary for Aging and listening to individuals and families in a variety of settings, I have seen firsthand how the OAA reflects the American values we all share:
- Supporting freedom and independence;
- Helping people maintain their health and well-being so they are better able to live with dignity;
- Protecting the most vulnerable among us; and
- Providing basic respite care and other supports for families so that they are better able to take care of loved ones in their homes and communities for as long as possible, which is what Americans of all ages overwhelmingly tell us they prefer.
For more than a year, we have received reports from more than 60 listening sessions held throughout the country, and received online input from interested individuals and organizations, as well as from seniors and their caregivers, about the reauthorization of the OAA. This input represented the interests of thousands of consumers of the OAA’s services. We continue to encourage ongoing input and discussions.
During our input process we were consistently told that, as it is currently structured, the OAA is very helpful, flexible and responsive to people’s needs. We also heard a few themes, I will mention two today:
FIRST: Improve program outcomes by:
- Embedding evidence-based interventions in disease prevention programs;
- Encouraging comprehensive, person-centered approaches;
- Providing flexibility to respond to local nutrition needs; and
- Continuing a strong commitment to efforts to fight fraud and abuse.
SECOND: Remove barriers and enhancing access by:
- Extending caregiver supports to parents caring for their adult children with disabilities;
- Providing ombudsman services to all nursing facility residents, not just older residents; and
- Using Aging and Disability Resource Centers as single access points for long-term care information to public and private services;
Let me give three brief examples of areas we would like to discuss as you consider legislation:
- Ensuring that the best evidence-based interventions for helping older individuals manage chronic diseases are utilized. These have been effective in helping people adopt healthy behaviors, improve their health status, and reduce their use of hospital services and emergency room visits.
- Improving the Senior Community Service Employment Program (SCSEP) by integrating it with other seniors programs. The President’s 2012 budget proposes to move this program from the Department of Labor to the Administration on Aging at HHS. We would like to discuss adopting new models of community service for this program, including programs that engage seniors in providing community service by assisting other seniors so they can remain independent in their homes, while also continuing to support community organizations that rely on SCSEP participants for their valuable work contributions.
- Combating fraud and abuse in Medicare and Medicaid by making permanent the authority for the Senior Medicare Patrol Program (SMP) as an ongoing consumer-based fraud prevention and detection program -- and by using the skills of retired professionals as volunteers to conduct community outreach and education so that seniors and families are better able to recognize and report fraud and abuse.
The Older Americans Act has historically enjoyed widespread, bipartisan support. One of its great strengths is that it does not matter if an individual lives in a very rural or frontier area, or in an urban center – the programs and community-based supports it provides are flexible enough to meet the needs of individuals in diverse communities and settings. Based in part upon the extensive public input we received, we believe that the reauthorization can strengthen the OAA and put it on a solid footing to meet the challenges of a growing population of seniors, while continuing to carry out its critical mission of helping elderly individuals maintain their health and independence in their homes and communities. We look forward to working with this Subcommittee as the reauthorization process moves forward.
Thank you again, Chairman Sanders and members of the Subcommittee for your leadership on these important issues and for your invitation to testify today. We look forward to working with this Subcommittee as the reauthorization process moves forward. I would be happy to answer any questions “The Causes, Consequences, and Future of Senior Hunger in America.” James P. Ziliak, Ph.D., Gatton Endowed Chair in Microeconomics and Director of the Center for Poverty Research, University of Kentucky; Craig Gundersen, Ph.D., Associate Professor, Department of Human Development and Family Studies, Iowa State University. Sponsored by the Meals on Wheels Association of America. March 2008. Serving Elders at Risk – National Evaluation of the Elderly Nutrition Program, 1993-1995, pp.117-118.
Last revised: June 22, 2011