Statement by
Josefina Carbonell
Assistant Secretary for Aging
U.S. Department of Health and Human Services

Reauthorization of the Older Americans ACT (OAA)

The Subcommittee on Select Education Committee on Education and
the Workforce, US House of Representatives

Tuesday, May 2, 2006

Chairman Tiberi, Congressman Hinojosa, distinguished members of the Committee, thank you for inviting me here today to discuss the reauthorization of the Older Americans Act (OAA). I appreciate all of your efforts to develop a bi-partisan reauthorization bill for the Older Americans Act. I am pleased with the direction you have taken to modernize the OAA for the 21st century. I look forward to continuing to work with you on this important piece of legislation.

The OAA embodies our nation's noblest aspirations for ensuring the dignity and independence of our older citizens by promoting older people's full participation in society, and supporting their overwhelming desire to remain living in their own homes and communities for as long as possible.

Last July we celebrated the fortieth anniversary of the OAA. For four decades, the OAA has guided the development of the national aging services network (aging services network) that today consists of the Administration on Aging, 56 State Agencies on Aging, 655 Area Agencies on Aging, almost 237 tribal organizations, 29,000 community-based provider organizations, over 500,000 volunteers, and a wide variety of national and local non-profit organizations. This network reaches into every community in this nation, and each year provides direct support to 8,000,000 older individuals and 600,000 family caregivers.

The OAA and the aging services network accomplished a lot in forty years. It produced a wide array of innovative programs to help older Americans retain their independence in the community. It brought Federal support to meals-on-wheels, making it one of the most significant and worthwhile volunteer ventures in the history of this nation. It brought consistency and quality to senior center programs across the country, providing seniors an opportunity to socialize with each other, to improve their nutritional status with healthy meals, and to see other aspects of their health status addressed through health screening, medication management, and physical activity programs. More recently, through the National Family Caregiver Support Program (NFCSP), the OAA brought recognition and support to family caregivers, who to this day account for some two-thirds of all of the long-term care provided to elderly and disabled people across the U.S.

As we move ahead to reauthorize the OAA we can look back with pride on our accomplishments, but that is not enough. We must look forward to the changing realities facing our nation. In January, the baby boom generation started turning age 60, and over the next 25 years, the number of Americans over the age of 65 will double. By 2050, when the baby boomers will be age 85 and older, there will be over 86 million people age 65+ living in the United States, compared to 35 million today.

Not only is the number of older Americans increasing at unprecedented rates, but those reaching age 65 are living longer than ever before. This increase in age will dramatically expand the demand for long-term care. Long-term care is what people need to accommodate their inability to perform basic activities of daily living, such as bathing, cooking, and cleaning the house. Among those over the age of 85, the proportion of people who are impaired and require long-term care is about 55 percent. While the precise number of people who will need long-term care in the future could be affected by numerous variables, including possible declines in rates of impairment, the expected increase in the number of seniors is so great that most experts agree that there will be far more people in need of home and community-based long-term care in the future than there are today.

These unprecedented shifts in the size and composition of our population are creating both challenges and opportunities for our society, our families and our individual citizens. Since the last reauthorization, AoA and the Department of Health and Human Services (HHS) have recognized this reality and laid the groundwork for the current reauthorization of the OAA.

Older Americans Act Accomplishments since Reauthorization in 2000

Strategic Planning
The successful implementation of the provisions of reauthorization of 2000 focused closely on the implementation of the caregiver program and brought vision, strategic planning, and performance accountability to the day-to-day management of the program. With new information about the capacity of AoA and the aging network to assist frail elderly people with long-term care services, AoA steered our discretionary innovation resources toward the pursuit of program efficiency in long-term care, enhancing core programs, and toward improving the well-being of elderly clients through the science of prevention. AoA did this in partnership with the other Federal agencies, the private sector and our nationwide network.

In this strategic planning process, AoA repeatedly and formally listened to our consumers and to those who serve them to ensure that we can move OAA programs forward in a way that will efficiently serve elders, including the baby boom generation for years to come. Many called for flexibility in implementing the OAA. Nearly half of the comments were ideas for future amendments to the OAA. These also focused on flexibility, particularly with regard to allowing greater integration of long-term care programs and funding streams to create a more seamless program of services for elderly people and caregivers.

These efforts yielded a focused set of strategies to modernize the OAA to better serve the current and emerging needs of this country for efficient and cost-effective home and community-based long-term care. These strategies are designed to strengthen the OAA capacity to promote the dignity and independence of older people, and they build on the OAA unique mission and capabilities. They include: 1) empowering people to make informed decisions about their health and long-term care options, and making it easier for consumers to access the care they need; 2) helping older people who are at high-risk of nursing home placement to remain at home; and 3) empowering seniors to stay active and healthy. AoA program activities have a fundamental common purpose reflecting the primary legislative intent of the OAA: to promote the development of a comprehensive and coordinated system of support at the Federal, State and local level making community-based services available to elders, especially those who are at risk of losing their independence; to help prevent disease and disability through community-based activities; and to support the efforts of family caregivers who are struggling to keep their loved ones at home.

Performance Accountability
OAA services are delivered through efficient, high-quality, compassionate programs that help maintain independence for older people. The core OAA home and community-based long-term care services such as in-home services, congregate and home delivered meals, transportation, information and referral, outreach, and caregiver services have made living at home a real choice for many older adults. This nationwide infrastructure provides these services across the United States, U.S. Territories and the Tribes to more than 8 million elderly persons age 60 and over each year - which is 17 percent of all people aged 60 and older including 3 million individuals who require intensive services, many of whom meet the functional requirements for nursing home care. These services improve quality of life, create community connections, make people safer and healthier, and are the foundation of this nation's long-term care system.

A comprehensive set of performance measures consistently indicates that OAA services make a positive difference in the lives of older adults. The results of these performance measures show that OAA programs serve those most in need, including people who are poor, who live in rural areas, and who historically were disadvantaged. The results also show OAA programs are cost-effective and maintain high consumer satisfaction. For example, AoA and the aging network increased the number of clients served per million dollars of AoA funding by 15 percent in the last two years. AoA achieved a 16 percent increase in complaint resolutions per million dollars of ombudsman funds. AoA maintained client satisfaction rates for home-delivered meals in the mid-80 to low-90 percentiles, and equally high percentages of elderly people report each year that the meals programs help them remain independent in their own homes.

The need and expectation for successful performance was also a critical factor for AoA with the implementation of the National Family Caregiver Support Program (NFCSP). Providing service to caregivers is critical because we recognize that they are the backbone of long-term care in this country. Sixty-four percent of people with Medicare who receive personal care support receive that care only from informal or family caregivers. Fewer than 10 percent of people with Medicare who receive personal care receive that care only from professionals. Fortunately, the implementation of the NFCSP provides a fine example of the results that are being produced by the aging network to help elderly people maintain their independence. Because of State and local efforts, we now serve approximately 600,000 caregivers each year. This occurred in large part because of very successful outreach campaigns by State and local programs that provided information about caregiving to over 12 million people in the last two years alone.

AoA includes family caregivers in annual performance outcome measures surveys. The surveys show that over 85 percent of caregivers reported that AoA services help them care longer for family and friends. Improvements in information and access surveys reduced to below 50 percent the number of caregivers reporting difficulty in getting the information they need. A number of States have developed programs to make it easier for consumers and their family caregivers to learn about the options that are available in their communities, and to assess the care they need. We have built on these best practices to develop our Aging and Disability Resource Center initiative, which fosters one-stop shops for information and access to community-based long-term care discussed later in the testimony.

One of the most significant accomplishments of the OAA is the emergence of a community-based, cost-effective, nationwide network that is now one of the largest providers of home and community-based long-term care for the elderly in the U.S. In addition to administering OAA investments in long-term care and related State and community-funded programs, this network also administers and manages over 60 percent of the funding made available under Medicaid home and community-based waiver programs for the elderly and disabled. Many States used their OAA program as the foundation for their home and community-based long-term care systems.

Emerging Solutions
Just as the OAA was the solution for so many significant policy challenges affecting frail elderly people in the past, the OAA may be a vehicle for addressing emerging long-term care challenges that we now face as a result of our rapidly growing older population. Building on policies that the President and the Secretary of HHS have already instituted, the OAA has the potential to increase the quality of life for our seniors and also make our system of care more cost-efficient.

President Bush's vision for the future of long-term care is outlined in his 2001 New Freedom Initiative (NFI). This Initiative aims to create a system of care that is responsive to the needs and preferences of Americans of all ages with disabilities, and the values of choice, control and independence. Since 2001, HHS and Congress provided the States and communities with a variety of new tools to help them advance the goals and values embedded in the NFI. These tools included: the Real Choice Systems Change grants, new Medicaid waiver options, implementation of the NFCSP, replication of the successful Cash and Counseling model, the Aging and Disability Resource Center (ADRC) Initiative, and the Own Your Future Campaign.

Most recently, HHS and the Congress took significant steps forward to modernize Medicaid long-term care working with the nation's governors and the Congress. Major Medicaid changes contained in the recent Deficit Reduction Act, such as Money Follows the Person, empowers consumers and gives more support to community-living options. Congress recognized through the expansion of the Long-Term Care Partnership program and other changes that our long-term care policy strategies must go beyond the parameters of the Medicaid program. This is especially important for our nation's older population.

The Choices for Independence demonstration (Choices) aims to educate and provide community-based long-term care options to the elderly. Specifically, the demonstration targets non-Medicaid eligible elderly take greater control of their long-term care by helping them make better use of their personal resources, thereby avoiding unnecessary nursing home placement. Choices also will empower middle-aged individuals to plan ahead for their long-term care.

The Choices demonstration will test ways to help States and communities be more consumer-directed, more supportive of community living, and more cost-effective. Choices builds on recent HHS initiatives and the unique assets inherent in the OAA, including the ability to reach people while they are still healthy.

This demonstration funds implementation of Choices in a limited number of States and is intended to test and document the potential impact of Choices on the health and well-being of older people, their family caregivers, and on health care costs under Medicaid and Medicare. I was pleased to see that many of the Administration's concepts as well as our clarifying technical amendments are embedded in the Committee's proposed legislation.

As noted previously, Choices embodies three interrelated strategies for advancing systems change at the State and community level and is intended to test the effectiveness of this combined set of strategies. The demonstration builds on the unique assets of the aging network, its core programs and the best practices that have come from AoA's strategic investments since the last reauthorization. These strategies include: empowering consumers to make informed decisions, including streamlining access to needed care; helping high-risk individuals avoid unnecessary nursing home placement; and, assisting older people with lifestyle and behavioral changes proven to reduce their risk of disease and disability.

Empowering Consumers
The Empowerment component of Choices will build upon two complementary initiatives launched by the AoA in partnership with CMS and other HHS agencies to help people to make informed decisions about their support options, and easily access the supports they need.

One initiative, the Own Your Future Campaign, launched this past year, encourages more people to plan ahead for their long-term care. The project is a joint effort of the AoA, the Assistant Secretary for Planning and Evaluation (ASPE), the CMS, the National Governors Association, and the National Conference of State Legislatures. It was piloted in five States (Arkansas, Idaho, Nevada, New Jersey, and Virginia), and is currently being expanded to three additional States (Kansas, Maryland, and Rhode Island). The Campaign involves a variety of outreach activities, including the targeted mailing of a letter from the governor of each State to every household headed by an individual between the ages of 50 and 70. To date, almost eight percent of the individuals receiving letters requested a free Long-Term Care Planning Kit made available by HHS. This response rate is significantly higher than comparable private sector direct mail campaigns which might see responses of 0.5-2.0 percent.

The concepts of the Own Your Future Campaign were incorporated into the Choices demonstration because studies show that many people do not think about their future long-term care needs and therefore fail to plan appropriately. If individuals and families are more aware of their potential need for long-term care, they are more likely to take steps to prepare for the future. From a public policy perspective, increased planning for long-term care is likely to increase people's ability to remain at home with better use of their own resources, and may also reduce pressures on public programs.

The second initiative, the Aging and Disability Resource Center program, was launched in 2003 by the AoA and CMS, to help people plan ahead for their long-term care, and address the immediate problems consumers face when they try to learn about and access needed care. This program builds on the strength and experience of the extensive aging network by providing competitive grants to States to assist them in developing and implementing coordinated access to information, individualized advice to consumers on their options, and streamlined eligibility determination for publicly supported programs, including OAA, State revenue programs and Medicaid long-term care services. The goal is to have ADRCs serving as "visible and trusted" sources where people of any age or income can turn to get information and personalized assistance on options that are available in their community. By streamlining access to publicly supported care options, ADRCs also reduce the confusion and frustration people encounter when they try to access the various programs with different, and often duplicative, eligibility forms, requirements, and procedures.

To date, AoA and CMS have provided close to $40 million to fund ADRC projects in 43 States. In the first 24 funded States, 66 pilot sites opened and now provide specialized information and assistance to the elderly and people with disabilities. All of the pilot sites are now implementing activities that streamline access to publicly funded long-term care. These activities include: the use of uniform assessment and eligibility determination processes; using integrated management information systems; developing websites to streamline access to information and eligibility determination; developing electronic applications for Medicaid eligibility; co-location of aging services and Medicaid eligibility staff; and outreach to hospitals and nursing homes to divert or transition consumers from institutional placement.

Under this joint initiative, AoA and CMS are giving States considerable flexibility in how to best implement their ADRC programs. For example, Ohio is using the ADRC to create multiple avenues by which consumers and their caregivers can access the ADRC network, via internet, phone or in-person. These new consumers and their caregivers will experience a seamless process in accessing information and services, including long-term care and related services such as housing, transportation, and employment. The South Carolina ADRC efforts are being spearheaded by the Lt. Governor's Office on Aging which is piloting an ADRC in two counties, Aiken and Barnwell. One of the most exciting efforts underway in the South Carolina project is the launching of Medicaid eligibility e-forms and the co-location of Medicaid staff at the local level. As a result of the successful development of an electronic application for Medicaid, the State is now considering developing e-forms for other applications. South Carolina is also using the ADRC model to develop a "No Wrong Door" approach where consumers can access an integrated array of home and community-based supports accessible by telephone, internet and personal appointments.

Targeting High-Risk Individuals
Choices will test ways to provide States and communities greater flexibility under the OAA to help individuals who are at high risk of institutional placement but not eligible for Medicaid to remain at home and delay their premature entry into nursing homes. The Community-Living Incentive (CLI) component of Choices is similar to "Money Follows the Person" with the difference being that CLI will help people before they go into nursing homes, while the recently enacted "Money Follows the Person" initiative is targeted at people who are already in nursing facilities.

Currently, OAA dollars are allocated to specific service categories. Under the CLI, program dollars will be tied directly to consumers and their unique functional needs and circumstances. This way, States and communities will have the flexibility to provide the necessary assistance to help a senior stay at home. CLI will incorporate the Cash and Counseling approach into the OAA.

The Cash and Counseling model has been tested through a controlled experiment conducted over several years in New Jersey, Arkansas and Florida with funding from the HHS Assistant Secretary for Planning and Evaluation and the Robert Wood Johnson Foundation. This model gives clients control over individualized budgets to manage the types of services and supports they received and the manner in which they were provided. This included the option of hiring a member of their family, a friend or a neighbor. The results showed three major positive outcomes when compared to those achieved under the traditional model of care: enhanced consumer satisfaction; improved quality of care; and an absence of fraud and abuse. HHS made it a policy to encourage States to use the Cash and Counseling option under their Medicaid home and community-based care programs, and now want to do the same with the OAA program.

Prevention into Long-Term Care
Choices will also test strategies that best empower older individuals to make lifestyle changes to reduce their risk of disease, disability and injury. Most long-term care needs emerge from chronic diseases and other conditions, such as arthritis, diabetes, heart or lung disease, stroke and dementia, as well as from injuries suffered as a result of a fall or other accident. These conditions and their effects can be mitigated, even for people who are very old, through life-style changes and disease management programs. In acute care we have learned the importance of prevention. Prevention is equally important in the long-term care system.

There is a growing body of scientific research from the National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality and others, documenting the effectiveness of evidence-based programs in reducing the risk of disease, disability and injury among the elderly. To reinforce the utility of the aging services network as a vehicle for making these evidence-based programs more widely available at the community level, the AoA launched an Evidence-Based Prevention Program in 2003 in partnership with NIA, CDC, AHRQ, CMS and the John A. Hartford, Robert Wood Johnson, and several smaller foundations. AoA funded more than a dozen local projects with models that focus on disease self-management, fall prevention, nutrition, physical activity, medication management, and depression. These models hold considerable potential for long-term improvement in the quality of life and lowered health care costs.

One example of a very successful model is the Chronic Disease Self-Management Program developed at Stanford University. This program begins with a six week workshop designed to empower and educate people with various chronic diseases to better mitigate and control their symptoms. The program significantly improves participant health status and reduces the use of hospital care and physician services. Another evidenced-based model is a program developed at Yale University to prevent falls. Falls are a leading cause of serious injury and death among the elderly and are a major contributor to health costs. The Yale program uses a multifaceted approach to help older individuals cope with key risk factors. Participants are trained to improve balance, gait and posture, better manage their medication, and to remove home hazards. The program significantly reduces the incidence of falls among participants.

A culturally sensitive nutrition program launched by the Alamo Area Council of Governments in San Antonio, Texas is another model program that is helping low-income, Hispanic seniors head off diabetes before it starts. The program is based on a landmark study by the Diabetes Prevention Research Group which showed that diet and exercise could effectively delay the onset of Type 2 diabetes - even in adults who are already showing glucose intolerance. Participants in the program receive regular health monitoring and eat specially prepared "tex-mex" lunches at their local nutrition center. They also take part in a three-day-a-week education program that promotes physical activity, healthy cooking practices and better disease self-management. Sponsors have set a goal that participants will increase their physical activity to at least 150 minutes per week and experience a seven percent weight loss.

Finally, the Partners in Care Foundation in Burbank, California is helping low-income older adults who are homebound improve their health through an evidence-based exercise program. The activity portion of this intervention is modeled after a research-tested approach called "LifeSpan: A Physical Assessment Study Benefiting Older Adults." The approach was developed by researchers at California State University at Fullerton. After an initial assessment, clients are taught a variety of easy exercises by professional care managers and receive ongoing support and encouragement from volunteer peer coaches. The care managers monitor clients' participation during regularly scheduled appointments and reassess them at six-month intervals.

Reauthorization of the Older Americans Act: Another Opportunity for Long-Term Care Systems Change
The reauthorization of the OAA provides a unique and timely vehicle to accelerate the changes needed in long-term care policy to help our nation fully prepare for the aging of the baby boom and the emergence of long-term living as a common experience of life. When the OAA was passed in 1965, Congress charted out a vision for a nationwide network of public and private agencies organized around the common purpose of promoting the dignity and independence of older people through a coordinated system of services and supports to help them live in their own homes and communities for as long as possible.

The network envisioned in the OAA is now a reality. It is a consumer-driven, locally designed, nationwide infrastructure, supported by multiple funding streams, and capable of reaching people with low-cost social interventions long before they need intensive services. OAA programs have reached people of all income levels, while targeting its limited resources to those most in need, including low-income minority, rural or isolated populations. Early reauthorizations of the OAA created area agencies on aging and fostered the principle of local flexibility through a "bottoms-up" planning process that ensures OAA programs continually reflect local needs and conditions.

Many States have looked to their aging network to lead the development of their long-term care systems, including States with the most balanced and cost-efficient systems of care such as Oregon, Washington and Vermont. The OAA network is one of the largest providers of home and community-based care and manages between $3 and $4 billion each year in public and private resources. All State Agencies on Aging have the responsibility to administer State revenue programs; over 30 State agencies administer Medicaid Waiver Programs and State Health Insurance Assistance Programs; over 25 States have the authority of the State Aging Agencies to serve younger populations with disabilities.

In short, the aging services network created by the Older Americans Act and led by the AoA is well positioned to help ensure the modernization of long-term care in our country. I have tremendous respect for and confidence in the long-term care network I have spoken about today. The Administration supports your efforts to reauthorize the OAA and looks forward to working with you to modernize and strengthen our nation's home and community-based long-term care system.

I am proud to have served in this network for more than 34 of its 41 years. I truly believe, with the support of Congress, our reauthorization proposal and principles will give consumers the choices they need to lead more healthy and productive lives.

Thank you, Mr. Chairman, for the opportunity to speak to you today about the reauthorization of the Older Americans Act. I would be pleased to answer any questions you may have.

Last Revised: May 3, 2006